Early gallbladder carcinoma does not warrant radical resection

BACKGROUND: This study was designed to address whether gallbladder cancer invading the muscle layer (stage pT(1b)) is a local disease and whether radical resection is necessary. METHODS: A retrospective analysis of 25 patients with pT(1b) gallbladder tumours, 13 of whom underwent simple cholecystectomy and 12 radical resection with regional lymph node dissection, was performed. A total of 147 regional lymph nodes was examined for metastasis. The median follow-up time was 95 months. RESULTS: No patient had blood vessel or perineural invasion on histology. Lymphatic vessel invasion was seen in one patient. Both overt metastasis and micrometastases were absent in all lymph nodes examined. Overall 10-year survival was 87 per cent. The outcome after simple cholecystectomy was comparable to that after radical resection (P = 0.16). Two patients who underwent radical resection died from tumour relapse in distant sites. CONCLUSION: Most pT(1b) gallbladder carcinomas spread only locally. Additional radical resection is not necessary when the depth of invasion of gallbladder carcinoma is limited to the muscle layer after simple cholecystectomy.     

Immunohistochemically demonstrated lymph node micrometastasis and prognosis in patients with gallbladder carcinoma

OBJECTIVE: To investigate whether immunohistochemically demonstrated lymph node micrometastasis has a survival impact in patients with advanced gallbladder carcinoma (pT2-4 tumors). SUMMARY BACKGROUND DATA: The clinical significance of immunohistochemically detected lymph node micrometastasis recently has been evaluated in various tumors. However, few reports have addressed this issue with regard to gallbladder carcinoma. METHODS: A total of 1476 lymph nodes from 67 patients with gallbladder carcinoma (pN0, n = 40; pN1, n = 27) who underwent curative resection were immunostained with monoclonal antibody against cytokeratins 8 and 18. The results were correlated with clinical and pathologic features and with patient survival. RESULTS: Lymph node micrometastases were detected immunohistochemically in 23 (34.3%) of the 67 patients and in 37 (2.5%) of the 1476 nodes examined. Of the 37 nodal micrometastases, 21 (56.8%) were single-cell events, and the remaining 16 were clusters. Five micrometastases were detected in the paraaortic nodes. Clinicopathologic features showed no significant associations with the presence of lymph node micrometastases. Survival was worse in the 27 patients with pN1 disease than in the 40 with pN0 disease (5-year survival; 22.2% vs. 52.6%, P = 0.0038). Similarly, survival was worse in the 23 patients with micrometastasis than in the 44 without micrometastasis (5-year survival; 17.4% vs. 52.7%, P = 0.0027). Twenty-eight patients without any lymph node involvement had the best prognosis, whereas survival for the 11 patients with both types of metastasis was dismal. The grade of micrometastasis (single-cell or cluster) had no effect on survival. The Cox proportional hazard model identified perineural invasion, lymph node micrometastasis, and microscopic venous invasion as significant independent prognostic factors. CONCLUSIONS: Lymph node micrometastasis has a significant survival impact in patients with pN0 or pN1 gallbladder carcinoma who underwent macroscopically curative resection. Extensive lymph node sectioning with keratin immunostaining is recommended for accurate prognostic evaluation for patients with gallbladder carcinoma.     

Perineural invasion has a negative impact on survival of patients with gallbladder carcinoma

BACKGROUND: The clinical significance of perineural invasion of gallbladder carcinoma remains unclear. The aim of this study was to elucidate the incidence and mode of perineural invasion of gallbladder carcinoma and clarify its prognostic significance. METHODS: A clinicopathological study was conducted on 68 patients who underwent attempted curative resection for gallbladder carcinoma. According to the pathological tumour node metastasis (pTNM) classification of the Union Internacional Contra la Cancrum, there were five (7 per cent), nine (13 per cent), 20 (29 per cent) and 34 (50 per cent) patients with pT1, pT2, pT3 and pT4 disease respectively. Twenty patients (29 per cent) had pM1 disease, including involved para-aortic nodes, liver metastases and localized dissemination. RESULTS: The overall incidence of perineural invasion was 71 per cent (48 of 68 patients). Forty-four (96 per cent) of 46 patients with extrahepatic bile duct invasion had perineural invasion. Although several histological factors were associated with perineural invasion, multivariate analysis demonstrated that extrahepatic bile duct invasion was the only significant factor correlated with perineural invasion (odds ratio 99.0, P < 0.001). The perineural invasion index, defined as the ratio of the number of involved nerves to the total number of nerves examined, was significantly higher at the centre than in the proximal and distal parts of the tumour in the 46 patients with extrahepatic bile duct invasion (P < 0.001). The 5-year survival rate for patients with perineural invasion was significantly lower than that for patients with no invasion (7 versus 72 per cent; P < 0.001). Cox proportional hazard analysis identified perineural invasion (relative risk (RR) 5.3, P < 0.001) and lymph node metastasis (RR 2.5, P = 0.008) as significant independent prognostic factors. CONCLUSION: Perineural invasion is common in advanced gallbladder carcinoma and has a significant negative impact on patient survival.     

Clinical Significance of Lymph Node Micrometastasis in Ampullary Carcinoma

Background This study aimed to clarify the clinical significance of lymph node micrometastasis in ampullary carcinoma. Materials and Methods Pancreaticoduodenectomy with regional lymphadenectomy was performed for 50 consecutive patients with ampullary carcinoma. A total of 1,283 regional lymph nodes (median, 25 per patient) were examined histologically for metastases. Overt metastasis was defined as metastasis detected during routine histologic examination with hematoxylin and eosin. Micrometastasis was defined as metastasis first detected by immunohistochemistry with an antibody against cytokeratins 7 and 8. The median follow-up period was 119 months after resection. Results Overt metastasis was positive in 90 lymph nodes from 27 patients. Micrometastasis was positive in 33 lymph nodes from 12 patients, all of whom also had overt nodal metastases. Patients with nodal micrometastasis had a larger number of lymph nodes with overt metastasis (median, 3.5) than those without (median, 0; P < 0.001). Overt metastasis to distant nodes (superior mesenteric nodes, para-aortic nodes) was more frequent (P = 0.001 and P = 0.038, respectively) in patients with nodal micrometastasis. Nodal micrometastasis was found to be a strong independent prognostic factor on univariate (P < 0.0001) and multivariate (relative risk, 5.085; P = 0.007) analyses. From among the 27 patients with overt nodal metastasis, the outcome after resection was significantly worse in the patients with nodal micrometastasis (median survival time of 11 months) than in those without (median survival time of 63 months; P = 0.0009). Conclusions Immunohistochemically detected lymph node micrometastasis indicates intensive lymphatic spread, and thus adversely affects the survival of patients with ampullary carcinoma.     

Retrospective analysis of outcome in 63 gallbladder carcinoma patients after radical resection

BACKGROUND/PURPOSE: The aim of this study was to evaluate factors influencing outcome in gallbladder carcinoma after radical resection, in order to identify those patients benefiting from radical surgery. METHODS: Sixty-three patients (13 pT1, 28 pT2, 14 pT3, and 8 pT4) who underwent surgical resection for gallbladder carcinoma were retrospectively reviewed. Correlations were sought between survival and factors such as the depth of invasion (pT) including the status of infiltration of the hepatoduodenal ligament (pBinf) and liver bed (pHinf), the extent of lymph node metastasis, and other pathologic factors. RESULTS: Multivariate analysis showed that pBinf, pHinf, and lymph node metastasis were significant prognostic factors. We also analyzed survival rates for each operative procedure. There was no difference in survival between patients with or without bile duct resection for lymph node metastasis. The 5-year survival rates of pHinf-negative patients with stage 1B or more advanced disease after gallbladder bed resection or bisegmentectomy 4a,5 versus those without liver resection were 66% and 0%, respectively. Twelve patients survived for more than 5 years after surgery, including one patient undergoing HPD (liver resection with pancreatoduodenectomy) with positive lymph node metastasis; none was pBinf-positive. CONCLUSIONS: Several factyors were identified as having prognostic significance for survival in patients with gallbladder carcinomas, and we suggest that radical surgery may be indicated for selected patients with advanced disease.     

Prognostic significance of vascular and perineural invasion in urothelial bladder cancer treated with radical cystectomy

PURPOSE: Data on the prognostic significance of tumor invading lymphatic and blood vessels in bladder cancer are controversial, while little is known about perineural invasion in this tumor. We determined the prognostic value of these parameters in radical cystectomy specimens. MATERIALS AND METHODS: Slides of 283 radical cystectomy specimens obtained from 1986 to 1997 were examined retrospectively with respect to tumor invasion in lymphatic and blood vessels, and perineural spaces. This review was performed while blinded to lymph node tumor involvement or the postoperative disease course. The Kaplan-Meier probability analysis of tumor-free survival and the log rank test were used to determine the prognostic effects of vascular and perineural invasion. Multivariate analysis using the Cox proportional hazards model was also performed. RESULTS: Lymphatic, blood vessel and perineural tumor invasion were present in 54.1%, 13.1% and 47.7% of specimens, respectively. Tumor progressed in 46.3% of patients. On univariate analysis all 3 factors showed strong prognostic significance. However, on multivariate analysis only blood vessel invasion, invasion depth and regional lymph node status were independent prognostic factors (p <0.05). CONCLUSIONS: Lymph node metastases, pT classification and blood vessel invasion are independent prognostic parameters of tumor-free survival that should be used to guide patient treatment after radical cystectomy. Invasion of the blood and lymphatic vessels should be commented on separately in the pathology report.     

A Curative Resection Improves the Postoperative Survival Rate Even in Patients with Advanced Gallbladder Carcinoma

The aim of this study was to evaluate the results of our series of 90 operations for gallbladder carcinoma according to the Japanese Society of Biliary Surgery (JSBS) classification system and to clarify the appropriate surgical strategy for advanced gallbladder carcinoma based on the depth of primary tumor invasion and lymph node metastasis. Generally, only a surgical resection can achieve a prognostic improvement of the advanced gallbladder carcinoma. The survival of patients with this neoplasm depends strictly on the depth of histological primary tumor invasion and lymph node metastasis. A retrospective analysis was conducted on 90 patients from 1990 to 2004 who underwent a surgical resection of gallbladder carcinoma. The factors influencing survival were examined. Thirty-nine patients with palliative treatment (not resected cases), which was diagnosed as T3 or T4 by preoperative imagings, were also included in this study. The significance of the variables for survival was examined by the Kaplan-Meier method and the log-rank test followed by multivariate analyses using Cox's proportional hazard model. Portal invasion, lymph node metastasis, the surgical margin (+ vs. -) and the final curability (fCurA, B vs. C) were all found to be independent prognostic factors in the multivariate analysis. In pT2 gallbladder carcinoma, a better survival was achieved in an aggressive surgical approach, in order of a S4a+S5 hepatic resection, an extended cholecystectomy and a cholecystectomy. In pT3 and pT4, although radical extended surgery did not provide the opportunity for good survival even after lobectomy of the liver, the survival of patients with curative surgery was statistically better than in those without curative surgery. In addition, the nodal involvement of pN1 to pN2 was better than that with pN3. A S4a+S5 hepatectomy, therefore, appears to be adequate for the treatment of pT2 gallbladder carcinoma. Even in patients with pT3 and pT4 gallbladder carcinoma, long-term survival can be expected by an operation with a tumor-free surgical margin. The role of radical surgery, however, is considered to be limited in patients with pN3 lymph node metastasis.     

EMA在pT1-3N0胃癌淋巴结微转移检测中的意义

目的pT1-3N0期胃癌术后临床病理因素（性别、年龄、肿瘤部位、肿瘤直径、大体分型、浸润胃壁深度、分化程度、血管侵润和淋巴管浸润）和淋巴结微转移对术后5年无瘤生存率的影响。方法纳入研究对象为pT1-3N0期胃癌共有108例,均为胃肠组医师行胃癌根治术。术后平均随访65.12个月（22～120个月）,每位患者淋巴结9枚至28枚不等,将所有淋巴结用EMA指标进行免疫组化染色。临床病理因素及微转移对5年无瘤生存率的影响进行统计分析。结果“肿瘤直径”（P=0.033）,“浸润胃壁深度”（P=0.024）和“是否有淋巴管浸润”（P=0.005）与淋巴结的上皮膜抗原（EMA）表达有正相关性,而其他临床病理因素与淋巴结EMA表达无明显相关性。临床病理因素对5年无瘤生存率无明显影响。淋巴结EMA表达阴性,孤立肿瘤细胞巢（Isolated Tumor Cells,ITCs）和微转移（Micrometastasis,MCM）的患者,5年无瘤生存率分别为88.50%,75.60%和44.40%。ITCs与EMA（-）的患者5年无瘤生存率无显著差别（P=0.360）,而MCM与EMA（-）的患者5年无瘤生存率出现明显差别（P=0.002）。结论对于pT1-3N0期胃癌,若淋巴结中检测出微转移,其预后较差,术后复发率较高,术后应予以积极的辅助治疗。     

Prognostic significance of vascular invasion in patients with bladder cancer who underwent radical cystectomy

BACKGROUND: The objective of this study was to determine whether vascular invasion (i.e. lymphatic and blood vessel invasion) could be a useful prognostic predictor in patients with locally invasive transitional cell carcinoma (TCC) of the bladder who underwent radical cystectomy. METHODS: This series included 114 consecutive patients undergoing radical cystectomy for primary TCC of the bladder between November 1989 and July 2003. Several clinicopathological characteristics of these patients were analyzed, focusing on the association between vascular invasion and disease recurrence after radical cystectomy. RESULTS: Lymphatic and blood vessel invasions were detected in 55 (48.2%) and 33 (29.8%) specimens, respectively. Lymphatic invasion was significantly associated with pathological stage, tumor grade, lymph node metastasis, blood vessel invasion and disease recurrence, whereas blood vessel invasion was significantly related to pathological stage, lymph node metastasis, lymphatic invasion and disease recurrence. Recurrence-free survival in patients with lymphatic invasion was significantly lower than that in those without lymphatic invasion, and a similar significant difference in recurrence-free survival was observed between patients with and without blood vessel invasion. However, multivariate analysis using the Cox proportional hazards model showed that only pathological stage and lymph node metastasis could be used as independent predictors for disease recurrence after radical cystectomy. CONCLUSIONS: Despite a significant association between several prognostic parameters, vascular invasion was not an independent predictor of disease recurrence; therefore, if there are other conventional parameters available, there might not be any additional advantage to considering the presence of vascular invasion when predicting the prognosis of patients undergoing radical cystectomy for TCC of the bladder.     

Significance of immunohistochemical nodal micrometastasis as a prognostic indicator in potentially curable oesophageal carcinoma

BACKGROUND: The number of positive lymph nodes is an important prognostic predictor in patients with oesophageal cancer. However, the significance of nodal micrometastasis in patients with overt nodal metastasis is unknown. The aim of this study was to clarify the clinical implications of nodal micrometastasis in patients undergoing curative oesophagectomy for oesophageal cancer. METHODS: Cervical, mediastinal and abdominal lymph nodes systematically removed from 104 patients with oesophageal cancer were examined immunohistochemically to detect cells that stained positively for cytokeratins with the monoclonal antibody cocktail AE1/AE3. The postoperative course and survival rates were compared among patients with and without micrometastases, after numerical classification of overt metastatic nodes (none, between one and four, five or more). RESULTS: Univariate analysis showed T stage, nodal micrometastasis and number of overt nodal metastases to be significant prognostic factors after oesophagectomy. Multivariate analysis revealed nodal micrometastasis and number of overt nodal metastases to be independent prognostic factors. The presence of micrometastases had a significant adverse effect on postoperative survival in patients with no overt metastasis and in patients with one to four overt metastatic nodes, but no such impact in patients with five or more overt metastatic nodes. CONCLUSION: Assessment of nodal status by both histological examination for overt metastases and immunohistochemical examination for micrometastases is useful in stratifying patients undergoing curative oesophagectomy.     

Strategies for surgical treatment of gallbladder carcinoma based on information available before resection

HYPOTHESIS: Precise preoperative staging for gallbladder carcinoma is difficult, despite recent advances in hepatobiliary imaging. However, the most accurate preoperative staging may be possible by integrating preoperative key data. OBJECTIVE: To establish useful strategies for the surgical treatment of gallbladder cancer based on information available before resection. DESIGN: Retrospective review. SETTING: University hospital and tertiary referral cancer center.Patients and METHODS: From January 1, 1978, through March 31, 2001, 152 patients with gallbladder cancer underwent surgical resection with curative intent. Preoperative diagnoses of the T factor (image-T) and N factor (image-N) in the TNM classification were determined by evaluating all findings of diagnostic imaging, including ultrasonography, enhanced computed tomography, endoscopic ultrasonography, and angiography. The distribution of lymph node metastasis and prognostic factors were also analyzed. RESULTS: The overall diagnostic accuracy for image-T was 52.6% (95% confidence interval, 44.7%-60.6%) and was lower in patients with pT1 and pT2 disease (37.2% and 33.9%, respectively). However, image-T was a significant predictor of lymph node metastasis and patient outcome. Preoperative staging for N was more difficult, with only 24.5% (95% confidence interval, 12.4%-36.5%) of the node-positive patients being correctly diagnosed. An analysis of harvested lymph nodes showed that the cystic, pericholedochal, and posterosuperior peripancreatic nodes were the most prevalent sites of metastasis, and these were considered key nodes for the lymphatic spread of gallbladder cancer. By combining data on image-T and positivity of these key nodes, more accurate TNM staging was possible. Although an extended lymph node dissection provided significantly better survival in patients with pN2 disease, there was no survival advantage to more radical operations, including bile duct resection or pancreaticoduodenectomy. CONCLUSIONS: Although precise preoperative TNM staging for gallbladder carcinoma was difficult, the most accurate staging before resection was possible by integrating image-T classification and data from the intraoperative histopathologic examination of key lymph nodes. Based on this staging, we propose algorithms for the surgical treatment of gallbladder carcinoma.     

Lymphatic involvement in early gastric cancer: prevalence and prognosis in France

BACKGROUND: The prognosis of early gastric cancer (EGC) is considered better than that of invasive gastric carcinoma, with a 5-year survival rate of more than 90% after surgery. The prevalence of lymph node metastasis in EGC ranges from 8% to 20% and is associated with a poor prognosis. HYPOTHESIS: The main prognostic factor of EGC in patients in France is lymphatic involvement. DESIGN, SETTING, AND PATIENTS: From January 1979 to December 1988, 332 patients with EGC were operated on in 23 centers of 2 of the French Associations for Surgical Research. Clinical, pathological, and therapeutic data were reviewed, and the reckoning point was in June 1996. MAIN OUTCOME MEASURES: The cumulative 5- and 7-year specific survival rates of EGC with or without lymphatic involvement. RESULTS: The cumulative 5- and 7-year specific survival rates of 332 patients with EGC (mean follow-up time, 80 months), excluding both operative and unrelated mortality, were 92% and 87.5%, respectively. Thirty-four patients (10.2%) had metastatic lymphatic spread: 13 exclusively in the lymphatic vessels close to the tumor, 17 in at least 1 lymph node, and 4 in both the lymphatic vessels and nodes. The rate of lymph node involvement (regardless of lymphatic vessel involvement) correlated significantly with submucosal invasion (P =. 05) and histologic undifferentiation (P =.03). Lymphatic vessel involvement correlated positively with lymph node involvement (P =. 003). Since 5- and 7-year survival rates of the 13 patients with EGC who had lymphatic vessel involvement without lymph node involvement did not differ significantly from those of patients who had EGC with lymph node involvement (85% and 84% vs 72% and 63%, respectively [P =.42]), all patients with lymph node and/or lymphatic vessel involvement were considered unique. Prognosis was poorest in these patients according to both univariate analysis (94% for 298 without node or vessel involvement vs 78% for 34 with node and/or vessel involvement; P =.006) and multivariate analysis (P =.01). Submucosal invasion was a prognostic factor independent of lymphatic involvement (P =.05). Five- and 7-year survival rates did not differ when the group of 211 patients for whom less than 15 lymph nodes were retrieved were compared with those (n = 51) for whom 15 or more lymph nodes were retrieved (95.5% vs 92% and 95.5% vs 88%, respectively), whether according to univariate (P =.21) or multivariate (P =.31) analysis. CONCLUSIONS: Our results suggest that both lymph node and lymphatic vessel involvement are important prognostic factors in patients with EGC. Lymphadenectomy in EGC is important to identify the high-risk population for whom prognosis is worse. The extent of lymphadenectomy (at least 15 nodes) in these patients, however, does not alter prognosis.     

Predictive factors for lymph node metastasis in early gastric cancer with submucosal invasion: analysis of a single institutional experience

OBJECTIVE: An accurate assessment of a potential lymph node metastasis is an important issue for the appropriate treatment of early gastric cancer. Minimizing the amount of invasive procedures used in cancer treatment is critical for improving the patient's quality of life. Therefore, this study analyzed the predictive risk factors for a lymph node metastasis in early gastric cancer with a submucosal invasion. METHODS: The data from 1043 patients surgically treated for early gastric cancer with submucosal invasion between 2002 and 2005 were reviewed retrospectively. The patients were divided into 3 layers according to their depth: SM1, SM2, and SM3. The clinicopathological variables predicting a lymph node metastasis were evaluated. RESULTS: A lymph node metastasis was observed in 19.4% of patients. The tumor size, histologic type, Lauren classification, tumor depth, and perineural invasion showed a positive correlation with the rate of lymph node metastasis and N category by univariate analysis. Multivariate analyses revealed the tumor size (>or=2 cm) and lymphatic involvement to be significantly and independently related to lymph node metastasis. The presence of lymphatic involvement was the strongest predictive factor for a lymph node metastasis, being observed in 43.8% of cases in which a lymph node metastasis had been revealed. No lymph node metastasis was observed in the 12 cases with no lymphatic involvement, SM1 invasion, and tumor size <1 cm. CONCLUSIONS: Lymphatic involvement and tumor size are independent risk factors for a lymph node metastasis in early gastric cancer with submucosal invasion. Minimal invasive treatment, such as endoscopic mucosal resection, may be possible in highly selective submucosal cancers with no lymphatic involvement, SM1 invasion, and tumor size <1 cm.     

Predictors of nonsentinel node metastasis in patients with breast cancer after sentinel node metastasis

HYPOTHESIS: The presence of nonsentinel lymph node (NSLN) metastasis after having a positive sentinel lymph node dissection finding is associated with tumor size and stage, the presence of lymphovascular invasion, micrometastasis, and extranodal extension. DESIGN: Retrospective case series. SETTING: University hospital. PATIENTS: Four hundred seven consecutive patients at a single institution who underwent sentinel lymph node dissection as part of breast conservation or mastectomy with biopsy-proved cancer. INTERVENTION: Completion axillary lymph node dissection and definitive therapy. MAIN OUTCOME MEASURES: Sentinel node metastasis, NSLN metastasis, tumor size and stage, lymphovacular invasion, micrometastasis, extronodal extension, histological tumor characteristics, and number of sentinel nodes removed. RESULTS: In a univariate analysis, size of the primary tumor and extranodal extension were associated with having positive NSLN findings. The presence of micrometastasis was associated with negative NSLN findings. When all factors were included in a logistic regression analysis, the significant predictor of NSLN metastasis was extranodal extension (P =.002). Lymphovascular invasion was not associated with positive NSLN findings (P =.11). The number of sentinel nodes removed also had no bearing on the status of the NSLNs (P =.37). CONCLUSIONS: Although primary tumor size and micrometastases correlate with the status of the NSLNs, extranodal extension is the most important independent predictor of NSLN metastasis. These findings may ultimately spare patients a full axillary lymph node dissection. However, pending results of larger clinical trials, full axillary lymph node dissection is still recommended for patients with sentinel lymph node metastases.     

Prognostic factors after oesophagectomy and extended lymphadenectomy for squamous oesophageal cancer

BACKGROUND: The prognosis of patients without nodal metastasis of oesophageal cancer is generally good, but recurrence develops in some cases. METHODS: Data on 88 consecutive patients with squamous oesophageal cancer who underwent three-field lymph node dissection from 1986 to September 1998 and who had no evidence of nodal disease were reviewed retrospectively. Disease status was based on histological examination of the section of each node with the largest surface area, stained with haematoxylin and eosin. RESULTS: The 3- and 5-year survival rates of patients without lymph node metastasis were 85 and 81 per cent respectively, better than in patients with metastasis. Twelve patients died from recurrence. Recurrence was haematogenous in nine patients and locoregional in three. Survival was worse in men, for patients with lesions located in the upper thoracic oesophagus, and in those with lymphatic or blood vessel invasion. Only the presence of lymphatic invasion correlated with survival on multivariate analysis (P = 0.04). CONCLUSION: Although survival was generally good in patients without nodal metastasis from oesophageal cancer following three-field lymph node dissection, patients with lymphatic invasion remained at risk for haematogenous dissemination.     

Clinical outcome of radical cystectomy for patients with pT4 bladder cancer

Objective:   The objective of this study was to analyze the outcomes of radical cystectomy for patients with pT4 bladder cancer.
Methods:   Between 1995 and 2003, 583 patients underwent radical cystectomy for bladder cancer at our institution and related hospitals, including 76 pathologically diagnosed as having pT4 disease. Of these 76, this study included 60 patients after excluding 16 with pT4Tis disease, and a retrospective review of their records was carried out.
Results:   Pathological examinations demonstrated that seven (11.6%) and 53 (88.4%) patients were Grades 2 and 3, respectively, and 48 (80.0%), 38 (63.4%), 10 (16.7%) and 30 (50.0%) were positive for lymphatic invasion, microvenous invasion, surgical margin and lymph node metastasis, respectively. During the observation period of this study (median, 24.5 months; range, 2–89 months), disease recurrence occurred in 38 (63.3%), and the median time to recurrence after radical cystectomy was 7.0 months (range, 1–38 months). One-, 3- and 5-year cancer-specific survival rates of the 60 patients were 68.8%, 48.5% and 23.9%, respectively. Univariate analysis identified lymph node metastasis, lymphatic invasion, microvenous invasion and positive surgical margin as significant predictors for cancer-specific survival; however, only lymph node metastasis was shown to be independently associated with cancer-specific survival by multivariate analysis.
Conclusions:   The prognosis of patients with pT4 bladder cancer is generally poor, particularly for those with nodal involvement. Therefore, it would be potentially important to carry out careful follow-up for such patients following radical cystectomy and, if necessary, to consider a multimodal therapeutic approach in an adjuvant setting.     

影响胆管癌患者生存预后因素的研究

目的 探讨影响胆管癌切除术后的预后因素。方法 对1980-1995年86例胆管癌切除术后患各进行研究。选择15个可能对胆管癌切除术后预门产生影响的非重要性特证性临床因素,通过Cox比例风险模型对胆管癌切除术后患者预后进行多因素分析。结果 全组1年生存率为72.6％,3年生存率为32.4％,5年生存率为18.7％。单因素分析得出肿瘤的组织学类型、淋巴结转移、胰腺浸润、十二指肠浸润、神经浸润、周围血管浸润、切缘癌残留和浸润浙度对预后有影响（P<0.05）。Cox模型多因素分析结果表明胰腺浸润、神经浸润和淋巴结转移是影响预后的主要因素。结论 胰腺浸润、神经浸润和淋巴结转移状况足胆管癌切除术后影响预后的最重要因素。     

应用Cox模型分析影响胆管癌切除术后的预后因素

目的：探讨影响胆管癌切除术后的预后因素。方法：对1980－1995年86例胆管癌切除术后患者进行研究。选择15个可能对胆管癌切除术后预后产生影响的非重复性特征临床因素，通过Cox比例风险模型对胆管癌切除术后患者预后进行多因素分析。结果；全组1年生存率为72．6％，3年生存率为32．4％，5年生存为18．7％。单因素分析得出肿瘤的组织学类型，淋巴结转移，胰腺浸润，十二指肠浸润，神经浸润，周围血管浸润，切缘癌残留和浸润深度对预后有影响（P＜0．05）。Cox模型多因素分析结果表明，胰腺浸润，神经浸润和淋巴结转移是影响预后的主要因素。结论：胰腺浸润，神经浸润和淋巴结转移状况是胆管癌切除术后影响预后的最重要因素。     

Role of Surgery for Gallbladder Carcinoma with Special Reference to Lymph Node Metastasis and Stage Using Western and Japanese Classification Systems

The role of radical resection in the treatment of gallbladder carcinoma was examined with special reference to lymph node metastasis using two classifications: one proposed by the American Joint Committee on Cancer (AJCC) and the other by the Japanese Society of Biliary Surgery (JSBS). Histologic evaluations for the depth of tumor invasion (T), lymph node metastasis (N), stage, and follow-up for a mean period of 38 months (range 4-185 months) were completed in 52 patients with gallbladder carcinoma who underwent surgical resection from 1982 to 1997. The definition of T was similar in the two classifications. The extent of nodal involvement (N, AJCC; n, JSBS), stage, and survival were examined. In the absence of lymph node metastasis, the 5-year survival rate reached 71%. The 5-year survival rate in patients with involved nodes confined to the hepatoduodenal ligament, posterosuperior pancreaticoduodenal region, or along the common hepatic artery (N1 and part of N2 by AJCC; nl and n2 by JSBS) approximated 28%. In contrast, postoperative survival was poor in the presence of more extensive nodal involvement (rest of N2 by AJCC; n3 and n4 by JSBS), with no 2-year survivors. The definition of stage I was the same in both classifications, and all patients in this stage are alive. The 5-year survival rates in stages II and III by the AJCC were 70.7% and 22.4%, respectively, and those by JSBS 61.9% and 23.1%, respectively. Thus the survival rates in stages I to III were essentially similar irrespective of the staging system. Stage IV showed significantly worse survival than stage III by the JSBS classification. In contrast, the differentiation of stage IV from III by the AJCC was not significant because of the better survival in stage IV that contained any T with nodal involvement in the posterosuperior pancreaticoduodenal region and along the common hepatic artery. Radical resection should be considered for patients with stage I to III disease defined by either classification and applied to the tumor invasion up to T3 with nodal involvement confined to the hepatoduodenal ligament, posterosuperior pancreaticoduodenal region, and along the common hepatic artery. The role of radical surgery seems to be limited in patients with more extensive tumor invasion or lymph node metastasis.     

The prognostic impact of pelvic lymph node metastasis and lymphovascular invasion on bladder cancer

Objectives:   To present long-term results of a single-center series of patients undergoing bilateral pelvic lymphadenectomy and radical cystectomy for bladder cancer and to analyze the impact of pelvic lymph node metastasis and lymphovascular invasion on clinical outcome.
Methods:   Between 1986 and 2005 833 patients were treated with bilateral pelvic lymphadenectomy and radical cystectomy at our institution. 614 of them with valid clinical follow-up information and no neoadjuvant therapy could be evaluated.
Results:   Disease-free and overall survival in the entire cohort was 56.7% and 49.5% at 5 years and 52.4% and 38.2% at 10 years, respectively. 28.1% of all patients had pelvic lymph node metastasis. We found organ-confined tumor stages (≤pT2) in 43.8%. Patients with non-organ-confined tumor stages (≥pT3) and positive pelvic lymph nodes had a significantly shorter overall survival than those without lymph node metastasis ( P  < 0.0001). In the subgroup of ≤pT2, the presence of pelvic lymph node metastasis did not show a statistically significant effect on overall survival ( P  = 0.618). The presence of lymphovascular invasion was associated with an impaired survival ( P  < 0.0001). In multivariate analysis, pathological tumor stage ( P  < 0.0001), lymph node stage (≥pT3) ( P  = 0.004) and lymphovascular invasion ( P  = 0.001) were independent prognostic parameters.
Conclusions:   According to the present series, survival for patients with ≤pT2 does not depend on the lymph node stage. Lymphovascular invasion is an independent parameter of impaired survival and should be determined routinely in cystectomy specimens to identify patients, who may benefit from adjuvant systemic therapy.