Adequate Nodal Staging Research Articles

Level I axillary dissection in patients with breast cancer and tumor-involved sentinel lymph node after NAC is not sufficient for adequate nodal staging.

The purpose of the study was to investigate the oncological sufficiency of level I axillary dissection for adequate histological nodal staging (ypN) in patients with breast cancer and tumor-involved sentinel lymph node (SLN) after neoadjuvant chemotherapy (NAC). A prospective multicentre pilot study took place from 01.01.2018 to 30.11.2020 in three mammary centres in the Czech Republic in patients with breast cancer after NAC (NCT03556397). Patients in the cohort with positive histological frozen section of SLN were indicated to separate axillary dissection of levels I and II. Sixty-one patients with breast cancer after NAC were included in the study according to inclusion and exclusion criteria. Twelve patients with breast cancer and tumour involved SLN after NAC were further included in the analysis. Two (16.7%) patients had positive non-sentinel lymph nodes in level I only, one (8.3%) patient had positive lymph nodes in level II only, and seven (58.3%) patients had positive lymph nodes in both levels. Level I axillary dissection in a patient with tumour involved SLN after NAC would have resulted in understaging in five (41.7%) patients, mostly ypN1 instead of ypN2. According to our pilot result, level I axillary dissection is not sufficient in terms of adequate histological nodal staging in breast cancer patients after NAC, and level II axillary dissection should not be omitted.

Survival Outcome of Gastric Signet Ring Cell Carcinoma Based on the Optimal Number of Examined Lymph Nodes: A Nomogram- and Machine-Learning-Based Approach.

The optimal number of examined lymph nodes (ELNs) for gastric signet ring cell carcinoma recommended by National Comprehensive Cancer Network guidelines remains unclear. This study aimed to determine the optimal number of ELNs and investigate its prognostic significance. In this study, we included 1723 patients diagnosed with gastric signet ring cell carcinoma in the Surveillance, Epidemiology, and End Results database. X-tile software was used to calculate the cutoff value of ELNs, and the optimal number of ELNs was found to be 32 for adequate nodal staging. In addition, we performed propensity score matching (PSM) analysis to compare the 1-, 3-, and 5-year survival rates; 1-, 3-, and 5-year survival rates for total examined lymph nodes (ELNs < 32 vs. ELNs ≥ 32) were 71.7% vs. 80.1% (p = 0.008), 41.8% vs. 51.2% (p = 0.009), and 27% vs. 30.2% (p = 0.032), respectively. Furthermore, a predictive model based on 32 ELNs was developed and displayed as a nomogram. The model showed good predictive ability performance, and machine learning validated the importance of the optimal number of ELNs in predicting prognosis.

Pathological Nodal Staging Score for Gastric Signet Ring Cell Carcinoma: A Clinical Tool of Adequate Nodal Staging.

Background: Gastric signet ring cell carcinoma (GSRCC) is a subset of gastric cancer with distinct histological and inconsistent prognosis outcome. Currently, the association between the adequate regional lymph node and proper nodal staging in GSRCC is rarely noticed. Materials and methods: Clinical data of GSRCC were retrieved from the Surveillance, Epidemiology, and End Results database. Beta-binomial distribution model was employed for the estimation of the probability of missing nodal disease, followed by the development of a nodal staging score (NSS). Results: A total of 561 GSRCC patients were included in this study, with 193 in lymph node-negative and 368 in lymph node-positive diagnoses. As the number of examined lymph nodes increased, the probability of missing nodal disease decreased rapidly, with T stage-specific curves. The probability of missing nodal disease in T4 was lower than that in T1. NSS calculation indicated that T1 stage patients commonly had NSS > 0.8. However, with the NSS of T2–T4 to reach 0.8, the number of examined lymph node was required to be larger than 12 in T2, 17 in T3 and 27 in T4. NSS ≥ 0.75 (quantile 75%) subgroup in T2–T4 subgroups tended to have better outcome; however, without significant prognostic value. Conclusions: NSS is served as a reliable and feasible tool in adequate nodal staging of GSRCC with statistical basis and provides further evidence for clinical decision making.

Minimally invasive evaluation of the clinically negative inguinal node in penile cancer: Dynamic sentinel node biopsy.

The presence of lymph node metastasis is the most important prognostic factor in penile cancer (PeCa). Due to limited sensitivity of currently available imaging modalities, invasive staging approaches remain indispensable for adequate nodal staging. As an alternative to radical inguinal lymphadenectomy and with the aim to reduce morbidity, staging strategies such as modified lymphadenectomy and dynamic sentinel node biopsy (DSNB) have been introduced. Over the years, DSNB evolved into a safe and reliable staging technique when performed in high volume centers. Recent enhancements of the procedure such as Single-photon emission computed tomography/computed tomography (SPECT/CT) and the introduction of hybrid tracers have improved pre- and intraoperative sentinel node (SN) visualization. Other technologies such as superparamagnetic iron oxide nanoparticles could have a potential future role to further refine DSNB. Future efforts should be aimed at optimizing diagnostic accuracy whilst minimizing perioperative morbidity.

Ultrasound lymphatic imaging for the diagnosis of metastatic central lymph nodes in papillary thyroid cancer.

Up to 40% of papillary thyroid cancer (PTC) patients have lymph node metastasis, a condition that implies persistent, recurrent, or progressive disease. However, the American Joint Committee on Cancer Manual states that there is no reliable examination for adequate lymph node staging. Therefore, our aim is to develop a lymphatic imaging technique using ultrasonography to address this challenge. We consecutively enrolled PTC patients who underwent ultrasound (US) lymphatic imaging via the peritumoral injection of contrast media. Identification of the sentinel lymph nodes and the targeted sentinel lymph nodes was separately based on the lymphatic drainage pathway and the enhancement patterns. Every identified targeted node was assigned a score, according to the features on conventional US and enhancement patterns, and was referred for ultrasound-guided fine-needle aspiration. Cytological and histopathologic results represented the statuses of the targeted lymph nodes and overall central lymph nodes, respectively, which were applied to evaluate the diagnostic performance of US lymphatic imaging. In total, 100 PTC patients were included. On the basis of the cytological results, the sensitivity (97.1%, 95% confidence interval [CI]: 84.7-99.9%) of detecting positive targeted nodes by US lymphatic imaging significantly increased by 45.5% at a threshold of 4 or higher (p = 0.0001), without loss of specificity (p = 1.0000). The surgical results showed that the metastatic degree was positively correlated with an increase in the score (τ: 0.671, p < 0.001). Ultrasound lymphatic imaging has a high diagnostic performance, and its corresponding scoring system facilitates grading of the nodal burden in the central compartment. • Ultrasound neck lymphatic imaging is an effective contrast-enhanced ultrasound (CEUS) technique (applied after the peritumoral injection of contrast media) for identifying sentinel lymph nodes in the central compartment by tracing the imaged afferent lymphatic vessel. • Lack of enhancement or perfusion defects is the typical enhancement pattern for recognizing the involved central lymph nodes. • Ultrasound lymphatic imaging for identification of positive central lymph nodes before surgery may effectively avoid complications associated with the surgical sentinel node procedure.

A large real-world cohort study of examined lymph node standards for adequate nodal staging in early non-small cell lung cancer.

BackgroundThe current National Comprehensive Cancer Network (NCCN) guidelines for non-small cell lung cancer (NSCLC) recommend that surgeons sample is not clear. We aimed to define a minimal number of examined lymph nodes for removal or sampling for optimized nodal staging recommendation, with a focus on T1–3N0M0 patients.MethodsA total of 55,101 consecutive patients were selected, including 52,099 patients with US Surveillance, Epidemiology, and End Results (SEER) data and 3,002 patients in a Chinese multicenter database from 11 thoracic referral centers, who underwent complete resection plus lymph node dissection or sampling for stage T1–3N0M0 NSCLC. Propensity score-matching analysis was performed with R software, and a cut-off value was calculated using X-tile software. Survival was evaluated using the Kaplan-Meier method and Cox proportional hazard models.ResultsFive-year survival rates with respect to total examined lymph nodes numbers (examined lymph nodes <10 vs. examined lymph nodes ≥10) were 69% and 64% (group A), 66% and 63% (group B), 62% and 58% (group C), 81% and 75% (group D). There were significant differences between examined lymph nodes <10 and examined lymph nodes >10 in each group (P<0.001).ConclusionsA minimum of 10 examined lymph nodes would significantly improve T1–3N0M0 NSCLC prognosis and patients’ survival rates if implemented as a minimum standard for lymphadenectomy. Therefore, we recommended a minimum of 10 examined lymph nodes for T1–3N0M0 patients.

Robot-assisted lobectomy versus completely portal robotic lobectomy: What is the difference?

Background This study aims to compare robot-assisted lobectomy versus completely portal robotic lobectomy. Methods Between January 2014 and December 2019, a total of 41 patients (10 males, 31 females; median age 62 years; range, 50 to 68 years) underwent robotic anatomical pulmonary resection in our institution were retrospectively analyzed. The patients were consecutively divided into two groups: the first 20 (48.8%) patients underwent pulmonary resection by robot-assisted lobectomy technique, while the next 21 (51.2%) patients underwent pulmonary resection by completely portal robotic lobectomy with four arms. Data including age, sex, diagnosis, surgery type and duration, rate of conversion to open surgery, and length of stay of the patients were recorded. The operation time, docking time, console time, and closure duration for each patient were also noted. Results There was no statistically significant difference in age, sex, comorbidities, complications, length of hospital stay, adequate lymph node staging, or tumor size and side between the two groups (p>0.05). However, the mean console and operation times were statistically significantly shorter in the patients receiving completely portal robotic lobectomy with four arms (p=0.001). Conclusion The advantage of completely portal robotic lobectomy with four arms is relative, although it significantly shortens the operation time. Based on our experiences, this technique may be preferred in case of inadequate lung deflation, as carbon dioxide insufflation allows sufficient workspace for robotic lung resection.

Prognostic Role of Examined and Positive Lymph Nodes after Distal Pancreatectomy for Non-Functioning Neuroendocrine Neoplasms

Background: The most appropriate nodal staging system for non-functioning pancreatic neuroendocrine tumours (NF-PanNETs) remains unclear. Despite some evidence is available for pancreaticoduodenectomy, the adequate nodal staging is still unknown for distal pancreatectomy (DP). The aim of the present study was to evaluate the prognostic impact of the number of positive lymph nodes (PLNs) after DP for NF-PanNETs and to define the minimal number of lymph nodes to be harvested for an appropriate nodal staging. Methods: Data were retrospectively collected from patients who underwent DP with curative intent (R0-R1) for sporadic well-differentiated NF-PanNETs in 4 European high-volume centres. NF-PanNETs with nodal involvement (N+) were subclassified into N1 (1–3 PLNs) and N2 (4 or more PLNs). Univariate and multivariate analyses of disease-free survival (DFS) were performed. Results: Of 271 patients in the study, 62 (23%) had nodal involvement (N+). A higher probability of N+ was associated with the following factors: grading, resection margin status, perineural and microvascular invasion, and the number of examined lymph nodes. Three-year DFS rate for N0, N1, and N2 patients was 92, 72, and 50%, respectively (p < 0.001). At multivariate analysis, independent predictors of DFS were grading, T stage, presence of necrosis, and nodal status. For patients with ≥12 examined/resected lymph nodes, the N status remained a significant predictor of disease recurrence (p < 0.001), while it failed to predict recurrence in patients with <12 lymph nodes examined/resected (p = 0.116). Conclusions: A minimal number of 12 nodes should be harvested in case of DP for NF-PanNET for an appropriate nodal staging. The number of positive lymph nodes is an independent predictor of DFS after DP for NF-PanNET, and the N0/N1/N2 nodal classification seems to be more relevant than the current N0/N+ staging.

Comparative Effectiveness of Robotic-Assisted Surgery for Resectable Lung Cancer in Older Patients

Robotic-assisted surgery (RAS) is a novel surgical approach increasingly used for patients with non-small cell lung cancer (NSCLC). However, data comparing the effectiveness and costs of RAS vsopen thoracotomy and video-assisted thoracoscopic surgery (VATS) for NSCLC are limited. Patients > 65 years old with stage I to IIIA NSCLC treated with RAS, VATS, or open thoracotomy were identified from the Surveillance, Epidemiology, and End Results-Medicare database and matched according to age, sex, stage, and extent of resection. Propensity score methods were used to compare adjusted rates of postoperative complications, adequate lymph node staging, survival, and treatment-related costs. In this matched study cohort of 2,766 patients with resected NSCLC, RAS was associated with lower complication rates (OR, 0.57; 95%CI, 0.42-0.79) compared with open thoracotomy, and similar complication rates (OR, 1.02; 95%CI, 0.76-1.37) compared with VATS. Patients undergoing RAS were as likely to have adequate lymph node sampling as those undergoing open thoracotomy (OR, 1.28; 95%CI, 0.94-1.74) or VATS (OR, 0.88; 95%CI, 0.66-1.18). There was no significant difference in overall survival after RAS vsopen thoracotomy (hazard ratio, 0.81; 95%CI, 0.63-1.04) or VATS (hazard ratio, 0.91; 95%CI, 0.70-1.18). Costs were similar for RAS ($54,702) vsopen thoracotomy ($57,104; P= .08), and higher compared with VATS ($48,729; P= .02). RAS led to improved operative outcomes compared with open thoracotomy but may not offer an advantage over VATS. The comparative effectiveness of RAS should be further evaluated prior to widespread adoption.

GR01.05 Site of Oligometastases

GR01.05 Site of Oligometastases

Development and external validation of a pathological nodal staging score for patients with clear cell renal cell carcinoma.

To develop and externally validate a model that quantifies the likelihood that a pathologically node-negative patient with clear cell renal cell carcinoma (cRCC) has, indeed, no lymph node metastasis (LNM). Data from 1389 patients treated with radical nephrectomy (RN) and lymph node dissection (LND) were analyzed. For external validation, we used data from 2270 patients in the Surveillance, Epidemiology and End Results (SEER) database. We estimated the sensitivity of pathologic nodal staging using a beta-binomial model and developed a pathological nodal staging score (pNSS), which represents the probability that a patient is correctly staged as node negative as a function of the number of examined lymph nodes (LNs). The mean and median number of LNs removed were 7.0 and 5.0 (standard deviation, SD 6.6; interquartile range, IQR 7.0) in the development cohort and 5.6 and 2.0 (SD 8.6, IQR 5.0) in the validation cohort, respectively. The probability of missing a positive LN decreased with increasing number of LNs examined. In both the validation and the development cohort, the number of LNs needed for correctly staging a patient as node negative increased with higher pathological tumor stage and Fuhrman grade. The number of examined LNs needed for adequate nodal staging in cRCC depends on pathological tumor stage and Fuhrman grade. We developed here and then externally validated a pNSS, which could help to refine patient counseling, decision-making regarding risk-stratified surveillance regimens and inclusion criteria for clinical trials of adjuvant therapy.

External Validation of the Pathologic Nodal Staging Score for Prostate Cancer: APopulation-based Study.

We sought to externally validate our pathologic nodal staging score (pNSS) model, which allows for quantification of the likelihood that a pathologically node-negative patient will not have lymph node (LN) metastasis after radical prostatectomy for prostate cancer (PCa) in a population-based cohort. We analyzed data from 50,598 patients treated with radical prostatectomy and pelvic LN dissection using the Surveillance, Epidemiology, and End Results database. We estimated the sensitivity of pathologic nodal staging using a β-binomial model and developed a novel pNSS model, which represents the probability that a patient's PCa has been correctly staged as node negative as a function of the number of examined LNs. These findings were compared against those from the original cohort of 7135 patients. The mean and median number of LNs removed was 6.5 and 5, respectively (range, 1-89; interquartile range, 2-8), and 96.9% of the patients (n= 49,020) had stage pN0. Similar to the original cohort, the probability of missing a positive LN decreased with the increasing number of LNs examined. In both the validation and the original cohort, the number of LNs needed to correctly stage a patient's disease as node negative increased with more advanced tumor stage, higher Gleason sum, positive surgical margins, and higher preoperative prostate-specific antigen levels. We have confirmed that the number of examined LNs needed for adequate nodal staging in PCa depends on the pathologic tumor stage, Gleason sum, surgical margins status, and preoperative prostate-specific antigen. We externally validated our pNSS in a population-based cohort, which could help to refine decision-making regarding the administration of adjuvant therapy.

The prognostic role of metastatic lymph node ratio-staging system in gastric cancer patients: Analysis of the National Cancer Database.

4044 Background: The NCCN recommends retrieval of at least 15 lymph nodes for adequate nodal staging in gastric cancer. There is an ongoing debate about the accuracy of the classification systems for nodal involvement based on the absolute number of positive nodes (AJCC-N) vs. the ratio of positive nodes (rN). In this study, we aim to assess the accuracy of each system in the prediction of 5-year survival using the National Cancer Data Base (NCDB) for gastric cancer. Methods: The database included 168,377 gastric cancer patients between 2004-2014. Patients who were approached with palliative intent, or had metastatic disease were excluded from the analysis. Only patients who had at least one regional node examined were included. A univariate and multivariate regression analysis were conducted to identify significant predictors of the 5-year survival among the perioperative patients’ characteristics. Bayesian Information Criterion (BIC) was used to compare the model fitting when the AJCC nodal staging is applied to that of the ratio nodal staging. Results: 48,126 patients were included in the final analysis. 23,102 (48%) patients had ≥15 nodes examined. The univariate and multivariate regression analysis identified age, male gender, Caucasian race, and presence of comorbidities as significant demographic predictors. TNM T-stage, N-stage, and rN-stage were significant predictors with worsening prognosis as the stage increases. Overall, BIC demonstrated that the model using rN had a better fit (rN = 30321 vs. AJCC-N = 30619). However, subgroup analysis showed that the AJCC-N functioned better when &lt; 15 nodes were examined (rN = 17367 vs. AJCC-N = 17311), whereas rN functioned better when ≥15 nodes were collected (rN = 16776 vs. AJCC-N = 16831). Conclusions: Both AJCC-N and rN are valid systems for nodal staging in terms of survival prediction in gastric cancer. When at least 15 nodes are resected in line with the current NCCN guidelines, the rN staging system for nodal metastasis appears to function more accurately in survival prediction. It might be advisable to consider the ratio of positive lymph nodes when a large number of nodes are collected to avoid over-staging and stage migration.

Assessment of the Lymph Node Status in Patients Undergoing Liver Resection for Intrahepatic Cholangiocarcinoma: the New Eighth Edition AJCC Staging System

IntroductionThe role of routine lymphadenectomy for intrahepatic cholangiocarcinoma (ICC) is still controversial. The AJCC eighth edition recommends a minimum of six harvested lymph nodes (HLNs) for adequate nodal staging. We sought to define outcome and risk of death among patients who were staged with ≥6 HLNs versus <6 HLNs. Materials and MethodsPatients undergoing hepatectomy for ICC between 1990 and 2015 at 1 of the 14 major hepatobiliary centers were identified. ResultsAmong 1154 patients undergoing hepatectomy for ICC, 515 (44.6%) had lymphadenectomy. On final pathology, 200 (17.3%) patients had metastatic lymph node (MLN), while 315 (27.3%) had negative lymph node (NLN). Among NLN patients, HLN was associated with 5-year OS (p = 0.098). While HLN did not impact 5-year OS among MLN patients (p = 0.71), the number of MLN was associated with 5-year OS (p = 0.02). Among the 317 (27.5%) patients staged according the AJCC eighth edition staging system, N1 patients had a 3-fold increased risk of death compared with N0 patients (hazard ratio 3.03; p < 0.001). ConclusionOnly one fourth of patients undergoing hepatectomy for ICC had adequate nodal staging according to the AJCC eighth edition. While the six HLN cutoff value impacted prognosis of N0 patients, the number of MLN rather than HLN was associated with long-term survival of N1 patients.

Prognostic factors affecting overall survival in right colon cancer

Background: The prognosis of patients who have carcinoma of the colon is dependent on several factors that are clinical, pathological, and biological. Adequate lymph node staging in patients with colon cancer is important for determining prognosis and planning further treatment. We aimed to determine what factors might predict survival in patients with right colon cancer. Methods: Between 2007 and 2014, consecutive patients undergoing operation for adenocarcinoma of the right-sided colon were enrolled in this study. The following factors were analyzed with the Cox regression model: age, gender, localization of the tumor, recurrence, pTNM stage, removed and invaded lymph node status (MLN) and survival rate. Multivariate models were used to assess the adjusted effects and to explore the interaction between survival and other factors. Results: A total of 56 (38,1%) men and 91 (61,9%) women, mean age being 61,8 ± 15,9 years, were included. The mean survival time was 46,5 ± 43,2 months. The mean LN number was 18,8 ± 9,44; MLN number was 2,66 ± 5,13. Age, total LN, MLN number and postoperative stage were significant in the univariate analysis for survival. Independent predictors of survival in multivariate analysis were age (p=0,019), postoperative stage (p=0,039), and MLN (p=0,003). Conclusions: LN metastasis is a prognostic feature in patients by means of colon cancer. It could not be changed independent of a number of prognostic factors, such as age, but LN number was dependent on operation in right colon cancer surgery. LN yields have been linked to improved survival and its determination is reliant on both the surgeon and the pathologist.

Determining the optimal number of lymph nodes harvested during esophagectomy

We examined the impact of the number of lymph nodes (LNs) removed during esophagectomy on outcomes in esophageal cancer (EC). From a comprehensive EC database we identified patients who underwent curative resection from 1994 to 2011. The impact of total LNs retrieved on disease-free survival (DFS) and overall survival (OS) was investigated. In total, 635 patients were identified. Patients were divided on the basis of total number of LNs removed (<8, 9-12, 13-20, and >20). The 5-year OS and DFS rates for the group by LN category were (43%, 42%, 55%, and 36%, P=0.1836) and (44%, 37%, 46%, and 36%, P=0.5166), respectively. Total number of LNs assessed did not correlate with reduced risk of recurrence or improved survival. On multivariate analysis controlling for age, sex, histology, neoadjuvant therapy, only removal of 13-20 LN's correlated to improved oncologic outcomes. In a tertiary cancer center, we demonstrated that only removal of 13-20 LNs during esophagectomy correlated to improved survival. While the importance of standardized pathologic examination and adequate nodal staging is of utmost importance for patients with EC undergoing esophagectomy the optimum number of LNs removed clearly warrants further investigation.

Response to “Minimally invasive gastrectomy for gastric adenocarcinoma in the United States: Utilization and short‐term oncologic outcomes”

Background and Objectives When performed at select centers, minimally invasive gastrectomy (MIG) for gastric adenocarcinoma is associated with reduced perioperative morbidity, and similar oncologic outcomes as compared to open gastrectomy (OG). Utilization of, and outcomes associated with, MIG in the United States have not been characterized. Methods The National Cancer Database (2010–2011) was queried for AJCC pStage IB-IIIC patients who underwent curative-intent OG (n = 2,303) or MIG (n = 331). Multivariable models identified factors associated with MIG utilization, R0 resection rates, and adequate lymph node staging (LNS). Results MIG was more frequently utilized for T1/T2 (P < 0.001), N0 (P = 0.022), and stage IB (P = 0.001) tumors. MIG was associated with shorter hospital stay (P < 0.001), equivalent lymph node examination (P = 0.337) and superior rates of R0 resection (P = 0.011) compared with OG. In patients undergoing MIG, R0 resection was associated with performance of near-total/total gastrectomy (OR 3.90, 95%CI 1.10–13.9) and tumors < 5 cm (OR 2.78, 95%CI 1.07–7.26). Adequate LNS was associated with surgery at academic (OR 1.99, 95%CI 1.19–3.32) or high-volume facilities (OR 2.97, 95%CI 1.59–5.54), tumor size ≥ 5 cm (OR 1.85, 95%CI 1.10–3.11), and node positivity (OR 1.75, 95%CI 1.04–2.93). Conclusions MIG is selectively utilized in cases with favorable tumor characteristics. In such cases, short-term oncologic outcomes are equivalent to those achieved with OG. Worse oncologic outcomes in specific subgroups underscore opportunities for quality improvement. J. Surg. Oncol. 2015;112:616–621. © 2015 Wiley Periodicals, Inc.

Multimodality Therapy Improves Survival in Resected Early Stage Gastric Cancer in the United States.

National guidelines endorse adjuvant chemotherapy±radiotherapy (C±RT) for early-stage gastric cancer (ESGC). Compliance with these guidelines and the specific impact of adjuvant C±RT on overall survival (OS) in ESGC have not been extensively explored. The National Cancer Data Base was queried for stage IB-II gastric adenocarcinoma patients undergoing gastrectomy (1998-2011). Multivariable modeling identified factors associated with adjuvant C±RT receipt and compared risk-adjusted OS by treatment type (i.e., adjuvant therapy versus surgery alone). Of 23,461 ESGC patients (1998-2011), 79.4% and 20.6% received surgery alone and adjuvant C±RT (chemoradiotherapy 17.7%; chemotherapy alone 2.9%), respectively. Predictors of adjuvant C±RT receipt included age <67years, pathologic nodal positivity, and adequate lymph node staging (LNS; ≥15 nodes examined; all p<0.001). Survival analyses included 15,748 patients (1998-2006); median, 1-, and 5-year survival were 63.5months, 86.0%, and 27.0% respectively. Omission of adjuvant C±RT conferred an increased hazard of risk-adjusted mortality in the overall cohort, and stage IB and II subgroups (all p≤0.001). The benefit of adjuvant C±RT was most pronounced in stage II and node-positive patients-regardless of LNS adequacy (all p<0.001)-and inadequately staged IB patients (p=0.003). While associated with a trend toward improved OS in node-negative patients overall (p=0.051), adjuvant C±RT did not improve OS if surgical LNS was adequate in this subgroup (p=0.960). Adoption of adjuvant C±RT in ESGC remains incomplete nationally. Receipt of adjuvant therapy is associated with improved risk-adjusted survival relative to surgery alone; however, in adequately staged patients without lymph node metastasis, this benefit is less certain.

The impact of age on nodal metastases and survival in gastric cancer

BackgroundIn gastric adenocarcinoma, the disparity in lymph node involvement between different age groups has not been thoroughly investigated. The objective of our study was to compare age-associated differences in adequate lymph node harvest and nodal involvement in gastric adenocarcinoma patients. MethodsWe analyzed data extracted from the Surveillance, Epidemiology and End Results database on 13,165 patients diagnosed with stage I-III gastric adenocarcinoma between 2004 and 2011. All patients underwent surgical resection. Statistical comparisons between various age groups were done using the chi-square test and Cox regression. ResultsAmong 13,165 gastrectomy patients, proportion of patients that had >15 lymph nodes examined decreases significantly with increasing age (P < 0.0001). When adequately staged, older patients had a significantly lower proportion of node-positive tumors (P < 0.0001). Adequate nodal staging was also associated with improved 5-y disease-specific survival across all age groups. ConclusionsIn gastric adenocarcinoma, older patients are less likely to be adequately staged. However, when adequately staged, they are less likely to have node-positive tumors. Adherence to national guidelines, regardless of age, is associated with improved survival outcomes and may alter multimodality management of gastric cancer in the elderly.

The sentinel lymph node biopsy for breast cancer over the years.

The sentinel lymph node biopsy (SLNB) has progressively substituted complete axillary lymph node dissection (CALND), and has dramatically changed breast surgery impact on women's psychophysical wellness, reducing surgical morbidity while granting an adequate nodal staging. The present authors have seen a gradual improvement in the technique in order to reduce both surgical time and the number of interventions required, in particular with the intraoperative histological examination of sentinel node. Anyway, there is still great debate about the predictability of axillary nodal status in case of negative SLNB, as well as in case of positive one. Therefore, the authors reviewed the SLNB history and discussed its controversial points.