Adequate Lymph Node Yield Research Articles

Robot-assisted inguinal lymphadenectomy to treat penile and vulvar cancers: a scoping review.

Inguinal lymph nodes dissection (ILND) is recommended in patients presenting with high-risk penile (PC) or vulvar cancers (VC). Though, this surgical procedure is underused because of its anticipated morbidity. Minimally invasive approaches were proposed to minimize complications associated with open surgery. In this review, we analyze current available data exploring intra and perioperative outcomes of robot-assisted ILND (RAIL). On April 9th, 2023, a literature search was conducted using the PubMed and Scopus databases. The search employed the combination of the following terms: ("robotic assisted" OR "robot-assisted" OR "robotic") AND ("inguinal lymph node dissection" OR "lymphadenectomy") AND ("penile cancer" OR "vulvar cancer"). Out of the 404 identified articles, 18 were used for the present scoping review and their results were reported according to the PRISMA statement. Data on 171 patients, ranging in age from 32 to 85 years, were obtained. Most of them (90.6%) harbored a penile squamous cell carcinoma and presented with no palpable nodes (85%). Operation time (OT) ranged between 45 and 300 min. Estimated blood loss varied from 10 to 300 mL. One single intra-operative complication was reported and one conversion to open was recorded. The lymph nodes (LNs) count spanned from 3 to 26 per groin, with 17 studies reporting a median yield >7 nodes. Hospital stay was 1-7 days, while the duration of drainage ranged from 4 to 72 days. Post-operative complications included lymphocele (22.2%; 0-100%), lymphedema (13.4%; 0-40%), cellulitis (11.1%; 0-25%), skin necrosis (8.7%; 0-15.4%). seroma (3.5%; 0-20%) and wound breakdown/wound infection (2.9%; 0-10%). Out of the included studies, 7 provided at least a 12-month follow-up, with recurrence-free rates ranging from 50% to 100% in patients affected by penile cancer and from 92% to 100% in vulvar cancer patients. The available evidence on RAIL for the treatment of PC and VC is limited. The approach appears to be safe and effective, as it provides an adequate lymph node yield while ensuring a minimally morbid postoperative course and a short hospital stay.

Surgical and Oncological Outcome of Laparoscopic Resection of Colorectal Cancers: A Single-Center Experience.

Laparoscopy is one of the major advances in surgery in the last 30 years and has many benefits. Although laparoscopy was initially used for resection of benign colon lesions, it is now widely used for colorectal cancer resections after strong evidence has confirmed its safety and efficacy. We aim to report both the surgical and oncological outcomes of our first series of laparoscopic colorectal cancer resections. In 2013, alaparoscopic colorectal resection service was established in northern Iraq at Zheen Hospital, Erbil. Data from all consecutive colorectal cancers were collected. Patients with locally advanced diseases and those who required emergency operations for bowel obstruction or perforation were excluded. We analyzed demographic, operative, postoperative, and histopathological data for all patients who were included in the study. A total of 124 patients with colorectal cancers presented to our unit between January 2013 and January 2023. Only 112 patients fulfilled the inclusion criteria and underwent laparoscopic resections. The median age of the patients was 54.5 years. The majority of patients were men (n=62; 55.4%). In 39 patients (35%), the cancer was located in the sigmoid; in 33 patients (29.5%) the cancer was in the rectum. Laparoscopic anterior resection was the most common procedure (n=50; 45%), followed by right hemicolectomy in 17cases (15.1%). The conversion rate to open surgery was 8% (nine cases). The most common causes of conversion to open surgery were dilated bowel loops and tumour adherence to other structures. The mean operative time was 190 minutes and the mean hospital stay was three days. No complications were reported in 94patients (84%). Among the complications, wound infection was seen in sevenpatients (7.8%). There were six anastomotic leaks (6.7%). The mean number of lymph nodes harvested was 13. In 70 patients (62.5%), the lymph node count was ≥12 with a median of 13. The mean distal resection margin was 6 cm and 2.5 cm for colon and rectal resections, respectively. This study reveals that laparoscopic resection for colorectal cancers is surgically practicable and safe with the benefits of a short hospital stay, adequate resection margins, and adequate lymph node yield.

Assessing the Association Between Endoscopic Tattooing and Lymph Node Yield in Rectal Cancer

IntroductionPreoperative endoscopic tattooing is an effective tool for intraoperative tumor localization in colon cancer. Endoscopic tattooing in rectal cancer may have unidentified benefits on lymph node yield, making it easier for pathologists to identify nodes during histopathologic assessment. There remains concern that tattoo ink may alter anatomical planes, increasing surgical difficulty. MethodsRetrospective chart reviews from 2016 to 2021 of n = 170 patients presenting with rectal cancer were divided into two groups: with (n = 79) and without (n = 91) endoscopic tattoos. Demographics, operative details, tumor characteristics, prior chemoradiation, and pathologic details were collected. Primary outcome was total lymph node yield. Secondary outcomes were rates of adequate (> 12) nodes, margin status, and operative variables including operative time. ResultsNo differences between pathologic stage, tumor height, high inferior mesenteric artery ligation, operative times, conversion rate, or surgical approach (open versus minimally invasive) were noted between groups. Receipt of neoadjuvant chemoradiation was less frequent in the endoscopic tattooing group (53.2% versus 76.9%, P ≤ 0.001). Total node number and rate of adequate lymph node yield were higher with endoscopic tattooing (20.5 ± 7.6 versus 16.8 ± 6.6 lymph nodes and 100.0% versus 83.5% adequate lymph node harvest, both P ≤ 0.001). Rates of positive circumferential and distal margins and complete total mesorectal excision were also similar. Regression analysis identified endoscopic tattooing (Incidence Risk Ratio 1.17, 95% confidence interval 1.04-1.31) and operative time more than 300 min (Incidence Risk Ratio 0.88, 95% confidence interval 0.77-0.99) had significant effects on lymph node harvest. Removal of patients with inadequate lymph node yield resulted in similar rates of total and positive lymph nodes. ConclusionsEndoscopic rectal tattooing is associated with increased lymph node yield (including after neoadjuvant chemoradiotherapy) without sacrificing oncologic or perioperative outcomes, although this effect is inconsistent when only considering patients with an adequate lymph node yield.

Lymph node yield after rectal resection is a predictor of survival among patients with node-negative rectal adenocarcinoma

BackgroundPathologic review of at least 12 lymph nodes is recommended by the American Joint Committee on Cancer following surgical resection of rectal cancer. However, implications of lymph node yield on prognosis are unclear. This study evaluates the impact of lymph node yield on survival among pathologic node-negative patients who received appropriate neoadjuvant chemoradiation. MethodsThe National Cancer Database from 2010 to 2016 was queried for clinical stage II and III rectal adenocarcinoma with neoadjuvant chemoradiation, resection of the primary tumor, negative surgical margins, and pN0M0 pathologic stage. Data were analyzed with χ2, student’s t test, or Mann-Whitney U test as appropriate. Propensity score matching controlled for clinicodemographic variation. Survival was estimated with Kaplan-Meier curves and Cox hazards analysis. ResultsInadequate lymph node yield (1–11 nodes on pathology) led to a 29% increased risk of mortality compared to adequate lymph node yield (≥12 nodes on pathology). Among patients with an incomplete pathologic complete response to neoadjuvant therapy, 5-year survival was estimated to be 73% for inadequate lymph node yield and 78% for adequate lymph node yield (P = .002). Among patients with a complete pathologic response, 5-year survival estimated to be 82% for inadequate lymph node yield and 90% for adequate lymph node yield (P = .006). Among patients with inadequate lymph node yield and complete pathologic response, 5-year survival improved with the use of adjuvant chemotherapy (90.4%), compared to those without adjuvant chemotherapy (78.5%, P < .001). ConclusionThese findings suggest an inadequate lymph node yield can negatively impact survival, despite negative nodal status and a pathologic complete response to neoadjuvant therapy.

Is Textbook Oncologic Outcome a Valid Hospital-Quality Metric after High-Risk Surgical Oncology Procedures?

"Textbook oncologic outcome" (TOO) is a composite quality measure representing the "ideal" outcome for patients undergoing cancer surgery. This study sought to assess the validity of TOO as a metric to evaluate hospital quality. Patients who underwent curative-intent resection of gastric, pancreatic, colon, rectal, lung, esophageal, bladder, or ovarian cancer were identified in the National Cancer Database (2006-2017). Cancer site-specific TOO was defined as adequate lymph node yield, R0 resection, non-length-of-stay outlier, no hospital readmission, and receipt of guideline-concordant chemotherapy and/or radiation. Mixed-effects analyses estimated the adjusted TOO rate for each hospital stratified by cancer site. The association between hospital adjusted TOO rates and 5-year overall survival was assessed using mixed-effects Cox proportional hazards analyses. Among 852,988 cancer resections, the TOO rate varied across cancer sites as follows: stomach (31.8%), pancreas (25%), colon (66.9%), rectum (33.6%), lung (35.1%), esophagus (31.2%), bladder (43%), and ovary (44.7%). After characterization of adjusted hospital TOO rates into quintiles, an incremental improvement in overall survival was observed, with higher adjusted TOO rates. Similarly, with the adjusted hospital TOO rate treated as a continuous variable, there was a significant 4% to 12% improvement in overall survival for every 10% increase in the adjusted hospital TOO rate for gastric (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.85-0.91), pancreatic (HR, 0.90; 95% CI, 0.88-0.93), colon (0.93; 95% CI, 0.91-0.94), rectal (HR, 0.90; 95% CI, 0.87-0.93), lung (HR, 0.96; 95% CI, 0.95-0.97), esophageal (HR, 0.93; 95% CI, 0.90-0.95), bladder (HR, 0.94; 95% CI, 0.91-0.97), and ovarian (HR, 0.96; 95% CI, 0.94-0.98) cancer. A direct association exists between adjusted hospital TOO rates and survival after high-risk cancer procedures. As a valid hospital metric, TOO can be used to compare the overall quality of cancer care across hospitals.

Effect of neoadjuvant systemic therapy given during window trials on quality metrics in resectable head and neck squamous cell carcinoma.

6033 Background: Quality oncologic care, including negative surgical margin status, adequate lymph node yield and prompt initiation of adjuvant treatment, impacts disease control and overall survival in patients with mucosal head and neck squamous cell carcinoma (HNSCC). The aim of this study was to ascertain the effect of neoadjuvant systemic therapy given during window trials on oncologic quality metrics in patients with delayed definitive surgery for a HNSCC. Methods: Treatment-naïve patients with HNSCC participating in one of two window of opportunity clinical trials at UPMC from 2009-2019 were included. Neoadjuvant regimens consisted of one dose of cetuximab (n = 33) or anti-ErbB3 antibody (n = 9) within 28 days of surgery. Sociodemographic, clinical and tumor staging were recorded. The primary outcome was overall oncologic quality, as defined as a composite measure of negative margin status, adequate lymph node yield, completion of adjuvant therapy (if indicated) and time to initiation of adjuvant therapy within 6 weeks of surgery. Secondary outcomes were difference in clinical and pathologic stages and overall survival (OS). Results: A total of 42 patients with a mean age of 57.1 (±10.2) years and median follow-up of 58 months were analyzed. 29 patients had clinical stage IVA disease with 43% (18/42) oral cavity, 36% (15/42) larynx/hypopharynx and 21% (9/42) oropharynx primaries. All patients underwent surgery following neoadjuvant systemic therapy. In 30 patients (71%), all oncologic quality markers were achieved. Pathological downstaging occurred in 21% (9/42) of patients with 4 patients no longer meeting criteria for adjuvant treatment and were observed. 3 patients showed pathological upstaging. The 3-year OS were 76% (95% CI of 63.6-88.4), respectively. Patients with a pathologic downstage migration (64.9%, 95% CI of 49.9-79.8) had higher 5-year OS compared to those without (57.8%, 95% CI of 40.1-76.4, P = 0.046). Conclusions: Most patients receiving neoadjuvant systemic therapy on window trials prior to surgery met all oncologic quality markers. Importantly, even with brief window trial therapy pathologic downstaging was achieved and associated with significantly better overall survival.

Comprehensive or specialty-specific cancer care in the United States: A story of continuing underperformance.

6577 Background: “Textbook oncologic outcome” (TOO) is a composite measure representing the “ideal” outcome for patients undergoing cancer surgery and is associated with improved survival. Using TOO as the primary outcome, we asked whether hospitals are high-performing across multiple cancer types. Methods: Patients undergoing potentially curative breast, colon, rectal, lung, or pancreatic cancer resection were identified within the National Cancer Database (2010-2016). Organ-specific TOO was defined as: adequate lymph node yield, R0 resection, non-length of stay outlier, no hospital readmission, no 90-day postoperative mortality, and receipt of guideline-concordant chemotherapy and/or radiation. Mixed-effects analyses estimated the risk-adjusted TOO rate for each hospital stratified by cancer type. Results: Among 1,094,550 cancer resections (breast = 690,442; colon = 213,918; lung = 121,771; rectum = 40,315; pancreas = 28,104), 434 hospitals performed ≥10 resections for each cancer type. Only 11 hospitals (2.5%) ranked in the top quartile for adjusted TOO rate for all five cancer types. Of the 323 hospitals (74.4%) that ranked in the top quartile for one cancer type, 149 hospitals (46.1%) also ranked in the bottom quartile for another cancer type. There was a weak correlation between hospital rankings across cancer types with the strongest correlations between colon and rectal cancer (R2= 0.148) and lung and pancreatic cancer (R2= 0.098). Conclusions: Most U.S. hospitals do not provide high-quality care across cancer types with respect to TOO. Perhaps this knowledge should be used to guide referral for oncology care.

Trends in outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma from 2005-2016: improvement has unfortunately not been uniform across hospitals

Presenter: Christopher T Aquina MD, MPH | The Ohio State University Background: A “textbook oncologic outcome” (TOO) is a composite measure representing the “ideal” outcome for patients undergoing cancer surgery. Although operative technique for pancreaticoduodenectomy for PDAC has improved, the impact on TOO is unknown. We assessed national trends in TOO and 1-year mortality following pancreaticoduodenectomy for PDAC. Methods: Patients who underwent curative-intent pancreaticoduodenectomy for PDAC were identified within the National Cancer Database (2005-2016). TOO was defined as: adequate lymph node yield (≥12), R0 resection, non-length of stay (LOS) outlier ( < 25 days), no hospital readmission, no 90-day mortality, and receipt of chemotherapy. Trends in outcome measures (2005-2007 vs. 2014-2016), TOO, and 1-year mortality were compared using bivariate and mixed-effects analyses. Results: Among 40,342 patients, there was significant improvement in all outcome measures except rate of readmission (adequate lymph node yield: 49.1%->76.7%; R0 resection: 75.6%->78.8%; LOS outlier: 8.9%->5.2%; 90-day mortality: 7.6%->5.5%; chemotherapy receipt: 59.2%->76.4%; TOO: 16.3%->34.3%; 1-year mortality: 34.8%->28.6%) (all p<0.001). Across 418 hospitals, wide variation was present in baseline risk-adjusted rates of TOO (median = 15.7%, range = 6.9%-50.8%) and 1-year mortality (median = 32.9%, range = 17.1%-49.8%) during 2005-2007. Wide hospital-level variation was also present in the degree of improvement in adjusted TOO (OR range = 0.67-8.32) and 1-year mortality (OR range = 0.44-2.05) over time. High hospital volume (≥20 pancreatic cancer resections/year) was the only hospital factor associated with greater improvement in adjusted TOO (median OR: 3.23 vs 2.69, p<0.001) and 1-year mortality (median OR: 0.75 vs 0.83, p = 0.006). Conclusion: There have been significant improvements in outcomes following pancreaticoduodenectomy for PDAC. However, wide variation in outcomes and improvement persists across hospitals, particularly among low-volume hospitals.

Multidisciplinary Approach in Improving Survival Outcome of Early-Stage Gastric Cancer

BackgroundThe necessity of extensive lymph node (LN) dissection/examination and adjuvant therapy for patients with early gastric cancer (EGC, Tis-T1, any N) remains controversial. We aim to refine treatment recommendations for patients with EGC through a reflective analysis for the survival gap between Eastern and Western countries. MethodsEGC patients diagnosed between 2004 and 2014 were identified from the National Cancer Database (NCDB) and a large medical center in China. Adequate LN yield was defined as ≥25 LNs examined. ResultsIn the US cohort, 14.4% of (1104/7641) patients with EGC had ≥25 LNs examined. The 5-y overall survival (OS) was significantly better than those with <25 LNs (78.9% versus 68.5%, P < 0.001). Examination of ≥25 LNs was an independent predictor of better OS after adjusting all known prognostic factors. Patients with ≥25 LNs examined had significantly higher chance of having LN-positive disease compared to patients with <25 LNs (14.9% versus 10.7%, P < 0.001). A similar stage migration phenomenon was observed in Chinese cohort (LN positive: 25.2% versus 18.4% in ≥25 LNs and <25 LNs examined group, respectively, P = 0.02). In the US cohort, adjuvant therapy was associated with a significant survival benefit for LN-positive patients (5-y OS: 71.0% versus 43.0% for with/without adjuvant therapy, respectively, P < 0.001) but not in LN-negative patients (5-y OS: 71.2% versus 71.5%, P = 0.90). ConclusionsAdequate lymphadenectomy and LN examination are critical components of EGC management. Adjuvant therapy should be strongly encouraged for all EGC patients with LN-positive disease in the United States.

Variation in Adequate Lymph Node Yield for Gastric, Lung, and Bladder Cancer: Attributable to the Surgeon, Pathologist, or Hospital?

The Commission on Cancer recently released quality-of-care measures regarding adequate lymphadenectomy for colon, gastric, lung, and bladder cancer. There is currently little information regarding variation in adequate lymph node yield (ALNY) for gastric, lung, and bladder cancer. The New York State Cancer Registry and Statewide Planning and Research Cooperative System were queried for stage I-III gastric, stage I-II lung, and stage II-III bladder cancer resections from 2004 to 2014. Hierarchical models assessed factors associated with ALNY (gastric ≥ 15; lung ≥ 10; bladder ≥ 2). Additionally, the proportions of variation attributable to surgeons, pathologists, and hospitals were estimated among Medicare patients. Among 3716 gastric, 18,328 lung, and 1512 bladder cancer resections, there were low rates of ALNY (gastric = 53%, lung = 36%, bladder = 67%). When comparing 2004-2006 and 2012-2014, there was significant improvement in ALNY for gastric cancer (39% vs. 68%), but more modest improvement for lung (33% vs. 38%) and bladder (65% vs. 71%) cancer. Large provider-level variation existed for each organ system. After controlling for patient-level factors/variation, the majority of variation was attributable to hospitals (gastric: surgeon = 4%, pathologist = 2.8%, hospital = 40%; lung: surgeon = 13.8%, pathologist = 1.5%, hospital = 18.3%) for gastric and lung cancer. For bladder cancer, most of the variation was attributable to pathologists (surgeon = 3.3%, pathologist = 10.5%, hospital = 6.2%). ALNY rates are low for gastric, lung, and bladder cancer, with only modest improvement over time for lung and bladder cancer. Given that the proportion of variation attributable to the surgeon, pathologist, and hospital is different for each organ system, future quality improvement initiatives should target the underlying causes, which vary by individual organ system.

ASO Author Reflections: Variation in Adequate Lymph Node Yield: Current Status and Where Do We Go from Here?

ASO Author Reflections: Variation in Adequate Lymph Node Yield: Current Status and Where Do We Go from Here?

Lymph Node Ratio in HPV-Associated Oropharyngeal Cancer: Identification of a Prognostic Threshold.

To evaluate the utility of lymph node ratio (LNR) as a prognostic factor for survival and recurrence in surgically treated patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC). Retrospective cohort study. In this retrospective cohort study of a tertiary healthcare system in a major metropolitan area, we reviewed 169 consecutive patients with HPV-related OPSCC treated using transoral robotic surgery. Univariable and multivariable Cox proportional hazards regression analysis with stratified models were used to compare LNR with other traditional clinicopathologic risk factors forrecurrence and survival. An LNR cutoff was found using the minimal P approach. Multivariable Cox regression models showed that each additional percentage increase in LNR corresponded to an adjusted hazard ratio (HR) of 1.04 (confidence interval [CI] 1.02-1.07). LNR was more significant when adjusted for adequate lymph node yield of ≥ 18 nodes (HR 5.05, 95% confidence interval [CI] 1.38-18.47). The minimal P generated cutoff point at LNR ≥ 17% demonstrated a HR 4.34 (95% CI 1.24-15.2) for disease-free survival. For HPV-related OPSCC, continuous LNR and an LNR threshold of 17% could be helpful in identifying recurrent disease in addition to measures such as lymph node number alone. 4.

Gastrectomy for Gastric Cancer in Patients with BMI ≥ 30 kg/m2

Obesity is a major health issue in the modern world population and a risk factor for surgical procedures. This study examined perioperative and oncologic results of gastrectomy in obese patients diagnosed with gastric cancer. BMI ≥30 kg/m² was used to designate obesity. Five hundred and one patients were operated throughout the study period (2009-2018). The outcomes in obese patients (n = 205) were compared with those with normal weight (n = 171) and overweight (n = 125). The mean BMI was significantly different between the groups: 21.9 versus 26.7 versus 33.3 kg/m² (P < 0.01), respectively. Obesity was associated with higher incidence of comorbidities, longer operative time, and increased blood loss. Postoperative and short-term oncologic outcomes were similar. Median follow-up was 24 months with similar recurrence rates in the three groups. Median survival was comparable between the normal weight, overweight, and obese patients-36 (27-45) versus 42 (30-53) versus 32 (17-47) months, respectively (P = 0.63). Obesity itself does not deteriorate the surgical outcomes of gastrectomy in patients with gastric cancer. Although technically demanding in obese patients, adequate lymph node yield and satisfactory long-term oncologic outcomes can be achieved in this group.

Adequacy of Lymph Node Yield for Papillary Thyroid Cancer: An Analysis of 23,131 Patients

BackgroundThreshold numbers for defining adequacy of lymph node (LN) yield have been determined for evaluation of occult nodal disease during papillary thyroid cancer (PTC) surgery. This study assesses the prevalence of adequate LN yield and estimates its association with patient clinicopathologic characteristics. Materials and methodsAdult patients with cN1 pT1b or pT2 and cN0 or cN1 pT3 M0 PTC ≥1 cm who received surgery with ≥1 LN resected were identified from the National Cancer Database, 2004-2015. Adequate yield was defined as removing ≥6, 9, and 18 LNs for pT1b, pT2, and pT3 stages, respectively, based on recently published literature. Univariable and multivariable logistic regression were used to determine factors associated with adequate yield. ResultsA total of 23,131 patients were included; 7544 (32.6%) had adequate LN yield. Rate of adequate yield increased from 19.9% to 36.6% over time. After adjustment, patients at academic facilities were more likely to have adequate yield than those at community centers [OR 1.94 (95% CI 1.55-2.41), P < 0.001]. Patients with more advanced tumors were less likely to have adequate yield (pT1b: 75.9% versus pT2: 64.5% versus pT3: 24.6% adequate LN yield, P < 0.001). Patients with adequate LN yield were 0.89 times likely to receive radioactive iodine compared with those with inadequate yield [OR 0.98 (95% CI 0.81-0.98), P = 0.02]. ConclusionsThe rate of adequate LN yield has increased over time, but only a minority of lymphadenectomies performed for PTC can be defined as adequate. Disparities still exist based on patient and facility characteristics; patients with more advanced tumors appear less likely to have adequate LN yield.

Nonelective colon cancer resection: A continued public health concern

Little is known regarding recent trends in the rate of nonelective colon cancer resection in the United States and its impact on both short-term and long-term outcomes. The New York State Cancer Registry and Statewide Planning & Research Cooperative System identified stage I-III colon cancer resections from 2004-2011. Propensity-matched analyses assessed differences in short-term adverse outcomes and 5-year disease-specific and overall survival between elective and nonelective colon cancer operations. Further analyses assessed the association among patient, surgeon, and hospital-level factors and outcomes within the nonelective operation group. Among 26,420 patients, 26.5% underwent nonelective operations. There was no significant change in the rate of nonelective resection from 2004-2011 (P=.25). Nonelective operations were independently associated with greater odds of 30-day mortality (odds ratio [OR]=3.42, 95% confidence interval [CI]=2.87-4.06), stoma creation (OR=4.49, 95% CI=3.95-5.09), intensive care unit admission (OR=1.68, 95% CI=1.53-1.84), complications (OR=2.34, 95% CI=2.18-2.52), and discharge to another health care facility (OR=2.46, 95% CI=2.26-2.68), longer duration of stay (incidence rate ratio=1.79, 95% CI=1.76-1.83), and worse disease-specific (hazard ratio=1.74, 95% CI=1.61-1.88) and overall survival (hazard ratio=1.64, 95% CI=1.55-1.75). Other than an association among high-volume surgeons, adequate lymph node yield, and receipt of adjuvant chemotherapy and lower mortality, no other potentially modifiable factors were associated with survival after nonelective operations. Nonelective colon cancer resection remains a concerning public health issue with >25% of cases being performed on a nonelective basis and an independent association with poor short-term and long-term survival compared with elective operations. Given that few potentially modifiable factors appear to have an impact on survival after nonelective operations, these findings highlight the importance of adherence to colon cancer screening guidelines to limit the number of nonelective colon cancer resections.

Factors predicting adequate lymph node yield in patients undergoing pancreatoduodenectomy for malignancy.

BackgroundMost pancreatoduodenectomy resections do not meet the minimum of 12 lymph nodes recommended by the American Joint Committee on Cancer for accurate staging of periampullary malignancies. The purpose of this study was to investigate factors affecting the likelihood of adequate nodal yield in pancreatoduodenectomy specimens subject to routine pathological assessment.MethodsSix hundred sixty-two patients subject to pancreatoduodenectomy between 1990 and 2013 for pancreatic, ampullary, and common bile duct cancers were reviewed. Predictors of yielding at least 12 lymph nodes were evaluated with a logistic regression model, and a survival analysis was carried out to verify the prognostic implications of nodal counts.ResultsThe median number of evaluated nodes was 17 (interquartile range 11 to 25), and less than 12 lymph nodes were reported in surgical specimens of 179 (27 %) patients. Tumor diameter ≥20 mm (odds ratio [OR] 2.547, 95 % confidence interval [CI] 1.225 to 5.329, P = 0.013), lymph node metastases (OR 2.642, 95 % CI 1.378 to 5.061, P = 0.004), and radical lymphadenectomy (OR 5.566, 95 % CI 2.041 to 15.148, P = 0.01) were significant predictors of retrieving 12 or more lymph nodes. Lymph node counts did not influence the overall prognosis of the patients. However, a subgroup analysis carried out for individual cancer sites demonstrated that removing at least 12 lymph nodes is associated with better prognosis for pancreatic cancer.ConclusionsFew variables affect adequate nodal yield in pancreatoduodenectomy specimens subject to routine pathological assessment. Considering the ambiguities related to the only modifiable factor identified, appropriate pathology training should be considered to increase nodal yield rather than more aggressive lymphatic dissection.

Lymph node yield and tumor location in patients with upper tract urothelial carcinoma undergoing nephroureterectomy affects survival: A U.S. population–based analysis (2004–2012)

PurposeThe purpose of the study was to characterize the contemporary trends in lymphadenectomy for the treatment of upper tract urothelial carcinoma in a population-based cohort and to determine if number of lymph nodes removed and tumor location are predictors of cancer-specific survival in patients undergoing nephroureterectomy. Materials and methodsIndividuals with upper tract urothelial carcinoma undergoing nephroureterectomy in the Surveillance, Epidemiology, and End Results program from 2004 to 2012 were identified. Linear regression was used to assess trends in lymphadenectomy. Patients were stratified based on nodal status, quartiles of nodes removed, and tumor location. Kaplan-Meier analysis, log-rank tests, and Cox proportional hazards models were used to compare cancer-specific survival and overall survival among groups. ResultsIn the cohort, 25% (721/2,862) of all patients and 27% (566/2,079) of grade 3/4 patients underwent lymphadenectomy. The percentage of patients undergoing lymphadenectomy increased from 20% (60/295) in 2004 to 33% (106/320) in 2012 (P = 0.02). Patients with the highest quartile of lymph nodes removed had improved the 5-year cancer-specific survival of 78% (95% CI: 69%–85%) compared to the second quartile (60%; 95% CI: 51%–67%; P = 0.003) and the third quartile (60%; 95% CI: 51%–68%; P = 0.002) of nodes removed. This trend held for node-negative and node-positive patients. In multivariable modeling, a lower number of lymph nodes dissected (hazard ratio = 0.94, 95% CI: 0.91–0.98) and ureteral tumors (hazard ratio = 1.29, 95% CI: 1.07–1.56) were predictors of worse cancer-specific survival. ConclusionsIn patients with upper tract urothelial carcinoma undergoing nephroureterectomy, rates of lymphadenectomy have increased from 2004 to 2012 in the United States. In this contemporary cohort, an increase in the number of nodes removed and renal pelvis tumors are associated with improved cancer-specific survival, which highlights the importance of intentional lymph node dissection with adequate lymph node yield in these patients.

Retraction of External Iliac Vessels and Obturator Nerve With the Vas Deferens During Extended Pelvic Lymph Node Dissection in Robot-assisted Radical Prostatectomy

To determine if the vas deferens during robot-assisted radical prostatectomy can be used to medially retract the iliac vessels and obturator nerve to achieve a dissection plane in the triangle of Marcille free of these structures while performing an extended pelvic lymph node dissection (PLND). In a single patient, an extended PLND was performed before prostatectomy. The external iliac lymph node (LN) group was dissected from the node of Cloquet to the ureteric crossing over the internal iliac artery. The vas deferens was then transected along its course medial to the external iliac artery. The vas deferens was subsequently grasped with bipolar forceps, passed under the external iliac vessels, lifted superiorly, and retracted medially in order to apply medial traction to the obturator nerve and external iliac artery and vein. Retraction using the vas deferens permitted excellent visualization of the LN packets. The iliac vessels and obturator nerve were maintained far from the plane of the dissection and were retracted only using the vas deferens. This technique yielded 25 LNs and our median LN yield for high-risk individuals is 20. Surgical time was comparable to PLNDs performed using instruments for retraction. Use of the vas deferens for retraction during an extended PLND can be an excellent method to improve visibility without risk of damage to important structures with surgical tools and still achieve an adequate LN yield. Use of this technique in future surgeries will permit a more detailed understanding of outcomes.

Therapeutic Advances in Pancreatic Cancer

Despite our improved understanding of pancreatic cancer biology and ability to perform more complex pancreatic cancer surgeries that produce better short-term outcomes, major progress toward increasing survival times has been painstakingly slow. Through the often-repeated, dismal survival statistics, it is easy to lose sight of real progress that has been made in pancreatic cancer therapy. It is particularly interesting to observe the extent to which these advances are interdependent and the effects they have had on practice. For example, during the past 5-10 years, we have seen widespread adoption of pancreatic imaging protocols that allow for objectively defined criteria of resectability. This has led to the definition of "borderline resectable pancreatic cancer"--a new clinical category that has affected the design of clinical trials. A major change in our surgical approach has been the move to minimally invasive pancreatectomy, which continues to gain broader acceptance and use, particularly for left-sided lesions. Although many new agents have been developed aimed at putative molecular targets, recent breakthroughs in therapy for advanced disease have arisen from our ability to safely give patients combination cytotoxic chemotherapy. We are now faced with the challenge of combining multidrug, cytotoxic chemotherapies with newer-generation agents. Ultimately, the hope is that drug combinations will be selected based on biomarkers, and strategies for pancreatic cancer therapy will be personalized, which could prolong patients' lives and reduce toxicity. We review the major advances in pancreatic cancer therapy during the last 5 years, and discuss how these have set the stage for greater progress in the near future.

Robotic Intracorporeal Urinary Diversion: Ileal Conduit

Radical cystectomy is considered the standard of care for muscle-invasive bladder cancer. The use of minimally invasive techniques, particularly robot-assisted radical cystectomy, is steadily increasing with an acceptable learning curve, adequate lymph node yield, and acceptable perioperative complications. Longer-term follow-up is necessary to confirm oncologic efficacy, but early data are encouraging. While the majority of urinary diversions are performed extracorporeally, several recent small case studies have reported successful totally intracorporeal diversions, including both ileal conduit and orthotopic neobladder creation. Operative and short-term clinical outcomes have thus far been comparable to those of previously reported extracorporeal techniques. As surgeons gain experience with the robotic techniques needed for radical cystectomy, the frequency of intracorporeal urinary diversions will similarly increase. In this article, we describe the stepwise surgical procedure and perioperative management of the robot-assisted laparoscopic intracorporeal ileal conduit.