Celiac Nodes Research Articles

Primary Esophageal Adenocarcinoma With Colon Metastases After Esophagectomy

Esophageal carcinoma is an aggressive cancer with predominance to squamous cell variation worldwide, but in the United States, adenocarcinoma is more common. Risk factors for esophageal adenocarcinoma (AC) include gastric acid reflux and tobacco use leading to an increase in oxidative stress resulting in inflammation and increase cellular turnover with metaplasia. Esophageal AC presents with manifestations of dysphagia, weight loss, malnutrition and advanced disease with dyspnea, cough or hoarseness. Esophageal AC can metastasize to the lung, liver, bone, celiac lymph nodes with rare spread to the colon. We present a case of primary esophageal AC status post chemoradiation and esophagectomy with metastatic disease found as asymptomatic colon polyps. Our patient is a 70 year-old male smoker presenting with dysphagia and weight loss of twenty pounds over 4 weeks. Esophagogastroduodenoscopy and endoscopic ultrasound revealed a nearly occlusive, friable mass invading the muscularis propria with celiac lymphadenopathy and biopsies confirming invasive, poorly differentiated AC without distant metastasis. Concomitant chemoradiation was initiated prior to surgical resection. An esophagectomy was performed with pathology consistent with prior biopsies. Routine CT scan four months later with enlarged para-aortic lymphadenopathy and liver lesions resulted in a colonoscopy to question the primary cancer. Colonoscopy exposed nodules throughout descending and ascending colon; biopsies consistent with similar immunoprofile as previous esophageal AC and liver lesions. Colon nodules were deemed consistent as metastasis from previous esophageal adenocarcinoma. Patient was started on FOLFOX therapy. Primary esophageal AC typically presents with advanced disease resulting in the likelihood of metastatic disease. Metastatic spread within the gastrointestinal tract, more specifically the colon, is rare with few case reports. Most case reports are of squamous cell carcinoma metastasizing, which can be explained by higher prevalence of disease worldwide. A definite challenge in this case is to determine the primary cancer. Colon nodules offer no differentiation from primary or secondary cancers with no particular features to be appreciated on imaging or endoscopy. Most nodules are asymptomatic and could be developing at the same time as the esophageal carcinoma. Treatment is based on the primary cancer with chemoradiation and surgical resection if applicable.

Distinct features of newly found liver-draining lymph nodes in mice (IRC4P.612)

Abstract Draining lymph nodes (LNs) are specialized sites where adaptive immune responses take place. Recently, the anatomical location of two LNs draining the mouse liver, named as portal LN (PLN) and celiac LN (CLN) respectively, has been characterized. However, the immune responses in the liver-draining LNs and their contribution to the establishment and maintenance of liver tolerance are still not fully understood. In our further study, we find that these two liver-draining LNs (PLN and CLN) have different lymphatic vessels, excluding the possibility that one LN is secondary to the other one. Interestingly, although both PLN and CLN can drain liver lymph directly, they are different in many aspects. The two liver-draining LNs have different cellular composition, with PLN being highly similar to mesenteric LN but different from periphery LNs, and CLN being special with unique composition of innate immune cells. Importantly, the development of these two liver-draining LNs might be controlled by different transcription factors. Moreover, our preliminary data shows that the immune responses of these two liver-draining LNs exhibit different features during exogenous pathogen infection. Overall, PLN and CLN are two liver-draining LNs with distinct characteristics and their contribution to liver tolerance remains to be defined.

40. Transgene Product-Specific Treg Are Initially Induced in the Celiac Lymph Node During Tolerance Induction By Hepatic AAV Gene Transfer

Previous work by us and several other laboratories has shown that liver-directed gene transfer can induce transgene product-specific immune tolerance. Induction of CD4+CD25+FoxP3+ regulatory T cells (Treg) is a critical component of the tolerance mechanism. Gaps in knowledge exist about the identity of the antigen-presenting cells (APCs) and the origin of peripherally induced Treg. To characterize the interaction of adeno-associated virus (AAV) antigen expression in the liver with immune cells, we used AAV8-EF1a vectors, which have a high tropism for murine liver, expressing either a secreted ovalbumin (AAV8-ova) or cytoplasmic ovalbumin (AAV8-Cytoova). In Treg-deficient mice transgenic for an ova-specific CD4+ T cell receptor (DO11.10-tg Rag-2-/- BALB/c), Treg were induced with either vector. For secreted ova, multiple organs (liver, spleen, lymph nodes [LN]) showed a similar level and time course of Treg induction, with greater than 1% of the CD4+ T cells being Treg starting at 4 weeks. Substantial T cell activation using the very early activation marker CD69 was also observed in these tissues starting at 3 weeks after AAV8-ova. However, Treg induction was observed in the celiac LN (one of the liver-draining LN) as early as 3 weeks after AAV8-Cyto-ova gene transfer, followed by induction of Treg in other tissues by 4 weeks. Interestingly, T cell activation was notably higher in liver and celiac LN after AAV8-Cyto-ova with over 70% activated CD4+ T cells after 4 weeks. In addition, T cell activation was observed earlier in all tissues after AAV8-Cyto-ova when compared to AAV8-ova. Literature data document a role for tolerogenic antigen presentation in the liver itself via sinusoidal endothelial cells and possibly hepatocytes. Our data suggest an important role of conventional mechanisms of adaptive immunity involving draining LNs that survey tissue antigens leading to early T cell activation and Treg induction of hepatic expressed non-systemic antigens. To start defining the critical APCs, BALBc mice were given AAV8-ova vector two weeks prior to adoptive transfer of CellTrace Violet-labeled CD4+ T cells from DO11.10 donor mice and their proliferation was measured using flow cytometry after 5 days. Half of these mice had their Kupffer cells and M1 macrophages inactivated with Gadolinium chloride for two days prior to DO11.10 adoptive transfer. DO11.10 cells proliferated in an antigen-specific manner, and proliferation was blocked by Gadolinium chloride, supporting a role for professional APCs in presentation of hepatic transgene product. Our data suggest and reinforce the importance of Kupffer cells as key APCs for hepatic antigens and further characterize the impact of the route of antigen expression on T cell activation and Treg induction.

Tu1659 Forward Viewing EUS Versus Standard Oblique Viewing EUS in the Performance of EUS-Guided Fine Needle Aspiration of Solid Lesions: a Prospective Randomized Controlled Study

Tu1658 Does EUS Add to the Value of High-Resolution CT Staging in Pancreatic Carcinoma? Jayaprakash Sreenarasimhaiah*, Deepak Agrawal Medicine/Gastroenterology, University of Texas Southwestern, Dallas, TX Background: Pancreatic carcinoma often presents at an advanced stage at diagnosis. Distant metastatic disease is easily detected by computerized tomography (CT). Additionally, the presence of vascular invasion or celiac node (CN) involvement may deem a tumor unresectable. Computerized tomography (CT) and endoscopic ultrasound (EUS) are frequently used to determine resectability. Aims: To determine if EUS provides additional detail to CT staging of pancreatic carcinoma in regard to vascular invasion and CN involvement. Methods: The endoscopic database was examined retrospectively for a 5 year-period between July 2007 and July 2012. Consecutive patients with pancreatic carcinoma proven by EUS-FNA (fine needle aspiration) were included. Patients with CN visualized by EUS were examined and compared to pancreas protocol CT scan performed with 2 and 5mm image slices. The detection of invasion into great vessels adjacent to the tumor was also examined for each modality. Results: 117 patients with EUS-biopsy-proven carcinoma were identified. Mean age was 60 years with 59% males. Mean size of largest tumor dimension was 3.9cm. Tumors were located in the pancreas head or uncinate process in 88 (75%), tail in 10 (9%), and in the body or neck in 19 (16%). 30/117 (26%) had visible CN on EUS while 10/117 (9%) had visible CN on CT scan. In 21/30 nodes seen on EUS, size was O1cm and had morphology suspicious for malignancy. EUSFNA demonstrated 11/21 CN with malignant, 4/11 atypical or non-diagnostic, and 6/ 11 benign cytology. 4/11 (41%) patients with malignant CN did not have visible nodes on CT. In 21 patients with abnormal CN, EUS identified 13 with vascular invasion, 4 with portal vein abutment, and 4 without invasion. CT imaging was consistent with EUS in identifying vascular invasion in all 21 patients. Conclusions: Celiac lymphadenopathy was detected three-fold more commonly by EUS than CT scan. Malignant CN was missed in approximately 40% of cases that EUS identified. While vascular invasion was identified similarly by both modalities, its presence did not predict CN. Thus, complete staging of pancreatic carcinoma should include EUS despite findings by high-resolution CT imaging. AB548 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015 HIGH-RESOLUTION

Metastatic renal cell carcinoma from a native kidney of a renal transplant patient diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy.

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy sampling of enlarged lymph nodes is increasingly used to diagnose metastatic tumors, especially of the gastrointestinal tract and the lungs. Herein, we describe the diagnosis of metastatic renal cell carcinoma from a native kidney of a 54 year-old male patient, who had a 5-years history of renal transplant, by EUS-FNA of mediastinal and celiac lymph nodes. Histological and immunohistochemical findings confirmed the origin of metastatic tumor. EUS-FNA with proper cytological evaluation can be useful in the diagnosis of metastatic renal cell carcinoma in renal transplant patients.

Frequency and characterization of celiac ganglia diagnosed on fine-needle aspiration.

Introduction:Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is frequently used to sample intra-abdominal lesions and lymph nodes. Celiac ganglia normally located near the celiac artery may be sampled during these procedures. The aim of this study was to determine the frequency of detection and cytologic findings of celiac ganglia diagnosed on FNA.Materials and Methods:A 14-year retrospective review of radiologic and endoscopic FNA cases involving the celiac region was performed. Cases in which ganglia were reported were further analyzed and slides reviewed.Results:A total of 354 patients underwent FNA of a suspected celiac lymph node (334 patients) or celiac mass (20 cases). In 9 of these patients (2.5%), ganglion cells were identified. These were identified in cases only after 2008 via EUS-guided FNA. Aspirates were hypocellular and bloody. Large ganglion cells were either sparsely dispersed or present in clusters. Ganglion cells had a low N: C ratio, granular cytoplasm with neuromelanin, and eccentric small round nucleus with a prominent nucleolus. One specimen had concomitant pancreatic adenocarcinoma. None of these cases had a false positive on-site adequacy assessment or final misdiagnosis.Conclusions:These data show that celiac ganglia may be infrequently encountered, especially with intra-abdominal EUS-guided FNA targeting nodes or masses near the celiac region. Therefore, cytologists should be aware of the possibility of finding ganglionic cells in EUS-guided FNA samples.

Presence of Maedi-Visna in Costa Rican sheep flocks

A total of 359 sheep serum samples from 15 farms were analyzed for the presence of antibodies against Maedi Visna Virus (MVV) by Enzyme-linked Immunosorbent Assay (ELISA). Additionally, a survey was applied to the sheep owners in order to determine management measures and presence of clinical symptoms of Maedi-Visna in the flocks. Logistic regression with random effects was performed to assess risk factors to seropositivity. Seven serum samples were positive to MVV belonging to six flocks, determining low flock seropositivity (0 to 7.1%). Only one of the five regions studied was negative, determining low overall prevalence (1.95%) and low positivity by region (0.0% to 0.84%). One seropositive animal with symptoms related to MVV was sacrificed for necropsy. An enlargement of mesenteric and celiac lymph nodes was determined, histopathology of lungs revealed acute interstitial pneumonia. Analysis of organs, fluids and blood of this sheep by Polymerase Chain Reaction (PCR) to detect MVV yielded negative results. In order to confirm the serological results, serum and blood samples from two remaining seropositive animals were analyzed six months later, one resulted seronegative and the other seropositive in ELISA, but both negative in PCR. No risk factors were associated to seropositivity. Since MVV produces latency, we conclude, that the positive serological results were due to false positive reactions. Even though, 52.0% of the participating farms had introduced animals, embryos, or semen from other farms or from abroad without any sanitary certification, MVV seems to be present in Costa Rica probably in a very low prevalence. Further studies are required to implement control measures and prevent the spread of the disease.

Clinical significance analysis of lymph node metastasis on the middle and lower segment of 186 cases of II and III stage of esophageal squamous cell carcinoma patients

Objective To investigate lymph node metastasis on the middle and lower segment of Ⅱ and Ⅲ stage of esophageal squamous cell carcinomas, understand the factors influencing the lymph node metastasis, and provide the basis for the key areas of lymph node cleaning. Methods A retrospective study was made on the specimens of 186 patients who were middle and lower segment of Ⅱ and Ⅲ stage of esophageal squamous cell carcinomas, who had underwent radical operation through left thoracic, thoraco abdominal two field lymph node cleaning. All the cases were patients from April 2010 to December 2013 at the Inner Mongolia Medical University Clinical Medical College of Chifeng. Results A percentage (67.9%) of patients (126/186) was found with lymph node metastasis. A total of 4259 lymph node was dissected, with an averaged cleaning of (22.9±8.1) lymph nodes for each case. A total of 622 lymph nodes (14.6%=622/4 259) existed metastasis. The rate of mediastinum metastasis for middle and lower segment of esophageal cancer was 56.1% and 16.5%, respectively. The rate of metastasis to the lower mediastinal lymph nodes was 34.6% and 54.4%, respectively. The rate of metastasis to the celiac lymph nodes was 23.4% and 46.8%, respectively. A significant difference was found in the metastasis locations of middle and lower segment of esophageal carcinomas (P 0.05). Conclusions The lower segment of Ⅱ, Ⅲ stage esophageal squamous cell carcinoma with lymph node metastasis occurs in the lower mediastinal and abdominal lymph nodes. The middle segment Ⅱ, Ⅲ stage esophageal squamous cell carcinoma with lymph node metastasis occurs in the thoracic and abdominal lymph nodes with Jump transfer characteristics. The lymph node cleaning of the middle segment includes the left artery near the stomach, paraesophageal, and carina lymph node. The lymph node cleaning of the lower segment includes paraesophageal, cardia, and gastric lymph nodes. The metastasis rate of vascular tumor thrombus is related to the depth of tumor invasion and differentiation degree. Key words: Esophageal neoplasms/pathology; Neoplasms, squamous cell/pathology; Lymphatic metastasis; Retrospective studies

Involvement of mediastinal/intra.abdominal lymph nodes, spleen, liver, and left adrenal in presumed isolated pancreatic tuberculosis: An endoscopic ultrasound study

AbstractBackground: Isolated pancreatic tuberculosis is very rare and closely mimics pancreatic cancer. Extra pancreatic involvement is very rare and has been rarely reported. Aim: Study the involvement of mediastinal/intra-abdominal lymph nodes, spleen, liver, and left adrenal in patients of isolated pancreatic tuberculosis using endoscopic ultrasound (EUS). Patients and Methods: Retrospective analysis of the records of 16 patients (12 males; mean age 37.8 ± 9.3 years) with pancreatic tuberculosis seen over last 4 years was done. Results: All 16 patients had a well-defined predominantly hypoechoic mass lesion in the pancreatic head and 7/16 (43%) patient had isolated pancreatic tuberculosis with no lymphadenopathy or extrapancreatic involvement. Nine (57%) patients had involvement of the peripancreatic lymph nodes and 6 (38%), 3 (19%), and 2 (13%) patients had celiac, periportal, and mediastinal nodes involvement, respectively. The diameter of the lymph nodes ranged from 1.2 cm to 2.6 cm with celiac lymph nodes being the largest. The left adrenal had normal morphology on EUS in all patients. The spleen and left lobe of the liver were also normal on EUS. Conclusions: Extra pancreatic involvement is seen in up to one-third of patients with presumed isolated pancreatic tuberculosis with involvement of peri-pancreatic and celiac lymph nodes being the commonest.

Laparoscopic gastric tube formation with pyloromyotomy for reconstruction in patients with esophageal cancer.

PurposeTo analyze the benefit and feasibility of this procedure compared with those of open method.MethodsAbdominal procedure includes laparoscopic gastric mobilization, celiac axis lymph node dissection, formation of the gastric tube, and pyloromyotomy. The actual procedure performed during open surgery is the same as those of laparoscopic surgery except for the main incision. Minimally invasive esophagectomy (MIE) was performed on 54 patients with esophageal cancer. The short-term outcomes, including postoperative complications were analyzed and compared with 44 cases of open method.ResultsAlthough the total operative time was not different between 2 groups (349.8 minutes vs. 374.8 minutes, P = 0.153), the operation time of abdominal procedure was shorter in laparoscopic group (90.6 minutes vs. 162.1 minutes, P < 0.001). Operation related complications and hospital stay were not significantly different between the 2 groups. The number of transfused patients was significantly smaller in laparoscopic group (11.1% vs. 27.9%, P = 0.030).ConclusionLaparoscopic gastric tubing with pyloromyotomy is a feasible and safe treatment option for patients with esophageal cancer.

Small cell carcinoma arising in a pancreatic neuroendocrine tumour (PNET) in a patient with family history of multiple endocrine neoplasia type 1 (MEN1): a case report

Case presentation A 47-year-old woman with family history of MEN1 underwent an abdominal CT scan to reveal a 20mm cystic mass in the distal pancreas and an enlarged coeliac lymph node. FNA of lymph node showed features of a neuroendocrine tumour (NET). Distal pancreato-splenectomy and regional lymphadenectomy was performed and histology showed pancreatic neuroendocrine tumour with progression into small cell carcinoma in an involved lymph node. There were also two separate pancreatic microadenomas and background islet cell hyperplasia favouring underlying MEN1. Discussion and conclusion Poorly differentiated PNETs are rare. Neoplastic progression of well differentiated NETs has been proposed as the origin of some poorly differentiated pancreatic neuroendocrine carcinomas. 1,2 Although the frequency with which pancreatic well differentiated (WHO grade 1 and 2) NETs may transform to true poorly differentiated neuroendocrine carcinomas is unknown, most observation to date suggest this is an uncommon pathway. 1 This is the first report of PNET with progression into small cell carcinoma in MEN1 patient.

Local Control May be the Key in Improving Treatment Outcomes of Esophageal Squamous Cell Carcinoma Undergoing Concurrent Chemoradiation

Background/Aim: Little is known about the patterns of treatment failure following definitive chemoradiotherapy (CCRT), especially in esophageal squamous cell carcinoma (SCC). We evaluated definitive CCRT failure patterns and determined the predictive factors for treatment response in esophageal SCC. Methods: We evaluated 136 consecutive patients with esophageal SCC treated with definitive CCRT. We evaluated the factors associated with complete remission (CR) after CCRT and analyzed the pattern of treatment failure of recurred patients and incomplete remission patients. The failures were categorized as either within (locoregional failure) or outside the radiation field (out-field failure). Results: Fifty-seven patients achieved CR after CCRT. Consolidation chemotherapy was significantly associated with CR. Only 4 (7.0%) patients had CR after CCRT in patients with M1a node (Celiac or subclavian lymph nodes involvement by 6th AJCC). During follow-up, 74 patients (54.4%) experienced locoregional failure, 26 (19.1%) out-field failure, and 35 (25.7%) no failure. Esophageal obstruction prior to CCRT, residual tumor according to the first follow-up endoscopy, and poor follow-up computed tomography responses were significantly associated with locoregional failure. Conclusion: Approximately 70% of treatment failures were local failures. Future therapeutic strategies need to focus on improving local control to increase treatment outcomes of CCRT.

Quality indicators for EUS.

EUS has become integral to the diagnosis and staging of GI and mediastinal mass lesions and conditions. EUS-guided FNA (EUS-FNA) allows the endoscopist to obtain tissue or fluid for cytologic and chemical analysis, adding to the procedure's utility. Furthermore, the recent development of EUS-guided core biopsy techniques enables his-tologic sampling in selected cases and for obtaining tissue for molecular analysis in neoadjuvant and palliative settings. The clinical effectiveness of EUS and EUS-FNA depends on the judicious use of these techniques.

Tuberculous celiac axis lymphadenopathy mimicking cystic pancreatic neoplasm - a diagnostic dilemma.

Cystic pancreatic neoplasms are tumors with malignant potential treated surgically. Isolated tuberculosis of celiac lymph nodes is rare, treatment of this entity being non-surgical. Radiological appearances of cystic pancreatic neoplasm and tuberculous peripancreatic lymph nodal mass is similar and difficult to differentiate. Here we present a case of mass lesion in the region of pancreatic head mimicking cystic pancreatic neoplasm which was actually abdominal tuberculous lymphadenopathy proven by biopsy.

Novel Laparoscopic Gastric Tubing with Pyloromyotomy for Treatment of Esophageal Cancer

Purpose: We report on a novel method and outcomes of laparoscopic gastric tubing with pyloromyotomy. Methods: The abdominal procedure includes laparoscopic gastric mobilization, celiac axis lymph node dissection, formation of the gastric tube, and pyloromyotomy. Between January 2009 and April 2013, our minimally invasive esophagectomy (MIE) was performed on 54 patients with esophageal cancer. The short-term outcomes, including postoperative complications, were analyzed. Results: There were no cases of conversion to open surgery. Of 54 patients, 52 patients had squamous cell carcinoma (SCC) and two had adenocarcinoma. The total operative time was 349.8±77.4 minutes, of which 90.6±27.6 minutes was required for the abdominal procedure. The mean estimated operative blood loss during the abdominal procedure was 40.0 ±355.5 m l. The postoperative complication rate was 24.1%; three patients died of pneumonia. Conclusion: Laparoscopic gastric tubing with pyloromyotomy is a feasible and safe treatm ent option for patients with esophageal cancer.

Aberrant Vasculature During Minimally Invasive Transhiatal Esophagogastrectomy

Fig 3. Aadenocarcinoma of the gastroesophageal junction. He underwent neoadjuvant chemotherapy and radiation therapy followed by a minimally invasive transhiatal esophagogastrectomy. Duringmobilization of the stomach, a suspected aberrant left hepatic artery (LHA) was identified within the gastrohepatic ligament (Fig 1). Given the extent of residual celiac nodal disease, a complete celiac dissection and lymphadenectomy was performed, including skeletonization of the left gastric artery (LGA) and aberrant LHA (Fig 2; IVC, inferior vena cava). Careful attention was then paid to ligating the LGA distal to the aberrant LHA takeoff to preserve hepatic arterial supply. Three-dimensional reconstructions of the preoperative imaging were able to elucidate the aberrant anatomy, revealing a replaced LHA. Further, the patient also had a replaced right hepatic artery (RHA) branching from the superior mesenteric artery (Fig 3). A critical pitfall of an esophagogastrectomy is recognizing and preserving aberrant hepatic vasculature to prevent subsequent hepatic ischemia. A replaced LHA originating from the LGA is an anomaly found in up to 10% of people [1]. It is important to work with radiology colleagues to perform time contrast studies to allow for clear delineation of aberrant anatomy, as well as to view in detail axial and coronal projections. Finally, awareness

Efficacy evaluation of laparoscopy-assisted surgery for Siewert I adenocarcinoma of the esophagogastric junction

To evaluate the safety and efficacy of laparoscopy-assisted surgery for Siewert I adenocarcinoma of the esophagogastric junction (AEJ). Clinical data of 36 patients who underwent left transthoracic dissection of lower mediastinal lymph node followed by laparoscopy D2 lymph node dissection for Siewert I AEJ in the Fujian Provincial Cancer Hospital between March 2008 and March 2013 were analyzed retrospectively. A left thoracic-abdominal single incision was used without transection of costal arch. Celiac lymph nodes dissection was performed laparoscopically followed by left transthoracic dissection of lower mediastinal lymph node. Digestive tract reconstruction was carried out by esophagus-gastric posterior wall end-to-side anastomosis. Laparoscopy-assisted surgery was successfully achieved in all the 36 patients and there were no in-hospital deaths. The mean operation time, blood loss and number of harvested lymph node were (216.4±46.0) min, (252.1±41.1) ml and 30.7±3.2 respectively. All the procedures were R0 resections. The complication rate was 16.7% (6/36). All the complications were managed by conservative treatment, and there were no re-operations. The lymphatic metastasis rate was 50.0% (18/36), and the lymph node groups with high metastatic rate (all >10.0%) were groups 1, 2, 3, 7, 9, 110 and 111. The median follow-up was 25 months. The overall 3-year survival was 48.0%. Laparoscopy-assisted surgery for Siewert I AEJ is safe and feasible.

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

The aim of this retrospective study was to investigate the incidence of mesenteric lymph node (MLN) involvement, and its prognostic role in advanced ovarian cancer (OC). OC patients undergoing rectosigmoid resection during primary debulking surgery or interval debulking surgery were recorded. Progression-free survival (PFS) and overall survival were calculated from the date of diagnosis to the date of relapse/progression, death of disease, or the date of last follow-up. MLNs were detected in 102/148 cases (68.9 %); the rate of MLN involvement was 47.0 %. The percentage of metastatic MLNs was higher in cases with >5 MLNs removed compared with cases with ≤ 5 MLNs removed (62.7 % vs. 31.3 %; p = 0.0027). A progressive increase in the rate of metastatic MLNs was documented in association with depth of bowel infiltration (p = 0.026). Cases with metastatic MLNs experienced isolated celiac trunk or aortic lymph node recurrences more frequently than patients without MLN involvement (44.8 % vs. 10.7 %; p = 0.0008). PFS did not differ between cases with positive versus negative MLN involvement (2-year PFS = 31 % vs. 43 %; p = 0.58). OC patients undergoing rectosigmoid resection showed metastatic MLN involvement in 47.0 % of cases. Metastatic MLN status is associated with a high rate of isolated aortic and celiac trunk lymph node recurrences.

The initial report of RTOG 0436: A phase III trial evaluating the addition of cetuximab to paclitaxel, cisplatin, and radiation for patients with esophageal cancer treated without surgery.

LBA6 Background: RTOG 0436 is a randomized Ph III trial designed to evaluate the benefit of cetuximab added to the concurrent chemoradiation for patients undergoing non-operative management of esophageal carcinoma. Methods: Pts with biopsy-proven squamous cell or adenocarcinoma of the esophagus (T1N1M0; T2-4 AnyN M0; Any T/N M1a) were randomized to weekly concurrent cisplatin (50 mg/m2), paclitaxel (25 mg/m2), and daily radiation 50.4 Gy/1.8 Gy fractions ± weekly cetuximab (400 mg/m2 day 1 then weekly 250 mg/m2). Patients were stratified by histology, tumor size (&lt; 5 cm vs &gt; 5cm), and the status of celiac lymph nodal involvement. Overall survival (OS) was the primary endpoint, with a planned accrual of 420 pts to detect an increase in 2-year OS from 41% to 53%; 80% power and 1-sided 0.025 alpha. An interim analysis of cCR was planned for the first 150 of each histology. Results: The study accrued 344 pts from 2008-2013 and 328 were eligible. Based on interim analyses, the study stopped accruing adeno pts in 5/2012 and SCC pts in 1/2013. Pts were well matched for pretreatment characteristics: 80% with T3/4 disease, 66% N1, and 19% with celiac nodal involvement. Incidence of grade 3/4/5 treatment (tx) related AEs was 45%, 22%, 4% in Arm 1 (cetuximab) and 49%, 17%, 1% in Arm 2 (no cetuximab). A cCR rate of 56% was observed in Arm 1 vs 59% in Arm 2 (p=0.72). No differences were seen in cCR between tx arms for either histology. The 12 and 24 mo OS rates for cCR pts were 79% and 58% vs 53% and 30% for those with residual disease (p&lt;0.0001). Median follow-up for all pts is 15.4 mos. The 12 and 24 mo OS (95% CI) for Arm 1 is 64% (56%, 71%) and 44% (36%, 52%) vs 65% (57%, 72%) and 42% (34%, 50%) for Arm 2 (p=0.70). Adeno pts (n=203) had a 12 and 24 mo OS of 65% and 43% for Arm 1 vs 64% and 41% for Arm 2 (p=0.37). The 12 and 24 mo OS for the 125 SCC pts was 62% and 46% for Arm 1 vs 67% and 43% for Arm 2 (p=0.97). Conclusions: The addition of cetuximab to concurrent chemoradiation did not improve OS. There were no differences in cCR rates by tx arm. These Ph III results point to little benefit for current EGFR targeted agents in the tx of esophageal cancer. Supported by RTOG CA21661 and CCOP CA3742 NCI grants and Bristol Myers Squibb. Clinical trial information: NCT00655876.

Prognostic Relevance of Celiac Lymph Node Involvement in Ovarian Cancer

The aim of the study was to report on the oncologic outcome of the disease spread to celiac lymph nodes (CLNs) in advanced-stage ovarian cancer patients. All patients who had CLN resection as part of their cytoreductive surgery for epithelial ovarian, fallopian, or primary peritoneal cancer were identified. Patient demographic data with particular emphasis on operative records to detail the extent and distribution of the disease spread, lymphadenectomy procedures, pathologic data, and follow-up data were included. The median follow-up was 26.3 months. The median overall survival values in the group with positive CLNs and in the group with negative CLNs were 26.9 months and 40.04 months, respectively. The median progression-free survival values in the group with metastatic CLNs and in the group with negative CLNs were 8.8 months and 20.24 months, respectively (P = 0.053). Positive CLNs were associated with progression during or within 6 months after the completion of chemotherapy (P = 0.0044). Tumor burden and extensive disease distribution were significantly associated with poor progression-free survival, short-term progression, and overall survival. In multivariate analysis, only the CLN status was independently associated with short-term progression. Disease in the CLN is a marker of disease severity, which is associated to a high-risk group of patients with presumed adverse tumor biology, increased risk of lymph node progression, and worst oncologic outcome.