Celiac Nodes Research Articles

EOSINOPHILIC MYOCARDITIS IN A PATIENT WITH BIOPSY PROVEN SYSTEMIC SARCOIDOSIS WHO WAS REFERRED FOR BRADYCARDIA

Eosinophilic myocarditis (EM) is an understudied and often missed diagnosis whose constellation of symptoms are frequently attributed to other morbidities. A 57-year-old woman with mediastinal lymphadenopathy (Figure 1A), uveitis, celiac lymph node biopsy in 2013 demonstrating noncaseating

The Postoperative outcomes of thoracoscopic-laparoscopic Ivor-Lewis surgery plus D2 celiac lymphadenectomy for patients with adenocarcinoma of the esophagogastric junction.

Adenocarcinoma of the esophagogastric junction (AEG) is one of the most aggressive and poor prognosis cancers. To date, no standard procedures have been established for the surgical treatment of Siewert type II. In this study, we proposed the approach of thoracoscopic-laparoscopic Ivor-Lewis surgery plus D2 celiac lymphadenectomy (TLILD2) and aimed to investigate the patterns of lymph node metastasis and long-term survival. From June 2015 to June 2018, 72 patients accepted TLILD2 and enrolled in this study. Relevant patient characteristics and postoperative variables were collected and evaluated. The disease-free survival (DFS) and disease-specific survival (DSS) were determined by the Kaplan-Meier method and compared by log-rank tests. There was no case of postoperative death in this study, and the most common complication was anastomotic mediastinal fistula (5/72, 6.9%). A total of 2811 lymph nodes were retrieved, and the positivity rate was 11.9% (334/2811). The positivity rate of celiac and mediastinal lymph nodes was 14.4% (314/2186) and 3.2% (20/625), respectively. The percentage of patients who had positive celiac and mediastinal lymph nodes reached up to 58.3% (42/72) and 8.3% (6/72), respectively. The DFS and DSS of these 72 patients were 94% and 93.4% at 1year after surgery and 59.8% and 62% at 3years after surgery, respectively. The pTNM stage showed a significant difference between DFS and DSS. TLILD2 could be a potential way to promote long-term survival of AEG patients. On the basis of the patterns of lymph nodes metastasis, we suggest that lower mediastinal and D2 celiac lymphadenectomy is necessary to improve the oncological outcome.

The parameters to estimate postoperative severe complications classified through Clavien-Dindo after upper abdominal surgery in patients with primary and recurrent ovarian cancer.

The more surgical effort and performing extensive upper abdominal surgery (UAS) are often required to accomplish the highest rates of optimally cytoreduction in patients with ovarian cancer. Nonetheless, the rate of complications increases with extensive surgery. We have studied the upper abdominal surgery complications by Clavien-Dindo Classification (CDC) and analyzed parameters affecting post-operative severe complications classified through Clavien-Dindo. A retrospective cohort of patients diagnosed with epithelial ovarian cancer from January 1st 2009 to April 30th 2016 was evaluated. Patients who underwent at least one UAS procedure with or without optimal cytoreduction for epithelial ovarian cancer (stage IIIC-IV or recurrent) were included. Postoperative complications were recorded according to the Clavien-Dindo Classification. In total, 58 patients were included. There were 120 UAS procedures performed on the 58 patients. Diaphragm peritonectomy was the most performed surgery (50%, 29/58), and then the other UAS procedures were liver surgery (39.7%, 23/58), cholecystectomy (24.1%, 14/58), splenic surgery (24.1%, 14/58), full-thickness diaphragm resection (22.4%, 13/58), pancreatic surgery (19%, 11/58), resection of tumor from porta hepatis (17.2%, 10/58), celiac lymph node excision (8.6%, 5/58), partial gastrectomy (1.7%, 1/58), respectively. Thirteen patients (22.4%) had post-operative grade 3-5 complications according to CDC within 30 days after surgery. This current study demonstrated that the addition of extensive upper abdominal surgery procedures were not associated with increased postoperative severe complications in patients with recurrent or advanced ovarian cancer. These procedures are safe and feasible for patients in need and also can be performed with acceptable mortality and morbidity.

The Current Situation of Esophageal Cancer Staging and Perioperative Strategies Determination in Central and Southern China: A Cross Sectional Survey.

Purpose: We aim to investigate the current esophageal cancer staging according to the 7th edition TNM classification for esophageal carcinoma proposed by American Joint Committee on Cancer (AJCC) among oncology-related physicians in China.Methods: A specifically-designed 14-item questionnaire was distributed to 366 doctors who were working with esophageal cancer patients. We collected and analyzed the feedbacks and explored the possible associations within different departments, including thoracic surgery, the internal medicine of gastroenterology, oncology, and/ radiotherapy in eight different hospitals from central and southern China.Results: Among all the responses, 31.42% of them were from thoracic surgery department, 40.44% were from oncology and/or radiation therapy and 28.14% were from the internal medicine of gastroenterology, respectively. Surprisingly, in total 66.12% of all the physicians were unaware that the 7th edition of esophageal carcinoma TNM classification was released in 2009; only 21.86 and 16.67% of physicians recognized cervical nodes and celiac nodes as regional lymph nodes. Furthermore, 67.21% physicians didn't know that tumor location, histologic grade, and histopathology were accepted as new prognostic factors in the latest TNM system; and 51.37% physicians could not determine the correct TNM classification of esophagogastric junction cancers. Intriguingly, over 50% of them could still design appropriate perioperative strategies.Conclusions: The 7th edition of the TNM classification for esophageal carcinoma is poorly recognized and understood in central and southern China, which might contribute to the relatively low rates of appropriate perioperative procedures applied for esophageal cancer patients.

1558 Diffuse Primary Gastrointestinal Mantle Cell Lymphoma: A Rare Cause of Hematochezia

INTRODUCTION: Mantle cell lymphoma (MCL) is non-Hodgkin lymphoma that classically does not involve the gastrointestinal (GI) tract. Although in some cases MCL has been shown to spread to the GI tract, primary gastrointestinal MCL is exceedingly rare and has only been described anecdotally. Often, the diagnosis of MCL is made once the disease is metastatic given its largely nonspecific symptom profile. We present a case of diffuse MCL of the GI tract presenting as hematochezia, in a patient with ulcerative colitis. CASE DESCRIPTION/METHODS: An 80-year-old male with history of newly diagnosed ulcerative colitis (UC) presented with four weeks of worsening diarrhea and hematochezia associated with a 30-pound weight loss over five months. He had been on mesalamine for UC, but had not experienced symptomatic relief. On admission, the patient was anemic to a hemoglobin of 9.3 g/dL, white blood cell count of 21.6 × 103/L with 13% bands and 48% atypical lymphocytes, and an albumin of 1.7 g/dL with normal platelets and INR. Abdominal imaging showed diffuse mesenteric lymphadenopathy concerning for a lymphoproliferative process and circumferential gastric, rectal and sigmoid wall thickening and edema. Clostridium Difficile (C. Diff) stool PCR was positive, and he was started on oral vancomycin therapy. Colonoscopy showed diffuse inflammation and edema of the colon with poor mucosal integrity and a hypertrophic mass in the ascending colon. Upper endoscopy showed diffuse, hypertrophied, thickened folds within the stomach and duodenum along with ulcerations. Endoscopic ultrasound was performed to biopsy para-aortic and celiac lymph nodes. Given high suspicion for lymphoma, a bone marrow biopsy was also obtained. Histopathology from the multiple biopsies were all consistent with Stage 4 pleomorphic Mantle Cell Lymphoma. DISCUSSION: This case describes a rare presentation of MCL, complicated by C. Diff colitis in addition to UC. There has been little data to show that these unique clinical entities are significantly correlated. Although hematochezia is a rare presentation of MCL, clinicians should maintain a high index of suspicion for malignancy and pursue additional imaging and/or procedures, even in a patient that has other reasons to present with hematochezia. This case of advanced stage MCL of the GI tract adds to a small body of literature regarding primary gastrointestinal MCL and warrants further research in to this rare gastrointestinal malignancy.

1341 Not so Incidental: A Case of Incidentally Found Isolated Metastatic Melanoma of the Pancreas

INTRODUCTION: Metastatic lesions of the pancreas are uncommon, with reported frequencies of intrapancreatic metastases ranging from 4.5% to 11%, with isolated metastases around 2% of cases. Metastases from malignant melanoma is quite rare, with fewer then 200 cases reported in literature. CASE DESCRIPTION/METHODS: 79-year-old female who presented to ED in June 2018 with fever, dysuria, and dyspnea. Past medical history significant for prednisone dependent sarcoidosis, atrial fibrillation, and basal cell carcinoma. Labs showed elevated WBC and UA concern for UTI. She was admitted for treatment. CT scan was done due to dyspnea showing LLL consolidation. Incidentally, a new 2.6 × 1.8 cm mass within the pancreas neck was seen. At discharge she was referred to our facility for EUS and FNA. EUS showed a pancreatic mass abutting the superior mesenteric vein without invasion. Cytological analysis obtained by EUS-FNA (Figure 1) showed malignant melanoma with abundant melanin pigments (Figure 2). Positive for Sox-10, Melan A and HMB-45. Referral to medical oncology was made for further work-up. PET scan was preformed due to lack of previous melanoma history, showing no evidence of disease outside the pancreatic area (Figure 3). With no primary lesion identified further referrals to Dermatology and Ophthalmology, however these evaluations were negative for overt cutaneous or ocular melanoma. Colonoscopy was performed and showed no lesions. Due to the isolated lesion, deemed an appropriate candidate for resection. September 2018, partial pancreatectomy and regional lymph node resection completed. Pathology of the 4.5 cm pancreatic neck mass, in addition to celiac and portal lymph node, consistent with malignant melanoma. October 2018 started immunotherapy of Opdivo and Ipilumimab. Repeat PET scan showed nodule along right flank, superior to iliac crest, FDG avid, suspicious for melanoma and thought to be the sight of primary lesion. Tolerated immunotherapy well, but in December 2018, was admitted due to respiratory distress secondary to aspiration pneumonia, was transitioned to comfort cares due to worsening clinical status, passing away. DISCUSSION: This case is a unique presentation of an isolated metastatic pancreatic melanoma, found incidentally in an otherwise asymptomatic patient. With the widespread use of imaging, clinicians can expect an increasing number of “incidentalomas” being found, stressing the role of EUS-FNA in gaining a precise diagnosis which is critical in the overall prognosis and management of patients.

2991 Preoperative Imaging of Gastric Neuroendocrine Tumors and Lymph Node Metastases

INTRODUCTION: In recent years, detection of gastric neuroendocrine tumor (GNET) lymph node (LN) metastasis has become more apparent with innovative imaging such as endoscopic ultrasound and PET. Currently, the National Comprehensive Cancer Network recommends multiphasic CT or MRI as part of the initial workup for GNETS. We sought to evaluate these recommendations with respect to the detection of LN metastases and compare CT to alternative pre-operative modalities for gastric staging at our institution. METHODS: This is a single center retrospective study evaluating consecutive patients who underwent surgical resection or endoscopic submucosal dissection of biopsy proven GNET from April 1988 to January 2019 at a tertiary referral center. LN metastases were defined by positive nodes following resection. Local invasion was characterized by tumor involvement of any gastric layers beyond the mucosa. Regional metastases included perigastric (gastroduodenal, gastrohepatic, gastroepiploic, pyloric, pancreaticoduodenal), celiac, and peripancreatic LN abnormalities. Distant metastases were defined as involving another solid organ, retroperitoneal or distant LN. Imaging modalities included endoscopic ultrasound, CT, MRI, and PET. RESULTS: Thirty patients were included in the study with each patient's respective GNET imaging in Table 1. Mean age of diagnosis was 63.9 ± 12.3 years old. There were no type 2 NET's identified based on documented history. Twenty patients underwent CT, and 13 of these patients underwent additional imaging or preop staging (EUS, PET, MRI, Octreotide, pre-op surgical biopsy). Of those undergoing CT, 12.5% of patients were identified as having regional or distant metastases; however, when correlating CT findings in patients with LN pathology, no patients were correctly identified as having positive LN's (Table 2). Conversely, patients with regional LN metastases on biopsy had CT's showing no lymphadenopathy or local metastases. CONCLUSION: As in most cancers, successful interventions vary according to presence or absence of LN metastases. Despite a limited number of patients in this study who had true LN metastases resected, CT and alternative modalities appeared comparable in their ability to “rule out” LN metastases for GNET. Of some concern, none of the imaging appeared sensitive for GNET LN metastases. Investigation of imaging modalities more sensitive for GNET LN metastases, such as PET Dotatate, is needed to better inform decisions regarding medical and surgical intervention.

2643 A Rare Presentation of Duodenal Adenocarcinoma Concealed by Membranous Nephropathy

INTRODUCTION: Duodenal adenocarcinoma is rare and often has a vague clinical presentation. Therefore most patients have advanced disease (stage III or IV) at the time of diagnosis, which heralds poor prognosis. Membranous nephropathy can be associated with solid tumors; however duodenal adenocarcinoma presenting as membranous nephropathy has not been reported in the literature. CASE DESCRIPTION/METHODS: A 78-year-old male presented with worsening dyspnea, nausea and anorexia over a period of several months. Further workup revealed proteinuria secondary to biopsy-proven membranous nephropathy. PLA2R antibodies were negative, which initiated an evaluation for secondary membranous nephropathy. Physical examination revealed anasarca. His creatinine was 3.4 mg/dL, and extensive workup for a secondary cause of membranous nephropathy, including ANA, C3, C4, and hepatitis B and C testing was negative. CT of the abdomen showed upper abdominal and mesenteric adenopathy. His presentation was complicated by gastrointestinal bleeding with a hemoglobin of 5.3 g/dL. Esophagogastroduodenoscopy revealed a large villous, infiltrative sessile mass in the third portion of the duodenum [Figure 1]. Biopsies showed moderately differentiated adenocarcinoma. Endosonographic ultrasound showed malignant-appearing lymph nodes and fine needle aspiration of the largest celiac lymph node confirmed metastatic adenocarcinoma. Therefore surgical resection was not recommended. The patient was started on 5-fluorouracil and oxaliplatin. Membranous nephropathy was due to a paraneoplastic syndrome and its resolution was dependent on the course of the duodenal adenocarcinoma. Unfortunately, his course was complicated by worsening renal failure and he required intensive care with continuous renal replacement therapy and non-invasive ventilation for respiratory failure. He recovered slowly and was discharged home on hemodialysis. Follow up imaging periodically over the following year revealed peritoneal, lung and liver metastasis. The patient eventually pursued palliative care and he passed away. DISCUSSION: The unusual presentation of duodenal adenocarcinoma in the form of membranous nephropathy led to a delayed diagnosis with poor candidacy for surgical resection. Age- and risk-appropriate assessment for malignancy is recommended in secondary membranous nephropathy without a clear etiology. Gastrointestinal malignancy should be in the differential especially when anemia is present.

2630 Late Presentation of Caroli’s Syndrome: A Rare Cause of Cholangiocarcinoma

INTRODUCTION: Caroli’s syndrome (type 2) is a rare, complex form of Caroli’s disease (type 1) with an estimated incidence of 1/1,000,000. The syndrome manifests as saccular dilatations of the intra-hepatic biliary ducts and is associated with fibrosis and portal hypertension, distinguishing it from the disease form. Additionally, it predisposes patients to regionalized malignancy. Generally this presents before the age of 40. Intriguing however in our case, was the late presentation of the disease. The aim of this case report is to educate clinicians as to an obscure presentation of this rare disease, in an attempt to prevent cirrhosis, as well as subsequently increase the early detection of cancer. CASE DESCRIPTION/METHODS: We present a 78-year-old Asian female with a history of hypertension and cholelithiasis whom presented to the hospital with abdominal pain, jaundice, and fever. Magnetic resonance cholangiopancreatography (MRCP) revealed saccular intra-hepatic ductal dilations with a distal common bile duct (CBD) stone (Figure 1). Subsequent endoscopic retrograde cholangiopancreatography (ERCP) with biopsy, and balloon sweeping, removed the stone. Upon histologic examination of the targeted liver biopsy severe fibrosis was observed, confirming the diagnosis of Caroli’s syndrome (Figure 2). Two years later the patient returned to the office with new onset weight loss and nausea. CA19-9 was elevated at 1191. Magnetic resonance imaging (MRI) of the abdomen showed biliary duct dilation and enlarged lymph nodes (Figure 3). Endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) of the celiac lymph nodes was subsequently performed. Upon immunohistochemistry, the pathology showed tumor glands positive for CK7 and CDX2--consistent with metastatic adenocarcinoma of pancreaticobiliary origin. DISCUSSION: Caroli’s syndrome is a rare, autosomal recessive disorder that typically manifests in a patients early twenties. Interestingly, our patient did not develop any symptoms until the age of 78. Distinguishing Caroli’s syndrome from recurrent pyogenic cholangitis is key and can be done in the setting of saccular dilatations on imaging as in our case. If the disease is diagnosed prior to the development of cirrhosis or cancer, patients may benefit from liver transplant. Individuals with Caroli’s disease are at a higher risk for developing cholangiocarcinoma. Prompt diagnosis of Caroli’s syndrome and awareness of the risk for cancer is vital, as the potential for malignancy and metastasis is significant.

EUS-B-FNA for Diagnosing Liver and Celiac Metastases in Lung Cancer Patients

Background: In patients with suspected or proven lung cancer, assessment of regional nodal and distant metastases is key before treatment planning. By introducing the endobronchial ultrasound (EBUS)-guided scope into the esophagus and stomach (EUS-B), liver lesions and celiac nodes can be visualized. To date, the utility of EUS-B in diagnosing liver lesions and retroperitoneal lymph nodes is unknown. Objectives: To assess the feasibility, safety, and diagnostic yield of sampling of liver lesions and retroperitoneal nodes by EUS-B fine-needle aspiration (FNA) in a lung cancer staging setting. Method: Consecutive patients suspected of lung cancer in 2 Danish centers between 1 January 2015 and 31 December 2017 were included retrospectively when a lesion in the liver or a retroperitoneal lymph node was visualized and biopsied with EUS-B-FNA. Results: 23 left liver lobe lesions and 19 retroperitoneal lymph nodes were sampled by EUS-B-FNA. Sensitivity and diagnostic yield of sampled liver lesions were 86 and 83%, respectively. In 19/23 patients, there was a cytopathological diagnosis of malignancy. Sensitivity and diagnostic yield from retroperitoneal lymph node samples were 83 and 63%, respectively. In 10/19 patients, the diagnosis was malignancy. No complications were observed. Conclusion: EUS-B-FNA enables safe sampling of left liver lobe lesions and retroperitoneal lymph nodes. EUS-B should be considered as a minimally invasive technique to provide tissue proof of distant metastases lung cancer patients.

Duodenal and liver lesions in an adult with generalised weakness

A 73-year-old man with a history of heart failure and hypertension presented with a several-week history of generalised weakness, anorexia, 5 kg weight loss, intermittent small volume hematochezia and right...

A 62-Year-Old African American Woman With Stable Lymphadenopathy Over 5 Years

Abstract The patient is a 62-year-old African American female with medical history of Plummer Vinson syndrome and CT scan in 2014 showing lymphadenopathy of the porta hepatis. Needle core biopsy of enlarged lymph nodes revealed sheets of polytypic plasma cells with no aberrant B or T cells or granulomas or hyaline-like depositions identified. The findings were suspicious for unicentric Castleman disease. In 2019, the patient presented with chronic fatigue without other systemic symptoms. Contrast CT revealed persistent retroperitoneal lymphadenopathy and calcified granulomas in the liver, spleen, and lung. Excision of portal and celiac nodes showed preserved nodal architecture with mild mantle zone expansion and marked hyaline-like deposition in the follicles. Sheets of mature plasma cells and focally increased vasculatures were seen in the interfollicular areas. Focally frequent nonnecrotizing granulomas were noted. Occasional giant cells and rare asteroid bodies were identified in the granulomas. Immunohistochemistry stain workup revealed normal distribution of the B and T lymphocytes. CD138 stain highlighted marked increased plasma cells and HHV8 was negative. Immunofluorescence microscopy for kappa and lambda did not show monoclonality; IgA was positive in <10% of plasma cells; special stain for Congo red and serum amyloid associated protein (SSA) IHC stain were strongly positive in the follicles. The overall findings are consistent with reactive lymphadenopathy with interfollicular polytypic plasmacytosis, noncaseating granuloma formation, and reactive amyloidosis. The features of mantle zone hyperplasia and polytypic plasmacytosis are suggestive of HHV8-negative/idiopathic unicentric Castleman disease. This case possibly represents an example of concurrent amyloidosis, sarcoidosis, and idiopathic unicentric Castleman disease. Given that SSA was recently reported to have a pathogenic role in granulomatous inflammation of sarcoidosis through sustained inflammatory reaction, the possibility of increased SSA triggering sarcoidoisis in this patient can be considered. However, the exact pathogenesis of these concurrent findings needs further investigation and clarification.

Preservation of replaced left hepatic artery during 3D laparoscopic totally minimally invasive esophagectomy for cancer.

Preserving a replaced left hepatic artery may be feasible and safe during 3D laparoscopic totally minimally invasive esophagectomy. Avoidance of conversion to an open procedure may be achieved after careful dissection of the celiac trunk lymph nodes, expertise and the visual advantage that 3D vision offers.

Should the clinical significance of supraclavicular and celiac lymph node metastasis in thoracic esophageal cancer be reevaluated?

BackgroundLower thoracic esophageal cancer (LTEC) with celiac node metastasis and upper thoracic esophageal cancer (UTEC) with supraclavicular node metastasis were previously categorized as M1a diseases. Our study aimed to investigate whether the clinical significance of supraclavicular and celiac lymph node metastasis should be reevaluated in thoracic esophageal cancer.MethodsA total of 6178 patients with thoracic esophageal cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) database during 2004–2015. Treatment strategies and outcomes (OS, overall survival; CSS, cancer‐specific survival) of patients with different nodal status were reviewed. The Cox proportional hazards regression model was applied to evaluate the prognostic factors. Statistical analyses were performed in all subgroups.ResultsMultivariate analysis identified supraclavicular node metastasis but not celiac node metastasis as an independent predictor of both OS and CSS in LTEC. However, metastasis to supraclavicular or celiac nodes was not an independent predictor of OS and CSS in UTEC. Surgery was not associated with increased OS and CSS for UTEC with celiac or supraclavicular node metastasis but was favored as a predictor of better OS and CSS for LTEC with celiac or supraclavicular node metastasis. Radiotherapy benefited OS and CSS in LTEC involving celiac or supraclavicular nodes and in UTEC involving celiac nodes, while only OS benefited from radiotherapy in UTEC involving supraclavicular nodes.ConclusionsThese results provide preliminary evidence that the clinical significance of supraclavicular and celiac lymph node metastasis should be reevaluated in thoracic esophageal cancer with different prognostic information according to the primary sites.

Different prognosis of patients with esophageal carcinoma with M1a and regional node involvement

Background and purposeBased on the 6th edition of the American Joint Commission on Cancer (AJCC) staging system for esophageal squamous cell carcinoma (ESCC), M1a node involvement was classified as regional node involvement in the revised 7th/8th edition. However, the clinical significance of M1a node involvement is unclear. Thus, we analyzed the prognostic value of M1a node involvement in patients with ESCC after definitive concurrent chemoradiotherapy (CCRT). Materials and methodsIn total, 188 patients with ESCC had M0 disease according to the 7th/8th edition AJCC. We reclassified 31 (16.5%) of these patients as having M1a disease according to the 6th edition. After definitive CCRT, we compared baseline characteristics between the two groups and analyzed the rates of responders and recurrence. Finally, we compared prognoses according to overall survival (OS), disease-specific OS, and disease-free survival (DFS). ResultsAmong 31 patients reclassified to have M1a disease, 21 (67.7%) had supraclavicular lymph node metastasis and 10 (32.3%) had celiac lymph node metastasis. The number of responders was significantly lower for M1a disease based on univariate (p = 0.004) and multivariate (p = 0.011) analyses. Significantly lower survival rates were observed in individuals with M1a disease (median OS, 16.4 vs. 42.7 months; 5-year OS, 10.8% vs. 41.2%). ConclusionsM1a node involvement should be differentiated from regional node involvement.

Extended Lymphadenectomy Versus Regional Lymphadenectomy in Resectable Hilar Cholangiocarcinoma

AimThe aim of this study is to compare the effects of extended lymphadenectomy (E-LD) and regional lymphadenectomy (R-LD) on outcome after radical resection of hilar cholangiocarcinoma (HCCA). MethodsData of 290 patients who underwent radical resection of HCCA were retrospectively analyzed. Demographic characteristics, surgical variables, and tumor and LN characteristics were evaluated for association with survival. ResultsA total of 63 patients underwent E-LD. Patients who underwent E-LD were more likely to have portal vein embolization (14.3% vs. 5.7%), radical hepatectomy (36.2% vs. 26.0%), higher proportion of M1 patients (22.2% vs. 5.3%), more lymph nodes (LNs) retrieved (17 vs. 7), and positive common hepatic artery lymph nodes (21.4% vs. 12.6%) when compared with R-LD (all P < 0.05). The Kaplan–Meier curve of overall survival for patients who underwent E-LD indicated improvement over patients who underwent R-LD in M0 (33.39 vs. 21.31 months; P = 0.032) and R0 resection (32.97 vs. 21.02 months; P = 0.044) disease, but not observed in M1 disease (P > 0.05). After propensity score matching, E-LD was not associated with a significant improvement in overall survival (OS) even in all subgroup analysis (all P > 0.05). On multivariable analysis, E-LD was associated with improved overall survival, but not after propensity score matching. ConclusionE-LD is more likely to be performed in higher stage tumors. E-LD significantly increases LN retrieval, thereby preventing under-staging and improving survival prediction. E-LD should not be adopted for HCCA patients with intraoperatively confirmed distant LN metastases. Future studies are required to further assess whether E-LD should be performed in negative celiac, superior mesenteric, and para-aortic lymph node in HCCA patients.

Salvage Curative-Intent Reirradiation Stereotactic Body Radiation Therapy for Isolated Pelvic and/or Paraortic Recurrences of Gynecologic Malignancies

PurposeTo determine the feasibility of stereotactic body radiation therapy (SBRT) for isolated nodal recurrences of gynecologic malignancies within a previously irradiated area. Methods and MaterialsA retrospective review was performed on 20 patients who underwent 21 curative-intent reirradiation SBRT treatments for locoregional recurrences of gynecologic malignancies. Disease control and survival outcomes were analyzed with the Kaplan-Meier method and log-rank test. Treatment toxicities were graded according to Common Terminology Criteria for Adverse Events version 4.03. ResultsAll patients had an isolated pelvic, paraortic, or intra-abdominal nodal recurrence, with the exception of 1 patient who had a concurrent paraortic and right acetabulum metastasis, both of which were irradiated with SBRT. Primary sites included cervix (30.0%), uterus (55.0%), vulva (5.0%), vagina (5.0%), and ovary (5.0%). Median prior external beam radiation therapy dose was 45 Gy. Recurrences were in field in 14 (66.7%) and marginal in 7 (33.3%). SBRT was directed to the pelvis in 13 cases (61.9%) and to paraortic or celiac nodes in 8 (38.1%). The most common SBRT regimen was 40 to 45 Gy in 5 fractions (n = 12). At a median follow-up of 31.2 months, 3-year actuarial in-field local control, distant progression-free survival, and overall survival were 61.4%, 44.0%, and 51.9%, respectively. At the time of last follow-up, 9 (45.0%) patients remained alive without evidence of disease. Actuarial 3-year risk of grade ≥2 and grade ≥3 late toxicities was 38.1% and 14.3%, respectively. ConclusionsSBRT for isolated pelvic or intra-abdominal recurrences of gynecologic malignancies within a previously irradiated field is feasible with an acceptable toxicity rate. With this approach, about half of patients achieved durable disease-free survival.

A multicenter phase III study comparing Simultaneous Integrated Boost (SIB) radiotherapy concurrent and consolidated with S-1 versus SIB alone in elderly patients with esophageal and esophagogastric cancer \u2013 the 3JECROG P-01 study protocol

BackgroundThe importance of definitive radiotherapy for elderly patients with esophageal and esophagogastric-junction cancer is pronounced. However, little is known in terms of the best way to combine radiotherapy with other treatment options. This study aims to compare the efficiency of SIB radiotherapy alone with SIB radiotherapy concurrent and consolidated with S-1 for elderly patients. Comprehensive geriatric assessment is also incorporated in the procedure of treatment.Methods/designThe study is a two arm, open, randomized multicenter Phase III trial with patients over 70 years old with stage IIA-IVB (UICC 2002, IVB only with metastasis to supraclavicular or celiac lymph nodes) squamous cell carcinoma or adenocarcinoma of esophagus or gastroesophageal junction. A total of 300 patients will be randomized using a 1:1 allocation ratio stratified by disease stage and study site. Patients allocated to the SIB arm will receive definitive SIB radiotherapy (95%PTV/PGTV 50.4Gy/59.92Gy/28f) while those randomized to SIB + S-1 arm will receive definitive SIB radiotherapy concurrent and consolidated with S-1. The primary endpoint of the trial is 1-year overall survival. Secondary objectives include progression-free survival, recurrence-free survival (local-regional and distant), disease failure pattern, toxicity profile as well as quality of life. Besides, detailed radiotherapy protocol and quality assurance procedure have been incorporated into this trial.DiscussionThe proportion of elderly patients in esophageal cancer is now growing, but there is a lack of evidence in term of treatment standard for this group of patients, which is what we aim to obtain through this prospective phase III study.Trial registrationclinicaltrials.govNCT02979691. Registered November 22, 2016.

Robotic portal lymphadenectomy with segment 4b and 5 resection for gallbladder cancer

Background: Our video describes the use of the da Vinci Surgical System Xi® (Intuitive Surgical, Sunnyvale, CA) to perform a portal lymphadenectomy with resection of segment 4B and 5 of the liver for gallbladder cancer. The patient is a 76 y.o. female who was found to have an incidental pT2pNx gallbladder adenocarcinoma following a laparoscopic cholecystectomy. CT of the chest, abdomen and pelvis were negative for metastasic disease. The procedure was begun with diagnostic laparoscopy which was negative for peritoneal metastasis. Results: The round ligament was taken down using the monopolar scissors and left attached to the under surface of the liver. This was later used as a vascularized pedicle flap to cover the resection bed of the liver at the end of the procedure. Firefly™ fluorescence imaging was used to confirm the junction of the cystic duct stump and the common bile duct. The cystic duct stump was then clipped and divided close to the common bile duct. Intra operative ultrasound was used to identify critical vascular structures and their relationship to the common bile duct and portal lymph nodes. The lymphadenectomy was begun at the lateral aspect of the porta hepatis by incising the peritoneum overlying the porta hepatis and common bile duct. The lateral portal and posterior duodenal lymph nodes were dissected off the common bile duct and portal vein using the mono polar scissors. The lesser omentum was then opened and the hepatic artery lymph nodes were dissected off the hepatic artery. The posterior medial lymph nodes and celiac nodes were also dissected and the specimen was removed en bloc. The EndoWrist® One™ vessel sealer was used to take a wedge of segments 4B and 5 of the liver with a 2 cm margin around the gallbladder fossa. The previously fashioned round ligament flap was then placed into the defect as a vascularized pedicle flap. Final pathology revealed six negative lymph nodes, with a negative cystic duct stump and liver parenchymal margin. The patient’s post-operative course was uneventful and as expected for the procedure.

Prognostic impact of celiac lymph node involvement in patients after frontline treatment for advanced ovarian cancer

IntroductionCompleteness of cytoreduction is the most important prognostic factor in patients with advanced ovarian cancer (OC). Extensive upper abdominal surgery has allowed to increase the rate complete cytoreduction and the feasibility of resection of celiac lymph nodes (CLN) and porta hepatis disease in these patients has been demonstrated. The aim of our study was to assess the prognostic impact of CLN involvement in patients with primary advanced OC undergoing a complete cytoreductive surgery (CRS). Material and methodsWe designed a retrospective unicentric study. We reviewed data from patients who underwent CLN resection with or without porta hepatis disease resection, within upfront or interval complete CRS in the frontline treatment of advanced epithelial OC between January 2008 and December 2015. Patients were classified in two groups according to CLN status. Univariate and multivariate analyses were conducted. Survival rates were estimated using Kaplan-Meier method. ResultsForty-three patients were included and positive CLN were found in 39.5% of them. The median disease-free survival in the group of patients with positive and negative CLN were 11.3 months and 25.8 months, respectively. In multivariable analysis, both CLN involvement and high peritoneal cancer index were independently associated with decreased disease-free survival. Computed tomography re-reading by an expert radiologist has good sensitivity for detection of positive CLN. ConclusionCLN involvement and high preoperative tumor burden are independently associated with decreased survival after complete cytoreduction for OC. CLN involvement is a marker of diffuse disease and an independent risk factor for early recurrent disease.