cT1 N0 Research Articles

Comparative analysis of laparoscopic low rectal resections

Objective: to study the immediate results of laparoscopic intersphincteric resection (ISR) and ultralow anterior resection (ULAR) of the rectum. Subjects and methods. The results of surgical treatment in 42 patients operated on in the Saint Petersburg Clinical Research-Practical Center for Specialized Medical (Oncology) Cares in March 2014 to January 2015 are given. The inclusion criteria were the lower edge of cT1–3N0 adenocarcinoma 2-5 cm above the dentate line and no signs of invasion into the sphincter and levators. All the patients were divided into 2 groups: 1) 24 patients who had undergone laparoscopic ISR; 2) 18 patients who had laparoscopic ULAR. Both groups were matched for gender, age, body mass index, and CR-POSSUM predicted mortality scores. Thirty-two patients received neoadjuvant chemoradiotherapy. Results. The mean duration of operations did not differ significantly in the groups: 206 ± 46 and 216 ± 24 min (р = 0.72). The differences in the mean volume of blood loss were also insignificant: 85 and 113 ml (р = 0.93). Circular and distal resection margins were intact in all the cases. In 18 (75 %) patients in Group 1 and in 14 (77.8 %) patients in Group 2, the quality of total mesorectumectomy (TME) was rated as grade 3 according to the Quirk criteria (p = 0.83). In Group 1, complications requiring no reoperation occurred in 5 (20.8 %) cases: anastomotic incompetence in 3 (12.5 %) cases, anastomotic stricture with further bougienage in 1 (4.2 %), and urinary retention in 1 (4.2 %). In Group 2, postoperative coтplications were also observed in 5 (27.8 %) cases: necrosis of the brought-out bowel in 2 (11.1 %) patients and coloanal incompetence in 1 (5.6 %) required reoperation; 2 (11.1 %) patients underwent bougienage due to established anastomotic stricture. One month postoperatively, the Wexner constipation scoring system was used to rate the degree of encopresis: anal incontinence turned out to be significantly higher in Group 2 and amounted to 9.3 versus 6.2 in Group1. ULAR required consumables costing an average of 45 000 rubles more than did ISR. Conclusion. Both surgical procedures are comparable in the duration of a surgical intervention, the volume of intraoperative blood loss, and the quality of TME. ULAR with a reservoir is functionally more preferential.

Minimally invasive selective neck dissection: a prospective study of endoscopically assisted dissection via a small submandibular approach in cT(1-2_N(0) oral squamous cell carcinoma.

Selective neck dissection (SND) in clinical N0 (cN0) cases of oral squamous cell carcinoma (SCC) has been performed by surgeons using a retroauricular or modified facelift approach with robotic or endoscopic assistance. However, these procedures provide cosmetic satisfaction at the cost of possible maximal invasiveness. In this prospective study, we introduced and evaluated the feasibility as well as surgical invasiveness and cosmetic outcome of endoscopically-assisted SND via a small submandibular approach. Forty-four patients with cT1-2N0 oral SCC (OSCC) were randomly divided into two groups of endoscopically-assisted SND and conventional SND. Perioperative and postoperative outcomes of patients were evaluated, including the length of the incision, operating time for neck dissection, estimated blood loss during the operation, amount and duration of drainage, total hospitalization period, total number of lymph nodes retrieved, satisfaction scores based on the cosmetic results, perioperative local complications, shoulder syndrome, and follow-up information. The mean operation time in the endoscopically-assisted group (126.04±12.67min) was longer than that in the conventional group (75.67±16.67min). However, the mean length of the incision was 4.33±0.76cm in the endoscopically-assisted SND group, and the amount and duration of drainage, total hospital stay, postoperative shoulder pain score, and cosmetic outcomes were superior in the endoscopically-assisted SND group. Additionally, the retrieved lymph nodes and complications were comparable. Endoscopically-assisted SND via a small submandibular approach had a longer operation time than the conventional approach. However, endoscopically-assisted SND was feasible and reliable while providing minimal invasiveness and satisfactory appearance.

Sentinel Node Mapping in Adenocarcinoma of the Esophagogastric Junction

The incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing, but the surgical strategy for AEG remains controversial. We hypothesized that sentinel node (SN) mapping for AEG could be validated to avoid unnecessary lymphadenectomy and permit minimally invasive surgery. We examined the feasibility of SN mapping for AEG. We enrolled 15 patients with preoperatively diagnosed cT1 N0 M0 primary AEG (Siewert type I, N = 3; Siewert type II, N = 12) lesions measuring <4 cm in diameter. The dual tracer method employing radioactive colloid and blue dye was used to detect SNs. The distribution of SNs was compared with that of metastatic lymph nodes in 52 patients who were surgically treated without SN mapping. SNs were successfully identified in all the patients. Two patients with lymph node metastasis had positive SNs identified via an intraoperative pathological examination, and the diagnostic sensitivity and accuracy based on the SN status were both 100 %. For Siewert type II AEG, the SNs were not detected in the lower mediastinum by intraoperative gamma probing. Thus, all surgical procedures were performed via a transhiatal approach. No patient without SN metastasis experienced cancer recurrence during a 38-month median follow-up. The distribution of SNs was similar to that of lymph node metastasis in the patients who were surgically treated without SN mapping. We achieved 100 % SN detection. Our results suggested that SN mapping is feasible for AEG and highly sensitive and accurate in diagnosing lymph node metastasis. SN mapping may clarify the necessity of mediastinal lymph node dissection and individualize minimally invasive surgery.

Accuracy of Fluorodeoxyglucose-Positron Emission Tomography Within the Clinical Practice of the American College of Surgeons Oncology Group Z4031 Trial to Diagnose Clinical Stage I Non-Small Cell Lung Cancer

Fluorodeoxyglucose-positron emission tomography (FDG-PET) is recommended for diagnosis and staging of non-small cell lung cancer (NSCLC). Meta-analyses of FDG-PET diagnostic accuracy demonstrated sensitivity of 96% and specificity of 78% but were performed in select centers, introducing potential bias. This study evaluates the accuracy of FDG-PET to diagnose NSCLC and examines differences across enrolling sites in the national American College of Surgeons Oncology Group (ACOSOG) Z4031 trial. Between 2004 and 2006, 959 eligible patients with clinical stage I (cT1-2 N0 M0) known or suspected NSCLC were enrolled in the Z4031 trial, and with a baseline FDG-PET available for 682. Final diagnosis was determined by pathologic examination. FDG-PET avidity was categorized into avid or not avid by radiologist description or reported maximum standard uptake value. FDG-PET diagnostic accuracy was calculated for the entire cohort. Accuracy differences based on preoperative size and by enrolling site were examined. Preoperative FDG-PET results were available for 682 participants enrolled at 51 sites in 39 cities. Lung cancer prevalence was 83%. FDG-PET sensitivity was 82% (95% confidence interval, 79 to 85) and specificity was 31% (95% confidence interval, 23% to 40%). Positive and negative predictive values were 85% and 26%, respectively. Accuracy improved with lesion size. Of 80 false-positive scans, 69% were granulomas. False-negative scans occurred in 101 patients, with adenocarcinoma being the most frequent (64%), and 11 were 10 mm or less. The sensitivity varied from 68% to 91% (p=0.03), and the specificity ranged from 15% to 44% (p=0.72) across cities with more than 25 participants. In a national surgical population with clinical stage I NSCLC, FDG-PET to diagnose lung cancer performed poorly compared with published studies.

Clinical evaluation of cisplatin sensitivity germ line polymorphisms in neoadjuvant chemotherapy (NAC) for urothelial cancer (UC).

342 Background: Cisplatin-based NAC in UC confers a survival benefit, but prediction of which patients (pts) will benefit is not possible. We attempted to validate pharmacogenomic (PGx) markers of cisplatin sensitivity derived from a cell-based model and previously associated with response in a population of pts receiving NAC. Methods: Three germline single nucleotide polymorphisms (SNPs) were previously associated with pathologic response at cystectomy in a single-institution discovery set of 59 cT2 UC pts. These SNPs were tested for association with NAC response in a prospectively-identified, multi-institution, independent cohort. The primary analysis tested for association between rs244898 and rs7937567 and pathologic complete response (pT0). A replication set of 134 pts would provide 80% power to detect effects of both SNPs at p=0.05 independently using a multivariate logistic model. Results: N=146 pts with ≥cT2 N0 disease were identified from three institutions. All pts received ≥3 cycles of cisplatin-based NAC and underwent definitive surgery. Rates of pT0 and &lt;pT2 were 26% and 50%, respectively, comparable to the discovery population. Though each SNP had a &gt;5 odds ratio of effect on pT0 in the discovery set, neither was associated with achievement of pT0 in the replication set. The third SNP (rs10964552) which was associated with pathologic downstaging in the discovery set, also failed to replicate. All three SNPs were in Hardy-Weinberg equilibrium, and minor allele frequencies were similar between discovery and validation. Conclusions: Three germline SNPs previously associated with platinum sensitivity in pre-clinical and clinical models were not associated with NAC response in a large replication cohort of UC pts. Reasons for failure may include unmeasured clinical differences between the pt cohorts, a higher proportion of MVAC use in the replication set compared to gemcitabine/cisplatin in discovery pts, or simply spurious association in the discovery cohort. These results emphasize the need for replication when evaluating PGx markers, and demonstrate that multi-institutional efforts are feasible and will likely be necessary to achieve advances in UC PGx.

Comments on “Sentinel lymph node biopsy versus elective neck dissection in patients with cT1-2 N0 oral tongue squamous cell carcinoma”

Comments on “Sentinel lymph node biopsy versus elective neck dissection in patients with cT1-2 N0 oral tongue squamous cell carcinoma”

Response to “Sentinel lymph node biopsy versus elective neck dissection in patients with cT1-2N0 oral tongue squamous cell carcinoma”

Objective This study aimed to compare the value of sentinel lymph node biopsy (SLNB) with that of elective neck dissection (END) for the prediction of cervical lymph node metastasis in patients with clinically diagnosed T1-2N0 (cT1-2N0) oral tongue squamous cell carcinoma (OTSCC), and it aimed to examine the prognostic value of individualized treatment in sentinel lymph node (SLN)-negative patients. Study Design The study entailed a retrospective review of 82 patients with cT1-2N0 OTSCC. Thirty patients underwent SLNB, and 52 patients underwent END. Results There was a significant difference between the SLNB and END groups in the incidence of occult cervical lymph node metastasis in initial specimens (30% vs 11.5%; P = .037). However, there were no significant differences between the groups for 10-year overall and cervical recurrence-free survival rates and 10-year overall survival rate. Conclusions SLNB is superior to END for the prediction of cervical lymph node metastasis in patients with cT1-2N0 OTSCC. Neck dissection may be reduced for SLN-negative patients, owing to the comparable prognosis of SLNB.

Management of axillary staging in breast cancer patients treated with neoadjuvant chemotherapy

SUMMARY Sentinel lymph node (SLN) biopsy is standard care for patients with cN0 breast cancer, and SLN-negative patients do not require axillary dissection (ALND). It is now clear that many patients with positive SLN do not require ALND. In ACOSOG Z0011, 6-year locoregional control and survival (in cT1–2N0 patients with ≤2 positive SLN treated by breast conservation and whole breast radiotherapy) were comparable for SLN biopsy alone compared to SLN biopsy plus ALND. A growing body of data now suggests that ALND may not be required for selected patients outside the Z0011 eligibility criteria, including those treated with neoadjuvant chemotherapy (NAC). Retrospective and prospective studies confirm that the success of SLN biopsy after NAC is slightly lower and the false-negative rate slightly higher than those of SLN biopsy in general. The performance of SLN biopsy after NAC is optimized by the use of combined dye–isotope mapping and by the removal of at least two SLN. After NAC, ALND remains standard care for those who remain SLN-positive but may not be required for SLN-negative patients. Future trials will focus on patients with proven axillary node metastasis prior to NAC, and ask whether axillary radiotherapy is required for those who become SLN negative, and whether ALND is required for those who remain SLN-positive.

Which Patients with Sentinel Node–Positive Breast Cancer Can Avoid Axillary Dissection?

Sentinel lymph node (SLN) biopsy is standard care for patients with cN0 breast cancer. An extensive literature, including seven randomized trials, has established that patients with negative SLN do not require axillary dissection (ALND), that axillary local recurrence after a negative SLN biopsy is rare, that disease-free and overall survival are unaffected by the addition of ALND to SLN biopsy, and that the morbidity of SLN biopsy is substantially less than that of ALND. It is now clear that many patients with positive SLN do not require ALND. In ACOSOG Z0011, 6-year locoregional control and survival were equivalent with versus without the performance of ALND in cT1-2N0 patients with ≤2 positive SLN treated by breast conservation with whole breast radiation therapy. A small but growing body of data now suggests that ALND may not be required for selected patients outside the Z0011 eligibility criteria, specifically those treated by mastectomy (without post-mastectomy radiation therapy), by partial breast irradiation, and by neoadjuvant chemotherapy. Looking ahead, the principal goals of axillary staging, prognostication, and local control will be accomplished by SLN biopsy for a substantial majority of patients, and the role of ALND will continue to diminish.

Which Patients with Sentinel Node–Positive Breast Cancer Can Avoid Axillary Dissection?

Sentinel lymph node (SLN) biopsy is standard care for patients with cN0 breast cancer. An extensive literature, including seven randomized trials, has established that patients with negative SLN do not require axillary dissection (ALND), that axillary local recurrence after a negative SLN biopsy is rare, that disease-free and overall survival are unaffected by the addition of ALND to SLN biopsy, and that the morbidity of SLN biopsy is substantially less than that of ALND. It is now clear that many patients with positive SLN do not require ALND. In ACOSOG Z0011, 6-year locoregional control and survival were equivalent with versus without the performance of ALND in cT1–2N0 patients with ≤2 positive SLN treated by breast conservation with whole breast radiation therapy. A small but growing body of data now suggests that ALND may not be required for selected patients outside the Z0011 eligibility criteria, specifically those treated by mastectomy (without post-mastectomy radiation therapy), by partial breast irradiation, and by neoadjuvant chemotherapy. Looking ahead, the principal goals of axillary staging, prognostication, and local control will be accomplished by SLN biopsy for a substantial majority of patients, and the role of ALND will continue to diminish.

Single-Incision Robot-Assisted Transaxillary Surgery for Early-Stage Papillary Thyroid Cancer

We describe the surgical details, results, and learning curve of a proposed technique for single-incision transaxillary robot-assisted thyroid surgery for early-stage thyroid cancer. We performed single-incision transaxillary robot-assisted total thyroidectomy with the da Vinci surgical system in 29 patients (5 male, 24 female; median age, 45 years; age range, 19 to 69 years) with papillary thyroid cancer (cT1 NO) using our proposed technique with selected instrumentation. Preoperative ultrasound examination, fine-needle aspiration cytology, and contrast computed tomographic scanning were performed in all subjects. Ultrasound examination was carried out 1 month after surgery to assess the amount of residual thyroid tissue. No procedure was converted to conventional open surgery. The mean total operation time was 178.51 +/- 24.18 minutes, and the mean console time was 126.10 +/- 14.47 minutes. A progressive reduction of console time was noted (160 minutes for the first procedure versus 102 minutes for the last one). No cases of permanent hypocalcemia, recurrent laryngeal nerve palsy, or postoperative bleeding occurred. The mean amount of postoperative residual thyroid tissue on ultrasound examination was 8.93 +/- 2.15 mm. The single-incision transaxillary robot-assisted total thyroidectomy we propose is a feasible and relatively safe procedure in selected patients with early-stage thyroid cancer.

Endoscopic submucosal dissection with sentinel node navigation surgery for early gastric cancer

We combined endoscopic submucosal dissection (ESD) and sentinel node navigation surgery with the purpose of achieving complete resection of early gastric cancer while preserving the organ and assessing pathological nodal status. A total of 13 patients with cT1( ≤ 3 cm)N0 early gastric cancer underwent combined ESD and sentinel node navigation surgery (ESN) at a single tertiary referral center. Sentinel node navigation surgery using indocyanine green was performed during ESD and all suspected sentinel nodes were removed laparoscopically and examined intraoperatively. ESN was converted to gastrectomy with D2 dissection if there was evidence of metastasis on frozen section. ESN was completed in 12 patients and in 1 patient was converted to gastrectomy after sentinel node navigation surgery. En bloc tumor resection was achieved in all cases. Two patients underwent additional gastrectomy because they had tumor-positive vertical margins. In all cases ESN was conducted without intraoperative or postoperative adverse events. ESN is a feasible minimally invasive procedure that allows en bloc tumor resection to be achieved while assessing the pathological status of the lymph nodes.

Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy

In selected patients with early low rectal cancer, locoregional excision combined with neoadjuvant therapy may be an alternative treatment option to total mesorectal excision (TME). This prospective randomized trial compared endoluminal locoregional resection (ELRR) by transanal endoscopic microsurgery versus laparoscopic TME in the treatment of patients with small non-advanced low rectal cancer. Patients with rectal cancer staged clinically as cT2 N0 M0, histological grade G1-2, with a tumour less than 3 cm in diameter, within 6 cm of the anal verge, were randomized to ELRR or TME. All patients underwent long-course neoadjuvant chemoradiotherapy. Fifty patients in each group were analysed. Overall tumour downstaging and downsizing rates after neoadjuvant chemoradiotherapy were 51 and 26 per cent respectively, and were similar in both groups. All patients had R0 resection with tumour-free resection margins. At long-term follow-up, local recurrence had developed in four patients (8 per cent) after ELRR and three (6 per cent) after TME. Distant metastases were observed in two patients (4 per cent) in each group. There was no statistically significant difference in disease-free survival (P = 0·686). In selected patients, ELRR had similar oncological results to TME. Unique Protocol ID: URBINO-LEZ-1995; registration number: NCT01609504 (http://www.clinicaltrials.gov).

Staged operation for synchronous quintuple cancer in the oral cavity, hypopharynx, and esophagus

Esophageal cancer is frequently associated with head-and-neck cancer. It is difficult to select treatment modalities for synchronous multiple cancers in the upper aerodigestive tract. A 58-year-old woman had synchronous quintuple cancer of the upper aerodigestive tract and was in a poor nutritional state due to oral pain and dysphagia. Clinical stages of cancer in the oral cavity, hypopharynx, cervical esophagus, middle thoracic esophagus, and lower thoracic esophagus were IVA (cT4a N2b M0), I (cT1 N0 M0), IA (cT1 N0 M0), IA (cT1 N0 M0), and IIA (cT3 N0 M0), respectively. After preoperative chemoradiotherapy, curative resection of oral cavity cancer and a tube jejunostomy were performed. Then, pharyngolaryngectomy, total esophagectomy, and pharyngostomy were performed. Finally, after additional radiotherapy to the oral cavity, pharyngogastrostomy with gastric tube and microvascular anastomosis were performed. The patient achieved oral intake and is in good condition and has at this writing remained recurrence free for 26 months. This report suggests that even if there are multiple cancers, adopting multimodal treatment strategies for controlling each cancer may lead to a chance to obtain a complete cure.

Reply to Nosotti et al.

[6] admitted ‘attempting to make a loose comparison for patients in particular radiographic subgroups, with recognition that this assessment must be taken with a large grain of salt’. The definition of ‘peripheral’ is a loose one and creates a loop hole that might give excuses for omitting SND. Based on the American College of Chest Physicians clinical practice guidelines, ‘invasive staging is probably not needed in patients with peripheral tumours with no nodal involvement on CT and PET scans’. Logically it follows that this category should also be exempt from routine mediastinoscopy, a recommendation that is missing from both guidelines of the ACCP and the European Society for Thoracic Surgeons. In our series, we have shown clearly that mediastinal involvement [N2] in patients with cT1-3 N0 M0 was 10%. These patients had a completely innocent mediastinum, within the radiological group 1–2 of Detterbeck’s classification. We therefore believe that an SND is mandatory for every patient with NSCLC even if mediastinal involvement was thought unlikely, and irrespective of the how peripheral the primary is.

Neoadjuvant Chemoradiation Therapy Is Beneficial for Clinical Stage T2 N0 Esophageal Cancer Patients Due to Inaccurate Preoperative Staging

It remains unclear if patients with clinical stage T2 N0 (cT2 N0) esophageal cancer should be offered induction therapy vs surgical intervention alone. This was a retrospective cohort study of cT2 N0 patients undergoing induction therapy, followed by surgical resection, or resection alone, at the Johns Hopkins Hospital from 1989 to 2009. Kaplan-Meier analysis was used to compare all-cause mortality in cT2 N0 patients who had resection alone vs those who had induction chemoradiation therapy, followed by resection. A study cohort of 69 patients was identified and divided into two groups: 55 patients (79.7%) received induction therapy and 14 (20.3%) did not. No statistically significant difference in 5-year survival rate was observed for the two groups: 49.5% for the resection-only group and 53.8% for the induction group. More than 50% of cT2 N0 patients were understaged. For cT2 N0 esophageal cancer patients, the benefit of neoadjuvant therapy is still unclear. Induction therapy for cT2 N0 did not translate into a statistically significant improvement in survival. However, due to the significant understaging of T2 N0 patients, we recommend neoadjuvant therapy to all cT2N0 patients before operation.

Is completion lobectomy merited for unanticipated nodal metastases after radical segmentectomy for cT1 N0 M0/pN1-2 non–small cell lung cancer?

To examine the role of radical segmentectomy, defined as a segmentectomy with extensive hilar/mediastinal lymph node dissection and a sufficient surgical margin, for local control in cT1 N0 M0/pN1-2 non-small cell lung cancer (NSCLC), we examined the following: (1) whether metastases were observed in specimens additionally resected by completion lobectomy undertaken after segmentectomy because of pN1-2 disease and (2) prognostic outcome in patients whose operations were completed with segmentectomy regardless of pN1-2. Of 275 patients with cT1 N0 M0 NSCLC who were scheduled to undergo radical segmentectomy, 15 (6%) had a diagnosis of pN1 or N2 disease. Of these patients, 10 were additionally treated with completion lobectomy, whereas the operations of the remaining 5 were completed with segmentectomy. None of the 10 patients who underwent completion lobectomy showed residual metastases in the specimens additionally resected by completion lobectomy. Two of the 5 patients whose operations were completed with segmentectomy, regardless of N1 or N2 disease, had tumor recurrence, but their first recurrence was not local. Radical segmentectomy, with extensive hilar/mediastinal lymph node dissection and a sufficient surgical margin, may play a role in local control in patients with cT1 N0 M0/pN1-2 NSCLC.

Proteomic analysis for detection of NSCLC: Results of ACOSOG Z4031.

7003 Background: NCI CT Screening Trial demonstrated a significant decrease in lung cancer mortality. This will dramatically increase the number of suspicious nodules discovered by CT. Unfortunately CT scans have a high false-positive rate for lung cancer requiring invasive diagnostic intervention. This study aim was to prospectively determine whether the serum proteomic profile can predict the presence of primary NSCLC in patients with CT suspicious lung lesions. Methods: One-thousand seventy-four patients with a clinically suspicious stage I (cT1-2 N0 M0) lung lesion were enrolled in Z4031 between 02/2004 and 05/2006. Fresh-frozen and FFPE tumor with pre- and post-operatively blood were collected prospectively after informed consent. Ciba Chrome Blue was used to capture low molecular weight proteins in pre-operative serum (un-digested) followed by mass analysis on a prOTOF 2000 MALDI-TOF mass spectrometer (MS) in duplicate. The spectra were normalized and the maximum and sum amplitudes within a m/z bin were used as abundance values. Features were identified by m/z values. Results: 913 patients were eligible: 723 patients with NSCLC and 190 patients with benign nodules. Patients with NSCLC were older (median 67.2 yrs vs 59.7 yrs, p < 0.0001) and had larger nodules (57.9% vs. 29.3% ≥ 2.0 cm, p < 0.0001). Of patients with NSCLC, 28% were squamous, 61.3% were adenocarcinoma, and 10% were other NSCLC. 690 eligible patients had at least one analyzable spectra. The MS proteomic profiles failed to discriminate between the groups. The spectra contained only a handful of proteins per patient and bins that had statistically significant different abundance values were in the noise region of the data and did not contain proteins. Conclusions: The proteomic platform did not have sufficient sensitivity to detect low abundance proteins. Furthermore, the limit of detection for the newest MS platforms are not sufficient for discovering discriminate protein profiles due to the dynamic range of the human proteome. A targeted approach beginning with analysis of gene expression in tissue followed by confirmation of corresponding proteins in tissue, and then assessing these proteins in serum will likely be much more fruitful and is underway.

Clinical analysis of mucinous tubular and spindle cell carcinoma of the kidney

Objective To explore the clinical features, treatment and prognosis of mucinous tubular and spindle cell carcinoma of the kidney. Methods Patient 1, a 42-year-old woman presented with space-occupying lesion of the lower pole of the left kidney with no symptoms in physical examination for 1 week. CT revealed a low-enhanced tumor located in the lower pole of the left kidney in cT1b N0M0. Radical left nephrectomy was performed. Patient 2, a 76-year-old woman presented with space-occupying lesion of the middle of the left kidney with no symptoms in physical examination for 10 d. CT revealed a low-enhanced tumor located in the middle of the left kidney in cT1b N0 M0. Laparoscopic radical left nephrectomy was performed. The patient received adjuvant treatment with IL-2 and interferon-α 3 months after nephrectomy. Patient 3, a 50-year-old woman presented with lumbago for 3 months. CT revealed a low-enhanced tumor located in the right kidney in cT2 N0 M0. Radical right nephrectomy was performed. The patient received adjuvant treatment with IL-2 and interferon-α 3months after nephrectomy. Patient 4, a 60-year-old woman presented with lumbago and hematuria for 15 d. CT revealed a low-enhanced tumor located in the lower pole of the left kidney in cT1a N0M0.Radical left nephrectomy was performed. Results Histological examination of the tumors showed that they consisted of spindle cells arranged in tubular and trabecular patterns embedded in a myxoid stroma. Pathologic diagnosis of all 4 patients were MTSCCa. There was no evidence of recurrence in all patients for 9- 46 months. Conclusions MTSCCa is a rare low-grade renal cell carcinoma.There is a female predominance. Early surgical excision is the best treatment and the prognosis is relatively good. Key words: Kidney neoplasms; Mucinous tubular and spindle cell carcinoma; Diagnosis; Treatment; Prognosis

Prognostic value of micrometastases in sentinel lymph nodes of patients with breast carcinoma: a cohort study

Background: The prognostic meaning and thus indication for adjuvant therapy of lymphogenic micrometastases in breast cancer patients is still under debate.Patients and methods: From 1999 to 2007, 703 patients with cT1–2N0 breast cancer underwent surgery including sentinel lymph node biopsy. Examination of sentinel lymph nodes consisted of hematoxylin and eosin and immunohistochemistry staining following serial sectioning of the sentinel node. Patients were divided into four groups: pN0 (n = 423), pN1micro (n = 81), pN1a (n = 130) and pN≥1b (n = 69). Median follow-up was 40 months.Results: At the end of follow-up, 53 patients had died and 64 had recurrent disease. Compared with pN0 and following adjustment for possible confounders, including adjuvant systemic treatment, overall survival was not significantly different for pN1micro while significantly worse for pN1a and pN≥1b {hazard ratio (HR) [95% confidence interval (CI)]: 0.59 [0.14–2.58], 4.31 [1.85–10.01], 10.66 [4.04–28.14], respectively}. Likewise, disease-free survival was not significantly different for pN1micro and worse for pN1a and pN≥1b (HR [95% CI]: 1.43 [0.67–3.02], 2.79 [1.37–5.66], 7.13 [3.27–15.54], respectively). Distant metastases were more commonly observed in the pN1micro than in the pN0 group, but still not as common as in the pN1a or pN≥1b group (HR [95% CI]: 4.85 [1.79–13.18], 10.34 [3.82–28.00], 23.25 [7.88–68.56], respectively).Conclusion: Although the risk of distant metastases was higher in patients in the pN1micro than in the pN0 group, no statistically significant differences were observed in overall or disease-free survival between pN0 and pN1micro. Micrometastatic lymph node involvement in itself should not be an indication for adjuvant chemotherapy in breast cancer patients.