Evidence Of Node Involvement Research Articles

Covering the Cover

Covering the Cover

PWE-078 Incidence and management of malignant polyps in the North Essex bowel cancer screening programme

IntroductionThe outcome of colonic cancer in the UK population has sensibly improved since the introduction of the Bowel Cancer Screening Programme (BCSP) in 2006. This is mainly due to early...

Optimization of mediastinal staging in potential candidates for stereotactic radiosurgery of the chest

Patients with medically inoperable nonsmall-cell lung cancer generally have limited staging of the mediastinum using computed tomography and combined positron emission tomography and computed tomography, before stereotactic radiosurgery. Historical data have demonstrated the superiority of tissue sampling techniques such as endobronchial ultrasonography and mediastinoscopy compared with imaging studies in accurately determining the nodal stage. We believe, that at a minimum, mediastinal interrogation with endobronchial ultrasonography should be performed before patients undergo stereotactic radiosurgery. A retrospective review of 59 consecutive patients undergoing bronchoscopic fiducial marker placement as potential candidates for stereotactic radiosurgery was done. All these patients had undergone endobronchial ultrasonography to assess the mediastinum. Transbronchial needle aspirates were taken using standard criteria defined by a lymph node size greater than 5 mm in diameter and/or in the appropriate lymph node drainage pathway. The biopsies were reviewed by the institution's pathologists. Mediastinal lymph node specimens were not taken in 9 patients because they did not meet our criteria. Of the 50 patients who underwent mediastinal lymph node sampling, 10 had evidence of nodal involvement. On review, 2 of these 10 patients had evidence of mediastinal adenopathy on computed tomography. After excluding those 2 patients, the mediastinal lymph nodes were positive for metastatic disease in 8 (16%) of 50 patients without previous radiographic evidence of disease. These patients were previously thought to be suitable candidates for stereotactic radiosurgery. Also 5 of 10 patients with endobronchial ultrasound-positive lymph nodes had had positron emission tomography-negative findings in the mediastinum. Finally, 10% of the patients suspected to have stage II or III were downstaged with endobronchial ultrasonography and considered for stereotactic radiosurgery. Endobronchial ultrasonography-transbronchial needle aspirates is more accurate than computed tomography and positron emission tomography in staging the mediastinum, can be performed with minimal morbidity, and should be considered for all patients considered candidates for stereotactic radiosurgery.

Effectiveness of alternating mammography and magnetic resonance imaging for screening women with deleterious BRCA mutations at high risk of breast cancer

Magnetic resonance imaging (MRI) has been used to supplement screening mammography and clinical breast examination (CBE) in women who are at high risk of developing breast cancer. In this study, the authors investigated the efficacy of alternating screening mammography and breast MRI every 6 months in women who had a genetically high risk of developing breast cancer. A retrospective chart review was performed on all women who were seen in a high-risk breast cancer clinic from 1997 to 2009. Patients with breast cancer gene (BRCA) mutations who underwent alternating screening mammography and breast MRI every 6 months were included in the study. Mammography, ultrasonography, MRI, and biopsy results were reviewed. Of 73 patients who met the study criteria, 37 had BRCA1 mutations, and 36 had BRCA2 mutations. Twenty-one patients (29%) completed 1 cycle of mammography and MRI surveillance, 23 patients (31%) completed 2 cycles, 18 patients (25%) completed 3 cycles, and patients 11 (15%) completed ≥ 4 cycles. The median follow-up was 2 years (range, 1-6 years). Thirteen cancers were detected among 11 women (15%). The mean tumor size was 14 mm (range, 1-30 mm), and 2 patients had bilateral cancers. Twelve of 13 cancers were detected on an MRI but not on the screening mammography study that was obtained 6 months earlier. One cancer (a 1-mm focus of ductal carcinoma in situ) was an incidental finding in a prophylactic mastectomy specimen. One patient had ipsilateral axillary lymphadenopathy identified on ultrasonography but had no evidence of lymph node involvement after neoadjuvant chemotherapy and surgery. In women who were at genetically high risk of developing breast cancer, MRI detected cancers that were not identified on mammography 6 months earlier. Future prospective studies are needed to evaluate the benefits of this screening regimen.

Regional lymph node status in patients with bladder cancer found to be pathological stage T0 at radical cystectomy following systemic chemotherapy.

•To evaluate the effect of preoperative cisplatin-based chemotherapy on the regional lymph nodes of patients with bladder cancer who attain pathological T0 status in the bladder after chemotherapy followed by radical cystectomy. •Patients who underwent radical cystectomy at MSKCC for urothelial carcinoma of the bladder were retrospectively reviewed. •Those patients achieving pT0 status after preoperative chemotherapy were identified and classified into two groups, those rendered pT0: (i) after receiving neoadjuvant chemotherapy and (ii) after receiving definitive chemotherapy (defined in this case as chemotherapy given for unresectable or regionally metastatic disease). •These two groups were analyzed separately for lymph node status at cystectomy and regional lymph node recurrence. •Of 169 pT0 patients, 24 patients (14%) had received neoadjuvant chemotherapy, whereas 17 patients (10%) had received definitive chemotherapy for unresectable or regionally metastatic disease. •No patient rendered pT0 after neoadjuvant chemotherapy had lymph node involvement at radical cystectomy or recurrence within the regional lymph node template. •Among patients with advanced disease rendered pT0 by definitive chemotherapy, 35% had lymph node involvement at radical cystectomy or subsequent recurrence within the dissection template. •Patients achieving pT0 status after receiving neoadjuvant chemotherapy had no evidence of lymph node involvement at cystectomy. •Patients undergoing definitive chemotherapy for advanced disease followed by cystectomy experienced reduced rates of nodal involvement compared to the lymph node-positive rates predicted by preoperative clinical staging. However, there remains a risk of regional lymph node involvement in this group.

Malignant giant-cell tumor of bone with lymph node involvement in a cat

The present study describes giant-cell tumor of bone (GCToB) with lymph node involvement in a 5-year-old crossbred cat. The animal was referred to the surgery clinic with progressive subcutaneous swelling in the left proximal femoral region, severe lameness, constipation, and dysuria. A moderately firm, subcutaneous, palpable mass, 9 cm in diameter, was observed, and biopsy samples were taken. Histopathologically, the mass was constituted by ovoid-shaped mononuclear cells intermixed with many multinucleated giant cells (MGC). Immunohistochemically, the giant cells were positively stained with antivimentin, and the same cells were negative for antidesmin and anti-S100 staining. Tartrate-resistant acid phosphatase (TRAP) activity in tumor cells was evaluated and the tumor was diagnosed as malignant GCToB; the cat was euthanized. Macroscopically, while the regional lymph nodes were intact, giant cells were found in the left popliteal lymph node during microscopy. Although a few cases of GCToB have been reported in cats, the case herein displays, for the first time, evidence of lymph node involvement during the process of metastasis.

Influence of prophylactic central lymph node dissection on postoperative thyroglobulin levels and radioiodine treatment in papillary thyroid cancer

Prophylactic central lymph node dissection with total thyroidectomy (TT) for the treatment of papillary thyroid cancer (PTC) is controversial because of the possibility of increased morbidity with uncertain benefit. The purpose of this study is to determine whether prophylactic central neck dissection provides any advantages over TT alone. Retrospective cohort study of patients with PTC without preoperative evidence of lymph node involvement undergoing either TT or TT with bilateral central lymph node dissection (TT + BCLND). From 2002 to 2009, 143 patients with clinically node-negative PTC underwent either TT (n = 65) or TT + BCLND (n = 78). The groups were similar in age, gender, tumor size, multifocality, angioinvasion, and metastasis/age/completeness-of-resection/invasion/size score. The presence of involved central neck lymph nodes upstaged 28.6% of patients in the TT + BCLND group to stage III disease, which resulted in higher radioactive iodine ablation doses. Stimulated serum thyroglobulin levels and the number of patients with undetectable stimulated thyroglobulin levels before and 1 year after radioactive iodine ablation were equivalent. The addition of routine central lymph node dissection to TT for the treatment of PTC upstages nearly one third of patients over the age of 45 thereby changing the dose of radioactive iodine ablative therapy, but does not change postoperative thyroglobulin levels after completion of radioiodine treatment.

Does nodal micrometastasis impact outcome in biliary cancer?

Microscopic deposits of tumor cells in regional lymph nodes can be detected using immunohistochemical techniques in patients without conventional histopathological evidence of lymph-node involvement. In the case of bile duct cancer, these micrometastases have an intermediate prognostic significance between that of positive and negative conventional pathology.

Initial evaluation of the nonsmall cell lung cancer patient: diagnosis and staging

The initial diagnosis and staging of nonsmall cell lung cancer patients is complex and involves multiple technologies. This review evaluates the recent literature and integrates it into a systematic method for evaluating patients. The goal of the initial diagnosis and staging of nonsmall cell lung cancer is to provide sufficient information to allow definitive treatment. Initial steps should include a history and physical, basic laboratory tests, pulmonary functions, and PET-computed tomography (CT) imaging. If there is evidence of metastatic disease, then biopsy of the most advanced lesion is warranted. If there is no evidence of metastatic disease, the evaluation should focus on evaluation of the mediastinal lymph nodes. If there is evidence of nodal involvement by PET-CT, then endobronchial ultrasound-guided transbronchial needle aspiration is warranted. If there is no evidence of nodal involvement on PET-CT, then either surgery or CT-guided fine needle aspiration is warranted. Other factors that should be kept in mind when selecting a diagnostic strategy include whether or not the patient is a surgical candidate, the impact of comorbidities, the type of cancer, the need for predictive biomarker analysis, and the range of possible treatment options. Integrating new technologies such as PET-CT and endobronchial ultrasound into the initial evaluation of patients can save unnecessary diagnostic procedures and lead to more rapid and accurate staging.

Sentinel node biopsy in colorectal cancer: Must we believe it?

Lymph node metastasis predicts survival and recurrence in colon cancer (CC), so decisions regarding adjuvant therapy are largely based on nodal status. Chemotherapy is not a routine treatment for node-negative CC because its toxicity and expense exceed its limited benefit in patients without evidence of nodal involvement. The sentinel lymph node (SLN) procedure is a selective sampling technique that can be used to ultrastage regional nodes. The real problem of SLN biopsy in CC is the procedure sensitivity rate. In future, studies concerning SLNs will have to consider issues such as the role of laparoscopy in colorectal resection (which cause technical difficulties in identification of SLNs) and the risk of overstaging of illness as well as the need to exclude T4 CC and, probably, rectal cancer from the studies. Is this the future of correct staging of colorectal cancer? Lymphadenectomy is at the present an integral part of colorectal surgery and surgeons must perform it correctly to improve their results. Nevertheless, for the future another "staging system" is necessary in colorectal cancer which takes into account biologic aspects of the tumor to identify patients with aggresive illness in order to treat them with more effective and less toxic therapies.

Intracorporeal stapled anastomosis following laparoscopic segmental gastrectomy for gastric cancer: technical report and surgical outcomes

Limited gastrectomy for early gastric body cancers can offer a better functional outcome by preserving more remnant stomach. Intracorporeal stapled techniques result in cosmesis and avoid awkward anastomosis through a minilaparotomy. Laparoscopic segmental gastrectomy is indicated for early gastric cancers of the body of the stomach with no evidence of lymph node involvement. Laparoscopic pylorus-preserving gastrectomy is a specific type of segmental resection for lower-body lesions with dissection of lymph nodes in station 6. Intracorporeal gastrogastric anastomosis is performed by the delta-shaped technique using linear staplers. Since January 2008 we have performed 12 laparoscopic pylorus-preserving gastrectomies and 13 laparoscopic segmental gastrectomies. All procedures were completed by laparoscopy. One patient with minor anastomotic leakage was managed conservatively. Bleeding from the anastomosis was not encountered in any of the patients. One patient developed narrowing at the anastomotic site and was treated successfully by balloon dilatation. There was no stasis encountered in any of the patients. Laparoscopic segmental gastrectomy with acceptable surgical outcomes is technically feasible. Although the impact of such resections on oncological outcomes remains to be further evaluated, laparoscopic segmental gastrectomy represents a minimally invasive limited resection that maximizes the potential for a better quality of life following gastric cancer surgery.

St. Gallen 2009 recommendations on the treatment of early breast cancer: consensus and controversy

Th e 11th St. Gallen consensus meeting on the primary treatment of early breast cancer put a special emphasis on a tailored approach for patient subgroups, and by the selection of targetted treatments according to tumour biology. Sentinel node procedure was considered as the standard in invasive breast cancer with no clinical evidence of lymph node involvement. Concerning ductal carcinoma in situ (DCIS), the panellists voted for adjuvant radiotherapy to be considered standard for excised DCIS, but irradiation might be avoided in the elderly and in patients with low-grade DCIS. Accelerated whole breast radiotherapy was considered an acceptable optional after tumour excision, especially in patients above the age of 60 years. Furthermore, the panel supported validated multigene assays to be considered as an additional tool for choosing chemotherapy in endocrine-responsive disease. Concerning endocrine treatment, the panellists preferred upfront endocrine therapy with an aromatase inhibitor on the basis of the updated results of BIG 1-98, especially for cases with high risk of early recurrence. Changing the aromatase inhibitor to tamoxifen after 2 years of treatment was accepted as a treatment option. Finally, dose-dense doxorubicin/cyclophosphamide chemotherapy followed by paclitaxel, and docetaxel/cyclophosphamide were added to the group of standard adjuvant regimens.

Outcome of patients (pts) with metastatic renal cell carcinoma (mRCC) treated with systemic therapy without cytoreductive nephrectomy (CN)

e16035 Background: Targeted therapies (TT) have replaced cytokines in the management of pts with mRCC. CN has been incorporated in the management of pts with mRCC but many pts are not suitable candidates for CN. The median overall survival (OS) time of pts treated with interferon alfa (IFN-α) without CN was 7.8 months (mos) [Flanigan et al. Journal of Urology 2004]. The median OS time for pts with mRCC treated with TT sequentially without CN is unknown. Methods: We retrospectively reviewed the medical records of pts with mRCC who did not undergo CN and who received one or more TT (bevacizumab, sorafenib, sunitinib, or temsirolimus) sequentially for at least one month with or without chemotherapy (gemcitabine + capecitabine or 5-FU). We calculated OS time from date of diagnosis until date of death or last follow up. We excluded pts who had embolization, radiofrequency ablation or cryotherapy of the primary tumor. Results: We identified 88 pts between Jan 2002 and Dec 2007. Median follow-up time is 9.7 mos (range: 1.2–49.2). Median OS time for all pts is 10.7 mos (95% CI: 7.6–15.4). 55 pts (62.5%) had clear-cell and 33 (37.5%) had non-clear cell histology, with median OS times of 15.1 mos (95% CI: 9.6–17.7) and 7.4 mos (95% CI: 4.4–13.0), respectively. ECOG performance status (PS) at time of diagnosis was correlated with OS (HR 1.54; 95% CI: 1.16–2.05; p<0.01). Pts with PS 0, 1, 2, and 3 had median OS times of 22.8 mos (95% CI: 5.7,*), 16.5 mos (95% CI: 8.1–24.7), 7.6 mos (95% CI: 5.7–11.9), and 7.1 mos (95% CI: 3.3–9.6), respectively. Pts with clinical evidence of lymph node (LN) involvement had worse outcome,with median OS time of 7.6 mos (95% CI: 5.6–9.8) versus 17.2 mos (95% CI: 9.8–35.5) for pts without clinical evidence of LN involvement. Conclusions: In this analysis, median OS time for pts with mRCC treated in the modern era with TT without CN is superior to historical experience with IFN- α.Compromised PS, LN involvement, and non-clear cell histology were associated with worse outcome. This data is useful in the design of randomized trials investigating the role of CN in mRCC. [Table: see text]

Survival in Lymph Node Negative Adenocarcinoma of the Esophagus after R0 Resection With and Without Neoadjuvant Therapy: Evidence for Downstaging of N Status

After esophagectomy, many patients who received neoadjuvant therapy have no evidence of lymph node involvement (N0 disease). Whether lymph nodes were initially involved and eradicated by the neoadjuvant therapy (down-staged) or if the nodes were never involved is a subject of debate. To address this issue, we compared clinical outcomes in N0 patients treated with neoadjuvant therapy with outcomes in patients treated with surgery alone. We reviewed records of 100 consecutive patients who underwent R0 esophagectomy for adenocarcinoma with pathologic N0 status. Seventy-five patients were treated by operation alone and 25 received neoadjuvant therapy. Tumor characteristics including length, depth, lymphovascular invasion, and degree of differentiation were compared and longterm survival was assessed by Kaplan-Meier analysis at a median of 46 months (interquartile range 26 to 77 months). Tumor characteristics were similar between groups. Recurrence was more common in patients who received neoadjuvant therapy compared with those treated with surgery alone (10 of 25 versus 10 of 75, p=0.0063). Patients with N0 disease after neoadjuvant therapy had a significantly worse survival than patients treated by surgery alone (49% versus 85%, p=0.005). Although neoadjuvant therapy may eradicate lymph node metastases, it does not result in the same outcomes as those achieved in patients with N0 disease treated with surgery alone. The poor clinical outcomes observed in N0 patients after neoadjuvant therapy suggest that they initially had node involvement and were downstaged by eradication of lymph node disease.

Rapid Progression of Submucosal Invasive Micropapillary Carcinoma of the Colon in Progressive Systemic Sclerosis: Report of a Case

A 71-year-old woman presented with hematochezia and narrowing of the stool. She suffered from progressive systemic sclerosis for 12 years and underwent home oxygen therapy due to pulmonary fibrosis and moderate pulmonary hypertension. Colonoscopy revealed a pedunculated, cauliflower-like polyp with a depressed surface in the sigmoid colon. The polyp was regarded as early colon cancer with possible submucosal invasion, and subsequent computed tomographic (CT) scans showed no evidence of lymph node involvement or distant metastases. Because of perioperative risks due to moderate pulmonary hypertension, she underwent an endoscopic resection of the early colon cancer. Pathological examination of the resected specimen of 20 mm diameter revealed the peculiar morphology of an adenocarcinoma with moderate lymphatic invasion. Immunohistochemical analysis for epithelial membrane antigen showed the specific 'inside-out growth pattern' indicative of invasive micropapillary carcinoma (IMPC). Taking the perioperative risks into consideration, she opted to undergo close follow-ups without an additional sigmoidectomy. At 6 months after the resection, the follow-up colonoscopy revealed a local recurrence of the colon cancer, and subsequent CT scans revealed multiple distant metastases including the lung, liver, lymph nodes and spleen. This is a rare case of a pure, submucosal IMPC of the colon. Furthermore, pure IMPC of the colon may represent a reliable predictor of lymphogenous and/or hematogenous metastases. Therefore, one should recommend an additional colectomy after endoscopic mucosal resection treatment when pathological findings confirmed IMPC of the colon and should continue a close follow-up for IMPC patients even when curative resections were performed at an early stage.

Occurrence of medullary thyroid carcinoma, bronchial carcinoid tumor, and papillary thyroid carcinoma in a family bearing the RET G691S polymorphism

RET mutations play an important role in the development of human neuroendocrine tumors. The prevalence of the RET polymorphism G691S of exon 11 is higher in patients with medullary thyroid carcinoma (MTC) as compared to the general population. A weak association between RET polymorphisms and sporadic papillary thyroid carcinoma (PTC) has also been described. We hereby describe the association of MTC, bronchial carcinoid tumor, and PTC in a familial setting. A 75-yr-old woman developed MTC 7 yr after successful treatment of a bronchial carcinoid. Serum calcitonin was 12.9 pg/ml with a peak response to pentagastrin (151.0 pg/ml). The patient underwent total thyroidectomy and a genetic mutational analysis of the RET gene. Histological evaluation confirmed MTC with no evidence of lymph nodes involvement. After thyroidectomy serum calcitonin was <2.0 pg/ml. A germline missense mutation at codon 691 in exon 11 of the RET gene was found. The mutational analysis was extended to the patient's offspring, and her daughter was found to bear the G691S polymorphism of RET. Wild type RET gene was found in the son. The daughter, who showed a nodular goiter, autoimmune thyroiditis and normal serum calcitonin, also underwent thyroidectomy. Histologic examination of the thyroid revealed an incidental PTC. This is the first description of a bronchial carcinoid tumor occurring in association with MTC. The occurrence of apparently unrelated NET in the same subject, or within a family, should be regarded as a challenge for deeper investigations into the possible oncogenic role of this genetic alteration.

Primary small intestinal lymphoma presenting as a groin abscess

Sir, Small bowel cancers are rare; primary small intestinal lymphoma accounts for 15–20% of these tumours. Patients with small intestinal lymphoma frequently present with abdominal emergencies to the surgeon.[1] A 50-year-old man presented with a 6-month history of a right groin swelling. On further questioning, the patient reported weight loss and reduced appetite. He reported no abdominal pain and changes in bowel habits. Physical examination revealed a large right groin swelling measuring approximately 15 cm in diameter. The swelling had the features of an abscess (red, hot, tender, and fluctuant) extending downwards into the right thigh and upwards into the right lower quadrant of the abdomen. Laboratory tests showed a mild leucocytosis of 12.3 × 109/L, a haemoglobin concentration of 11.4 g/100 mL and a C-reactive protein of 311 mg/L. A computed tomography (CT) scan revealed a soft tissue mass measuring 12 cm × 12 cm × 23 cm occupying the right hemipelvis and extending into the right inguinal region [Figure 1]. There was no thoracic or abdominal lymphadenopathy. Figure 1 CT image showing mass extending into the right side of the pelvis The patient underwent incision and drainage of this abscess. There was a large amount of faeculant material filling the entire abscess cavity; this appeared to be extending upwards medial to the femoral vessels, along the femoral canal. Laparotomy through a right lower transverse incision was made. Surprisingly, there was no intraperitoneal faecal contamination. Exploration revealed a full thickness retroperitoneal perforation of the terminal ileum with fecal contamination of the retroperitoneal space of the right iliac fossa. It was evident that part of the circumference of the terminal ileum was incarcerated in the femoral ring resulting in a femoral hernia and consequent perforation. An ileocaecal resection was performed. Histopathological examination confirmed diffuse large B-cell lymphoma. Two months later, a repeat CT scan showed a reduction of the right pelvic mass to 7.5 cm × 12 cm, with no evidence of lymph node involvement elsewhere. The patient has currently fully recovered from surgery and is receiving chemotherapy. The gastrointestinal tract is the most common site of extranodal non-Hodgkin lymphoma.[1] In 20–30% of cases, the small intestine, particularly the ileum, is affected.[2] Small intestinal lymphomas most commonly cause abdominal pain (82%).[3,4] Other presenting symptoms include changes in bowel habits (16%), a palpable abdominal mass (16%), and blood in the stool (15%).[2] In approximately 30–50% of patients, however, the initial presentation of small bowel lymphoma is an abdominal emergency,[1,5] with perforation present in up to 37% of cases.[5] A review of literature in English revealed no cases of small intestinal lymphoma presenting as a groin abscess. What was unique about this patient was that despite having a small bowel perforation, he did not present with an abdominal emergency. As the perforation was extraperitoneal, the presentation was that of a chronic right groin swelling, which was diagnosed clinically as an abscess. The duration of the symptoms before seeking medical advice was also unusually long (6 months). This perhaps reflected the patients own beliefs and character. This is believed to be the first documented case of primary small intestinal lymphoma causing a groin abscess as a result of intestinal perforation. This case highlights the variable and somewhat unusual presentation of these tumours.

Merkel Cell Carcinoma of the Lower Extremity

Merkel cell carcinoma (MCC) is a rare neuroendocrine cutaneous malignancy that predominantly arises in the head and neck region. We describe clinical features, diagnosis, and treatment in 4 cases of MCC, presenting an uncommon female predominant occurrence and an unusual primary site: the lower limb. In all cases diagnosis was established by histopathologic examination. Primary MCC and locally recurrence disease were treated in all patients with a wide surgical excision (3-cm margin) including fascia. Lymphadenectomy was reserved for a patient with clinical evidence of nodal involvement. Both chemotherapy administered in 2 cases and radiotherapy in 1 case produced limited responses. Early diagnosis is critical because this tumor is aggressive and has a high rate of local recurrence and metastatic spread. However, its nondistinctive appearance frequently delays diagnosis and its rarity avoids an optimal treatment guideline setting.

Laparoscopic resection for rectal adenocarcinoma

Aims Laparoscopic surgery for rectal cancer is still under discussion, but there is evidence that minimal access surgery can be feasible and safe also in this field. The aim of this study was to confirm that laparoscopic resection for rectal cancer can afford good results in terms of recurrence rate and survival. Patients and methods Since June 1998 through December 2007 as many as 252 patients underwent laparoscopic resection for rectal cancer. Laparoscopic anterior resection (LAR) was performed in 209 and laparoscopic abdominoperineal resection (LAPR) in 43. Neoadjuvant radiochemotherapy (nCRT) was administered in 48 patients with mid-low rectal cancer stage II and III with evidence of nodal involvement in preoperative work up. Results Patients who received nCRT showed a significant longer duration of surgery compared to patients who did not ( p = 0.004). Conversion to laparotomy was needed in 24 cases, (21 LAR and three LAPR) but no patient receiving nCRT needed conversion. Postoperative surgical complications occurred in 38 patients, 20 of which were represented by anastomotic leak after LAR. Six patients died postoperatively, in half the cases for surgery related causes. Downstaging after nCRT was seen in 40 patients, and complete histological response was observed in six cases. The mean number of lymph nodes harvested was 12, also in patients receiving nCRT. The mean follow-up was 48 ± 33 months (range 0.1–120.4), and 10 patients experienced local recurrence. Cumulative 5 year survival was 73.7%. Conclusion Laparoscopic resection for rectal cancer is feasible and safe, with morbidity and long-term results quite acceptable also in patients receiving neoadjuvant treatment.

The impact of positive soft tissue surgical margins following radical cystectomy for high-grade, invasive bladder cancer

We evaluate the incidence and risk factors associated with positive soft tissue surgical margins (STSM) and determine the association with various surgical and pathological characteristics and clinical outcomes in patients undergoing radical cystectomy (RC) for bladder cancer. From November 1971 to December 2005, 1,591 patients with primary transitional cell carcinoma (TCC) of the bladder underwent RC, with an extended bilateral pelvic lymphadenectomy and urinary diversion. A positive STSM was defined as tumor identified at the inked perivesical soft tissue surrounding the cystectomy specimen. Data were analyzed according to various clinical and pathologic variables, and survival analysis was performed. A total of 18 patients (1%) demonstrated pathologic evidence of a positive STSM following RC. Positive STSM were significantly associated with lymphovascular invasion, advanced pathologic stage, lymph node involvement, extent of nodal involvement and lymph node density. No patient with an organ-confined primary bladder tumor had a positive STSM, while 3% with extravesical tumor extension demonstrated a positive STSM. Recurrence-free and overall survival at 5 and 10 years for patients with a positive STSM was 29 and 22%, and 29 and 11%, respectively (p < 0.001). A positive STSM increased the risk of recurrence by threefold and the overall risk of death by 2.6 times. Only nine patients (1%) without evidence of nodal involvement had a positive STSM with a worse survival compared to those same pathologic subgroup and negative STSM. Nine patients (2%) with lymph node tumor involvement had positive STSM and also demonstrated significantly worse survival. Although a positive STSM was present in only 1% of patients undergoing a RC for TCC of the bladder, it was found to be an independent risk factor for advanced disease, lymph node involvement and tumor progression with worse survival. A dedicated effort should be made to avoid a positive STSM at the time of RC.