Inadequate Lymph Node Sampling Research Articles

Minimally invasive radical cholecystectomy as a safe alternative to open radical cholecystectomy

Background: Gallbladder cancer today accounts for an estimated 1.2% of all new cancer diagnoses worldwide. For localized stage T1b gallbladder cancer and above, the treatment of choice is a radical cholecystectomy with negative gross and histologic margins. This procedure involves removal of the gallbladder and a portion of the liver, with or without concurrent resection of the bile duct and regional lymph nodes. In the past, performing this resection laparoscopically has been contraindicated due to fears of increased metastasis and inadequate lymph node sampling. With the advancement of laparoscopic techniques, however, minimally invasive radical cholecystectomies have the potential to be as safe and effective as the classic, open approach. This study seeks to use the current available literature to compare outcomes between an open and a laparoscopic radical cholecystectomy.

Surgical aspects, violations and outcomes of Wilms tumor\u2014a multicenter study in a resource-limited country

BackgroundWilms tumor is the commonest malignant renal neoplasm in children. Surgery plays a pivotal role in the management, and evidence-based guidelines for surgical resection have been established by the major international groups. Any deviation from the protocol is considered as a violation. The goal of this study was to evaluate outcomes of the patients with unilateral Wilms tumor treated at a developing country and to analyze surgical violations (SV) and their impact on the prognosis. A retrospective review was conducted for 37 patients who were presented to our hospitals and underwent nephrectomy for WT from January 2016 to December 2018. All participating centers adopt Children’s Oncology Group protocol. The SV were analyzed by logistic regression. Overall survival (OS) and event-free survival (EFS) were estimated by the Kaplan-Meier method.ResultsThere were 12 (32.4%), 11 (29.7%), 10 (27%), and 4 (10.8%) stages I, II, III, and IV, respectively. Their median age at time of diagnosis was 3.1 years. Upfront nephrectomy was performed for 30 cases. Six patients had tumor relapse (2 lungs and 4 local recurrences) at a median follow-up of 15.7 months. Out of the relapsed patients, two had unfavorable histology, and regarding their staging, four were stage III, one was stage II, and one was stage IV. Thirty-month OS and EFS were 84.3% and 81.1%, respectively. Twenty-seven SV occurred within 25 patients. Lack or inadequate lymph node sampling represented 74.07% (20/27), intraoperative tumor rupture and spillage accounted for 18.52% (5/27), and unwarranted preoperative biopsy happened in 7.41% (2/27). The SV were not correlated with mortality (p value = 0.381); however, they had a significant impact on the relapse (p value = 0.001). On further analysis; tumor rupture and spillage was a predictor for recurrence reaching a statistical significance (p value = 0.003), whereas the other violations were not.ConclusionsFavorable outcomes could be achieved by compliance with evidence-based guidelines even in a resource-limited country like ours. Violations were correlated with relapse; however, only tumor rupture and spillage was of statistical significance in multivariate analysis. Failure of lymph node documentation was the main problem encountered, and it should be avoidable in future practice.

Gastrectomy case volume and textbook outcome: an analysis of the Population Registry of Esophageal and Stomach Tumours of Ontario (PRESTO).

To determine the association between gastric cancer surgery case-volume and Textbook Outcome, a new composite quality measurement. Textbook Outcomeincluded (a) negative resection margin, (b) greater than 15 lymph nodes sampled, (c) no severe complication, (d) no re-intervention, (e) no unplanned ICU admission, (f) length of stay of 21days or less, (g) no 30-day readmission and (h) no 30-day mortality following surgery. All patients undergoing gastrectomy for non-metastatic gastric adenocarcinoma registered in the Population Registry of Esophageal and Stomach Tumours of Ontario between 2004 and 2015 were included. We used multivariable generalized estimating equation (GEE) logistic regression modelling to estimate the association between gastrectomy volume (surgeon and hospital annual volumes) and Textbook Outcome. Volumes were considered as continuous variables and quintiles. Textbook Outcome wasachieved in 378 of 1660 patients (22.8%). The quality metrics least often achieved were inadequate lymph node sampling and presence of severe complications, which occurred in 46.1% and 31.7% of patients, respectively. Accounting for covariates and clustering, neither surgeon volume nor hospital volume were significantly associated with Textbook Outcome. However, hospital volume was associated with adequate lymphadenectomy and fewer unplanned ICU admissions. Higher case volume can impact certain measures of quality of care but may not address all care structures necessary for ideal Textbook recovery. Future quality improvement strategies should consider using case-mix adjusted Textbook Outcome rates as a surgical quality metric.

Adequacy of Intraoperative Nodal Staging during Surgical Resection of NSCLC: Influencing Factors and Its Relationship to Survival.

Adequate intraoperative lymph node sampling is a fundamental part of lung cancer surgery, but adherence to standards is not well known. This study sought to measure the adequacy of intraoperative lymph node sampling at a regional Thoracic Surgery Centre and a tertiary lung cancer center in the United Kingdom. This retrospective study analyzed the pathological reports from NSCLC resections over the 4-year period 2011-2014. Adequacy of sampling was assessed against International Association for the Study of Lung Cancer recommendations of at least three mediastinal lymph node stations: station 7 in all patients, station 5 or 6 in left upper lobe tumors, and station 9 in lower lobe tumors. The influence of clinical variables (age, tumor T stage, type of surgery, and laterality) on adequacy of sampling and the effect of adequacy on overall survival were also assessed. A total of 1301 NSCLC resections were performed from January 11, 2011, to December 31, 2014. Adequate intraoperative lymph node sampling increased significantly from 14% (22 of 160) in 2011 to 53% (206 of 390) in 2014 (p= 0.001). Secondary analysis of clinical variables also revealed that patients with T1a or T4 tumors, those undergoing sublobar resections, those undergoing video-assisted thoracic surgery resections, and those undergoing left-sided resections have significantly higher rates of inadequate lymph node sampling. Overall, there was no statistically significant difference in survival between patients with adequate versus inadequate intraoperative lymph node sampling or when survival was stratified according to overall stage. There was worse survival in inadequate sampling for patients with pN2 disease than for patients with pN2 disease and adequate sampling. This study provides a much-needed benchmark of current thoracic surgical practice in lung cancer in the United Kingdom and important granularity to facilitate changes to improve adequacy of staging.

Abstract 5254: Postoperative adjuvant chemotherapy improves survival in stage II colon cancer? A propensity score matching analysis

Abstract Objective : Stage II colon cancer with high-risk features have been traditionally considered more likely to benefit from postoperative adjuvant chemotherapy (POAC). National Comprehensive Cancer Network (NCCN) guidelines do not recommend routine administration of adjuvant chemotherapy for Stage II patients, except for those with high risk features, such as poorly-differentiated tumors, T4 disease, perforated tumors and those with inadequate lymph node sampling. However, the use of POAC after surgery for patients with Stage II colon cancer remains controversial. The current study was conducted to investigate the effectiveness of POAC using propensity score (PS) matching analysis, which can reduce or minimize the confounding that is seen frequently in observational studies of the effect of treatment on outcomes, based on prognostic factors. Materials : Two hundred and nineteen patients with Stage II colon cancer who underwent surgery with curative intent between 1995 and 2005 were enrolled. The decision regarding the use of POAC was made for each case based on individual patient/physician discussions. All patients were required to provide informed consent. During the present study period, patients received 5-FU drugs orally, starting 4~8 weeks after surgery. The median observation period was 73.4 months (range: 2.2 - 184.2 months). Methods : PS matching analysis was used to adjust for differences in clinicopathological severity between the patients with and without POAC. Recurrence-free and cancer-specific survival were calculated using the Kaplan-Meier method and univariate analyses were performed using the log-rank test. The Cox proportional-hazard model was used to determine Hazard ratios and 95% confidence intervals. Results : One hundred and nineteen patients (54.3%) underwent POAC. In univariate analysis, there were significant differences in age, invasion depth, lymphatic invasion and venous invasion between the patients with and without POAC. After PS matching analysis, in univariate analysis, there were no significant differences with respect to the clinicopathological factors between the patients with and without POAC. Before PS matching analysis significant survival benefits from POAC were not recognized for recurrence-free survival (Hazard ratio= 0.76, 95% CI 0.40-1.45, P=0.41) or cancer-specific survival (Hazard ratio= 0.52, 95% CI 0.22-1.19, P=0.12). After PS matching analysis significant survival benefits from POAC were not recognized for recurrence-free survival (Hazard ratio= 0.55, 95% CI 0.23-1.23, P=0.15) or cancer-specific survival (Hazard ratio= 0.46, 95% CI 0.16-1.18, P=0.11). Conclusions : The one-to-one pair PS matching successfully balanced the clinicopathological factors between the patients with and without POAC. The PS matching analysis demonstrated no significant difference in survival in the patients with Stage II colon cancer. Citation Format: Ryoichi Tsukamoto, Kiichi Sugimoto, Shingo Kawano, Koichiro Niwa, Shun Ishiyama, Hirohiko Kamiyama, Hiromitsu Komiyama, Makoto Takahashi, Yutaka Kojima, Michitoshi Goto, Yuichi Tomiki, Kazuhiro Sakamoto. Postoperative adjuvant chemotherapy improves survival in stage II colon cancer? A propensity score matching analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5254. doi:10.1158/1538-7445.AM2017-5254

Can laparoscopic liver resection provide a favorable option for patients with large or multiple intrahepatic cholangiocarcinomas?

The role of laparoscopic liver resection (LLR) for large or multiple intrahepatic cholangiocarcinomas (ICCs) remains equivocal. The main concerns are potential risks of inadequate resection margin, tumor rupture, uncontrollable bleeding, tumor seeding, and inadequate lymph node sampling. In this study, we aimed to determine the safety, feasibility, and oncological efficacy of LLR for large (≥5cm) or multiple (≥2) ICCs. Among 50 patients receiving liver resection for ICC between May 2004 and January 2016, 12 patients who had undergone LLR for large or multiple ICCs (Group A, n=12) were compared with 18 patients who had undergone LLR for small solitary ICCs (Group B, n=18), as well were compared with 20 patients who had undergone open liver resection for large or multiple ICCs (Group C, n=20). Perioperative and long-term outcomes were analyzed. Compared with Group B, Group A had fewer patients with T1 tumors (58.3 vs. 100%; P=0.006) and a longer hospital stay (14 vs. 9days; P=0.039); operating time, blood loss, surgical margin, cases receiving lymph node dissection, conversion rates, and morbidity were comparable. There were no life-threatening complications and no mortality. No tumor rupture or dissemination occurred, nor did port-site recurrence follow surgery. After a median follow-up of 22months, no difference was noted in 3-year overall survival (56.3 vs. 59.5%; P>0.05) and recurrence-free survival (43.8 vs. 50%; P>0.05) between the two groups. Similarly, perioperative and long-term outcomes were comparable between Group A and Group C. LLR for large or multiple ICCs is technically safe, feasible, and oncologically effective in select patients. It provides a favorable option for patients seeking curative treatment. The minimally invasive nature will benefit these patients without compromising the oncological efficacy. Future larger-scale studies and well-designed randomized trials are warranted to evaluate this issue.

Clinical effectiveness of adjuvant chemotherapy (AC) with or without oxaliplatin following neoadjuvant chemoradiotherapy (nCRT) in stage II rectal cancer (RC).

686 Background: Use of AC in RC following nCRT is controversial because of concerns regarding its potentially small magnitude of benefit. We aimed to 1) examine real-world patterns of AC use in stage II RC and assess its impact on outcomes and 2) determine whether the addition of oxaliplatin to fluoropyrimidines modifies effectiveness. Methods: Using a cohort of yp stage II RC patients from 5 Canadian centers that underwent curative surgery, we assessed the relationship between AC +/- oxaliplatin and overall (OS) and disease free survival (DFS). Cox models adjusting for age, gender, ECOG, and high risk features (T4 lesion, poor differentiation, inadequate lymph node sampling, lymphovascular/perineural invasion, and obstruction/perforation) were constructed. Results: Among 485 pts, 74% received AC of whom 19% received oxaliplatin-based treatment. Median follow up was 4.5 yrs. Pts in the AC group were younger (median age 61 vs 64; P= 0.003) and had higher rates of TME (82% vs 79%; P= 0.049), but they had similar demographics, ECOG, high risk features, preoperative CEA, margin status and nCRT regimen when compared to pts in the non-AC group (all P> 0.05). Multivariate analyses demonstrated that receipt of any AC (OS HR 0.93 95% CI 0.58-1.50 P =0.77; DFS HR 0.91 95% CI 0.58-1.43 P =0.69), fluoropyrimidine AC (OS HR 0.82 95% CI 0.49-1.36 P =0.44; DFS HR 0.83 95% CI 0.51-1.34 P =0.44), or oxaliplatin-based AC (OS HR 1.37 95% CI 0.74-2.55 P =0.32; DFS HR 1.17 95% CI 0.66-2.05 P =0.59) did not improve outcomes versus no AC. In subgroup analyses that stratified pts by high risk features, presence of 1, 2, or 3 high risk factors, preoperative CEA and margin status, AC did not result in better OS or DFS in any subgroup. A further exploratory analysis that focused only on those receiving AC within 12 weeks of surgery did not reveal any consistent correlations between AC and survival. Conclusions: Use of fluoropyrimidine or oxaliplatin-based AC in this multi-institutional cohort of yp stage II RC pts after nCRT did not improve outcomes compared to observation. Conventional high risk features used to risk stratify stage II colon cancer for AC decision making have limited utility in RC after nCRT.

Quality of surgical resection for nonsmall cell lung cancer in a US metropolitan area

Curative treatment of early stage nonsmall cell lung cancer (NSCLC) requires good quality surgical resection (GQR). The degree of compliance with national recommendations for GQR is poorly defined. We sought to quantitatively define the degree of compliance in a consecutive series of NSCLC resections. Medical records of patients who underwent curative-intent resection for NSCLC in the Memphis, TN metropolitan area from January 1, 2004 to December 31, 2007 were retrospectively reviewed (N = 746 patients). GQR criteria were obtained from the National Comprehensive Cancer Network (NCCN), the RADIANT adjuvant study of erlotinib, and the American College of Surgeons Oncology Group (ACOSOG) Z0030 study. Factors associated with or without achievement of GQR were evaluated. Categorical variables were compared using chi-square or Fisher exact test, and survival curves by the log-rank test. Twenty-three and one-half percent of patients met GQR criteria as established by RADIANT, 8.2% by NCCN, and 0.9% by ACOSOG. The most common limiting factor in achieving GQR was inadequate lymph node sampling. The only patient factor associated with GQR was race (African-Americans were more likely than Caucasians to have GQR per RADIANT and NCCN criteria [P = .022 and P = .0489, respectively]). There was no significant survival difference between GQR and non-GQR patients. The vast majority of curative-intent resections did not achieve GQR standards. The greatest deficit is in surgical sampling of mediastinal (Level 2) lymph nodes, but evaluation of Level 1 lymph nodes is also suboptimal. Interventions are needed to improve current surgical practices and achieve minimum standards for accurate staging, prognostication, and eligibility for clinical trials.

Adjuvant Therapy for completely resected Stage II Colon Cancer

Colon cancer is potentially curable by surgery. Although adjuvant chemotherapy benefits patients with stage III disease, there is uncertainty of such benefit in stage II colon cancer. A systematic review of the literature was performed to better define the potential benefits of adjuvant therapy for patients with stage II colon cancer. To determine the effects of adjuvant therapy on overall survival and disease-free survival in patients with stage II colon cancer. Ovid MEDLINE (1986-2007), EMBASE (1980-2007), and EBM Reviews - Cochrane Central Register of Controlled Trials ( to 2007) were searched using the medical headings "colonic neoplasms", "colorectal neoplasms", "adjuvant chemotherapy", "adjuvant radiotherapy" and "immunotherapy", and the text words "colon cancer" and "colonic neoplasms". In addition, proceedings from the annual meetings of the American Society of Clinical Oncology and the European Society of Medical Oncology (1996 to 2004) as well as personal files were searched for additional information. Randomized trials or meta-analyses containing data on stage II colon cancer patients undergoing adjuvant therapy versus surgery alone. :Three reviewers summarized the results of selected studies. The main outcomes of interest were overall and disease-free survival, however, data on toxicity and treatment delivery were also recorded. With regards to the effect of adjuvant therapy on stage II colon cancer, the pooled relative risk ratio for overall survival was 0.96 (95% confidence interval 0.88, 1.05). With regards to disease-free survival, the pooled relative risk ratio was 0.83 (95% confidence interval 0.75, 0.92). Although there was no improvement in overall survival in the pooled analysis, we did find that disease-free survival in patients with stage II colon cancer was significantly better with the use of adjuvant therapy. It seems reasonable to discuss the benefits of adjuvant systemic chemotherapy with those stage II patients who have high risk features, including obstruction, perforation, inadequate lymph node sampling or T4 disease. The co-morbidities and likelihood of tolerating adjuvant systemic chemotherapy should be considered as well. There exists a need to further define which high-risk features in stage II colon cancer patients should be used to select patients for adjuvant therapy. Also, researchers must continue to search for other therapies which might be more effective, shorter in duration and less toxic than those available today.