To compare oncological outcomes after extended pelvic lymph node dissection (PLND) versus limited in patients with high-risk prostate cancer (PCa) undergoing curative external beam radiation therapy (EBRT). From 3627 men with PCa at a single centre between 2000 and 2013, 167 with high-risk, age ≤75, Gleason score 6-10, clinical stage T1-T3, PSA < 100 ng/ml, no distant metastases (M1) and node-negative at the obturator fossa, underwent PLND before curative EBRT. Of these, 90 received limited, and 77 underwent extended PLND. Mean follow-up (SD) was 14.9 yr (5.8) for the limited and 12.3 yr (3.3) for the extended PLND. Primary endpoint was biochemical recurrence (BCR), secondary M1, cancer-specific mortality (CSM), overall mortality (OM). HR, KM and Cox regression models adjusted for age and Cambridge prognostic group (CPG) score. RR, RD at 11 yr. Extended PLND was associated with a significantly lower risk for BCR (HR: 0.51, 95% CI: 0.31-0.86, p =0.01) (RR: 0.43, 95% CI: 0.26-0.69, p = 0.001), lower risk of M1 (HR: 0.22, 95% CI: 0.08-02.65, p = 0.006) (RR: 0.26, 95% CI: 0.09-0.73, p = 0.004) and lower CSM compared with limited PLND (HR: 0.31, 95% CI: 0.08-0.65 p= 0.035) (RR 0.27, 95% CI: 0.08-0.91, p= 0.028). OM did not differ significantly. Extended PLND prior to curative ERBT shows reductions in BCR, M1 and CSM long-term outcomes following extended versus limited PLND. Extended PLND can be considered in cases with high-risk PCa prior to curative EBRT.

We report a case of synchronous double cancer involving the left lung and esophagus treated with a minimally invasive one-stage procedure combining thoracoscopic lobectomy and mediastinoscopic esophagectomy. Although a two-stage approach is often selected due to the technical complexity and invasiveness of simultaneous surgery, both tumors in this case were advanced, and a single-stage resection was considered the most appropriate option to avoid losing the opportunity for curative treatment. The postoperative course was complicated by anastomotic leakage, which was managed conservatively;however, early recurrence of esophageal cancer occurred, followed by multiple brain metastases from small cell lung carcinoma. These recurrences may have been related to limited mediastinal lymph node dissection, performed to preserve bronchial blood flow, and to the delayed initiation of adjuvant therapy due to treatment for esophageal recurrence. This case demonstrates not only the feasibility and advantage of a less invasive simultaneous approach but also emphasizes the need to optimize lymph node dissection strategies and the timing of postoperative therapy in complex synchronous malignancies.

A0562 Comparative perioperative outcomes of extended versus limited pelvic lymph node dissection in radical prostatectomy for intermediate- and high-risk prostate cancer: A phase III randomized trial

Lymphadenectomy through a triple-instrument cervical approach: a technical advance in single-port mediastinoscopic radical esophagectomy for esophageal cancer.

Colorectal cancer (CRC) is a major cause of cancer-related mortality. Current prognostic models rely primarily on tumor-specific features and may overlook host-tumor interactions. We conducted this study to assess the prognostic value of the cancer-inflammation prognostic index (CIPI), which combines carcinoembryonic antigen and neutrophil-to-lymphocyte ratio, in patients with stage II CRC. The subjects of this retrospective study were 326 patients with pathologically confirmed stage II CRC who underwent curative resection at our hospital between 2008 and 2018. The optimal CIPI cutoff for predicting 5year survival was established using receiver operating characteristic analysis. Patients were classified into High- and Low-CIPI groups, and survival outcomes were compared. Multivariate analysis identified a high CIPI (≥ 56.9) and inadequate lymph node dissection (≤ 12 nodes) as independent predictors of worse disease-free survival (DFS), and a high CIPI, older age, performance status ≥ 3, and limited lymph node dissection as independent predictors of worse overall survival (OS). Patients with a high-CIPI had significantly lower 5year DFS and OS. CIPI is a simple, objective preoperative biomarker independently associated with recurrence and survival in patients with stage II CRC and may enhance risk stratification for adjuvant therapy and postoperative surveillance.

Abstract Background Salvage esophagectomy involves higher surgical stress and a greater risk of severe complications than standard surgery. Minimizing invasiveness is ideal, but it may compromise curability. We analyzed our outcomes to evaluate strategies for salvage surgery. Methods We investigated the short-term and long-term outcomes of 134 cases of salvage subtotal esophagectomy performed in our department between 2001 and 2023. All cases were performed using thoracoscopic surgery, including robotic surgery. We try to preserve the bronchial arteries as much as possible, with an awareness of tracheal blood flow, and do not perform lymph node dissection of the tracheal bifurcation unless metastasis is suspected. In addition, in cases where the risk of pneumonia is high, we refrain from prophylactic lymph node dissection around the recurrent laryngeal nerve. Results R0 resection was achieved in 79% of cases. Major complications included pneumonia (26%), recurrent laryngeal nerve palsy (31%), and anastomotic leakage (26%), with severe leakage (≥G4) in 5% and tracheal necrosis in 3%. The median hospital stay was 32 days, improving to 27 days in the past decade. Five-year overall and disease-specific survival rates were 41% and 55%. Recurrence occurred in 42 cases, mainly in lymph nodes (17), solid organs (22), and peritoneal dissemination (11). Pneumonia was the leading non-cancer cause of death (7 cases). Conclusion Our study showed that salvage esophagectomy was performed safely with minimally invasive techniques and limited lymph node dissection. Recent complication reductions may be due to ERAS, including early rehabilitation. No disadvantages of limited dissection were observed in long-term outcomes. However, non-cancer deaths, especially from pneumonia and heart failure, remain high. Further efforts are needed to reduce surgical stress and pneumonia risk. A less invasive approach with fewer complications is essential for salvage surgery.

The number of patients aged ≥80 years with gastric cancer (GC) has recently been increasing. Many have severe comorbidities linked to high mortality after curative surgery. Although minimally invasive surgery is widely performed for GC, elderly patients may benefit from even less invasive, non-standard strategies. We assessed the treatment outcomes of 122 patients aged ≥80 years who underwent curative gastrectomy at our hospital between 2010-2020. In pStage I, most deaths were from comorbidities, whereas deaths in pStage II/III were both disease-specific and from comorbidities. Multivariate analysis of pStage I variables identified low prognostic nutritional index, open surgery, and American Society of Anesthesiologists physical status classification ≥3 as poor prognostic factors. For pStage II/III, no factors were significantly associated with mortality. Forty-seven out of 69 patients with T1 disease would have been classified as achieving Endoscopic Curability C-2 (eCuraC-2) if endoscopic resection rather than surgery had been performed. The 5-year overall survival rates were similar (58.8% vs. 68.6%, p=0.66) in the 20 patients judged as having eCuraC-2 status after endoscopic resection, with no other additional treatment. Minimally invasive surgery with limited lymph node dissection is preferred for elderly patients with GC with severe comorbidities, including malnutrition, and observation after noncurative endoscopic resection is viable.

Background: In solid cancer cases, surgery is the effective treatment for removing the mass and evaluating the locoregional lymph nodes. The extension of lymph node dissection (LND) is a challenging question in cancer surgery. At present, limited LND is a high topic accepted in breast cancer surgery. It is interesting to know that with limitations in LND in breast cancer surgery, there are no animal studies on this topic. Objectives: This study investigated local management with and without LND on the overall survival (OS) of mice inducted with 4T1 breast cancer cells. Methods: Fifty-four inbred female Balb/C mice were divided into seven groups, except for group seven as the healthy control group; all were injected with 4T1 breast cancer cells. Ten (early diagnosis and management) and twenty days (late diagnosis and management) following injection, in groups 1 and 2, the leg was amputated above the knee; in groups 3 and 4, inguinal LND was done without amputation (AMP). In the group five, the combination of AMP and LND was performed. Group six was only injected with tumor cells, and group seven was left intact without intervention. Finally, metastasis and survival time were evaluated. Results: Survival time in group 1, group 2 (local Management), and group 5 was significantly higher compared to the control group (P &lt; 0.005). However, LND alone did not improve survival, and its combination with AMP did not provide additional survival benefits over AMP alone. AMP treatment significantly reduced the amount of breast tumor cell metastasis (P &lt; 0.002), while LND did not affect metastasis. Also, simultaneous treatment of leg AMP and LND reduced the metastasis rate of breast tumor cells (P &lt; 0.05). Conclusions: The most effective step in solid tumors is removing cancer (local management) as soon as possible. Evaluating the regional lymph nodes is the next step. Lymph nodes should be removed if tumors involve lymph nodes. However, removing negative lymph nodes will not affect OS. More investigations are recommended in this field.

Impact of Extended Versus Limited Lymph Node Dissection on Surgical Outcome, Recurrence Patterns and Survival After Radical Cystectomy.

To elucidate the real-world oncological outcomes of robot-assisted radical prostatectomy (RARP) and effectiveness of extended pelvic lymph node dissection (ext-LDN) in the RARP era. Data from 8 194 patients who underwent RARP, including age, clinical T stage, prostate-specific antigen (PSA) before prostate cancer diagnosis (initial PSA), follow-up years, biopsied specimen grade group (GG), and whether they underwent lymph node dissection or not and presurgical androgen deprivation therapy, were recorded. Oncological outcomes among three risk groups (low, intermediate, and poor risks) were analyzed using Kaplan–Meier curves. In intermediate and poor risk cohorts, PSA failure-free, clinical recurrence-free, castration-resistant prostate cancer (CRPC)-free survival, and overall survival (OS) were compared between the ext-LDN groups and no or limited lymph node dissection (no-ltd-LND) groups before and after propensity matching for initial PSA, clinical stage, GG, and androgen deprivation therapy. Four survivals (PSA failure-free, clinical recurrence-free, CRPC-free survival, and OS) were noted among the three risk groups that generally reflected the risks. In comparison between ext-LDN and no-ltd-LND groups, propensity matching matched four factors. No significant difference was observed in the four survivals with or without ext-LDN. In the intermediate-risk, high-risk, and locally advanced cohorts (cT3–4), similar analyses were performed as the subanalyses; no significant difference was observed in the three subanalyses. We showed survival differences among the risk groups and that extended pelvic lymph node dissection has no oncological effectiveness using the largest patient cohort in the literature.

Background:Optimal extent of lymph node dissection for colon cancer is debatable. Extensive lymphadenectomy may increase complication rate, while limited lymph node dissection may compromise oncological outcome. One of promising ways to find balance is to tailor extent of lymph node dissection to patient’s individual anatomy using ICG lymphatic mapping.Methods:This is a single center interventional phase II trial with single group assignment aiming to determine if ICG lymphatic mapping sensitivity is sufficient to guide resection margins selection in colon cancer surgery. The trial’s primary endpoint is proportion of pN+ patients in which affected lymph nodes are detected only within margins of ICG spread. Sample size of 101 patients was calculated using Buderer method [19] with a confidence level (1 − α) of 0.95 as a minimum of cases required to test accuracy of lCG lymphatic mapping for estimated sensitivity of 0.99 and precision of 0.03. The average of pN+ cases in our center (42%) was used as prevalence. Secondary endpoints are incidence of adverse events related to ICG lymphatic mapping, feasibility of ICG lymphatic mapping for colon cancer, incidence of lymph node metastases outside conventional resection margins (10 cm), colon cancer lymphatic spread patterns, proportion of operations which extent is affected by ICG lymphatic mapping. The trial is conducted among female or male patients, 18 years or older, with signed informed consent, and diagnosed primary colon cancer. Inclusion criteria include pathologically confirmed adenocarcinoma of the colon, T1-4aN0-2bM0-1b, clinical indications to colonic resection, ECOG – 0–2. Exclusion criteria consist of acute bowel obstruction, bleeding or perforation, adjacent organ invasion or peritoneal carcinomatosis, and contraindications to ICG administration. Eligible patients are allocated for colonic resection with intraoperative ICG mapping. During pathological examination, lymph nodes are assessed for presence of metastases and location in relation to tumor and fluorescence margins. The study began on 26 July 2022 and is conducted in and financed by N.N. Petrov NMRC of Oncology in Saint Petersburg, Russia, it is conducted in.Results:If after 101 ICG lymphatic mapping procedures, sensitivity of >96% is observed, this will provide rationale behind tailoring resection margins to fit ICG spread.Conclusions:ICG lymphangiography allows a surgeon to see locoregional lymphatics of a tumor site in real time and tailor colon and mesentery resection margins to meet oncological and functional needs. More data is needed to make this approach more widespread.

Single-port (SP) transvesical (TV) robot-assisted radical prostatectomy (RARP) is an extraperitoneal approach that regionalizes surgery to the area of disease, therefore sparing surrounding tissues to promote a fast recovery and early return of functional outcomes. The technique is possible because of the narrow profile of the SP robotic arm, the fully wristed endoscope, and the double-jointed instruments. SP TV RARP is indicated in men with clinically localized prostate cancer. The access to the bladder is obtained in an open fashion through a 3.5 cm midline incision. Once the patient cart is docked, the console surgeon dissects the prostate in the following order: posterior bladder neck, vas deferens and seminal vesicles, anterior bladder neck, neurovascular pedicles, and apex. Subsequently, the urethra is transected, and the prostatic specimen is extracted. At this point, a limited pelvic lymph node dissection can be done in the obturator fossa of each side. Finally, a vesicourethral anastomosis is performed starting with a posterior reconstruction and suturing bilaterally toward the anterior portion of the bladder neck. In our experience of 210, all cases have been performed successfully without conversion or the use of additional ports. There was minimal blood loss (median 70 mL). The median console time was two hours. Most patients underwent nerve-sparing procedures (87.1%). Lymph node dissection was done in 22.4% of cases with a median node yield of four. Ninety-two percent of planned outpatient cases were discharged in < 24 hours with a median length of stay of 4.7 hours, low pain scores, and 96.2% without an opioid prescription. This video article aims to provide a detailed description of the updated surgical technique, discuss special scenarios, and present updated outcomes from a large series of SP TV RARP cases.

Salvage esophagectomy for esophageal cancer after definitive chemoradiotherapy (dCRT) is a high-risk surgery, and radical lymph node dissection (RLND) can cause severe complications. However, the significance of RLND in salvage surgery remains unclear. This study included 55 patients who underwent curative-intent salvage esophagectomy after dCRT for esophageal squamous cell carcinoma. We evaluated the prognostic impact of lymph node dissection of each station using efficacy indexes (EIs) and compared the outcomes between RLND and limited lymph node dissection (LLND). Nine (16.4%) patients underwent RLND and 46 (83.6%) underwent LLND. Patients who underwent RLND had greater operative blood loss and a greater number of resected lymph nodes compared to patients who underwent LLND (P = 0.053 and 0.002, respectively). However, the incidence of postoperative complications was not significantly different between the groups. The EIs of the cervical and mediastinal lymph nodes were zero because no patients with involved nodes at these stations remained alive at 5years. In contrast, perigastric lymph nodes had relatively high EIs. Overall and cancer-specific survival did not differ significantly between patients who underwent RLND and those who underwent LLND (P = 0.475 and 0.808, respectively). The EIs of the cervical and mediastinal lymph nodes were zero, and RLND did not improve survival. Depending on tumor status, LLND may be sufficient for salvage esophagectomy.

Management of bladder cancer in kidney transplant recipients: A narrative review.

Background: Although the current literature has shown an increasing interest in surgical treatment of gastric cancer (GC) in older adults in recent years, there is still no consensus on proper management in this subgroup of patients. This study was designed with the objective of evaluating the current evidence that compares limited lymph node dissection with extended lymph node dissection in older adult patients (≥65 years) coursing with resectable GC. Methods: A systematic review of PubMed, Cochrane library, and ScienceDirect was performed according to PRISMA guidelines. All studies before 2018 were selected using a systematic review by Mogal et al. Studies were eligible for this meta-analysis if they were randomized controlled trials or non-randomized comparative studies comparing limited lymph node dissection versus extended lymph node dissection in patients with resectable GC taken to gastrectomy. Results: Seventeen studies and a total of 5056 patients were included. There were not any statistically significant differences in OS (HR = 1.04, CI95% = 0.72-1.51), RFS (HR = 0.92, CI95% = 0.62-1.38), or CSS (HR = 1.24, CI95% = 0.74-2.10) between older adult patients taken to limited and extended lymphadenectomy in addition to gastrectomy as the current surgical treatment for GC. Although a higher rate of major complications was observed in the extended lymphadenectomy group, this difference was not statistically significant in incidence between both groups of patients (OR = 1.92, CI95% = 0.75-4.91). Conclusions: Limited lymphadenectomy must be considered as the better recommendation for surgical treatment for GC in older adult patients, considering the oncological outcomes and lower rates of complications compared with more radical lymph node dissections.

Abstract Background Sentinel lymph node navigated surgery (SNNS) has been adopted for various cancers to reduce the negative impact of lymphadenectomy. Limited lymph node dissection using SNNS might be employed in the management of clinically lymph node negative early esophagogastric junction adenocarcinoma (EGJAC). However, it must be sure that sentinel lymph nodes (SLNs) reflect the patient's overall pN status. The aim of this study was to determine the feasibility and safety of SNNS using near-infrared fluorescence imaging and to obtain preliminary data about sensitivity of prediction of lymph node metastasis using SNNS. Methods Patients with cT1-2cN0 EGJAC without neoadjuvant therapy were prospectively included. One patient was enrolled after non-radical endoscopic resection of a high-risk pT1 tumor. Solution of indocyanine green (ICG) and 10% human serum albumin (ICG concentration 1,25mg/mL) was injected endoscopically into the submucosal layer at four quadrants (á 0.5mL) around the tumor or endoscopic resection scar just before the surgery. Subsequently, SLNs were identified and removed laparoscopically using fluorescence imaging. Then, esophagectomy or gastrectomy with radical lymphadenectomy were performed in all patients. Results A total of nine patients underwent SNNS followed by radical surgery. Histopathology revealed pT0pN0 in 1 patient, pT1bN0 in 3 patients, pT1bN3 in 1 patient, pT2pN1 in 2 patients, pT3pN0 in 1 patient and pT3pN2 in 1 patient. Overall, 62 SLNs were detected (median 7 SLNs per patient, range 1-16). Metastases in SLNs were found in four patients. All patients with pathologically positive lymph nodes had at least one SLN positive for metastasis. Sensitivity of prediction of pN positive status was 100%, false negative rate was 0%. There were no ICG-related adverse events or complications associated with SNNS procedure. Conclusion These results suggest that SNNS using ICG and fluorescence imaging in early EGJAC is feasible and safe. Our pilot data show promising diagnostic accuracy of predicting pathological lymph node status using SNNS. However, further studies with a larger number of patients are needed before introducing SNNS into clinical practice.

Background: Despite the strong declining trends in incidence and mortality over the last decades, gastric cancer (GC) is still burdened with high mortality, even in high-income countries. To improve GC prognosis, several guidelines have been increasingly published with indications about the most appropriate GC management. The Italian Society of Digestive System Pathology (SIPAD) and Gastric Cancer Italian Research Group (GIRCG) designed a survey for both surgeons and patients with the purpose of evaluating the degree of application and adherence to guidelines in GC management in Italy. Materials and Methods: Between January and May 2022, a questionnaire has been administered to a sample of Italian surgeons and, in a simplified version, to members of the Patient Association "Vivere Senza Stomaco" (patients surgically treated for GC between 2008 and 2021) to investigate the diagnosis, staging, and treatment issues. Results: The survey has been completed by 125 surgeons and 125 patients. Abdominal CT with gastric hydro-distension before treatment was not widespread in both groups (47% and 42%, respectively). The rate of surgeons stating that they do not usually perform minimally invasive gastrectomy was 15%, but the rate of patients who underwent a minimally invasive approach was 22% (between 2011 and 2022). The percentage of surgeons declaring to perform extended lymphadenectomy (>D2) was 97%, although a limited lymph node dissection rate was observed in about 35% of patients. Conclusions: This survey shows several important discrepancies from surgical attitudes declared by surgeons and real data derived from the reports available to the patients, suggesting heterogeneous management in clinical practice and, thus, a not rigorous adherence to the guidelines.

In 2015, the World Health Organization (WHO) included spread through air space (STAS) as a new invasive mode of lung cancer. As a new mode of lung cancer dissemination, STAS has a significant and negative impact on patient prognosis. The surgical approach as well as lymph node dissection (LND) for STAS-positive patients is currently unclear. The aim of this study was to investigate the impact of different surgical approaches to STAS and LND on the prognosis of patients with ≤2 cm stage IA lung adenocarcinoma (LUAD). This study also investigated the possible relationship between STAS and the micropapillary histological subtype and its impact on patient prognosis. A total of 212 patients with LUAD were included in this study from January 2016 to December 2017, and the overall survival (OS) of the patients was compared. The chi-square test and t-test were applied to compare the clinicopathological data of the patients, and the Cox model was used for the multivariate survival analysis. Of the 212 patients, 93 (43.9%) were STAS positive. The univariate analysis showed that the surgical approach, LND type, micropapillary pattern (MP), solid pattern, and STAS were risk factors for OS. The multivariate analysis showed that the surgical approach, MP, and STAS were risk factors for OS. The STAS-positive patients who underwent lobectomy had a better prognosis than those who underwent sublobar resection; however, there was no significant difference between the two surgical procedures in the STAS-negative group. Additionally, the STAS-positive patients who underwent systematic lymph node dissection (SLND) had a better prognosis than those who underwent limited lymph node dissection (LLND); however, there was no significant difference between the two LNDs in the STAS-negative group. STAS plays an important role in patient prognosis and is an independent risk factor for OS of patients with ≤2 cm stage IA LUAD. When STAS is positive, the choice of lobectomy with SLND may result in a better long-term prognosis for patients.

For patients with gastric cancer, a well-balanced treatment that considers both oncological aspects and surgical risk is demanded. This study aimed to explore the optimal extent of lymph node dissection (LND) for patients with gastric cancer according to surgical risk, stratified by the risk calculator system produced by the Japan National Clinical Database (NCD). We retrospectively evaluated 187 patients who underwent radical gastrectomy for gastric cancer. Using the median predicted anastomotic leak rate obtained by the NCD risk calculator as the cutoff value, we classified 97 and 90 patients as having high and low risks, respectively. In low-risk patients, although limited LND reduced the postoperative intraabdominal infectious complications (IAIC), multivariate analysis revealed standard LND as an independent prognostic factor that improved Relapse-free survival (RFS). In high-risk patients, the rates of postoperative IAIC and RFS were similar between standard and limited LND. Pancreatic fistula was not observed in the limited dissection group. Limited LND might be the optimal treatment strategy for patients with gastric cancer with high surgical risk.

Fluorescence in prostate cancer surgery