LN Count Research Articles

Prognostic Relevance of Negative Lymph Node Count in Resected Stage I-IIIa Small-cell Lung Cancer.

The prognostic significance of the negative lymph node (NLN) count has been confirmed in various cancers but not in small-cell lung cancer (SCLC). We aimed to evaluate the correlation between the NLN count and the prognosis of patients with stages I-IIIa SCLC who underwent lobectomy. Data on the clinical characteristics of SCLC patients who underwent lobectomy between 2000 and 2019 were collected from the SEER database and organized based on the X-tile plots to identify the optimal cutoff point for the NLN count. Kaplan-Meier curves and a Cox proportional hazard model were used to evaluate the prognostic factors for overall survival (OS) and lung cancer-specific survival. Based on the X-tile plot-determined cutoff points of 3 and 7, the participants were grouped into the low (<3), middle (3-7), and high (>7) NLN subgroups for the analysis of OS. Univariable analysis showed that a higher NLN count correlated with more favorable OS and lung cancer-specific survival (both P <0.001). Multivariate analysis demonstrated that, after adjustment for related factors, the NLN count was positively associated with the prognosis and might thus be an independent risk factor for prognosis. Subgroup analyses revealed that, among different LN statuses and varied positive LN counts, the NLN count could predict the prognosis independently. Higher NLNs correlated with better survival for patients who underwent lobectomy of stages I-IIIa SCLC. A predictive marker that combines the NLN count with the N stage and positive LN count could provide more prognostic information in SCLC.

Concurrent prognostic utility of lymph node count and lymph node density for men with pathological node-positive prostate cancer.

While both the number (+LN) and density (LND) of metastatic lymph nodes on radical prostatectomy lymphadenectomy predict mortality in prostate cancer, the independent impact of each on overall mortality (OM) is unknown. We sampled men who underwent radical prostatectomy and lymphadenectomy between 2004 and 2013 from the National Cancer Database. Multivariable Cox proportional hazards analysis with restricted cubic spline was used to assess the non-linear association of +LN count and LND with OM. Of 229,547 men in our sample, 3% (n = 7507) had +LNs, of which 89% had 1-3 +LN and 11% had ≥4 +LN. In multivariable Cox analysis across all patients, OM increased with each additional +LN up to four (HR 1.14, 95%CI 1.06-1.23 per node), with no increase beyond 4 +LN. LND was an independent predictor of OM (HR 1.09, 95%CI 1.06-1.12 per 10% increase). However, after excluding patients with inadequate nodal sampling (<5 LN examined), the variation in OM explained by LND was negligible for patients with ≤3 +LN. In men with 1, 2, and 3 +LN, there was a 0.28%, 0.02%, and 0.50% increase in OM for each 10% increase in LND, compared with 1.9% and 1.6% for men with 4 or 5+ LNs. While +LN count and LND independently predict OM, the impact of LND is negligible in men with ≤3 +LN, who comprise the vast majority of men with +LN. Pathological nodal staging should primarily rely on LN count rather than LND.

Omalizumab for treatment of idiopathic angioedema

BackgroundOmalizumab has been found to improve outcomes in patients with chronic spontaneous urticaria (CSU). Idiopathic angioedema (IAE) is increasingly being recognized as a condition with similar underlying mechanisms as CSU and a form of CSU. We hypothesized that add-on therapy with omalizumab would benefit patients with uncontrolled IAE. ObjectiveTo study the safety and efficacy of omalizumab for the treatment of IAE in adults. MethodsWe conducted a randomized, placebo-controlled trial to study the efficacy of omalizumab in adults with 2 or more episodes of angioedema (AE) in the past 6 months for which no clinical or laboratory cause of AE could be found. A total of 10 patients were randomized on a 1:1 basis to receive omalizumab 300 mg subcutaneously or placebo every 4 weeks for 24 weeks with a 12-week follow-up period. The primary endpoint was the change in the Angioedema Activity Score. Secondary endpoints included the Angioedema Quality of Life Questionnaire, the Visual Analogue Scale, and the number of angioedema episodes per month. ResultsWe observed improvement in the Angioedema Activity Score (−2.93 ln odds; 95% confidence interval [CI], −4.84 to −1.02; P = .003), Visual Analogue Scale (−3.49 ln odds; 95% CI, −6.58 to −0.40; P = .03), Angioedema Quality of Life Questionnaire (−9.43 score; 95% CI, −17.63 to −1.24; P = .03), and number of angioedema episodes per month (−1.93 ln count; 95% CI, −3.23 to −0.63; P = .005) in patients who received omalizumab vs placebo. ConclusionThis study provides preliminary prospective evidence that omalizumab improves outcomes in patients with IAE. Trial RegistrationClinicalTrials.gov Identifier: NCT02966314. ClinicalTrials.gov URL:https://clinicaltrials.gov/ct2/show/NCT02966314?term=omalizumab&cond=Angioedema&draw=2&rank=1.

Oncologic Outcomes of Multi-Institutional Minimally Invasive Inguinal Lymph Node Dissection for Melanoma Compared with Open Inguinal Dissection in the Second Multicenter Selective Lymphadenectomy Trial (MSLT-II).

Minimally invasive inguinal lymphadenectomy (MILND) is safe and feasible, but limited data exist regarding oncologic outcomes. This study performed a multi-institutional retrospective cohort analysis of consecutive MILND performed for melanoma between January 2009 and June 2016. The open ILND (OILND) comparative cohort comprised patients enrolled in the second Multicenter Selective Lymphadenectomy Trial (MSLT-II) between December 2004 and March 2014.The pre-defined primary end point was the same-basin regional nodal recurrence, calculated using properties of binomial distribution. Time to events was calculated using the Kaplan-Meier method. The secondary end points were overall survival, progression-free survival, melanoma-specific survival (MSS), and distant metastasis-free survival (DMFS). For all the patients undergoing MILND, the same-basin regional recurrence rate was 4.4 % (10/228; 95 % confidence interval [CI], 2.1-7.9 %): 8.2 % (4/49) for clinical nodal disease and 3.4 % (6/179) for patients with a positive sentinel lymph node (SLN) as the indication. For the 288 patients enrolled in MSLT-II who underwent OILND for a positive SLN, 17 (5.9 %) had regional node recurrence as their first event. After controlling for ulceration, positive LN count and positive non-SLNs at the time of lymphadenectomy, no difference in OS, PFS, MSS or DMFS was observed for patients with a positive SLN who underwent MILND versus OILND. This large multi-institutional experience supports the oncologic safety of MILND for melanoma. The outcomes in this large multi-institutional experience of MILND compared favorably with those for an OILND population during similar periods, supporting the oncologic safety of MILND for melanoma.

Prognostic value of examined lymph node count in patients with lymph node negative pancreatic head carcinoma: A single-center experience

Background/Aim: One of the important prognostic factors for pancreatic cancer is the count of examined lymph nodes (ELN). The ratio of metastatic to ELNs reflects survival and is required for accurate staging. The survival effect of the count of ELNs in patients with an absence of metastatic lymph nodes is unclear. However, the single-center survival outcomes related to higher ELN count based on only lymph node negative-patients are limited to a few studies with controversial results. We aimed to present the single-center experience in survival outcomes based on ELN count in patients with lymph node-negative pancreatic head cancer after pancreaticoduodenectomy. Methods: The data of 129 patients who underwent pancreaticoduodenectomy for pancreatic cancer from October 2011-December 2021 were analyzed. Among them, those who had metastatic lymph nodes, those who died from non-PC causes, died in the first 90 days postoperatively, or had missing follow-up data were excluded. Finally, 37 patients with negative lymph nodes who satisfied our criteria were included. The cut-off value for the examined lymph node count was 15, according to the minimum LN count recommended by the International Study Group of Pancreatic Surgery and the European Society for Medical Oncology for accurate staging. Thus, node-negative patients were divided into ELN

Evaluating Zr/Rb Ratio From XRF Scanning as an Indicator of Grain‐Size Variations of Glaciomarine Sediments in the Southern Ocean

AbstractThe ln(Zr/Rb) count ratio derived from X‐ray fluorescence (XRF) core scanning holds potential as a high‐resolution tracer for grain‐size variations of glaciomarine sediments, and hence current strength. To evaluate this approach, we conducted high‐resolution grain‐size measurements, together with Rb and Zr measurements by XRF core scanning and inductively coupled plasma‐mass spectrometry (ICP‐MS), on a series of sediment cores from different regions of the Southern Ocean. Downcore changes of the ln(Zr/Rb) count ratio from XRF core scanning are consistent with Zr/Rb concentration ratios derived from ICP‐MS analyses, even though Rb and Zr counts deviate significantly from concentrations due to specimen and matrix effects. The ln(Zr/Rb) count ratio displays discrepancies with the bulk mean grain‐size, but correlates well with the mean grain‐size of the sediment fractions that do not include unsorted sand delivered by ice‐rafting. These observations are supported by evidence from a grain‐size separation experiment, which indicates that Zr and Rb are concentrated in different grain‐size fractions. Consistent with its lack of sensitivity to coarse grain‐size fractions derived from ice‐rafting, the ln(Zr/Rb) ratio records similar trends to the sortable silt percent (SS%) and sortable silt mean () grain‐size. Universal gradients exist in plots of SS% versus ln(Zr/Rb), and versus ln(Zr/Rb), such that the ln(Zr/Rb) ratio provides a convenient way to estimate the magnitude of changes in SS% and . Overall, our results support the use of the ln(Zr/Rb) ratio as an indicator of bottom current strength in cases where the sediment is current‐sorted.

Race Associated With Variable Risk of Lymph Node Involvement in Endometrial Cancer

Nomograms for predicting lymph node involvement in endometrial adenocarcinoma (EAC) typically include various tumor features, including depth of invasion, grade, and lymphovascular invasion (LVI). Whether demographic factors such as age and/or race impact the risk of nodal involvement is not clear. The purpose of this study was to investigate demographic, clinical, and pathologic predictors of LN involvement among patients with EAC. All EAC patients between 2004-2015 (n = 429,084) in the National Cancer Database (NCDB) were initially identified. Patients with non-adenocarcinoma histology, AJCC tumor stage other than primary pathologic T1b or T2, fewer than 10 LN sampled at the time of surgery, undifferentiated histology, or missing data regarding LVI, tumor grade, tumor size, or LN count were excluded. This left 15,117 patients for analysis. Logistic regression identified predictors of LN involvement. Chi-square tests were performed to assess for statistically significant differences in frequencies between groups. Significance was set at a p value of < 0.05. From 2004-2014, 15,117 patients with EAC were included, of whom 2,756 had positive pelvic and/or paraaortic LN identified at the time of surgical staging. On multivariate analysis, predictors of LN involvement identified as significant on univariate analysis were included, and all factors remained significant, including increasing age per year (odds ratio [OR] 0.986, 95% confidence interval [CI] 0.982-0.991, p<0.001), black race relative to white race (OR 1.32, 95% CI 1.12-1.57, p = 0.001), pathologic T2 relative to T1b (OR 1.65, 95% CI 1.49-1.82, p<0.001), poorly differentiated relative to well differentiated tumor grade (OR 1.35, 95% CI 1.20-1.53, p<0.001), presence versus absence of LVI (OR 5.17, 95% CI 4.71-5.68, p<0.001), increase in tumor size per millimeter (OR 1.004, 95% CI 1.003-1.005, p<0.001), and number of LNs sampled at the time of surgical staging (OR 1.015, 95% CI 1.011-1.020, p<0.001). Multivariate logistic regression of 1,087 black women revealed that age (OR 0.981, 95% CI 0.963-0.998, p = 0.03), tumor grade (OR 3.75, 95% CI 2.25-6.50, p<0.001), and LVI (OR 4.13, 95% CI 3.04-5.68, p<0.001) remained significant predictors of LN involvement. Multivariate logistic regression of 14,030 white women revealed that age (OR 0.979, 95% CI 0.973-0.985, p<0.001), tumor grade (OR 1.44, 95% CI 1.29-1.63, p<0.001), and LVI (OR 5.32, 95% CI 4.85-5.85, p<0.001) remained significant predictors of LN involvement. In addition to more traditional pathologic risk factors for LN involvement, patient race was also found to be a significant risk factor for positive LNs. The odds ratio of pathologic risk factors predicting involved lymph nodes also varied by race, and investigation into the underlying etiology of this difference warranted.

Number of paraaortic lymph node dissections as a prognostic factor in locally advanced cervical cancer

BackgroundLymph node (LN) metastases are the most important prognostic factor in locally advanced cervical cancer. Paraaortic lymphadenectomy is the only method able to confirm the presence of metastasis and thereby help to determine the most adequate treatment approach. There is no standard regarding the minimal number of LNs that should be removed in paraaortic lymphadenectomy. Women with undiagnosed positive paraaortic LNs (false negatives) due to a low LN count do not receive extended-field radiation therapy, which may lead to worse survival outcomes. The aim of this study is to confirm LN metastases as poor prognosis and to assess whether in cases of locally advanced CC with negative paraaortic LN status, the number of paraaortic LN laparoscopically removed carries a prognostic value. MethodsWe analyzed 78 patients with locally advanced cervical cancer that underwent complete paraaortic lymphadenectomy. ResultsFifteen (19.2%) women had paraaortic LN metastases. The mean number of LN extracted was 11.1 (SD 7.5). Patients with paraaortic LN metastases presented a worse overall survival (127.1 months [95% CI 111.7–142.4] vs. 59.6 months [95% CI 31.2–87.9]; p<0.01). Nevertheless, there were no differences regarding disease-free survival. There were no prognostic differences according to the number of LNs resected in patients with negative lymphadenectomy. ConclusionsPatients with locally advanced cervical cancer and paraaortic LN metastases present worse survival. In women with negative paraaortic LN, the number of LNs removed does not imply shorter survival.

Association of lymph node count and survival after primary retroperitoneal lymph node dissection (RPLND) for testicular nonseminomatous germ cell tumor (NSGCT).

e17052 Background: RPLND for clinical stage (CS) I &amp; IIA/B NSGCT has both staging and therapeutic implications. Single center studies have reported on the impact of lymph node count on outcome after 1° RPLND for men with NSGCT. However, this has yet to be corroborated in a nationally representative dataset. Methods: Using the National Cancer Database, patients who received a 1° RPLND from 2004-2014 for CS I &amp; IIA/B NSGCT were identified. The analytic cohort was stratified according to LN count (≤20, 21-40, and &gt; 40 LNs). Sociodemographic characteristics were compared among groups. The Kaplan-Meier method was calculated and pairwise comparisons performed. Based on sensitivity analyses to determine LN cutoff that impacts survival, subsequent analysis compared patients with ≤20 and &gt; 20 LNs resected. Multivariate analysis using stepwise regression was used to determine factors associated with receipt of an RPLND with &gt; 20 LNs resected. Results: Of 1,376 men who received 1° RPLND for Stage I or IIA/B NSGCT, 35.6%, 27.4%, and 14% had ≤20, 21-40, and &gt; 40 LNs resected, respectively. LN count was associated with overall survival (OS), with 95%, 97%, and 98% 8-year OS for men with LN count ≤20, 21-40, and &gt; 40 LNs, respectively. OS in men with ≤20 vs 21-40 (p = 0.018) and &gt; 40 LNs (p = 0.042) resected differed significantly. However, no significant difference was observed when 21-40 vs &gt; 40 LNs were resected (p = 0.677). Therefore, subsequent analysis compared those who had ≤20 and &gt; 20 LN resected, and OS between these two groups differed significantly (Figure). Multivariate analysis demonstrated that patients with private insurance, surgery having been performed at an academic center or in the Northeast, and those with pT2 disease were more likely to have &gt; 20 LNs resected at the time of RPLND. Conclusions: Lymph node count after 1° RPLND for NSGCT is significantly associated with overall survival, with more favorable survival seen in those who receive an RPLND with &gt; 20 LNs resected when compared to ≤20 LNs.

MP11-12 ASSOCIATION OF LYMPH NODE COUNT AND SURVIVAL AFTER PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION (RPLND) FOR TESTICULAR NONSEMINOMATOUS GERM CELL TUMOR (NSGCT)

You have accessJournal of UrologyPenile & Testicular Cancer: Penile & Testicular Cancer I (MP11)1 Apr 2020MP11-12 ASSOCIATION OF LYMPH NODE COUNT AND SURVIVAL AFTER PRIMARY RETROPERITONEAL LYMPH NODE DISSECTION (RPLND) FOR TESTICULAR NONSEMINOMATOUS GERM CELL TUMOR (NSGCT) Hiren Patel*, Arnav Srivastava, Sinae Kim, Isaac Kim, Eric Singer, and Thomas Jang Hiren Patel*Hiren Patel* More articles by this author , Arnav SrivastavaArnav Srivastava More articles by this author , Sinae KimSinae Kim More articles by this author , Isaac KimIsaac Kim More articles by this author , Eric SingerEric Singer More articles by this author , and Thomas JangThomas Jang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000831.012AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: RPLND for clinical stage (CS) I & IIA/B NSGCT has both staging and therapeutic implications. Single center studies have reported on the impact of lymph node count on outcome after 1° RPLND for men with NSGCT. However, this has yet to be corroborated in a nationally representative dataset. METHODS: Using the National Cancer Database, patients who received a 1° RPLND from 2004-2014 for CS I & IIA/B NSGCT were identified. The analytic cohort was stratified according to LN count (≤20, 21-40, and >40 LNs). Sociodemographic characteristics were compared among groups. The Kaplan-Meier method was calculated and pairwise comparisons performed. Based on sensitivity analyses to determine LN cutoff that impacts survival, subsequent analysis compared patients with ≤20 and >20 LNs resected. Multivariate analysis using stepwise regression was used to determine factors associated with receipt of an RPLND with >20 LNs resected. RESULTS: Of 1,376 men who received 1° RPLND for Stage I or IIA/B NSGCT, 35.6%, 27.4%, and 14% had ≤20, 21-40, and >40 LNs resected, respectively. LN count was associated with overall survival (OS), with 95%, 97%, and 98% 8-year OS for men with LN count ≤20, 21-40, and >40 LNs, respectively. OS in men with ≤20 vs 21-40 (p=0.018) and >40 LNs (p=0.042) resected differed significantly. However, no significant difference was observed when 21-40 vs >40 LNs were resected (p=0.677). Therefore, subsequent analysis compared those who had ≤20 and >20 LN resected, and OS between these two groups differed significantly (Figure). Multivariate analysis demonstrated that patients with private insurance, surgery having been performed at an academic center or in the Northeast, and those with pT2 disease were more likely to have >20 LNs resected at the time of RPLND. CONCLUSIONS: Lymph node count after 1° RPLND for NSGCT is significantly associated with overall survival, with more favorable survival seen in those who receive an RPLND with >20 LNs resected when compared to ≤20 LNs. Source of Funding: This work is supported by a grant from the National Cancer Institute (P30CA072720). © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e139-e140 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hiren Patel* More articles by this author Arnav Srivastava More articles by this author Sinae Kim More articles by this author Isaac Kim More articles by this author Eric Singer More articles by this author Thomas Jang More articles by this author Expand All Advertisement PDF downloadLoading ...

Number of paraaortic lymph node dissections as a prognostic factor in locally advanced cervical cancer

BackgroundLymph node (LN) metastases are the most important prognostic factor in locally advanced cervical cancer. Paraaortic lymphadenectomy is the only method able to confirm the presence of metastasis and thereby help to determine the most adequate treatment approach. There is no standard regarding the minimal number of LNs that should be removed in paraaortic lymphadenectomy. Women with undiagnosed positive paraaortic LNs (false negatives) due to a low LN count do not receive extended-field radiation therapy, which may lead to worse survival outcomes. The aim of this study is to confirm LN metastases as poor prognosis and to assess whether in cases of locally advanced CC with negative paraaortic LN status, the number of paraaortic LN laparoscopically removed carries a prognostic value. MethodsWe analyzed 78 patients with locally advanced cervical cancer that underwent complete paraaortic lymphadenectomy. ResultsFifteen (19.2%) women had paraaortic LN metastases. The mean number of LN extracted was 11.1 (SD 7.5). Patients with paraaortic LN metastases presented a worse overall survival (127.1 months [95% CI 111.7–142.4] vs. 59.6 months [95% CI 31.2–87.9]; p<0.01). Nevertheless, there were no differences regarding disease-free survival. There were no prognostic differences according to the number of LNs resected in patients with negative lymphadenectomy. ConclusionsPatients with locally advanced cervical cancer and paraaortic LN metastases present worse survival. In women with negative paraaortic LN, the number of LNs removed does not imply shorter survival.

Is Negative Lymph Node Count Another Clinico-pathological Predictor in Breast Cancer with Neoadjuvant Chemotherapy?

To investigate the survival impact of negative lymph nodes (NLNs) in breast cancer (BC) patients who received neoadjuvant chemotherapy (NAC). We retrospectively evaluated 435 BC patients who presented and received NAC at our institute. The prognostic value of the number of NLNs and other clinic-pathological factors with respect to disease-free survival (DFS) and overall survival (OS) was analyzed. The median age was 49 years old. 385 patients were in ypT0-2, 187 patients in ypT3-4; 99 cases ypN0, 99 cases were ypN1, 108 cases were ypN2, and 129 cases were ypN3. With a median follow-up time of 61 months, the 5-year OS (5y-OS), 5-year loco-regional failure-free survival (5y-LRFS), 5-year distant metastasis-free survival (5y-DMFS) were 74.8%, 84.1%, and 71.4%, respectively. Negative LN count, estrogen receptor status, pathological T and N stage were independent prognostic factors associated with 5y-LRFS. A critical relationship was observed between NLNs and 5y-LFRS, with an HR of 0.948 (95% CI: 0.917-0.981), p=0.002. Patients with NLNs more than 10 showed significantly superior 5y-LRFS than those with NLNs no more than 10 (5y-LRFS were 90.6% in NLNs vs. 64.8% in ≤10 NLNs, p=0.000). The most survival benefit was found in patients with N-positive disease (5y-LRFS were 87.4% in >10 NLNs vs. 64.0% in ≤10 NLNs, p=0.000), relative to the N0 disease (5y-LRFS were 96.9% in >10 NLNs vs. 100% in ≤10 NLNs, p=0.724). In this survival beneficial group with >10 NLNs, post-mastectomy radiotherapy (PMRT) could not improve 5y-LRFS (5y-LRFS were 88.4% vs. 85.1% with or without PMRT, p=0.257), otherwise than that in patients with ≤10 NLNs (5y-LRFS were 69.0% vs. 27.6% with or without PMRT, p=0.002). This is the first study to confirm the relationship between negative lymph node count and prognosis of breast cancer with NAC. More NLNs imply higher local control and longer survival. This result might let NLNs be a prognostic factor for considering treatment decisions, such as PMRT.

A Picture is Worth a Thousand Words: Intraoperative Photography as a Quality Metric for Axillary Dissection.

The adequacy of an axillary lymph node dissection (ALND) is frequently assessed by the number of LNs pathologically identified. We hypothesized that intraoperative photographs facilitate objective measurement of the surgical quality of an ALND. Intraoperative photographs of the axilla were obtained prospectively following ALND by four surgeons. An objective scoring system was created based on the visibility of anatomic landmarks, with a maximum score of 7. Photographs of each case were scored independently by the other three surgeons. Factors thought to influence LN count were evaluated for correlation. Interrater variability was calculated. A total of 115 cases were evaluated: 98 breast and 17 melanoma. Mean LN count was 25.1 (SD 10.5): 23.2 (SD 7.9) for breast and 36.5 (SD 15.8) for melanoma. Ninety percent of cases had a LN count ≥15. Factors associated with a higher number of LNs were melanoma (p<0.001), visualization of the axillary vein (p=0.03), and long thoracic nerve (p=0.04). There was no association with age, body mass index, number of positive LNs, neoadjuvant chemotherapy, or matted LNs. Mean ALND photograph score was 4.8 (SD 1.3). A 1-point change in total score increased the mean LN count by 2.4 (p=0.002). Correlations for interrater reliability varied from 0.27 to 0.62. Photographic visualization of axillary anatomic structures correlates with the number of LNs identified on pathology. These findings support initiating a larger study with more surgeons to define the optimal photo metrics of an adequate ALND.

Effect of Lymph Node Count on Pathological Stage III Rectal Cancer with Preoperative Radiotherapy.

Lymph node (LN) status after surgery for rectal cancer is affected by preoperative radiotherapy. The purpose of this study was to perform a population-based evaluation of the impact of pathologic LN status after neoadjuvant radiotherapy on survival. A total of 1,650 patients receiving neoadjuvant chemotherapy in Surveillance, Epidemiology, and End Results Program (SEER)-registered ypIII stage rectal cancer was analyzed. We identified the optimal cutoff for retrieved LNs as 10 (χ2 = 14.006, P < 0.001), which was validated as an independent prognosis factors in a Cox regression model. Further analysis showed that the LN count was only a prognosis factor with the number from 8 to 16(except for 13).After the number 16, the 5-year survival rate decreased gradually. Collectively, our results confirmed that the number of LNs in yp III stage rectal patients was a prognosis factor only with the numbers from 8 to 16(except for 13). Using the total mesorectal excision technique with an adequate pathologic examination, a large number of LNs retrieved (≥17) might indicate worse tumor response grade and poorer survival.

Optimal assessment of lymph node status in gallbladder cancer

BackgroundLymph node (LN) metastasis is an important prognostic factor in gallbladder cancer (GBCA). LN status has been adopted as a critical element of staging systems. However, the influence of total lymph node count (TLNC) remains unclear. We determined the optimal minimum TLNC and compared the prognostic significance of LN status indices in GBCA. MethodsWe retrospectively reviewed medical records of 128 patients with T2 or greater GBCA who underwent LN dissection. We analyzed overall survival (OS) and relevance of the number of metastatic LNs, ratio of metastatic LNs to retrieved LNs (LNR), and TLNC in predicting OS. ResultsThe median OS durations were 120, 35, and 18 months in T2, T3, and T4 GBCA. Five-year OS rates were 73%, 43%, and 0% in T2, T3, and T4 GBCA. LN status did not significantly impact OS in T2 or T4 GBCA. However, all LN indices were significantly correlated with OS in T3 GBCA. Furthermore, multivariate analysis revealed that a metastatic LN count of more than four and a TLNC of more than eight were independent prognostic factors of OS in T3 GBCA. ConclusionsTLNC and the number of positive LNs may be more important prognostic factors than LNR in T3 GBCA. Additionally, accurate staging may not be achieved in cases of T3 GBCA if the total number of retrieved LNs is less than eight. Thus, to ensure proper staging, we recommend that surgeons harvest more than eight LNs in patients with T3 GBCA.

Minimum 5-year follow-up of 1138 consecutive laparoscopic radical prostatectomies.

To investigate the long-term outcomes of laparoscopic radical prostatectomy (LRP). In all, 1138 patients underwent LRP during a 163-month period from 2000 to 2008, of which 51.5%, 30.3% and 18.2% were categorised into D'Amico risk groups of low-, intermediate- and high-risk, respectively. All intermediate- and high-risk patients were staged by preoperative magnetic resonance imaging or computed tomography and isotope bone scanning, and had a pelvic lymph node dissection (PLND), which was extended after April 2008. The median (range) patient age was 62 (40-78) years; body mass index was 26 (19-44) kg/m(2) ; prostate-specific antigen level was 7.0 (1-50) ng/mL and Gleason score was 6 (6-10). Neurovascular bundle was preservation carried out in 55.3% (bilateral 45.5%; unilateral 9.8%) of patients. The median (range) gland weight was 52 (14-214) g. The median (range) operating time was 177 (78-600) min and PLND was performed in 299 patients (26.3%), of which 54 (18.0%) were extended. The median (range) blood loss was 200 (10-1300) mL, postoperative hospital stay was 3 (2-14) nights and catheterisation time was 14 (1-35) days. The complication rate was 5.2%. The median (range) LN count was 12 (4-26), LN positivity was 0.8% and the median (range) LN involvement was 2 (1-2). There was margin positivity in 13.9% of patients and up-grading in 29.3% and down-grading in 5.3%. While 11.4% of patients had up-staging from T1/2 to T3 and 37.1% had down-staging from T3 to T2. One case (0.09%) was converted to open surgery and six patients were transfused (0.5%). At a mean (range) follow-up of 88.6 (60-120) months, 85.4% of patients were free of biochemical recurrence, 93.8% were continent and 76.6% of previously potent non-diabetic men aged <70 years were potent after bilateral nerve preservation. The long-term results obtainable from LRP match or exceed those previously published in large contemporary open and robot-assisted surgical series.

Changing patterns in presentation and therapy of esophagogastric junction cancers in the United States.

22 Background: Esophagogastric junction cancer (EGJC) has recently been included within the esophageal cancer (EC) AJCC TNM staging criteria. Trends in clinical presentation, therapeutic approach and outcomes are of interest. Methods: We identified EGJCs from the U.S. population SEER database and examined incidence, demographic, therapeutic and outcomes information. Siewert classification-related EGJC subtype-associated findings were also examined. Results: EGJC age-adjusted incidence rates (x10-5) have increased from 3.3 in 1973 to 7.5 in 2009. While the incidence rate for females has remained around 2, rates in males have increased from 6 to 13. Among 30,710 EGJC patients diagnosed between 1992 and 2009, potentially curative resection increased from 31% to 36% and radiation increased from 32% to 41% (p&lt;0.0001). For resected EGJCs, significant trends over time include: increased total LN count (mean: 15.5 vs. 12.3), fewer positive LNs (3.1 vs. 4), smaller tumor size (29% vs. 36% &gt;5 cm), lower T category (39% vs. 29% T1/2), lower N category (42% vs. 35% N0), lower stage group (29% vs. 38% stage 3/4), increased preoperative radiation (26% vs. 3%), decreased 90-day mortality (6.5 vs. 14.1%), longer overall survival (OS, median: 2.9 vs. 1.7 years) and longer disease-specific survival (median: 3.9 vs. 2.0 years) (all at p&lt;0.0001). Multivariate predictors of OS include TNM categories, age, ethnicity, radiation, and total LN count (all at p&lt;0.0001). There were significant differences in stage-for-stage OS between EC subtypes based on histology and primary tumor location, and in DSS between EGJC subtypes (Siewert I, II or III) as well. Conclusions: EGJC incidence rates, diagnosis and treatment have undergone significant changes within the U.S. population. The regional dissection extent remains an area of importance as it is associated with OS. Comparisons of various survival outcomes do not support using the same staging criteria for EGJC as for EC.

Trends in Epidemiology, Clinical and Histopathological Characteristics of Breast Cancer in Iran: Results of a 17 Year Study

Breast cancer (BC) is the top cancer among women worldwide and the most frequent malignancy among Iranian women over the past few decades. The increasing trend and high mortality rate of BC in the developing world necessitates studies concentrating on its characteristics in countries in Asia. The current study focused on clinical and histopathological features of BC among Iranian females. This retrospective study involved 714 Iranian patients with histopathologically proven BC undergoing resection of primary tumours and axillary clearance. Demographic, clinical and histopathological data were obtained and studied between ten year age groups (≤ 40 years, 41-50 years, 51-60 years, 61-70 years, and ≤ 71 years) in four chronologic phases from 1994-2009. Mean age of patients was 49.4 ± 13.1 years. Most of cases (33.2%) were in 41-50 group. Mean size of primary tumors was 3.94 ± 2.47 cm and 87.1% of cases had infiltrative ductal carcinoma. Modified radical mastectomy was the most common method of surgery carried out (48.8%). Some 57.1% of tumors were in pT2 and tumor size decreased significantly during the period (p<0.05). The most common BC stage was llla (27%). Lower BC stages (0 and 1) constituted 13.9% of the diagnosed tumors. Our series of patients aged ≤ 40 had larger tumors (mean 4.73 ≤ 3.02 cm) compared to older age groups (p=0.003). Lower stages (0 and I) were more frequent among the oldest patients while nearly 50% of patients aged ≤ 40 had tumor stage III. We also observed a significant decreasing trend in the mean LN count (p<0.05) and blood vessel invasion (p=0.023) from younger to older age groups. More aggressive disease for younger age groups, earlier peak incidence age and high rate of advanced BC at the time of diagnosis among Iranian women, were the main findings of this study.

Estimating underreported N2 disease in rectal cancer patients with low lymph node counts

The variability in the number of lymph nodes examined needs to be taken into account for adequate staging. The definition of nodal staging was refined by quantifying the likelihood of N2 disease when the patient had fewer than four positive LN. In a retrospective study a total of 548 patients with node positive rectal cancer and curative surgery between 1990 and 2006 were identified. The misclassification of pN staging was estimated with a Bayesian computation. The prognostic value of the calculated probability, lymph node ratio (LNR), and nodal stage was assessed with Cox proportional hazard regression. A probability of understaging of 40% or more indicated worse prognosis of cancer-specific survival (CSS) with hazard ratio 2.6 (95%CI: 1.8-3.9, P < 0.001). The concordance index of a multivariate model with probability of N2 disease as a prognostic factor for survival was 0.68 for all patients and 0.75 for patients with less than 10 lymph nodes examined. Utilizing estimated probabilities of N2 disease improves our ability to predict survival, in particular in patients with low LN count. These probabilities allow for a simple rule in patient counseling and clinical decision making.

Evaluation of the learning curve associated with robotic radical cystectomy: Initial 100 cases

mains one of the most effective treatment for patients with localized, invasive bladder cancer. However, little study has been undertaken to evaluate less-invasive surgical approaches to this disease. Utilizing our mature experience with robotic-assisted laparoscopic radical cystectomy (RRC), we analyzed the changes in peri-operative outcomes that may reflect progress along the learning curve. METHODS: 100 patients underwent radical cystectomy and urinary diversion at our institution from 1-06‐8/08 for clinically-localized bladder cancer. Operative outcomes, pathological results, and complications were stratified by quintiles with 20 cases in each group. Multiple paired regression models were also constructed t evaluate co-variates predictive of changes or breakpoints in the learning curve. Statistical analysis was performed using SAS version 9.2 (Cary, NC). RESULTS: Table shows the mean outcomes based on time during the experience. Statistical cutpoint for OR time occurred at case 20. On multivariate analysis, statistical cutpoint for EBL was noted at the 20th case, with no significant changes thereafter. With regard to OR time, a statistical cutpoint was noted at the 40th case. No significant changes were noted for LN count, complication rates, bowel function, or length of stay. CONCLUSIONS: Our evolving experience with robotic radical cystectomy appears to be favorable with reduction in blood loss and operative times with increasing experience. These results come in the face of applying this technique to older patients with increased comorbidities.