Rate Of Lymph Node Invasion Research Articles

The Impact of Lymph Node Metastases Burden at Radical Prostatectomy

BackgroundWe hypothesized that a cut-off in positive lymph node (LN) counts may discriminate between cancer-specific mortality (CSM) rates in clinically localized prostate cancer patients treated with radical prostatectomy (RP). ObjectiveTo test this relationship, we relied on different LN count cut-offs, as well as the continuously coded number of positive LNs (NPN). MethodsWithin the Surveillance, Epidemiology, and End Results database (2004–2014), we identified patients with D’Amico intermediate- or high-risk characteristics who underwent RP and pelvic LN dissection, regardless of pathologic LN stage. Kaplan-Meier analyses and multivariable Cox regression models tested the effect of LN invasion (LNI) on CSM, according to the NPN. ResultsOf 30016 patients treated with RP, 6.2% (n=1869) exhibited LNI, with respectively higher rates of LNI in patients with D’Amico high- versus intermediate-risk characteristics (11.6% vs 3.4%). Overall, the median age was 63yr, median prostate-specific antigen value was 6.6ng/ml and the median number of removed LNs was six. At 60 mo after RP, CSM rates were, respectively, 6.0% versus 0.8% for patients with and without LNI: multivariable hazard ratio (HR) 4.4 (p<0.001). CSM rates were, respectively, 0.8% for NPN 0, 2.4% for NPN 1–2 (HR: 3.5, p<0.001), and 7.2% for NPN ≥3 (HR: 10.3, p<0.001). ConclusionsThe NPN is an independent predictor of higher CSM rate. Specifically, patients with one to two positive LNs are at moderately higher risk of CSM than those without LNI, and CSM risk increases sharply in those with ≥3 positive LNs. Our contemporary findings corroborate the NPN cut-offs within previous studies. Patient summaryPatients with three or more positive lymph nodes at radical prostatectomy have significantly higher cancer-specific mortality rates than those without or one to two positive lymph nodes. This stratification can be useful in considering adjuvant treatment options.

A Head-to-head Comparison of Four Prognostic Models for Prediction of Lymph Node Invasion in African American and Caucasian Individuals

BackgroundFour nomograms are available for the prediction of lymph node invasion (LNI) prior to radical prostatectomy (RP): the Cagiannos, the 2012-Briganti, the Godoy, and the online-Memorial Sloan Kettering Cancer Center (MSKCC). None was tested in African Americans (AAs). ObjectiveTo perform a validation and head-to-head comparison of four nomograms for the prediction of LNI in AAs. Design, setting, and participantsWithin the Surveillance Epidemiology and End Results database (2010–2014), we identified 14 077 Caucasians and 2668 AAs with clinically localised prostate cancer. InterventionRP and pelvic lymph node dissection (PLND). Outcome measurements and statistical analysisPredicted and observed LNI rates for the four nomograms were tested between AAs and Caucasians with Heagerty’s concordance index (C-index), calibration plots, decision curve analyses (DCAs), and nomogram-derived cut-offs for avoided PLND and missed LNI cases. Results and limitationsAll C-index values were lower in AAs than in Caucasians: Cagiannos (76.1% vs 79.5%), Godoy (73.0% vs 79.4%), 2012-Briganti (73.3% vs 81.3%), and MSKCC (72.6% vs 81.6%). All four nomogram calibration plots showed invariably worse performances in AAs. In DCAs focusing on AAs, the Cagiannos nomogram provided the highest net benefit relative to the remaining three nomograms. In nomogram cut-off analyses testing the number of avoided PLND against the number of missed LNI cases, the Cagiannos nomogram yielded the best results when tested in AAs. However, in DCAs and cut-off analyses that compared AAs with Caucasians, AAs yielded less favourable outcomes regardless of which nomogram was tested. We lack a central pathology review and standardisation of PLND templates. ConclusionsIn AAs, the Cagiannos nomogram provides the optimal results relative to the remaining three nomograms. Nonetheless, all tested nomograms yielded worse metrics in AAs than in Caucasians. Patient summaryAll four tested nomograms can be equally considered in Caucasians. Conversely, the Cagiannos nomogram should be preferred in African Americans.

Can Early Dissection of Cervical Lymph Nodes Improve Prognosis in Squamous Cell Carcinomas of the Hard Palate

Squamous cell carcinomas of the hard palate and maxillary alveolar ridge are rare tumours with a poor prognosis. Lymph node dissection is recommended for tumours with nodal involvement, and is rarely performed in the absence of adenopathy. We report a series of patients with squamous cell carcinomas and evaluate the rate of lymph node invasion and its impact on survival. This is a retrospective study of 72 patients treated for squamous cell carcinoma of the hard palate and maxillary alveolar ridge between January 1, 1998 and December 31, 2008 in two cancer centres. Using clinical and radiological assessment, tumours were classified as T1-T2 in 25 patients (34.7%) and T3-T4 in 47 patients (65.3%). At diagnosis, 16 (22.2%) patients had clinical and/or radiological nodal involvement and 7 patients (9.7%) distal metastasis. Among N0 patients, 13 (18%) experienced isolated lymph node recurrence. Two-year global survival was 60%; 5-year survival was 34%. The rate of lymph node invasion observed in squamous cell carcinoma of the hard palate and maxillary alveolar ridge does not differ from other oral cavity sites. Because nodal recurrence worsens the prognosis of such a patient, lymph node dissection should be considered at an early stage, even among N0 patients.

Association between ABO blood types and sporadic pancreatic neuroendocrine tumors in the Chinese Han population.

BackgroundAlthough the relationship between non-O blood types and the risk of exocrine pancreatic cancer has been demonstrated, the association between ABO blood types and sporadic pancreatic neuroendocrine tumor (PNET) has not been reported thus far.MethodsThis hospital-based, case-control study included 387 patients with PNET and 542 age- and sex-matched controls. Unconditional multivariable logistic regression analysis was performed to estimate the adjusted odds ratios (AORs) and 95% confidence intervals (CIs). The relationship between ABO blood types and clinicopathologic features was also analyzed.ResultsAfter adjusting for age, sex, smoking status, alcohol drinking, and first-degree family history of any cancer, the AORs (95% CI) of functional PNET were 0.87 (0.59–1.28) for blood type A, 0.86 (0.58–1.28) for blood type B, and 0.71 (0.39–1.26) for blood type AB compared with subjects with blood type O. A similar ABO blood-type distribution was observed among cases with non-functional PNETs compared with controls. On comparing blood type B with non-B blood type, cases with non-functional PNETs had marginally higher rates of lymph node invasion (P = 0.047), distant metastasis (P = 0.044), and advanced European Neuroendocrine Tumor Society Stage (P = 0.040).ConclusionsThere is no association between the ABO blood group and the development of functional and non-functional PNETs. The ABO blood types are not associated with the clinicopathologic features in patients with functional and non-functional PNETs.

Better cancer-specific survival in young patients with nonmetastatic intrahepatic cholangiocarcinoma: A retrospective study of SEER database.

e15637 Background: Intrahepatic cholangiocarcinoma (ICC) is a complicated and fatal malignancy. Aging plays a significant role in the occurrence and development of this liver cancer, but its prognostic role remains unclear. The purpose of this study is to compare the cancer specific survival (CSS) in young patients with elderly ones, and to further establish a nomogram, integrating age and other risk factors, to predict survival outcomes in ICC patients. Methods: Cases of intrahepatic cholangiocarcinoma diagnosed between 2004 and 2013 were extracted from SEER database. Patients were excluded if they had incomplete TNM staging, with distant metastasis (M1) or no evaluation on lymph node. The enrolled cases were divided into young (under 50 years of age) and elderly groups (50 years and over). 1-year and 3-year cancer CSS data were obtained. Kaplan-Meier methods were adopted and multivariable Cox regression models were built for the analysis of survival outcomes and risk factors. A predictive nomogram for prognosis was generated by software R, and the performance of the nomogram was assessed by C-index and validation curves. Results: There were 2385 patients meeting inclusion criteria with median follow up of 17.0 months. Compared with elderly group, young patients showed significantly higher pathological grading (P = 0.006), lower rate of lymph node invasion (P = 0.002), and early TNM stage (P = 0.005). The 1-year and 3-year CSS rates were 57.3% and 19.2% in young group, and 38.2% and 10.8% in elderly group. Both univariate analysis (P = 0.019) and multivariate analysis (P = 0.040) indicated significant difference of CSS between the two groups. The multi-factor, integrative nomogram was established to predict prognosis, whose predictive power was higher than the conventional tumor staging (AJCC 7thedition staging). And the calibration curves for the probability of 1- and 3-year CSS indicated that the nomogram-based prediction was in optimal agreement with actual observed survival. Conclusions: Compared with elderly patients, young patients with non-metastatic ICC appear to have more favorable clinicopathological characteristics and better prognosis.

Echo-Mammographic and Anatomo-Pathological Aspects of Male Breast Cancer in Togo

Studies of male breast cancer are rare in Africa. In Togo in particular, no work has focused on the epidemiological, mammo-echographic, pathological, therapeutic or prognostic aspects of male breast cancer. The aim of this study is to report cases of male breast cancer in Togo by describing the main epidemiological, mammo-echographic and pathological aspects. This was a retrospective, descriptive and analytical study of 10 cases of male patients presenting with breast cancer confirmed by the pathologic examination on the echo-guided samples over a period of 6 years in University Teaching Hospital in Lome. A total of ten patients were retained. The mean age of patients was 55 years with extremes of 39 years and 65 years. All patients had a palpable breast mass. The lesions were classified in 60% American College of Radiology (ACR) 5 and 40% ACR 4. The axillary lymph node invasion rate was 40%. Infiltrating ductal carcinoma was the histologic type diagnosed in all patients. Any breast mass in an elderly male subject is suspected with high predictive value. Mammography ultrasound plays an important role in the diagnosis alongside pathology.

Effect of Stage Migration on Bladder Cancer: A Slow but Steady Improvement in Long-Term Survival Rates After Radical Cystectomy in Previous 25 Years

IntroductionWe evaluated the effect of the year of surgery on the clinical, pathologic, and oncologic outcomes of patients with bladder cancer (BCa) treated with radical cystectomy (RC) at a single institution. Materials and MethodsThe present study included 1253 consecutive patients with BCa treated with RC and extended pelvic lymphadenectomy at a single institution from January 1990 to December 2014. Analysis of variance and χ2 trend tests were used to report the clinical and pathologic characteristics of the cohort over time. Multivariable Cox regression analysis was used to test the relationship between the year of surgery and recurrence, cancer-specific mortality (CSM) and overall mortality (OM). ResultsConsidering the clinical characteristics, patient age (P = .1) and gender (P = .2) remained steady during the study period. In contrast, the body mass index (P < .005) increased. Also, of the pathologic features, carcinoma in situ detection (P < .001) showed an increasing rate, and pathologic stage T3-T4 (P = .005) showed a decreasing trend. The number of lymph nodes removed increased during the study period (P < .001), resulting in an increased number of positive nodes (P < .001). However, the rate of lymph node invasion (P = .1) remained stable in the overall population. Multivariable Cox regression analyses revealed the year of surgery as a predictor of recurrence (hazard ratio [HR], 0.97), CSM (HR, 0.97), and OM (HR, 0.98), with a slight, but constant, reduction in all survival outcomes (P < .04 for all). ConclusionChanges were recorded considering the patient and tumor characteristics across the previous 25 years. These variations directly reflect the differences in long-term survival expectations we recorded.

Impact of stage migration and practice changes on high-risk prostate cancer: results from patients treated with radical prostatectomy over the last two decades.

To evaluate the impact of year of surgery on clinical, pathological and oncological outcomes of patients with high-risk prostate cancer. We evaluated 1033 patients with clinically high-risk prostate cancer, defined as the presence of at least one of the following risk factors: preoperative prostate-specific antigen (PSA) level >20ng/mL, and/or clinical stage ≥T3, and/or biopsy Gleason score ≥8. Patients were treated between 1990 and 2013 at a single institution. The year-by-year trends in clinical and pathological characteristics were examined. Multivariable Cox regression analysis was used to test the relationship between year of surgery and oncological outcomes. We observed a decrease over time in the proportion of patients with high-risk disease (preoperative PSA >20ng/mL or clinical stage cT3). A trend in the opposite direction was seen for biopsy Gleason score ≥8 tumours. We observed a considerable increase in the median number of lymph nodes removed, which was associated with an increased rate of lymph node invasion (LNI). On multivariable Cox regression analysis, year of surgery was associated with a reduced risk of biochemical recurrence (hazard ratio [HR] per 5-year interval 0.90, 95% confidence interval [CI] 0.84-0.96; P = 0.01) and distant metastasis (HR per 5-year interval 0.91, 95% CI 0.83-0.99; P = 0.039), after adjusting for age, preoperative PSA, pathological stage, LNI, surgical margin status, and pathological Gleason score. In this single-centre study, an increased diagnosis of localized and less extensive high-grade prostate cancer was observed over the last two decades. Patients with high-risk disease who were selected for radical prostatectomy showed better cancer control over time. Better definitions of what constitutes high-risk prostate cancer among contemporary patients are needed.

Extended pelvic lymph node dissection in patients with prostate cancer previously treated with surgery for lower urinary tract symptoms.

To evaluate the effect of previous prostate surgery performed for lower urinary tract symptoms (LUTS) on the ability to predict lymph node invasion (LNI) in patients subsequently diagnosed with prostate cancer, testing two widely used LNI predictive models. From 1990 to 2012, we collected data on 4734 patients with prostate cancer treated with radical prostatectomy and extended pelvic LN dissection (ePLND). Of these, 4453 (94%) had no prior prostate surgery ('naïve patients'), while 286 (6%) had previously undergone surgery for LUTS. Two LNI prediction models based on patients treated with ePLND were evaluated using the receiver operating characteristic-derived area under the curve (AUC), the calibration plot method, and decision-curve analyses. The rate of LNI was 12%, while the median number of LNs removed was 15 in both groups (P = 0.9). The two tested nomograms provided more accurate prediction in naïve patients than for those previously treated with prostate surgery for LUTS (AUC: 82% and 81% vs 68% and 71%, P = 0.01 and P = 0.04, respectively). In naïve patients the surgeon would have missed one LNI for every 53 and 34 avoided ePLND using the Briganti and Godoy nomograms, respectively; in patients previously treated with surgery for LUTS, a LNI would have been missed in 13 and 21 patients not undergoing ePLND. The accuracy and the clinical net-benefit of LNI prediction tools decrease significantly in patients with prior prostate surgery for LUTS. These models should be avoided in such patients, who should undergo routine ePLND.

External Validation of the European Association of Urology Recommendations for Pelvic Lymph Node Dissection in Patients Treated with Robot-Assisted Radical Prostatectomy

The European Association of Urology (EAU) guidelines recommend to perform extended pelvic lymph node dissection (ePLND) in all patients with a risk of lymph node invasion (LNI) higher than 5% estimated by the updated Briganti nomogram. However, this model has been developed in patients exclusively treated with open radical prostatectomy. No study has specifically assessed the accuracy of this model among men treated with robot-assisted radical prostatectomy (RARP). We hypothesized that EAU indications for PLND are accurate also among patients treated with RARP. We evaluated 615 patients treated with RARP and PLND between 2006 and 2012 at a single tertiary referral center. The predictive accuracy of the nomogram was quantified using the receiver operating characteristic-derived area under the curve, the calibration plot method, and decision curve analyses. Median of lymph nodes (LNs) removed was 9 (interquartile range: 6-13). The rate of LNI was 5%. External validation of the Briganti nomogram showed good accuracy (81.8%). A nomogram-derived cutoff of 5% would allow the avoidance of 75% of PLND at the cost of missing of 19.4% of patients with LNI. When the same analyses were repeated in men with at least 10 and 15 LNs removed, the 5% cutoff was associated with a reduction in PLND and with an LNI missing rates of 67.6% and 59.3% and 17.4% and 6.2%, respectively. Similarly, the prediction accuracy increased to 81.2% and 85.3%, respectively. The decision curve analysis showed an increase in the net-benefit in the prediction range between 2.5% and 54%. We report the first validation of the EAU guideline recommendation for PLND among patients exclusively treated with RARP. We demonstrated that the accuracy of Briganti nomogram is high, but the proposed 5% cutoff is valid only in the presence of adequate ePLND.

Invasiveness of papillary thyroid microcarcinoma with BRAF mutation

To explore the invasiveness of papillary thyroid microcarcinoma(PTMC)with BRAF mutation. Totally 99 patients with PTMC with BRAF mutation were enrolled in this study, meanwhile another 97 patients with papillary thyroid carcinoma (PTC) (tumor size>1 cm)with BRAF mutation were included as controls. The clinicopathologic factors including extrathyroidal invasion, multifocality, and distant metastasis were analyzed. The rates of extrathyroidal invasion and nodal metastasis in PTMC group were as high as 16.10% and 71.74%, respectively. In the PTMC group and PTC group,the extrathyroidal invasion rate was 16.10% and 39.18%, cervical lymph node metastasis rate was 71.74% and 91.75%, and distant metastasis rate was 1.01% and 9.28%, respectively. In the PTMC subgroups with tumor sizes ≤0.3 cm, 0.3-0.6 cm, and 0.6-1.0 cm, the cervical lymph node invasion rate was 60.00%, 72.50%, and 73.81%, the extrathyroidal invasion rate was 10.00%, 9.09%, and 24.44%, and the multifocality rate was 60.00%, 38.64%, and 57.78%, respectively. Univariate analysis showed that the tumor size was not significantly correlated with multifocality (Χ (2)=3.752, P=0.153), cervical lymph node metastasis (Χ (2) = 0.780,P = 0.677), extrathyroidal invasion (Χ (2) = 4.182, P = 0.124), and distant metastasis (Χ (2)=1.212, P = 0.545). While the BRAF group and PTC group were not significantly different in multifocality (Χ (2) = 1.742, P=0.187), they were significantly different in terms of extrathyroidal invasion (Χ (2) = 13.000, P = 0.000), nodal involvement (Χ (2) = 12.819, P = 0.000), and distant metastasis (Χ (2) = 5.316, P = 0.021). Multivariate analysis showed that nodal metastasis was independently associated with size>1 cm (P=0.001) and extrathyroidal invasion (P=0.003). BRAF mutant PTMC manifests relative high extrathyroidal involvement and nodal metastasis, and the similar multifocality as BRAF mutant PTC. Radioactive iodine should be considered in PTMC with the presence of BRAF mutation combined with extrathyroidal invasion or nodal metastasis.

WITHDRAWN: Expression analysis of Sca-1 and its significance in lung cancers.

Ahead of Print article withdrawn by publisher. The purpose of the present study was to determine the expression of Sca-1, the stem cell marker, among various lung cancers and evaluate their utility. Immunohistochemistry was done in 151 surgically resected lung cancer specimens or biopsies, including 76 cases of adenocarcinoma, 50 cases of squamous cell carcinoma, 15 cases of small cell carcinoma, 6 cases of adenosquamous cell carcinoma and 4 cases of large cell carcinoma. The results showed that 88 (58.3%) cases were Sca-1 positive. Further analysis showed that in cases of adenocarcinoma, the rate of lymph node invasion and poor differentiation level of Sca-1(+) specimens were respectively higher than those of Sca-1(-) specimens. In cases with small cell carcinoma and squamous cell carcinoma, the rates of lymph node invasion of Sca-1(+) specimens were respectively higher than those of Sca-1(-) specimens. Survival analysis showed that for patients with adenocarcinoma and small cell carcinoma, the average survival time of Sca-1(+) patients was significantly shorter than that of Sca-1(-) patients. Further mutation analysis showed that EGFR mutation rates in Sca-1 (-) adenocarcinoma patients were significantly higher than those of Sca-1 (+) patients, while p53 and KRAS mutation rates in Sca-1 (-) adenocarcinoma and squamous cell carcinoma patients were respectively lower than those of Sca-1 (+) patients. Western blots analysis showed that expression of a Src family tyrosine kinase, Fyn, was positively related with Sca-1 expression levels. These results suggested that Sca-1 expression in some human lung cancers was related with malignancy phenotype and survival time. Keywords: Sca-1 expression, stem cancer cell, lung cancer, malignancy phenotype.

National Comprehensive Cancer Network Practice Guidelines 2011: Need for More Accurate Recommendations for Pelvic Lymph Node Dissection in Prostate Cancer

The 2011 NCCN (National Comprehensive Cancer Network) guidelines for prostate cancer recommend pelvic lymph node dissection at radical prostatectomy in all individuals with a nomogram predicted lymph node invasion probability of 2% or greater. We examined the ability of these guidelines to correctly predict lymph node invasion in patients treated with extended pelvic lymph node dissection. We examined 3,064 consecutive patients treated with radical prostatectomy and extended pelvic lymph node dissection between 2000 and 2010. We formally validated the NCCN guideline nomogram using discrimination, calibration and decision curve analysis as benchmarks. Moreover the performance characteristics of the 2% nomogram cutoff as well as other cutoff values (range 1% to 10%) were tested. Overall 10.0% of patients had lymph node invasion. The discrimination accuracy of the NCCN guideline nomogram was 79.8%, with a maximum underestimation of the lymph node invasion risk of 41.2%. On decision curve analysis the NCCN nomogram fared better than not performing pelvic lymph node dissection in all patients. However, in the prediction range between 0% and 9% the nomogram did not fare better than performing pelvic lymph node dissection in all patients. The use of the 2% cutoff would allow the avoidance of 49.3% of pelvic lymph node dissections, at the cost of missing 20.3% of patients with lymph node invasion. The NCCN nomogram tends to significantly underestimate the real lymph node invasion rate. Moreover the use of the currently recommended cutoff of 2% to trigger pelvic lymph node dissection might not be appropriate.

185 MODELS ASSESSING THE NEED FOR PELVIC LYMPH NODE DISSECTION CANNOT BE RELIABLY USED IN MEN WITH PROSTATE CANCER PREVIOUSLY TREATED WITH SURGERY FOR BENIGN PROSTATIC ENLARGEMENT

You have accessJournal of UrologyProstate Cancer: Staging I1 Apr 2012185 MODELS ASSESSING THE NEED FOR PELVIC LYMPH NODE DISSECTION CANNOT BE RELIABLY USED IN MEN WITH PROSTATE CANCER PREVIOUSLY TREATED WITH SURGERY FOR BENIGN PROSTATIC ENLARGEMENT Umberto Capitanio, Alberto Briganti, Nazareno Suardi, Andrea Gallina, Firas Abdollah, Fabio Castiglione, Giulia Castagna, Alessandro Nini, Paolo Dell'Oglio, Paolo Capogrosso, Valerio Di Girolamo, Giorgio Guazzoni, Patrizio Rigatti, and Francesco Montorsi Umberto CapitanioUmberto Capitanio Milan, Italy More articles by this author , Alberto BrigantiAlberto Briganti Milan, Italy More articles by this author , Nazareno SuardiNazareno Suardi Milan, Italy More articles by this author , Andrea GallinaAndrea Gallina Milan, Italy More articles by this author , Firas AbdollahFiras Abdollah Milan, Italy More articles by this author , Fabio CastiglioneFabio Castiglione Milan, Italy More articles by this author , Giulia CastagnaGiulia Castagna Milan, Italy More articles by this author , Alessandro NiniAlessandro Nini Milan, Italy More articles by this author , Paolo Dell'OglioPaolo Dell'Oglio Milan, Italy More articles by this author , Paolo CapogrossoPaolo Capogrosso Milan, Italy More articles by this author , Valerio Di GirolamoValerio Di Girolamo Milan, Italy More articles by this author , Giorgio GuazzoniGiorgio Guazzoni Milan, Italy More articles by this author , Patrizio RigattiPatrizio Rigatti Milan, Italy More articles by this author , and Francesco MontorsiFrancesco Montorsi Milan, Italy More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.237AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We evaluated the effect of previous prostate surgery performed for lower urinary tract symptoms (SxLUTS) on the ability to predict lymph node invasion (LNI) in patients subsequently diagnosed with prostate cancer using two widely used LNI predictive models. METHODS From January 1985 to January 2011, we collected data on 5833 patients with clinical T1-T3 PCa treated with radical prostatectomy (RP) and extended pelvic lymph node dissection (eLND). Of these 292 (5.0%) had previously undergone SxLUTS. Cagiannos et al. (J Urol 2003;170:1798–1803) and Briganti et al. (Eur Urol 2006;49:1019-1026) nomograms predicting LNI were externally validated in patients previously treated with SxLUTS and in naïve patients, respectively. The accuracy of each model was tested using the area under the receiver operating characteristics (ROC) curve. Two-hundred bootstrap resamples were used to reduce overfit bias. RESULTS The rate of LNI was 13.5 in naïve patients vs. 9.9% in patients treated with previous SxLUTS (p=0.08). Mean number of lymph nodes removed was 18.7 vs. 17.5 in naïve patients vs. SxLUTS patients (p=0.09). PSA levels at RP was 13.0 vs. 8.2 ng/ml in naïve vs. SxLUTS patients (p<0.001). Clinical stage resulted cT1c in 53.4 vs. 61.5%, cT2 in 34.1 vs. 29.7%, cT3 in 12.5 vs. 8.8% in naïve vs. SxLUTS patients, respectively (p=0.04). Conversely, no significant differences were found between the two groups in terms of biopsy Gleason score (6, 7 and 8-10: 62.3, 28.3 and 9.4% vs. 61.0, 29.4 and 9.6%, p=0.9) as well as percentage of positive cores distribution (42.4 vs. 46.9% in naïve patients vs. SxLUTS patients, respectively; p=0.09). Overall, at multivariable analyses, PSA, clinical stage, biopsy Gleason score and percentage of positive cores achieved an independent predictor status for LNI prediction (all p<0.03). Cagiannos et al. and Briganti et al. LNI nomograms provided more accurate prediction in naïve patients relative to patients previously treated with SxLUTS (externally validated AUC: 86.8 and 87.6% vs. 72.8 and 69.9%, p<0.001). CONCLUSIONS When counseling patients diagnosed with prostate cancer, clinicians should be aware that the accuracy of nomograms predicting lymph node invasion significantly decreases if patients previously underwent prostatic surgery. Therefore, novel models are needed for the prediction of LNI in this patient category. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e78 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Umberto Capitanio Milan, Italy More articles by this author Alberto Briganti Milan, Italy More articles by this author Nazareno Suardi Milan, Italy More articles by this author Andrea Gallina Milan, Italy More articles by this author Firas Abdollah Milan, Italy More articles by this author Fabio Castiglione Milan, Italy More articles by this author Giulia Castagna Milan, Italy More articles by this author Alessandro Nini Milan, Italy More articles by this author Paolo Dell'Oglio Milan, Italy More articles by this author Paolo Capogrosso Milan, Italy More articles by this author Valerio Di Girolamo Milan, Italy More articles by this author Giorgio Guazzoni Milan, Italy More articles by this author Patrizio Rigatti Milan, Italy More articles by this author Francesco Montorsi Milan, Italy More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Indications for Pelvic Nodal Treatment in Prostate Cancer Should Change. Validation of the Roach Formula in a Large Extended Nodal Dissection Series

Previous studies have criticized the predicting ability of the Roach formula in assessing the risk of lymph node invasion (LNI) in contemporary patients with prostate cancer (PCa) due to a significant overestimation of LNI rates. However, all those studies included patients treated with limited pelvic lymph node dissection (PLND), which is associated with high rates of false negative findings. We hypothesized that the Roach formula is still an accurate tool for LNI predictions if an extended PLND (ePLND) is performed. We included 3,115 consecutive patients treated with radical prostatectomy and ePLND between 2000 and 2010 at a single tertiary referral center. Extended PLND consisted of removal of obturator, external iliac, and hypogastric lymph nodes. We externally validated the Roach formula by using the area under the receiver operating characteristics curve and calibration plot method. Moreover, we tested the performance characteristics of different formula-generated cutoff values ranging from 1% to 20%. The accuracy of the Roach formula was 80.3%. The calibration showed only a minor underestimation of the LNI risk in high-risk patients (6.7%). According to the Roach formula, the use of 15% cut off would have allowed 74.2% (2,311/3,115) of patients to avoid nodal irradiation, while up to 32.7% (111/336) of all patients with LNI would have been missed. When the cut off was lowered to 6%, nodal treatment would have been spared in 1,541 (49.5%) patients while missing 41 LNI patients. The sensitivity, specificity, and negative predictive values associated with the 6% cut off were 87.9%, 54%, and 97.3%, respectively. The Roach formula is still accurate and does not overestimate the rate of LNI in contemporary prostate cancer patients if they are treated with ePLND. However, the recommended cut off of 15% would miss approximately one-third of patients with LNI. Based on our results, the cut off should be lowered to 6%.

868 THE RATE OF SIDE SPECIFIC ECE IS CLOSELY RELATED TO THE RATE OF IPSILATERAL LYMPH NODE INVASION IN PATIENTS UNDERGOING RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Advanced III1 Apr 2010868 THE RATE OF SIDE SPECIFIC ECE IS CLOSELY RELATED TO THE RATE OF IPSILATERAL LYMPH NODE INVASION IN PATIENTS UNDERGOING RADICAL PROSTATECTOMY Lars Budäus, Pierre I. Karakiewicz, Jan Spethmann, Georg Salomon, Giovanni Lughezzani, Maxine Sun, Alexander Haese, Hartwig Huland, and Markus Graefen Lars BudäusLars Budäus Hamburg, Germany More articles by this author , Pierre I. KarakiewiczPierre I. Karakiewicz Montreal, Canada More articles by this author , Jan SpethmannJan Spethmann Hamburg, Germany More articles by this author , Georg SalomonGeorg Salomon Hamburg, Germany More articles by this author , Giovanni LughezzaniGiovanni Lughezzani Montreal, Canada More articles by this author , Maxine SunMaxine Sun Montreal, Canada More articles by this author , Alexander HaeseAlexander Haese Hamburg, Germany More articles by this author , Hartwig HulandHartwig Huland Hamburg, Germany More articles by this author , and Markus GraefenMarkus Graefen Hamburg, Germany More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1624AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Several risk stratification schemes are available for the prediction of the need for extended pelvic lymph adenectomy (ePLAD) in patients with prostate cancer undergoing radical prostatectomy (RP). None of those tools rely on pathological diagnosis. We examined the relationship between ECE and side specific and overall rate of LNI at ePLND. METHODS Between 1996 and 2008, 4806 patients underwent a RP with a ePLAD at a single European institution. Clinical and pathological information was available for 4790 men. Analyses were performed using the entire dataset as well as in a side specific fashion, where each lobe of the prostate and ipsilateral lymph node invasion was considered without accounting for contra lateral finding. RESULTS Overall, 7.9% of all patients undergoing LND had lymph node invasion (LNI). The rate of LNI was 0.8% in absence of ECE vs. 5.7 % and 15.1% when respectively side specific ECE or bilateral ECE was recorded. The rate of concordance (75.5%) between side specific ECE and side of LNI was statistical significant (p<0.001) and independent predictor status of ECE, (none vs. sidespecific (O.R. 5,66; p<0.001)) and (none vs. bilateral (O.R. 10,97; p<0.001)) was confirmed in multivariable models including PSA, biopsy Gleason sum and clinical stage. CONCLUSIONS Single sided ECE might indicate the predominant localization of the main tumor within the prostate. Our data demonstrated a relationship between ECE and the risk of ipsilateral LNI. These findings should be considered in future studies, including assessment of preoperative side specific tumor characteristics and side specific index tumor volume for testing the ability of developing side specific LNI prediction tools. These prediction tools could enable the surgeon to better decide if in such patients a side specific extended or pelvic LND is required. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e339 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lars Budäus Hamburg, Germany More articles by this author Pierre I. Karakiewicz Montreal, Canada More articles by this author Jan Spethmann Hamburg, Germany More articles by this author Georg Salomon Hamburg, Germany More articles by this author Giovanni Lughezzani Montreal, Canada More articles by this author Maxine Sun Montreal, Canada More articles by this author Alexander Haese Hamburg, Germany More articles by this author Hartwig Huland Hamburg, Germany More articles by this author Markus Graefen Hamburg, Germany More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Commentary on Pelvic Lymph Node Dissection in Prostate Cancer: Briganti A, Blute ML, Eastham JH, Graefen M, Heidenreich A, Karnes JR, Montorsi F, Studer UE, Department of Urology, Vita-Salute University, Milan, Italy

Pelvic lymph node dissection (PLND) is considered the most reliable procedure for the detection of lymph node metastases in prostate cancer (PCa); however, the therapeutic benefit of PLND in PCa management is currently under debate. To systematically review the available literature concerning the role of PLND and its extent in PCa staging and outcome. All of the existing recommendations and staging tools determining the need for PLND were also assessed. Moreover, a systematic review was performed of the long-term outcome of node-positive patients stratified according to the extent of nodal invasion. A Medline search was conducted to identify original and review articles as well as editorials addressing the significance of PLND in PCa. Keywords included prostate cancer, pelvic lymph node dissection, radical prostatectomy, imaging, and complications. Data from the selected studies focusing on the role of PLND in PCa staging, and outcome were reviewed and discussed by all of the contributing authors. Despite recent advances in imaging techniques, PLND remains the most accurate staging procedure for the detection of lymph node invasion (LNI) in PCa. The rate of LNI increases with the extent of PLND. Extended PLND (ePLND; i.e., removal of obturator, external iliac, hypogastric with or without presacral, and common iliac nodes) significantly improves the detection of lymph node metastases compared with limited PLND (lPLND; i.e., removal of obturator with or without external iliac nodes), which is associated with poor staging accuracy. Because not all patients with PCa are at the same risk of harboring nodal metastases, several nomograms and tables have been developed and validated to identify candidates for PLND. These tools, however, are based mostly on findings derived from lPLND dissections performed in older patient series. According to these prediction models, a staging PLND might be omitted in low-risk PCa patients because of the low rate of lymph node metastases found, even after extended dissections (<8%). The outcome for patients with positive nodes is not necessarily poor. Indeed, patients with low-volume nodal metastases experience excellent survival rates, regardless of adjuvant treatment. But despite few retrospective studies reporting an association between PLND and PCa progression and survival, the exact impact of PLND on patient outcomes has not yet been clearly proven because of the lack of prospective randomized trials. On the basis of current data, we suggest that if a PLND is indicated, then it should be extended. Conversely, in view of the low rate of LNI among patients with low-risk PCa, a staging ePLND might be spared in this patient category. Whether this approach is also safe from oncologic perspectives is still unknown. Patients with low-volume nodal metastases have a good long-term prognosis; to what extent this prognosis is the result of a positive impact of PLND on PCa outcomes is still to be determined.

Obesity does not increase the risk of lymph node metastases in patients with clinically localized prostate cancer undergoing radical prostatectomy and extended pelvic lymph node dissection

Several studies have shown that obesity is associated with more aggressive prostate cancer (PCa) variants. We hypothesized that obesity, quantified as body mass index (BMI), is associated with a higher risk of lymph node invasion (LNI) in patients undergoing extended pelvic lymph node dissection (ePLND). Clinical and pathological data were available for 994 consecutive men with PCa treated with radical prostatectomy (RP) and ePLND at a single European tertiary academic centre. Univariable and multivariable logistic regression analyses addressed the rate of LNI. Covariates consisted of pre-treatment prostate specific antigen (PSA), biopsy Gleason sum, clinical stage history of diabetes mellitus as well as BMI coded as either continuous or categorized (<25, 25.0-29.9, 30 kg/m(2) or more) variable. Predictive accuracy was assessed with area under curve estimates. Overall LNI was diagnosed in 105 patients (10.6%). Mean number of removed lymph nodes was 18.3 (range 7-60). Of all 994 patients, 372 (37.4%) were normal weight, 518 (52.1%) overweight, and 104 (10.5%) were clinically obese. Prevalence of LNI did not significantly differ across different BMI categories (<25, 25.0-29.9 and 30 kg/m(2) or more; 9.9, 10.6 and 12.5%, respectively; P = 0.75). In logistic regression models, neither continuously coded nor categorized BMI was a significant predictor of LNI at univariable or multivariable analyses (all P-values >or=0.1). Moreover, inclusion of BMI with PSA, clinical stage, biopsy Gleason sum and presence of DM did not increase the ability of these variables to predict LNI (82.2% without BMI vs 82.5% and 82.9% with BMI coded as continuous and categorized variable, respectively; all P >or= 0.4). In men undergoing RP and ePLND, increased BMI was not associated with increased risk of lymph node metastases. Therefore, routinely considering patient BMI in risk stratification schemes or prognostic LNI models may not be warranted.

External Validation of the Updated Partin Tables in a Cohort of North American Men

The Partin tables were updated in 2007. However, to our knowledge their accuracy and performance characteristics have not been confirmed in an external validation cohort. We examined the discrimination and calibration properties of the 2007 Partin tables in 1,838 men treated with radical prostatectomy between 2001 and 2005 at Cleveland Clinic Foundation. The ROC derived AUC and the Brier score were used to quantify the discriminant properties of the predictions of the 2007 Partin tables for extraprostatic extension, seminal vesical invasion and lymph node invasion. Loess based calibration plots were used to examine the relationship between the predicted and observed rates of extraprostatic extension, seminal vesical invasion and lymph node invasion. The rates of extraprostatic extension, seminal vesical invasion and lymph node invasion were 26.9%, 5.5% and 1.8%. The accuracy of extraprostatic extension, seminal vesical invasion and lymph node invasion prediction was 71%, 80% and 75% according to the AUC method, and 0.176, 0.051 and 0.037 according to the Brier score, respectively. Extraprostatic extension predictions between 0% and 25%, and lymph node invasion predictions between 0% and 5% correlated well with observed extraprostatic extension and lymph node invasion rates, respectively. Conversely a suboptimal correlation was recorded between predicted and observed seminal vesical invasion rates as well as between predicted and observed rates of extraprostatic extension and lymph node invasion for predicted extraprostatic extension and lymph node invasion values above 25% and 5%, respectively. In this examined validation cohort the overall accuracy (AUC) of the Partin tables was comparable to results reported in the original 2007 development cohort. However, performance characteristics indicate that predictions within specific probability ranges should be interpreted with caution.

Editorial Comment on: Impact of Surgical Volume on the Rate of Lymph Node Metastases in Patients Undergoing Radical Prostatectomy and Extended Pelvic Lymph Node Dissection for Clinically Localized Prostate Cancer

Abstract Background Previous trials have shown that the number of procedures done by a single surgeon, that is, surgical volume (SV), is associated with several outcomes after radical prostatectomy (RP). Objective To test the association between SV and the detection of lymph node metastases during extended pelvic lymph node dissection (ePLND). Design, setting, and participants The study cohort consisted of 1020 men surgically treated for clinically localized prostate cancer. Intervention All patients underwent RP and ePLND by a group of six surgeons who were trained by the surgeon with the highest SV. All surgeons performed an anatomically extended PLND, including removal of obturator, external iliac, and hypogastric nodes. Measurements Univariable and multivariable logistic regression models tested the association between SV (either continuously coded or dichotomized according to the most informative cut-off, namely >144 vs ≤144 ePLNDs) and the rate of lymph node invasion (LNI) after accounting for preoperative (baseline prostate-specific antigen [PSA], clinical stage, biopsy Gleason sum) and postoperative (pathologic stages and Gleason score, surgical margin status) patient characteristics. Results and limitations Mean number of nodes removed was 19.1 (median, 16; range, 7–63). Mean overall SV was 227 (range, 87–379). Overall, LNI rate was 11.8% (120/1020). No significant differences were found among patients treated by the different surgeons in terms of clinical and pathologic characteristics (all p ≥0.06). Conversely, the surgeon with the highest SV removed more nodes and found more nodal metastases compared with the other surgeons (21.1 vs 17.9 mean number of nodes removed; p p =0.01, respectively). At univariable logistic regression analysis, either continuously coded or dichotomized SV was a significant predictor of LNI ( p =0.007 and p p =0.04 and p =0.009, respectively) as well as for postoperative variables ( p =0.03 and p =0.002, respectively). Conclusions After adjusting for clinical and pathologic case-mix differences, patients treated by the highest-volume surgeons (>144 ePLNDs) were more likely to have LNI than those treated by low-volume surgeons, even though all surgeons used a similar extended template for node removal.