Staging Lymphadenectomy Research Articles

Prognostic and predictive value of metastatic lymph node ratio in stage III gastric cancer after D2 nodal dissection.

IntroductionThis study is to evaluate the prognostic and predictive value of metastatic lymph node ratio (MLR) in stage III gastric cancer following radical D2 dissection.Methods87 patients who underwent radical resection with D2 lymphadenectomy were retrospectively evaluated. The median age was 60 with a 2:1 ratio of male/female. Of these 87 patients, 83 underwent total gastrectomy, the remaining 4 underwent subtotal gastrectomy and 57 patients received adjuvant chemotherapy with fluoropyrimidines. Indexes of lymph node involvement and other clinicopathological data were analyzed. Survival was determined by the Kaplan-Meier method and log-rank test. Multivariate analysis was performed using the Cox proportional hazards model.ResultsMedian total retrieved lymph node number was 35 (range: 10-104) with median metastatic lymph node amount of eight (range: 0-71). Median survival time was 31.7 months with a 3-year survival rate of 36.4%. Patients were divided into four groups according to MLR: MLR0, 0; MLR1, <0.1; MLR2, 0.1-0.25; MLR3, >0.25. After median follow-up of 31 months, median OS rates of MLR0 to MLR3 were 37.1m, 35.9m, 31.5m and 20.8m, respectively (p=0.013). Median OS rates were significantly different among subgroups: 39.3m and 36.5m were obtained for low subgroups (MLR<0.24) with or without adjuvant chemotherapy, respectively; 22.9m and 12.2m were found in high subgroups (MLR>0.24) with and without chemotherapy, respectively (p=0.002). Finally, MLR constituted an independent prognostic factor in multivariable analysis.ConclusionsAfter R0 resection with D2 lymphadenectomy for stage III gastric cancer, MLR constitutes an effective prognostic indicator. Patients with high MLR may benefit the most from adjuvant chemotherapy.

A Comparison of Sentinel Lymph Node Biopsy to Lymphadenectomy for Endometrial Cancer Staging (FIRES Trial): A Multicentre, Prospective, Cohort Study

(Abstracted from Lancet Oncol 2017;18:384–392) In more than 75% of women with endometrial cancer, the disease is confined to the uterus. Recurrence risk is defined by surgical staging with lymphadenectomy and helps in the decision to give adjuvant treatment to high-risk patients.

Regional Metastatic Behavior of Nonfunctional Pancreatic Neuroendocrine Tumors: Impact of Lymph Node Positivity on Survival.

Literature addressing the significance of lymph node positivity in the management of nonfunctional pancreatic neuroendocrine tumors (PNETs) is conflicting. The National Cancer Data Base was queried for patients who underwent surgical resection of nonfunctional PNETs between 1998 and 2011. Clinical data and overall survival were analyzed using χ and Cox proportional hazards regression. Multiple imputation was used as a comparative analysis because of the high number of patients missing data on tumor grade. Two thousand seven hundred thirty-five patients were identified. The overall incidence of lymph node metastasis was 51%. In the subset of patients with grade 1 tumors less than 1 cm, 24% had positive lymph nodes. Overall median survival for patients with negative lymph nodes was 11 years compared with 8 years for lymph node-positive patients (P < 0.001). On multivariate survival analysis, tumor grade, distant metastases, regional lymph node involvement, positive surgical margins, male sex, and older age were predictive of decreased overall survival. Lymph node positivity was associated with decreased overall survival. The incidence of lymph node involvement in resected low-grade tumors less than 1 cm is higher than previously reported. Patients selected for resection of PNETs should be offered lymphadenectomy for staging.

Patterns of Lymph Node Metastases in Apparent Stage I Low-Grade Epithelial Ovarian Cancer: A Multicenter Study

The aim of this study was to determineoncological outcomes and incidence of lymph node (LN) metastases in women who underwent systematic pelvic and paraaortic lymphadenectomy for surgical staging ofapparent stage I low-gradeepithelial ovarian cancer (LGEOC). Aretrospective studywas performed at nine institutions across Europe and the US, and patients who underwent surgical staging for presumed stage I LGEOC between 2000 and 2016 were included. To ensure surgical quality, a minimum number of≥10pelvic and≥10 paraaortic LNs was required. Patients with preoperative radiologic or clinical evidence of extraovarian or LN disease, and thosewithnonepithelialhistology,were excluded. The overall incidence of LN metastases was 4.3% in the 163 evaluated patients, andthe incidence of LN involvement in serous, endometrioid, and mucinous subtypes was10.7, 1.5, and 0%, respectively. However, Upstaging due to LN involvement alone occurred in only 2.4% of the patients. Eighty-nine (54.6%) patients received adjuvant chemotherapy due to International Federation of Gynecology and Obstetrics stageIC or higher disease. The 5-year progression-free survival (PFS) and overall survival (OS) were 93.2% (95% confidence interval [CI] 89.4-97.1%) and 94.5% (95% CI 90.9-98.0%), respectively. There was no significant difference in PFS or OS between LN-negative and LN-positive patients. However, fewer patients received adjuvant chemotherapy in the LN-negative group.Multivariate analysis did not identify any independent prognostic factor of survival. The risk of LN involvement in nonserous apparent stage I LGEOC appears low, with a rate of<1% in this retrospective analysis, raising questions about the value of lymphadenectomy in those patients. Larger-scale prospective studies are warranted to evaluate the oncologic safety of omitting systematic LN staging in apparent stage I nonserous LGEOC.

The role of sentinel node mapping with indocyanine green and endoscopic near-infrared fluorescence imaging in endometrial and cervical cancer.

Endometrial and cervical carcinoma are common neoplasms in gynecological oncology. The prognosis and treatment depend on the stage of the cancer according to the FIGO staging system. Stage IAl may be treated by hysterectomy or even local surgical procedures. For Stage IA2, radical hysterectomy and lymphadenectomy must be performed. Lymph node metastasis is an important prognostic factor in both cancers, however lymphadenectomy is associated with long-term complications. Thanks to the sentinel lymph node biopsy (SLNB), we can more accurately discover the staging of the primary tumor, and in case of sentinel lymph node (SLN) negative patients, can resign regional lymphadenectomy. Some researchers claim that new techniques such as indocyanine green (ICG) and endoscopic near-infrared fluorescence imaging for sentinel node mapping can be used instead of the traditional techniques. To establish the role of sentinel node mapping technique in endometrial and cervical cancer. A retrospective study of medical records of five patients with cervical cancer (first group) Stage I and nine patients (second group) who underwent laparoscopic radical hysterectomy and SLNB or group of lymph nodes. These procedures were performed at Gynecology Department of the District Hospital in Garwolin. All lymph nodes were clear of metastases. All patients after histopathological diagnosis were finally referred to the Cancer Centre and Institute of Oncology due to consultation or for further treatment. Based on the present first results and literature review, intracervical ICG injection with fluorescence imaging seems to be the best SLN mapping technique, because of its simplicity, safety, and overall lower cost. More data is required to determine if the nodes identified with this technique are able to predict metastatic disease.

A comparison of sentinel lymph node biopsy to lymphadenectomy for endometrial cancer staging (FIRES trial): a multicentre, prospective, cohort study

Sentinel-lymph-node mapping has been advocated as an alternative staging technique for endometrial cancer. The aim of this study was to measure the sensitivity and negative predictive value of sentinel-lymph-node mapping compared with the gold standard of complete lymphadenectomy in detecting metastatic disease for endometrial cancer. In the FIRES multicentre, prospective, cohort study patients with clinical stage 1 endometrial cancer of all histologies and grades undergoing robotic staging were eligible for study inclusion. Patients received a standardised cervical injection of indocyanine green and sentinel-lymph-node mapping followed by pelvic lymphadenectomy with or without para-aortic lymphadenectomy. 18 surgeons from ten centres (tertiary academic and community non-academic) in the USA participated in the trial. Negative sentinel lymph nodes (by haematoxylin and eosin staining on sections) were ultra-staged with immunohistochemistry for cytokeratin. The primary endpoint, sensitivity of the sentinel-lymph-node-based detection of metastatic disease, was defined as the proportion of patients with node-positive disease with successful sentinel-lymph-node mapping who had metastatic disease correctly identified in the sentinel lymph node. Patients who had mapping of at least one sentinel lymph node were included in the primary analysis (per protocol). All patients who received study intervention (injection of dye), regardless of mapping result, were included as part of the assessment of mapping and in the safety analysis in an intention-to-treat manner. The trial was registered with ClinicalTrials.gov, number NCT01673022 and is completed and closed. Between Aug 1, 2012, and Oct 20, 2015, 385 patients were enrolled. Sentinel-lymph-node mapping with complete pelvic lymphadenectomy was done in 340 patients and para-aortic lymphadenectomy was done in 196 (58%) of these patients. 293 (86%) patients had successful mapping of at least one sentinel lymph node. 41 (12%) patients had positive nodes, 36 of whom had at least one mapped sentinel lymph node. Nodal metastases were identified in the sentinel lymph nodes of 35 (97%) of these 36 patients, yielding a sensitivity to detect node-positive disease of 97·2% (95% CI 85·0-100), and a negative predictive value of 99·6% (97·9-100). The most common grade 3-4 adverse events or serious adverse events were postoperative neurological disorders (4 patients) and postoperative respiratory distress or failure (4 patients). 22 patients had serious adverse events, with one related to the study intervention: a ureteral injury incurred during sentinel-lymph-node dissection. Sentinel lymph nodes identified with indocyanine green have a high degree of diagnostic accuracy in detecting endometrial cancer metastases and can safely replace lymphadenectomy in the staging of endometrial cancer. Sentinel lymph node biopsy will not identify metastases in 3% of patients with node-positive disease, but has the potential to expose fewer patients to the morbidity of a complete lymphadenectomy. Indiana University Health, Indiana University Health Simon Cancer Center, and the Indiana University Department of Obstetrics and Gynecology.

Role of hysterectomy and lymphadenectomy in the management of early-stage borderline ovarian tumors

ObjectiveTo examine survival of women with stage T1 borderline ovarian tumors (BOTs) stratified by hysterectomy and lymphadenectomy status at surgery. MethodsThis is a retrospective study examining The Surveillance, Epidemiology, and End Results Program to identify surgically-treated stage T1 BOTs between 1988 and 2003 (n=4943). Association of surgery patterns and cause-specific survival (CSS) was examined in multivariable analysis. ResultsMean age was 48.7. The majority had stage T1a disease (75.3%). Median follow-up was 15.6years and 159 (3.2%) women died of BOTs. Hysterectomy and lymphadenectomy were performed in 1909 (38.6%) and 1295 (26.2%) cases, respectively. Most commonly, neither procedure was performed (46.5%), followed by hysterectomy alone (27.3%), lymphadenectomy alone (14.9%), and both procedures (11.3%). Surgery patterns for hysterectomy and lymphadenectomy significantly differed across age, ethnicity, marital status, registry area, year at diagnosis, histology type, sub-stage, and tumor size (all, P<0.001). On multivariable analysis, surgery patterns for hysterectomy and lymphadenectomy were not associated with CSS: 20-year rates for neither hysterectomy and lymphadenectomy 96.7%, hysterectomy alone 94.5%, lymphadenectomy alone 95.7%, and both procedures 95.2% (adjusted-P>0.05). Age≥50, T1b-c stages, and mucinous histology remained independent prognostic factors for decreased CSS (all, P<0.05). Among 3723 women with stage T1a disease, hysterectomy and lymphadenectomy patterns were not associated with CSS in 2115 women aged <50 (P=0.14) and 1608 women aged ≥50 (P=0.48). ConclusionOur study suggests that both hysterectomy and lymphadenectomy may be omitted in the surgical management of women with stage T1 BOTs, especially for those with T1a disease regardless of age.

Sentinel Lymph Node Mapping in Patients with Endometrial Carcinoma: Less Can Be More.

The role and extent of lymphadenectomy for endometrial carcinoma has been debated for over 30 years. Many clinicians argue that there is therapeutic value for lymphadenectomy in patients deemed to be "at risk", a designation not universally defined, despite the lack of randomized data supporting this argument. However, lymphadenectomy is associated with morbidity, including lower extremity lymphedema. Sentinel lymph node (SLN) mapping is emerging as a viable alternative to comprehensive lymphadenectomy in the surgical staging of patients with endometrial cancer. Nodal disease status is an important prognostic and predictive factor. Surgical staging with lymphadenectomy remains an important part of the treatment of patients with newly diagnosed endometrial carcinoma despite the dispute regarding its therapeutic value. Many clinicians have argued for abandoning lymphadenectomy altogether; however, this too is not ideal, as it may lead to under-treatment due to inadequate staging or over-treatment with toxic therapies. SLN mapping has emerged as a viable compromise between a comprehensive lymphadenectomy and no lymph node sampling in the surgical staging of these patients, and may lead to reduced morbidity risks. In this review, we present the currently available data in this area of research, as well as our experience with SLN mapping.

Robotic single site staging in endometrial cancer: A multi-institution study

ObjectiveTo evaluate the feasibility and the safety of robotic single site hysterectomy (RSSH) plus or less pelvic lymphadenectomy in FIGO stage I–II endometrial cancer. Materials and methodsWe prospectively collected patient demographics, operative times, complications, pathologic results, and length of stay on all patients who underwent RSSH plus or less pelvic lymphadenectomy for clinical FIGO stage I or occult stage II endometrial carcinoma. ResultsFrom January 2012 to February 2015, 125 patients were included in our study. The median age of the patients was 59 years (range, 35–84 years) and the median body mass index was 27 kg/m2 (range, 19–52 kg/m2). One patient was converted to vaginal surgery due to problems of hypercapnia. The median docking time, console time, and total operative time was 11 min (range, 4–40 min), 80 min (range, 20–240 min) and 122 min (range, 35–282 min), respectively. The median blood loss was 50 ml (range, 10–250 ml). No laparoscopic/laparotomic conversion was registered. Twenty one patients underwent pelvic lymphadenectomy (16.8%) and the median pelvic lymph nodes was 13 (range, 3–32). The median time to discharge was 2 days (range, 1–3 days). No intra-operative complications occurred, while we observed 10 (8%) early post-operative complications. ConclusionRSSH plus or less pelvic lymphadenectomy is technically feasible, safe and reproducible and could be the treatment of choice for patients affected by FIGO stage I–II endometrial cancer. However, randomized controlled trials are needed to confirm these results.

Combined modality adjuvant therapy for high-risk endometrial cancer

Combined modality adjuvant therapy for high-risk endometrial cancer

The Impact of Combined Radiation and Chemotherapy on Outcome in Uterine Clear Cell Carcinoma Compared with Chemotherapy Alone

AimsTo investigate the impact of pelvic radiation on survival in patients with uterine clear cell carcinoma (UCC) who received adjuvant chemotherapy. Materials and methodsPatients with stage I–IV UCC who had undergone surgery and chemotherapy were identified from the Surveillance, Epidemiology, and End Results (SEER) programm 2000–2009. Patients were divided into those who received only chemotherapy and those who received both chemotherapy and radiation therapy. Kaplan–Meier curves and Cox regression models were used for analysis. ResultsOf the 317 patients included, 195 (62%) were in the chemotherapy only group and 122 (38%) were in the chemotherapy and radiation therapy group. Pelvic radiation was associated with significant improvement in overall survival (median 88 versus 25 months, 5 year survival: 58% versus 33%, P<0.001) in the chemotherapy and radiation therapy group compared with the chemotherapy only group for the entire cohort. On subset analysis, chemotherapy and radiation therapy was associated with improved overall survival in late stage disease (III–IV) (5 year 54% versus 22%, P<0.001) compared with the chemotherapy only group, whereas in stage I–II UCC, there was no difference in overall survival between the chemotherapy and radiotherapy group and the chemotherapy only group (5 year 65% versus 67%, P=0.69). In multivariable analysis, pelvic radiation was associated with improved survival in patients with late stage disease (hazard ratio 0.57, 95% confidence interval 0.35–0.94, P=0.03) but not for early stage disease (hazard ratio 0.81, 95% confidence interval 0.33–2.0, P=0.65). Other significant predictors were advanced stage, positive cytology and extensive lymphadenectomy. ConclusionsRadiation was associated with significant improvement in survival in advanced stage UCC, but not in early stage UCC. These data support the beneficial role of radiation therapy in UCC, especially in patients with advanced stage disease.

Staging lymphadenectomy in low-grade endometrial cancer: A prospective cohort study utilizing a standard algorithm

Staging lymphadenectomy in low-grade endometrial cancer: A prospective cohort study utilizing a standard algorithm

Five year survival surgical outcome for clinic stage I cervical cancer: Comparison of robotic vs. laparoscopic or laparotomy radical hysterectomy

Objectives: To determine if there is a difference in 5-year survival between robotic versus laparoscopic versus open radical hysterectomy in the treatment of clinical stage I cervical cancer. Methods: Retrospective case-matched cohort study was undertaken from 1999 to 2014. Age, subset of stage I, histology and tumor grade in the cohort, and robotic, laparoscopic, and open radical hysterectomy were analyzed. Overall survival for surgical treatment for stage I cervical cancer was analyzed. The 5-year survival for each respective surgical treatment was analyzed to determine if there was difference among robotic, laparoscopic and radical hysterectomy. Results: During the period 1999 to 2014, 110 patients underwent radical hysterectomy with bilateral pelvic lymphadenectomy (RHBPLND) for clinical stage I cervical cancer. From 1999 to 2008, 28 (25.5%) patients underwent open RHBPLND (ORHBPLND), and (30.9%) patients underwent laparoscopic radical hysterectomy with pelvic lymphadenectomy (LRHBPLND). From 2008 to 2015, 48 (43.6%) patients underwent robotic radical hysterectomy with bilateral pelvic lymphadenectomy (RoRHBPLND). Of those who underwent robotic surgery, 25% were stage 1a2, 47.9 % were stage 1B1, and 10.4% stage IB2. The overall 5-year survival was 87.5%. The 5-year survival for robotic, laparoscopic, and open surgical cohorts were 87.5%, 96.9%, and 82.1%, respectively. There was no difference in 5 -ear survival for stage IA2, IB1, and IB2 for all 3 surgical procedures. We also reviewed histology, grade, and parametrial as well as vaginal cuff measurements in all 3 groups. Conclusions: The overall 5-year survival for RoRHBPLND for treatment of clinical stage I cervical is 87.5%. There was no difference in 5-year survival among RoRHBPLND, LRHBPLND, and ORHBPLND.

Utilization and Outcomes of Chemotherapy in Women With Intermediate-Risk, Early-Stage Ovarian Cancer.

To examine utilization and efficacy of chemotherapy for stage I ovarian cancer. We conducted a retrospective cohort study using the National Cancer Data Base to identify women with stage I ovarian cancer treated from 1998 to 2012. Patients were classified into three groups based on grade and stage: stage IA or IB grade 1 (low risk); stage IA or IB grade 2 (intermediate risk); and stage IA or IB grade 3 or any stage IC (high risk). Multivariable models were developed to examine predictors of chemotherapy use and survival. We identified 21,758 patients including 4,196 (19.3%) low-risk, 3,777 (17.4%) intermediate-risk, and 13,785 (63.4%) high-risk women. The median follow-up of the cohort was 63.9 months. Use of chemotherapy within the groups was 15.5%, 39.5%, and 69.8%, respectively (P<.001). Among low-risk patients, chemotherapy was not associated with a change in survival (adjusted hazard ratio [HR] 1.10, 95% confidence interval [CI] 0.85-1.42), whereas chemotherapy was associated with reduced mortality for high-risk patients (adjusted HR 0.78, 95% CI 0.71-0.85). For intermediate-risk patients (stage IA-IB grade 2), chemotherapy was associated with a 26% reduction in mortality (adjusted HR 0.74, 95% CI 0.62-0.89). The association between chemotherapy and improved survival among intermediate-risk patients remained significant when limited to patients who underwent staging lymphadenectomy (adjusted HR 0.77, 95% CI 0.62-0.97). There is widespread variation in the patterns of care for early-stage ovarian cancer. Chemotherapy was associated with improved survival for stage IA-IB grade 2 patients.

Improving Double Docking for Robot-assisted Para-aortic Lymphadenectomy in Endometrial Cancer Staging: Technique and Surgical Outcomes

Robot-assisted para-aortic lymphadenectomy (PALND) may prove to be a challenging procedure, and the ability to reach the planned anatomic landmarks is critical. In this retrospective study between 2012 and 2015, we present surgical data using a modified technique to perform infrarenal PALND for endometrial cancer using double side docking. All women with high-risk endometrial cancer scheduled for complete robotic staging including infrarenal PALND were included in the analysis. During the study period, a total of 76 women were identified. Three patients had disseminated disease and were treated with palliative hysterectomy only. The remaining 73 women underwent surgery with the intention to perform infrarenal PALND. In 7 cases, PALND was aborted because of technical inability to reach the left renal vein (10%). A median of 36 lymph nodes were harvested (pelvic n = 20, para-aortic n = 16). The median operating time (skin to skin) for patients with completed infrarenal PALND was 228 minutes (range, 181–371 minutes). Among all 76 patients, postoperative complications according to the Clavien-Dindo nomenclature were observed in 27 (36%) patients, with 6 (8%) having grade III complications. No patient died within 30 days from surgery. Our technique of double docking for robot-assisted PALND was associated with a success rate of 90%. The described technique seems to be a useful strategy to maximize the likelihood of completing the planned procedure.

Survival impact based on the thoroughness of pelvic lymphadenectomy in intermediate- or high-risk groups of endometrioid-type endometrial cancer: A multi-center retrospective cohort analysis

ObjectiveTo investigate whether the number of lymph nodes obtained during lymphadenectomy affects the survival of patients with intermediate- or high-risk endometrioid-type endometrial cancer. MethodsA total of 476 patients who were diagnosed with FIGO stage IB to IIIC2 endometrioid adenocarcinoma through surgical staging, including hysterectomy and pelvic lymphadenectomy with or without paraaortic lymphadenectomy between 2000 and 2013 were retrospectively enrolled from four tertiary centers in Korea. Sentinel lymph node mapping was not performed in any patient. The number of nodes obtained and positive nodes, was extracted from pathologic report. ResultsParaaortic lymphadenectomy was performed in 298 (62.6%) patients and 164 (34.4%) had stage IIIC disease. The isolated paraaortic lymph node metastasis rate decreased as the number of pelvic nodes obtained increased. In the total study population, an increase of negative pelvic and paraaortic nodes was associated with improved recurrence-free survival (RFS) and overall survival (OS) independent of other prognostic factors. In the node-positive group, an increase of negative pelvic nodes was an independent prognostic factor for RFS [hazard ratio (HR), 0.946; 95% confidence interval (CI), 0.906–0.988] and OS [HR, 0.907; 95% CI, 0.849–0.968]. In stage IIIC2 patients, 14 or less negative pelvic nodes was associated with poor RFS and OS. ConclusionsRemoving as many pelvic nodes as possible is required to warrant accurate nodal staging and improve survival in patients with intermediate- or high-risk endometrial cancer. Sentinel lymph node mapping can be a resolution to minimize lymph node dissection without compromising staging accuracy.

Sentinel lymph node mapping with staging lymphadenectomy for patients with endometrial cancer increases the detection of metastasis

ObjectivesTo compare the performance of sentinel lymph node (SLN) mapping with staging lymphadenectomy versus staging lymphadenectomy alone for the detection of metastasis and the use of adjuvant therapies in patients with endometrial cancer. MethodsAll patients with apparent early-stage endometrial cancer (n=780) who underwent robotic-assisted hysterectomy with pelvic±aortic lymphadenectomy from July-2006 to June-2013 were compared [pelvic±aortic lymphadenectomy (n=661) versus SLN-mapped cases with pelvic±aortic lymphadenectomy (n=119)]. Isosulfan-blue and indocyanine-green with near-infrared imaging were used for SLN mapping. Clinico-pathological data, FIGO stage, GOG risk category, and adjuvant therapies were compared. ResultsNon-mapped and mapped cases were comparable with respect to BMI, histology, depth-of-invasion, and lympho-vascular space invasion. The mapped group had more pelvic lymph node (LN) harvested compared to non-mapped group (26.4±10.5 vs. 18.8±8.5, p<0.001). Aortic LN yields were identical for both groups (9.0±5.6 vs. 9.0±6.0). The mapped group had more LN metastasis detected (30.3% vs. 14.7%, p<0.001), more stage IIIC (30.2% vs. 14.5%, p<0.001), more GOG high-risk cases (32.8% vs. 21.8%, p=0.013), and received more chemotherapy+radiation (28.6% vs. 16.3%, p<0.003). The SLN was the only metastasis in 18 (50%) mapped cases with positive nodes. The SLN false negative rate was 1/36 (2.8%). Micrometastases or isolated tumor cells were identified in 22/35 (62.9%) SLN metastases. Multivariate analysis demonstrated that SLN mapping imparted a significant effect on the detection of metastatic disease [adjusted OR=3.29, p<0.001]. ConclusionsThe performance of SLN mapping with staging lymphadenectomy increased the detection of lymph node metastasis and was associated with more use of adjuvant therapies.

Role of Adjuvant Therapy for Stage IA Serous and Clear Cell Uterine Cancer: Is Observation a Valid Strategy?

The adjuvant treatment of early stage IA serous and clear cell carcinomas of the uterus is controversial. The aims of the study were to report on a single institution experience treating these high-risk early uterine cancers and to identify women who may be suitable for observation alone. A retrospective review of patients presenting from 2003 to 2013 with pathologic stage IA (International Federation of Gynecology and Obstetrics 2009) serous or clear cell uterine carcinoma was performed. Patient and disease characteristics, surgical staging, treatment details, and recurrence data were collected. Recurrence rates and 5-year actuarial estimates of recurrence free survival (RFS) were the primary outcomes of interest. A total of 77 patients with stage IA were identified. Median (range) follow-up was 34 (1-108) months. Staging lymphadenectomy was performed in 83%. Adjuvant treatment was given to 27 patients, whereas 50 underwent observation. There were 12 recurrences total, with the 5-year RFS 79% for the cohort, with no statistically significant difference between observation and adjuvant treatment. Only 4 patients received adjuvant chemotherapy and none recurred. In the observation cohort, the presence versus absence of myometrial invasion showed a trend to poorer 5-year RFS (75% vs 93%, P = 0.06). Observation seems to be a valid strategy in those patients with stage IA serous and clear cell carcinoma without myometrial invasion. The presence of any myometrial invasion may confer a higher risk of recurrence, although further studies are needed to determine the optimal adjuvant treatment regimen.

Metastatic lymph node ratio as an independent prognostic factor in stage III gastric cancer after D2 nodal dissection.

738 Background: The aim of this study was to evaluate the prognostic impact of metastatic lymph node ratio (MLR) in stage III gastric cancer after D2 dissection, and to assess the value of MLR for adjuvant chemotherapy. Methods: A total of 87 patients who underwent radical resection with D2 lymphadenectomy between December 2007 and March 2014 was enrolled in this study. Survival was determined by Kaplan-Meier method and survival curves were assessed by log-rank test. Multivariate analysis was performed using the Cox proportional hazards model. Results: The median age of patients was 60 (range:21 to 83) with a male to female ratio of 2. 83 patients have undergone total gastrectomy (95.4%) and 4 subtotal gastrectomy (4.6%). 57 patients received chemotherapy, including 24 neoadjuvant chemotherapy and 33 adjuvant chemotherapy. All chemotherapy regimens have contained Flouropyrimidines (5-FU or capecitabine). There were only 5 patients received single-agent 5-FU or capecitabine as chemotherapy regimen, while 52 patients received combined-chemotherapy. The median total retrieved lymph node was 35 (range:10 to 104) and the median metastatic lymph nodes was 8 (range: 0 to 71). MLR was classified into 4 groups as follows: Group 1(MLR = 0), Group 2(MLR &lt; 0.1), Group 3(MLR = 0.1-0.25), Group 4(MLR &gt; 0.25). After a median follow-up of 28 months, the median PFS of group 1-4 was 37.1m, 35.9m, 31.5m and 16.9m, respectively (p = 0.025). The median PFS was significantly different in subgroups: 39.2m in low group (MLR &lt; 0.25) with adjuvant chemotherapy, 36.4m in low group without chemotherapy, 17.2m in high group (MLR &gt; 0.25) with chemotherapy and 11.5m in high group without chemotherapy (p = 0.012). The MLR was retained as an independent prognostic factor in multivariable analysis. Conclusions: After R0 resection with D2 lymphadenectomy for stage III gastric cancer, MLR can be a more effective and prognostic indicator. Patients with high MLR may most benefit from adjuvant treatments.

Video-Assisted Mediastinoscopic Lymphadenectomy for Staging Non-Small Cell Lung Cancer

The aim of this study was to evaluate the results of video-assisted mediastinoscopic lymphadenectomy (VAMLA) for staging of non-small cell lung cancer (NSCLC). This was a prospective observational study of all consecutive VAMLAs performed from January 2010 to April 2015 for staging NSCLC. For left lung cancers, extended cervical videomediastinoscopy was added to explore the subaortic and paraaortic nodes. Patients with negative VAMLA results underwent tumor resection and lymphadenectomy of the remaining nodes. Those with N2-3 disease underwent chemoradiation. The rate of unsuspected pathologic (p)N2-3 was analyzed in the global series and in the subgroups of patients according to their nodal status diagnosed by imaging and metabolic techniques. One hundred sixty VAMLAs were performed for staging NSCLC (138 tumors were clinical (c)N0-1 based on imaging techniques). The rate of unsuspected N2-3 disease was 18% for the whole series: 40.7% for cN1, 22.2% for cN0 and tumor size greater than or equal to 3 cm, and 6.4% for cN0 and tumor size less than 3 cm. Staging values were sensitivity, 0.96 (95% confidence interval [CI], 0.81-99.3); specificity, 1 (95% CI, 0.97-1); positive predictive value, 1 (95% CI, 0.87-1); negative predictive value, 0.99 (95% CI, 0.95-0.99); and diagnostic accuracy, 0.99 (95% CI, 0.96-0.99). The complication rate was 5.9%. VAMLA is a feasible and highly accurate technique. The high rate of unsuspected mediastinal node disease diagnosed by VAMLA in patients with cN1 or cN0 disease and tumor size larger than 3 cm suggests that preresection lymphadenectomies should be included in the current staging algorithms.