Mean Number Of Positive Nodes Research Articles

Abstract PS04-03: Survival benefit of regional nodal irradiation in clinically node-positive breast cancer following neoadjuvant chemotherapy and breast-conserving surgery

Abstract Introduction: In recent years, there has been increasing use of neoadjuvant chemotherapy (NAC) and pathologic complete response (pCR) rates for certain breast cancer phenotypes (40-70%). Although encouraging, this has resulted in uncertainties in traditional axillary management. Meanwhile, clinically node-positive (cN+) patients who have a low burden of disease downstaged to node-negative (ypN0) after NAC and get breast-conserving surgery (BCS) may avoid an axillary lymph node dissection (cALND) but still have regional nodal irradiation (RNI) recommended regardless of axillary surgery. Those who remain node-positive (ypN+) undergo cALND and RNI with an increased risk of lymphedema. In this study, we evaluated the survival benefit of RNI in cN+ patients after NAC and BCS. Methods: We reviewed (cN+) stage I-III non-inflammatory female breast cancer patients who underwent NAC followed by BCS between 2010 and 2020 in the National Cancer Database (NCDB). Patients having a history of another malignancy who received hormone therapy or radiotherapy before surgery or whose pathologic nodal status (ypN) was unknown were excluded. Overall survival (OS) from surgery was compared between those who did and did not receive RNI. Patient and tumor characteristics were compared across subgroups using chi-square and Wilcoxon rank sum tests. Weighted Kaplan-Meier curves and log-rank tests were used to assess the effect of RNI on OS. As a sensitivity analysis, analyses were stratified based on yPN status. Finally, multivariable logistic regression was used to determine predictors of receiving RNI. Results: The 8,250 cN+ patients had a mean age of 54.6±11.1 years. In total, 69.1% of patients were White, 23.9% were Black, and 10.2% were Hispanic. The mean number of removed and positive nodes were 10.0 ±7.8 and 2.3±3.8. The most common histology and phenotype were invasive ductal carcinoma (IDC) in 94.3% and hormone-positive (HR+) in 41.0%. Breast and nodal pCR rates were 25.9% and 34.7%, with nodal pCR achieved in 20.7%, 46.0%, and 44.4% of HR+, HER2+, and triple-negative tumors. RNI was performed in 52.1% of the patients (45.3% of the yPN0 and 55.9% of the yPN+). The mean number of nodes removed was 10.4±7.8 in the RNI+ and 9.6±7.7 in the RNI- groups (P < 0.01). The mean number of positive nodes was 2.6±4.0 in the RNI+ and 1.9±3.6 in the RNI- groups (P < 0.01). On multivariable analysis, the predictors of RNI administration included the number of positive nodes (p < 0.01), cN stage (p < 0.01), cT3 (p < 0.01), and tumor phenotype (p < 0.01). Grade I tumors (p=0.04) and Medicare beneficiaries (p=0.01) were less likely to get RNI. The survival rates were 79.9% and 81.9% in the RNI+ and RNI– groups, with a median follow-up of 62.1±31.4 and 62.8±32.2 in the RNI+ and RNI- groups. In the entire cohort, ypN0 patients had improved OS when compared with ypN+ patients (p < 0.001), but in adjusted analyses, there was no difference in OS between those who did and did not receive RNI (p=0.6). There was also no difference in OS comparing those who did and did not receive RNI in the ypN0 (p=0.96) or ypN+ (p=0.76) groups. Conclusion: For breast cancer patients having a modest nodal burden of disease and BCS after NAC, traditional prognostic factors such as stage and nodal status, as well as phenotype, grade, and the presence or absence of pCR, impact overall survival. Although some such factors appear to bias practitioners into giving RNI for patients undergoing NAC and BCS, RNI after NAC and BCS does not improve OS, regardless of pCR status, even at a mean follow-up time of 5.5 years. Further studies evaluating the impact on local control and longer-term outcomes should be pursued to enable the creation of specific guidelines surrounding indications for RNI based on the initial burden of disease and the final response from NAC administration. Citation Format: Mahtab Vasigh, Richard Bleicher, Austin Williams, Allison Aggon, Mary Pronovost, Andrea Porpiglia, Matthew Pierotti, Christian Cruz Pico. Survival benefit of regional nodal irradiation in clinically node-positive breast cancer following neoadjuvant chemotherapy and breast-conserving surgery [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PS04-03.

Metastatic profiles and survival differences between infiltrating ductal carcinoma and infiltrating lobular carcinoma in invasive breast cancer

BackgroundIn this study, we conducted a comprehensive evaluation of metastatic profiles and survival outcomes in patients with infiltrating ductal carcinoma (IDC) and infiltrating lobular carcinoma (ILC) treated at our university hospital center. MethodsWe collected and analyzed data from all patients diagnosed with invasive breast cancer at our center between January 1, 2007, and 31 December 2014. We specifically compared three subgroups: patients with IDC, patients with ILC and patients with mixed carcinoma, which is a combination of IDC and ILC. ResultsAmong the 1963 patients treated for invasive breast cancer in our center during the study period, 1435 had IDC, 466 had ILC, and 59 had mixed carcinoma. The incidence of patients with at least one positive axillary lymph node differed significantly: 40 % for IDC, 36 % for ILC, and 45 % for mixed carcinoma (p = 0.001). However, there was no significant difference in the mean number of positive nodes (p = 0.1633). The occurrence of distant metastases was lower in patients with ILC (p = 0.04), particularly in the case of brain metastases (p = 0.01), although there was no difference in bone or visceral metastatic sites. Patients with ILC exhibited a longer mean time to metastasis from the initial diagnosis of invasive breast carcinoma. Overall survival (p = 0.0525) and survival without locoregional recurrence (p = 0.026) were significantly different. Specifically, the 5-year overall survival rates for IDC, ILC, and mixed carcinoma were approximately 95 %. Distance metastatic-free survival at 5 years was 85 % for IDC, 91 % for ILC, and 87 % for mixed carcinoma (p = 0.00506). ConclusionOur findings indicate variations in the distribution of distant metastatic sites among patients with IDC, ILC, and mixed carcinoma, as well as differences in survival outcomes. This study sheds light on the unique characteristics and clinical implications associated with these two distinct subtypes of invasive breast cancer.

Primary retroperitoneal lymph node dissection (RPLND) in seminoma stage IIA-IIC ≤3cm: Combined results of the SWENOTECA (Swedish Norwegian Testicular Cancer Group) and Cologne.

Background: Chemotherapy or radiotherapy have been standard treatment for stage II seminomas with excellent survival but are associated with significant long-term treatment-related toxicities. Several prospective trials have shown primary retroperitoneal lymph node dissection (RPLND) to be an effective and safe alternative. The current SWENOTECA treatment program recommends primary RPLND in seminoma stage IIA to IIB ≤ 3 cm with 1-2 metastatic nodes as the standard treatment modality. We present preliminary results combined with data from Cologne. Methods: Within SWENOTECA, RPLND is centralized to 5 hospitals and Cologne is a tertiary centre for patients recruited from different parts of Germany. Both patients with recurrence after initial stage I disease and patients with primary stage IIA and IIB at diagnosis were included. We collected information on operation time, bleeding, peri- and postoperative complications. We also analyzed histologic outcome and whether adjuvant chemotherapy was given. We followed the patients for any recurrence of disease. Results: We have included 94 patients operated from May 2018 to November 2022. The number of operations per site varied from 4 to 28. The mean age of patients at time of RPLND was 41.8 years (range 21-79). Overall, 54 patients had recurrence after initial stage I disease and 40 patients had primary stage IIA/IIB disease at diagnosis (one missing data). At time of RPLND 62 patients had IIA-disease and 31 stage IIB-disease (one missing data). The histology from RPLND showed seminoma in 83 patients, benign/necrosis in eight patients, vital non-seminomatous GCT in one patient, teratoma only in one patient and lymphoma in one patient. Mean number of resected nodes was 19, and mean number of positive nodes were 1.5. Twenty-six patients (28%) were operated with robotic laparoscopic technique. Ten patients (10.6%) had a Clavien-Dindo postoperative complication > 2. Twenty-three of the patients were given adjuvant oncological treatment after RPLND, most of them one course of BEP. The patients have been followed for in median 18 months (range 2-59). Nine patients (9.6 %) have had recurrences, all but one in the first year after RPLND. Conclusions: Our early results of primary RPLND of seminomas IIA-IIB ≤ 3 cm are promising. Longer follow-up is required to ensure this as a safe treatment option.

Rate of occult neck nodal metastasis in primary and salvage laryngectomy.

Rate of occult neck nodal metastasis in primary and salvage laryngectomy.

Clinical application of parathyroid autotransplantation in endoscopic radical resection of thyroid carcinoma

PurposeThis study aimed to examine the effect of selective inferior parathyroid gland autotransplantation on central lymph node dissection(CLND) and incidence of postoperative hypoparathyroidism in patients undergoing endoscopic radical resection of thyroid carcinoma.MethodsThe data of 310 patients undergoing endoscopic radical resection of thyroid carcinoma will be retrospectively analyzed. The patients will be divided into the experimental group and the control group according to whether they combined with parathyroid autotransplantation. Statistics of the incidence rate of postoperative hypoparathyroidism, the concentration of PTH and Calcium in the systemic circulation at different time points in the two groups, the concentration of PTH in the cubital fossa vein in the transplantation region in the experimental group, and the number of central lymph nodes and positive lymph nodes dissection will be carried out.ResultsThe incidence rate of temporary and permanent hypoparathyroidism in the experimental group was 33.75% and 0.625%, respectively, and in the control group was 22% and 5%, respectively; its difference was statistically significant (X2 = 10.255, P=0.006). Parathyroid autotransplantation increased incidence of transient hypoparathyroidism (OR, 1.806; Cl, 1.088-2.998; P=0.022), and lower incidence of permanent hypoparathyroidism (OR, 0.112; Cl, 0.014-0.904; P=0.040). The diameters of thyroid cancer nodules was not associated with the occurrence of transient hypoparathyroidism (OR, 0.769; Cl, 0.467-1.265; P=0.301) or permanent hypoparathyroidism (OR, 1.434; Cl, 0.316-6.515; P=0.641). Comparison of systemic circulation PTH, between the two groups showed that the PTH of patients in the experimental group was higher than that in the control group from 1 week to 12 months after the operation, and the difference was statistically significant (P<0.05). In the experimental group, from 1 week to 12 months after surgery, PTH concentrations was significantly higher in the cubital fossa of the transplantation side than in the contralateral side, and the differences were statistically significant (P<0.05). The mean number of central lymph node dissected per patient was significantly higher in the experimental group (7.94 ± 3.03 vs. 6.99 ± 2.86; P <0.05); The mean number of positive nodes per patient was significantly higher in the experimental group (3.16 ± 1.86 vs. 2.53 ± 1.59; P <0.05).ConclusionsIn endoscopic radical resection of thyroid carcinoma, parathyroid autotransplantation is more beneficial to postoperative parathyroid glands function recovery, effectively preventing postoperative permanent hypoparathyroidism and realizing more thorough CLND.

Epigenetic Signatures Predict Pathologic Nodal Stage in Breast Cancer Patients with Estrogen Receptor-Positive, Clinically Node-Positive Disease.

Breast cancer patients with clinically positive nodes who undergo upfront surgery are often recommended for axillary lymph node dissection (ALND), yet more than half are found to have limited nodal disease (≤ 3 positive nodes, pN1) at surgery. In this study, we examined the efficiency of molecular classifiers in stratifying patients with clinically positive nodes to pN1 versus > pN1 disease. We evaluated the clinical and epigenetic data of patients in The Cancer Genome Atlas with estrogen receptor-positive, human epidermal growth factor receptor 2-negative invasive ductal carcinoma who underwent ALND for node-positive disease. Patients were divided into control (pN1, ≤ 3 positive nodes) and case (> pN1, > 3 positive nodes) groups. Machine learning algorithms were trained on 50% of the cohort and validated on the remaining 50% to identify DNA methylation signatures that predict > pN1 disease. Clinical variables and epigenetic signatures were compared. Controls (n=34) and case (n=24) cohorts showed similar mean age (56.4±12.2 vs. 57.6±16.7years; p=0.77), number of nodes removed (16.1±7.3 vs. 17.5±6.2; p=0.45), tumor grade (p=0.76), presence of lymphovascular invasion (p=0.18), extranodal extension (p=0.17), tumor laterality (p=0.89), and tumor location (p=0.42). The mean number of positive nodes was significantly different (1.76±0.82, pN1; 8.83±5.36, > pN1; p<0.001). Three epigenetic signatures (EpiSig14, EpiSig13, EpiSig10) based on DNA methylation patterns of the primary tumors demonstrated high accuracy in predicting > pN1 disease (area under the curve 0.98). Epigenetic signatures have an excellent diagnostic accuracy for stratifying nodal disease in patients with clinically positive nodes. Validation of this tool is warranted and may provide an accurate and cost-effective method of identifying patients with predicted low nodal burden who could be spared the morbidity of ALND.

Differentiated Thyroid Cancer: The Role of ATA Nodal Risk Factors in N1b Patients.

Nodal involvement is frequent in patients with differentiated thyroid cancers (DTCs), but its prognostic relevance is not univocal. Some characteristics of nodal metastases can increase the risk of recurrence. We attempted to quantify the impact on survival of nodal factors included in the American Thyroid Association (ATA) risk stratification system in N1b patients with DTC. Retrospective study. A retrospective analysis of patients affected by DTC who underwent therapeutic lateral neck dissection (ND) was performed. The impact on the prognosis of the number of positive lymph nodes (LNs), dimension of nodal metastasis, and microscopic and macroscopic extranodal extension (miENE and maENE, respectively) was investigated. The study included 347 N1b patients who underwent 401 therapeutic lateral NDs. Mean number of positive LNs was nine, mean nodal ratio was 0.27, and mean diameter of metastasis was 15.5 mm. ENE was detected in 25.9% of patients (22.5% miENE and 3.5% maENE). In univariate analysis, the presence of maENE had an impact on disease specific survival (DSS) (P = .023); increasing number of positive LNs affected DSS and locoregional control (LRC) (P = .009 and =.006, respectively); increasing metastatic node dimension was a risk factors for overall survival, DSS, and metastases free survival (MFS) (P = .05, =.013 and =.016). In multivariate analysis, number of positive LNs and LN dimension were independent risk factors for LRC and MFS, respectively (HR 1.1, P = .028; HR 1.1, P = .026). In our analysis on a cohort of N1b patients, the number of positive LNs and LN dimension were confirmed as independent risk factors for locoregional and distant recurrence, respectively. 4 Laryngoscope, 131:E1029-E1034, 2021.

Comparison of clinical outcomes between sentinel lymph node biopsy and axillary lymph node dissection in a single-center Z0011-eligible breast cancer cohort.

The ACOSOG Z0011 trial has proven the oncological safety of sentinel lymph node biopsy (SLBx) for node negative breast cancer. Accordingly, treatment paradigm including axilla surgery was changed. We retrospectively reviewed breast cancer patients to evaluate the clinical effect of paradigm shift in breast cancer surgery after applying the Z0011 criteria. All women who underwent breast-conserving surgery at the National Cancer Center between January 1, 2000, and December 31, 2015, were enrolled and classified according to the Z0011 criteria. The primary endpoint of the study was the disease-free survival rates, and the secondary was the adverse events, especially arm lymphedema. Total 361 patients were enrolled the study (271 axillary lymph node dissection [ALND] group, 90 SLBx group). After the Z0011 guideline was adopted in our institute, the use of ALND decreased, and lymph node sampling (removing only a few axillary lymph nodes) replaced ALND. The total mean number of retrieved nodes were more in ALND group (13.02) than SLBx group (3.43). However, there was no difference in the mean number of positive nodes between two groups (2.34 in ALND group vs. 1.12 in SLBx group, P=0.001). During follow-up, 25 patients experienced disease recurrence: 22 from the ALND group and three from the SLBx group. All of died seven patients were from the ALND group. The ALND group had more complications than the SLBx group (P=0.02). Arm edema occurred more frequently in the ALND group (29.5%) than in the SLBx group (5.6%), although without statistical significance (P=0.07). In our study, we concluded that SLBx can be used safely in Z0011-eligible cohort without increased risk of locoregional recurrence. Moreover, we found that omission of ALND is favored to reduce some serious complications such as arm lymphedema.

Comparison of different lymph node staging systems in patients with node-positive cervical squamous cell carcinoma following radical surgery.

Objective: We compared the prognostic accuracy of four lymph node (LN) staging systems - the 2018 International Federation of Gynecology and Obstetrics (FIGO) stage, number of positive lymph node (PLN), metastatic lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) systems - in patients with node-positive cervical squamous cell carcinoma (CSCC) following radical surgery and explored the optimal choice for clinical applications.Materials and methods: Data were retrospectively collected from 928 node-positive CSCC patients who underwent radical surgery between 2006 and 2014 in our center. Tree-based recursive partitioning was applied to split variables (PLN, LNR, and LODDS) into low-risk and high-risk groups. The log-rank test was used to compare survival curves, and Cox regression analysis was performed to identify prognostic factors. The relative discriminative abilities of the different staging systems were assessed using Harrell's concordance index (C index) and the Akaike information criterion (AIC).Results: The mean number of PLNs was 3.8 (range: 1-44 nodes). According to the 2018 FIGO staging system, 831 patients had stage IIIC1, and 97 had stage IIIC2. For the PLN system, 761 patients were included in the low-risk group, and 167 were included in the high-risk group. For the LNR system, 658 patients were included in the low-risk group, and 270 were included in the high-risk group. The low-risk LODDS group included 694 patients, while the high-risk LODDS group included 234 patients. All four staging systems had a significant influence on patients' progression-free survival (PFS, P < 0.001) and overall survival (OS, P < 0.001). Univariate analysis and multivariate Cox analysis adjusted for significant factors indicated that the four staging systems were significant prognostic factors for PFS and OS. Among them, the PLN system was noted to have the best prognostic performance for both PFS (C index: 0.582; AIC: 8213.33) and OS (C index: 0.624; AIC: 8433.80).Conclusion: The PLN system seemed to be the most accurate LN staging method for predicting node-positive CSCC following radical surgery.

Role of Pelvic and Para-Aortic Lymphadenectomy in Advanced Ovarian Epithelial Cancer

Background: the role of detection and removal of retroperitoneal lymph nodes in patients with advanced ovarian cancer disease is unclear. Aim of the work: this study was aimed to evaluate the therapeutic role of pelvic and paraaortic lymphadenectomy in patients with advanced epithelial ovarian cancer. Patients and Methods: this study was designed as a prospective randomized controlled trial. Thirty patients were divided into two equal groups; 15 patients underwent optimum cytoreduction and in the other 15 patient retroperitoneal lymphadenectomy was added. Results: the mean number of nodes removed was 26, and the mean number of positive nodes was 6. There was significant difference between the two groups of the study when considering operation time (Mean 122 min. Vs. 192 min.). Also there is significant difference between the two groups of the study when considering hospital stay in days (Mean 8 days Vs. 13 days). There was significant difference between the two group of the study when considering the blood loos and need for blood transfusion (26% Vs. 80%). There was no significant difference between the two groups of the study when considering recurrence (73.3% Vs. 60%). Conclusion: Our results show improvement towards decrease the recurrence in the lymphadenectomy group but with non-significant results.

Role of Pelvic and Para-Aortic Lymphadenectomy in Advanced Ovarian Epithelial Cancer

Background: the role of detection and removal of retroperitoneal lymph nodes in patients with advanced ovarian cancer disease is unclear. Aim of the work: this study was aimed to evaluate the therapeutic role of pelvic and paraaortic lymphadenectomy in patients with advanced epithelial ovarian cancer. Patients and Methods: this study was designed as a prospective randomized controlled trial. Thirty patients were divided into two equal groups; 15 patients underwent optimum cytoreduction and in the other 15 patient retroperitoneal lymphadenectomy was added. Results: the mean number of nodes removed was 26, and the mean number of positive nodes was 6. There was significant difference between the two groups of the study when considering operation time (Mean 122 min. Vs. 192 min.). Also there is significant difference between the two groups of the study when considering hospital stay in days (Mean 8 days Vs. 13 days). There was significant difference between the two group of the study when considering the blood loos and need for blood transfusion (26% Vs. 80%). There was no significant difference between the two groups of the study when considering recurrence (73.3% Vs. 60%). Conclusion: Our results show improvement towards decrease the recurrence in the lymphadenectomy group but with non-significant results.

Comparison of Stage and Lymph Node Ratio in Young and Older Patients with Colorectal Cancer Operated in a Tertiary Hospital in Nepal

Colorectal cancer is being diagnosed more frequently in the young and it presents in an advanced stage. In TNM staging, stage depends on tumor size and number of positive nodes, which depend on location of tumor as well as the extent of dissection.The lymph node ratio is regarded as a more reliable marker for prognosis. In this study, we compare epidemiology of colorectal cancer in the young (<40 years) and older patients as well as the LNR. Patients with colorectal cancer operated at the Tribhuvan University Teaching Hospital, Kathmandu, Nepal for a period of 4 years (2012 - 2016) were included in the study. Patients were grouped into young (? 40 years) and older (> 40 years) and clinic-pathological data such as site of lesion, clinical stage, and lymph node ratio were compared. Of the 95 patients of colorectal cancer, 25 patients were of age ? 40 years (26%) and they had a higher median stage at diagnosis. In patients above 40 years, it was diagnosed at a relatively earlier stage. The mean number of positive nodes was 11.64 in younger patients whereas it was 18.34in those more than 40 years of age,but younger patients had higher lymph node ratio than elderly (0.31 vs 0.13) (P-value ? 0.005). Young patients with colorectal cancer tend to have more advanced disease. The lymph node metastasis and lymph node ratio tend to be higher in young patients.

Number of Resected Lymph Nodes and Survival of Patients with Locally Advanced Esophageal Squamous Cell Carcinoma Receiving Preoperative Chemoradiotherapy.

The association of extended lymph node (LN) dissection with improved outcomes in patients with locally advanced esophageal squamous cell carcinoma (ESCC) who received preoperative chemoradiotherapy (CRT) followed by surgery is debatable. We reviewed data from patients with esophageal cancer enrolled in three phase II clinical trials of preoperative paclitaxel and cisplatin-based CRT during 2000-2012. Patients with ESCC who underwent planned esophagectomy were enrolled. The number of resected LNs and other clinicopathological factors were analyzed regarding their impact on progression-free (PFS) and overall (OS) survival using Cox proportional hazards model. In total, 139 patients were included. The median PFS and OS were 24.4 and 31.8 months, respectively. The median number of resected and positive LNs were 19 (range=2-96) and 0 (range=0-9), respectively. The mean number of positive LNs did not differ significantly among quartile groups of total resected LNs (quartile 1: 2-12, 2: 13-19, 3: 20-29, and 4: 30-96). The resected LN number analyzed as dichotomies divided by the median or as continuous variables was not associated with PFS or OS. However, in an exploratory analysis, patients of quartiles 2 and 3 had longer PFS and OS than those with quartiles of 1 and 4 in multivariate analysis (p=0.019 and 0.005, respectively). Although extensive LN dissection was not associated with improved survival, resection of 13-29 LNs was associated with improved survival in patients with locally advanced ESCC receiving preoperative paclitaxel and cisplatin-based CRT.

Abstract P3-01-13: FNAC: A predictor of final number of involved nodes at axillary clearance

Abstract BACKGROUND: A vital part of pre-operative breast cancer assessment is axillary staging. Fine needle aspiration cytology (FNAC) is performed on clinically or radiologically positive axillary nodes in breast cancer. Our study looks at the sensitivity of performing FNAC in these patients and whether positive FNAC of axillary nodes can predict the final number of diseased nodes on completion axillary clearance (ANC). METHODS: All primary breast cancer patients undergoing FNAC between Oct 2009 to Oct 2011 were identified from electronic computer records. Data was collected on FNAC positivity, whether sentinel lymph node biopsy (SLNB) was performed, total number of nodes harvested at ANC and also the total number of diseased nodes at ANC. Patients who underwent neoadjuvant chemotherapy after a positive FNAC were analysed separately. RESULTS: Of the 230 patients who underwent FNAC, 130 were positive (56.5%). Of those who had a negative FNAC, 32% had a positive SLNB. We compared the ANC results of those who were FNAC positive (Group 1) with those who were FNAC negative but SLNB positive (Group 2). There was no significant difference in the mean number of harvested nodes at ANC between the two groups (mean= 17, p=0.14 on t-test). There was a significant difference in the number of diseased nodes in group 1 (mean = 7 nodes) compared with group 2 (mean = 3 nodes). In group 1, 56% of patients had 4 ≥ diseased nodes compared with 8.5% of patients in group 2. Neoadjuvant chemotherapy was given to 28 patients with a positive FNA. In this cohort, the mean number of positive nodes at axillary clearance was 2 and 10 % of patients had 4≥ diseased nodes on ANC. There was no significant difference in mastectomy versus breast conserving surgery rates between FNA positive and negative patients (p= 0.28 on Chi Square). The sensitivity of performing an FNAC was 81% in this study. Outcome of Patients undergoing Axillary Fine Needle Aspiration Cytology Group 1:FNAC positiveGroup2: FNAC negative, SLNB positive Mean No Harvested Nodes at ANC1816p=0.14Mean No of diseased nodes at ANC73p&amp;lt;0.05% of Patients with 4 or more diseased nodes at ANC568.5p&amp;lt;0.05% of Patients who had Breast Conserving Surgery5453p=0.28Key: FNAC:fine needle aspiration cytology, SLNB: Sentinel lymph node biopsy, ANC: Axillary clearance CONCLUSION: This study provides a predictor of the number of diseased axillary nodes in those with positive FNAC preoperatively. Over 50% of patients with a positive FNA have four or more diseased nodes compared with less than 10% in the FNAC negative but SLNB positive group. After neoadjuvant chemotherapy, FNA positive patients have a similar disease burden in the axilla as the FNAC negative but SLNB positive patients. This information can help to guide pre-operative discussions on the likely disease burden and need for adjuvant therapies such as chemotherapy and radiotherapy. Being able to predict the need for radiotherapy in particular can guide surgical decisions regarding type and timing of reconstructions to reduce the risk of surgical complications. Citation Format: Khan A, Hussain N, Irvine T. FNAC: A predictor of final number of involved nodes at axillary clearance [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-01-13.

Abstract 17: Patterns of neck nodal metastases and recurrence in human papilloma virus-associated oropharyngeal squamous cell carcinoma after neck dissection

Abstract Background: The aim of this study is to address the paucity of data on the potentially unique patterns of neck nodal metastases in HPV-positive oropharyngeal squamous cell carcinoma (HPV+OPSCC). Methods: The neck dissection (ND) specimens of varying levels of HPV+OPSCC patients at University of California-San Francisco from 2010-2016 were reviewed for the numbers and frequencies of clinically evident and occult nodes by neck level, and for those with extra-capsular spread (ECS). Smoking history (&amp;gt;10 pack-years), T status, and local, regional and distal recurrences were also assessed for possible associations with nodal metastatic behavior. Results: Sixty HPV+OPSCC patients underwent primary site trans-oral robotic surgery and 65 NDs, of which 21 (32%) were elective. Forty-three (65%) NDs were in non-smokers. Overall, the mean number of positive nodes per ND was 2.5 (range 1-9). The frequencies of at least one pathologically positive node for neck levels 1b, 2, 2a, 2b, 3, 4, and 5 were 0% (0/41), 67.7% (44/65), 43% (23/53), 13% (7/53), 27.7% (18/65), 7% (4/54), and 8% (2/23), respectively. All positive level 5 positive nodes were clinically evident preoperatively. Five of 21 (24%) elective NDs had occult disease only in levels 2A, 2B, and 3, with a mean number of positive nodes of 1.8 (range 1-3). Three of 21 (14%) elective NDs had nodes with ECS. Six of 44 (13%) therapeutic NDs had occult nodes outside the known preoperative distribution in levels 2b, 3 and 4. There were no occult 2a nodes. Smoking history, primary site, and T status were not statistically significantly associated with a differing metastatic nodal behavior. Twenty-three of 60 and 18 of 60 patients underwent adjuvant radiation and adjuvant chemoradiation, respectively. Thirteen of the 19 patients who only underwent surgery had positive lymph nodes, of which five had N1 disease and four had N2b disease. All four of N2b disease patients refused adjuvant therapy and none have had a recurrence as of follow-up (mean 28 months, range 3-51). The overall mean follow-up was 29.1 months (range 2-76 months), with 72% of patients having at least 12 months. One of 65 (1.5%) NDs developed a neck recurrence in the skin overlying level 2 in a patient in the therapeutic ND cohort who had undergone chemoradiation for ECS. No undissected neck levels developed metastatic nodal disease. Two of 60 (3%) patients developed local recurrence. No patients developed distant metastases. One patient in the cohort died of an unrelated cause. There have been no cancer-related deaths. Conclusions: For HPV+OPSCC, therapeutic NDs should encompass any levels bearing suspicious nodes and levels 2a, 2b, 3, and 4, while elective NDs should be performed and encompass at least levels 2a, 2b, and 3. ECS may be present in occult nodes. For HPV+OPSCC, these selective ND plans, followed by the indicated adjuvant treatment, is associated with a low neck recurrence rate. Citation Format: Madeleine P. Strohl, Steven J. Wang, Patrick K. Ha, Jonathan R. George, Chase M. Heaton, Ivan H. El-Sayed, Jon Mallen St Clair, William R. Ryan. Patterns of neck nodal metastases and recurrence in human papilloma virus-associated oropharyngeal squamous cell carcinoma after neck dissection [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; April 23-25, 2017; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(23_Suppl):Abstract nr 17.

Abstract P2-01-24: Evaluating lymph node ratio (LNR) as a prognostic indicator in node-positive breast cancer

Abstract Purpose: To determine whether LNR can provide additional prognostic information to pN staging in node-positive breast cancer patients. Methods: We previously reported on the utility of LNR as a prognostic indicator in lymph node-positive early breast cancer. We present an updated analysis with a prolonged median follow-up of 85 months. A retrospective review of original histopathology reports was undertaken in a sample group of 214 patients diagnosed with node-positive breast cancer between January 2000 and January 2011. The LNR was defined as the number of positive lymph nodes divided by the total number of lymph nodes (LNs) removed. LNR cut off points were divided into low (≤0.14), intermediate (0.15-0.39) and high (≥0.40) by trichotomy. Patients were also divided into three groups based on nodal status in accordance with the AJCC staging system. Those with 1-3 positive nodes were classified as pN1, those with 4-9 positive nodes were pN2 and those with 10 or more positive nodes were classified as pN3. Overall survival (OS) and invasive Disease Free Survival (iDFS) were calculated using the Kaplan Meier Method. Results: The mean age at diagnosis was 58 (SD=12) years. The median follow-up time was 85 months. The 5-year OS and iDFS for node-positive patients were 80% and 70%, respectively. The mean number of lymph nodes examined was 15.2 (SD=6.6) and the mean number of positive nodes was 5.3 (SD=6.1). When patients were stratified according to LNR groupings OS was 80% in the low LNR group, decreasing to 67% in the intermediate LNR group and 47% in the high LNR group (p&amp;lt;0.0001). Similarly, iDFS in the low LNR group was 71% decreasing to 57% in the intermediate LNR group and 42% in the high LNR group (p&amp;lt;0.0009). Conclusions: These updated results from a cohort of patients with lymph node-positive early breast cancer at a median follow-up of over 7 years confirms the utility of LNR as a prognostic indicator. Univariate and multivariate analyses to assess the ability of LNR to discriminate risk in addition to AJCC nodal grouping will be presented. Citation Format: Kelliher A, Boyce M, Donnellan E, O Connor D, Murphy C, Bird B. Evaluating lymph node ratio (LNR) as a prognostic indicator in node-positive breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-24.

Cysteine Rhenium Colloid: A Novel Radiocolloid for Identifying Sentinel Lymph Nodes in Breast Cancer Surgery

BackgroundMedical isotopes are required for sentinel node lymphoscintigraphy in breast cancer, but are in critical shortage. Our center uses a modification of the standard SC, called CRC, that has been shown to require less medical isotope for the same procedure. Our objective was to determine if there was a significant difference between SC and CRC in successful lymph node identification in breast cancer patients. Patients and MethodsThis was a retrospective cohort study using prospectively-collected data on 1205 consecutive early, clinically node-negative breast cancer patients who underwent a SNB between 2002 and 2008 at 2 tertiary hospitals in Canada. ResultsThere was no difference in successful lymph node identification rate (P = .50) or in the mean number of positive nodes identified between the 2 colloids (P = .88). The CRC group had a significantly lower rate of delayed adverse events (4.91% vs. 0.59%, P < .0001) even after adjusting for whether axillary dissection occurred on the same day as the biopsy (adjusted odds ratio, 0.12; 95% confidence interval, 0.04-0.40; P = .001). ConclusionOur findings suggest that there is no significant difference between CRC and SC in detecting sentinel nodes; however, CRC uses less medical isotopes. In the current climate of critical shortages of medical radioisotopes, radiocolloids should be selected for use based on amount of radioisotope required.

Pancreaticoduodenal resection for malignancy in a low-volume center: long-term outcomes from a developing country.

The technical complexity of pancreatic resection has made it a specialized procedure performed in high-volume centers. It has been shown that patients operated on in high-volume pancreatobiliary centers have fewer complications and better survival. The purpose of this study was to share our experience with and report long-term outcomes of pancreaticoduodenal resections performed in a low-volume center in Pakistan. Data of patients who underwent pancreaticoduodenal resection for adenocarcinoma at our institute from 1999 to 2012 were reviewed. A total of 39 patients were included in the study. Variables included patients' clinical and histopathological characteristics. Outcome was determined based on complication rate, 30- and 90-day mortality, disease-free survival, and overall survival. For survival analysis, Kaplan-Meier curves were used and significance was determined using a log rank test. Univariate Cox analysis was performed to determine significant factors for multivariate analysis. The majority of tumors [20 (51 %)] were moderate grade, T1/T2 [20 (51 %)], ampullary adenocarcinomas [18 (46 %)]. Mean hospital stay was 14 ± 8 days. The mean number of nodes removed was 13.9 ± 6.9, while mean number of positive nodes was 1 ± 1.7. Expected 5-year overall survival and relapse-free survival were 38 and 48 %, respectively. Overall 5-year survival was significantly different with respect to nodal involvement, i.e., 47 vs. 28 % (P = 0.018). On univariate analysis, nodal involvement was the only factor associated with an increased risk of death (P = 0.02, hazard ratio [HR] 2.9, confidence interval [CI] 1.1-7.8). Low-volume centers are an acceptable alternate to high-volume centers for performing pancreaticoduodenal resection in carefully selected patients. Efforts should be directed at developing specialized hepatobiliary centers in developing countries.

Abstract P2-18-05: Axillary nodal burden in patients with a positive pre-operative ultrasound guided fine needle aspiration cytology

Abstract Introduction Recent years have seen a dramatic shift to more conservative management of the axilla and the presence of a positive sentinel lymph node biopsy does not now automatically mandate an axillary clearance. This is based largely on data from the American College of Surgeons Oncology Group (ACOSOG) Z11 study, which failed to demonstrate a difference in local recurrence or overall survival when an axillary clearance was omitted in a highly selective group of patients with a positive sentinel lymph node. However, the presence of a positive pre-operative ultrasound guided axillary FNAC(Fine Needle Aspiration Cytology) may be representative of a higher burden of axillary disease. Aim Therefore, the aims of this study were firstly to quantify the actual nodal burden in breast cancer patients with a positive pre-operative ultrasound guided axillary FNAC and secondly to identify the number of patients who may have been spared an axillary clearance based on Z11 eligibility criteria. Methods A retrospective review of a prospectively maintained database within a tertiary breast cancer referral centre was performed. All patients with a positive pre-operative axillary FNAC were identified within a five year period (2007 – 2011). Demographic, tumour and biological characteristics and final nodal status were analysed. Eligibility for randomisation according to the Z11 criteria was assessed based on the final pathology and the number of patients who could have been spared an axillary clearance was identified. Results A total of 360 patients were identified with a positive axillary ultrasound guided FNAC. Sixty-three patients had no axillary surgery and three patients had recurrent disease, leaving a total of 294 for analysis. The mean age was 56 years (range 22 – 87). The mean size of the tumour was 31.3mm (range 4mm – 132mm) and the majority were an invasive grade 3 (57%) ductal carcinoma (84%). Luminal A (63%) was the commonest sub-type. The mean number of nodes removed at axillary clearance was 24 (range 7 – 58) while the mean number of positive nodes excised was 6 (range 0 – 47). Of these, the mean number of level I positive nodes was 4, level II was 1 and level III nodes was &amp;lt;1. Overall a total of 78 patients had less than three positive nodes identified in the axilla and potentially may have been eligible for the Z11 study. However, when patients who had a mastectomy, neo-adjuvant chemotherapy were excluded and the presence of extra-capsular nodal involvement was accounted for only 19 (6.4%) patients may have been spared an axillary clearance. Conclusions The presence of nodal positivity on a pre-operative FNAC is associated with a higher burden of axillary disease. Only a minority of these patients would be able to avoid an axillary clearance in the setting of the recent Z11 study. Performing an axillary ultrasound and FNAC of suspicious nodes allows patients to avoid an unnecessary sentinel lymph node biopsy and proceed directly to an axillary clearance. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-05.

Role of different approaches to the abdominal retroperitoneum for aortic lymphadenectomy in patients with gynecological cancers

BackgroundParaaortic lymphadenectomy (PALN) is a standard part of many interventions, but currently there are no established care protocols effective in preventing gastro-intestinal (GI) symptoms. The aim of our study was to retrospectively evaluate patients with gynecologic cancers submitted to PALN, in order to evaluate if different approaches to the retroperitoneum could influence the radicality of the procedure and the onset of GI complications. MethodsWe divided 121 patients with gynecologic tumors submitted to PALN into 3 groups according the used right, left or combined left–right approach to the retroperitoneum, comparing the groups according the main surgical-pathological parameters, such as the number of nodes removed and the incidence and severity of GI complications. ResultsThe mean number of nodes removed did not significantly differ between the groups, while the mean number of positive nodes was significantly higher in combined approach. 39.8% of our patients experienced GI side effects, but those submitted to the combined approach had a significantly higher incidence of GI symptoms. ConclusionsOur data demonstrate that the choice of the retroperitoneal approach could be the most important feature for the appearance of post-operative GI side effects, even if there is no significant difference on the radicality of PALN performed retroperitoneal approach.