Median Lymph Node Research Articles

Laparoscopic pancreaticoduodenectomy for resection of periampullary tumors should be routine?

Background: PD is acomplex abdominal procedure. The hospital mortality rate has decreased to <5% however the rate of postoperative morbidities remains high 40%. Laparoscopic pancreaticoduodenectomy (LPD) has not yet been well established approach for periampullary tumour. We present our experience with LPD. Methods: Patients undergoing LPD between 2014 and 2018 Included in the study. Patients who underwent a hybrid LPD (HLPD) mobilization approach and resection followed by open reconstruction and totally LPD (TLPD) approach were included in this study. Operative characteristics, perioperative outcomes, and pathological were collected. Results: Thirty Eight patients underwent LPD including 10 HLPD (26.3%) and 28 TLPD (73.7%) patients. HLPD patients were mostly converted to open for planned reconstruction or anesthetic problem. Median operating time was 370 min (420 min for TLPD). Median length of hospital stay was 6 days. Histology showed 35 invasive malignancies, two neuroendocrine tumours, and one benign lesions. Median nodal harvest was 14. Margin negative resection was achieved in 97.4 % of patients. Twenty-two percent of patients developed a Grade 3∕4 complication, including 12% clinically significant pancreatic fistula. There was one perioperative mortality (2.6%) due to pancreatic fistula. These results are comparable with a well marched cases underwent open PD in the same period of study. Conclusions: LPD is a technically challenging operation with a steep learning curve. The early surgical outcomes are satisfactory. LPD offers benefits to patients as it is minimal invasive procedure so it should be a routine procedure in a well equipped center with good selection of the patients.

Validation of American Joint Committee on Cancer eighth staging system for gallbladder cancer and its lymphadenectomy guidelines

BackgroundFor gallbladder cancer (GBC), the American Joint Committee on Cancer eighth edition (AJCC 8) staging system classifies lymph node (LN) stage by the number of positive LN and recommends sampling of ≥6 LNs. We evaluated the prognostic capability of the AJCC 8 for patients undergoing resection and the current national trends in LN staging in the context of these new recommendations for nodal (N) sampling. MethodsUtilizing the National Cancer Data Base, we identified all gallbladder adenocarcinoma patients treated with surgical resection in 2004-2014. Cox regression modeling was used to calculate the concordance index of AJCC 8 in predicting overall survival. N sampling and positivity rates were analyzed over the study period. ResultsIn our cohort, predicted 5-year overall survival by AJCC 8 was: stage I, 62.5%; II, 50.2%; IIIA, 25.7%; IIIB, 22.1%; IVA, 15.7%; IVB, 6.7% (P < 0.01). The concordance index for the staging system was 0.832. Only 50.7% of the patients had any LN sampling to determine the N stage. LN sampling rates improved from 45.6% in 2004 to 55.1% in 2013 (P < 0.001). However, only 24.5% of patients with any LN sampling had ≥6 LNs resected (12.4% of eligible cohort), with a median LN sample of two. ConclusionsAJCC 8 offers adequate discrimination for GBC staging, especially for node-positive patients. With actual GBC LN sampling rates at 50.7%, and far short of the ≥6 LN threshold, quality improvement measures may need to focus on requiring any LN sampling before raising the minimum to six LNs.

Rates and Predictors of Conversion to Open Surgery During Minimally Invasive Radical Cystectomy.

To assess the frequency of minimally invasive radical cystectomy (MIRC) conversion to open surgery, what factors influence conversion, whether or not the benefits of MIRC vs open radical cystectomy (ORC) persist after conversion, and compare ORC and MIRC outcomes. We performed a retrospective cohort study from the National Cancer Data Base (2010 to 2013) analyzing patients who underwent completed MIRC (n = 5750), converted MIRC (n = 245), and ORC (n = 12,053) without prior radiotherapy. Multivariable logistic and linear regression analyses were used to assess the association between covariates, open conversion as well as surgical approach, and secondary outcomes such as positive surgical margins (PSMs), use of lymphadenectomy, lymph node yield, hospital length of stay (LOS), and 30-day readmission. Rates of conversion were independent of patient factors such as race, sex, use of neoadjuvant chemotherapy, and clinical stage. Conversion occurred in 245 of 5750 MIRCs (4.3%) and declined over time (5.8% in 2010 vs 3.2% in 2013, odds ratio [OR] 0.50, 95% confidence interval [CI] 0.34-0.75, p = 0.001). MIRC was associated with fewer positive margins, higher lymph node yield, shorter LOS, and fewer readmissions compared with ORC, however, patients requiring open conversion had longer median hospital stays (8 days vs 7 days, p = 0.013), lower median lymph node yields (14 vs 17, p = 0.007), more PSMs (17% vs 11%, p = 0.006), and more 30-day readmissions (14% vs 9%, p = 0.008) compared to nonconverted. Converted MIRC had similar hospital LOS and 30-day readmission rates compared to ORC. Open conversion during MIRC is uncommon and has decreased in recent years despite the rising use of MIRC. MIRC had better short-term outcomes compared with ORC. These benefits were negated with open conversion; however, outcomes were similar compared to planned ORC.

MP37-06 IS SURVEILLANCE WITHOUT IMMEDIATE TREATMENT AN OPTION FOR NEWLY DIAGNOSED TESTICULAR GERM-CELL CANCER PATIENTS WITH BORDERLINE SIZE RETROPERITONEAL LYMPH NODES ON COMPUTED TOMOGRAPHY SCAN?

You have accessJournal of UrologySexual Function/Dysfunction: Penis/Testis/Urethra: Benign Disease & Malignant Disease I1 Apr 2018MP37-06 IS SURVEILLANCE WITHOUT IMMEDIATE TREATMENT AN OPTION FOR NEWLY DIAGNOSED TESTICULAR GERM-CELL CANCER PATIENTS WITH BORDERLINE SIZE RETROPERITONEAL LYMPH NODES ON COMPUTED TOMOGRAPHY SCAN? Nadav Milk, Ilan Leibovitch, Daniel Keizman, Hadas Dresler, and Itay Sternberg Nadav MilkNadav Milk More articles by this author , Ilan LeibovitchIlan Leibovitch More articles by this author , Daniel KeizmanDaniel Keizman More articles by this author , Hadas DreslerHadas Dresler More articles by this author , and Itay SternbergItay Sternberg More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1212AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The AJCC TNM Staging System for Testicular Cancer (TC) does not set a minimal diameter to define positive lymph nodes (LN) on computed tomography scan. It is common to refer to LN ≥ 1 cm in diameter as positive, even though benign LN in the borderline size of 1-1.5cm are common. Our goal is to describe the outcome of TC patients with borderline size retroperitoneal LN of undetermined significance managed initially with surveillance. METHODS We retrospectively reviewed the medical records of all TC patients treated at our institution during 2006-2016. Demographic, clinical, laboratory, imaging, pathological, treatment and surveillance data were obtained. RESULTS Of a total of 109 TC patients, 24 patients (22.2%) with borderline size LN were assigned to an active surveillance protocol by our tumor board. Median age at the time of orchiectomy was 37.2 years (IQR, 23.9-40.5). With a median follow-up of 4.2 years (IQR 1.7-6.7), overall survival rate in the group was 100%. Nine of 24 patients (37.5%) relapsed and were treated within a median of 4.9 months (IQR 2.2-5.5). Median follow-up for 16 patients who did not relapse was 3.8 years (IQR 1.6-5.4). Relapse-free survival was 71% (95% CI 49-87), and 62% (95% CI 41-80) at one and two years, respectively.The median LN diameter at the time of diagnosis was 11 mm (IQR 9-12, mean 10.3). LN diameter was not associated with likelihood of relapse (p = 0.43). Orchiectomy pathology included pure seminoma in 17/24 (71%), and a nonseminomatous tumor in 7/24 (29%). Tumor type was not associated with likelihood of relapse (p = 0.63).Patients who relapsed during follow-up were significantly younger at the time of TC diagnosis than patients who did not relapse (Median age 34 years [IQR 22.4-37.3] and 40 years [IQR 36.1-47.9] respectively, p=0.025). CONCLUSIONS Surveillance alone for TC patients with borderline size LN of undetermined significance at diagnosis is a possible option and may help avoid overtreatment in 60% of these patients. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e493 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Nadav Milk More articles by this author Ilan Leibovitch More articles by this author Daniel Keizman More articles by this author Hadas Dresler More articles by this author Itay Sternberg More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Long-Term Results for Clinical Stage IA Lung Cancer: Comparing Lobectomy and Sublobar Resection

Lobectomy has been compared with sublobar resection for the treatment of stage IA non-small cell lung cancer (NSCLC). Accurate long-term data are lacking on the risk of recurrence in routine clinical practice. This study used a unique and representative dataset to compare recurrence, overall survival (OS), and lymph node staging between lobectomy and sublobar resection. The American College of Surgeons performed a Special Study of the National Cancer Data Base, by reabstracting records to augment NSCLC data with enhanced information on preoperative comorbidity and cancer recurrence from 2007 to 2012. For patients treated with lobectomy or sublobar resection (wedge resection or segmentectomy) for clinical stage IA NSCLC, propensity matching and competing risks models compared 5-year OS and risk of cancer recurrence. Secondary measures included lymph nodes collected, pathologic upstaging, and surgical margin status. A total of 1,687 patients with stage IA NSCLC were identified (1,354 who underwent lobectomy, and 333 who had sublobar resections). Propensity matching yielded 325 pairs. Lobectomy and sublobar resection groups had similar 5-year OS (61.8% vs 55.6%, p= 0.561). The sublobar group had a 39% increased risk of NSCLC recurrence (hazard ratio, 1.39; 95% confidence interval, 1.04 to 1.87). Median lymph node counts were higher for lobectomy-treated patients (7 [3, 10] vs 1 [0, 4], p < 0.001)]. In an enhanced national dataset representative of outcomes for stage IA NSCLC, sublobar resection was associated with a 39% increased risk of cancer recurrence. The majority of patients treated with sublobar resection had an inadequate lymph node assessment. These real-world results must be considered when existing clinical trial results comparing these treatments are extrapolated for clinical use.

High volume pancreaticoduodenectomy performed at a community cancer center

Background: Complex pancreatic surgery can be fraught with significant morbidity and mortality when performed in low volume centers. This has led to the concept that pancreatic surgery should be regionalized and performed in large high-volume academic centers. We sought to evaluate the post-operative outcomes of patients undergoing pancreaticoduodenectomy after the establishment of a dedicated surgical oncology team at a NCI selected community cancer center. Methods: A retrospective chart review of the medical record was performed to capture patients undergoing pancreatic head resections performed over a 10-year period with two dedicated pancreatic surgical oncologists. Results: Over a 10-year period (2007–2017), 213 patients underwent Whipple resection. Median patient age was 66 y. Most patients had significant comorbidities (ASA = 3) and were overweight (Median BMI = 27). Median operative time and blood loss were 253 minutes and 500 ml, respectively. 160 (75%) out of 213 patients had a malignant lesion on final pathology. 121 (76%) out of 160 had R0 resection. Median lymph nodes harvested was 13. Overall incidence of delayed gastric emptying (DGE) was 31% (67/213), with clinically significant DGE (Grade B/C) in 15% (32/213). Clinically significant pancreatic leak rate (Grade B/C) was 10 % (21/213). For all patients, median length of stay was 8 days with 36 (17%) patients being readmitted within 30 days. Grade 3 or 4 morbidity rate was 21% (44/213), and 30-day mortality was 2% (5/213). Conclusion: This is the largest series of patients undergoing pancreatic head resections from a community cancer setting. At a high volume community cancer center with a dedicated surgical oncology team, pancreaticoduodenectomy can be performed with excellent post- operative outcomes on par with any major academic center.

Robot-Assisted Retroperitoneal Lymphadenectomy in Testicular Cancer Treatment: A Systematic Review.

Retroperitoneal lymph node dissection (RPLND) in testicular cancer is a documented treatment along with active surveillance and chemotherapy. This study aims to summarize the current evidence on the use of Robot-assisted RPLND (RARPLND) in comparison with the laparoscopic and open approach. A search was conducted in the existing literature focusing on reports with outcomes of RARPLND for stage I-IIB testicular tumor. Eleven studies complied with the inclusion criteria, including 116 patients. The average follow-up of 21.2 months showed no retroperitoneal recurrence. The median lymph node yield was 22.3 and the overall positive rate was 26%. Complications were encountered in 8% of the patients. The robotic approach showed similar results to the laparoscopic approach and outperformed the open procedure in perioperative parameters. Relapse-free survival, nodal yield, and complication rates during RARPLND for clinical stage I-IIB are acceptable. Further studies are required to establish these findings and determine benefit from the use of robotic approach.

Is surveillance without immediate treatment an option for newly diagnosed testicular germ-cell cancer patients with borderline size retroperitoneal lymph nodes on computed tomography scan?

560 Background: The AJCC TNM Staging System for Testicular Cancer (TC) does not set a minimal diameter to define positive lymph nodes (LN) on computed tomography scan. It is common to refer to LN ≥ 1 cm in diameter as positive, even though benign LN in the borderline size of 1-1.5cm are common. Our goal is to describe the outcome of TC patients with borderline size retroperitoneal LN of undetermined significance managed initially with surveillance. Methods: We retrospectively reviewed the medical records of all TC patients treated at our institution during 2006-2016. Demographic, clinical, laboratory, imaging, pathological, treatment and surveillance data were obtained. Results: Of a total of 109 TC patients, 25 patients (22.7%) with borderline size LN were assigned to an active surveillance protocol by our tumor board. Median age at the time of orchiectomy was 37.2 years (IQR, 23.9-40.3). With a median follow-up of 3.9 years (IQR 1.7-6.5), overall survival rate in the group was 100%. Nine of 25 patients (36%) relapsed and were treated within a median of 4.9 months (IQR 2.2-5.5). Median follow-up for 16 patients who did not relapse was 3.4 years (IQR 1.5-5.4). Relapse-free survival was 71% (95% CI 48-85), and 61% (95% CI 38-77) at one and two years, respectively. Orchiectomy pathology included pure seminoma in 18/25 (72%), and a nonseminomatous tumor in 7/25 (28%). Tumor type was not associated with likelihood of relapse (p = 0.66). The median LN diameter at the time of diagnosis was 11 mm (IQR 9-12, mean 10.4). LN diameter was not associated with likelihood of relapse (p = 0.34). Patients who relapsed during follow-up were significantly younger at the time of TC diagnosis than patients who did not relapse (Median age 23.9 years [IQR 19.6-35.2] and 39.2 years [IQR 34.3-47.9] respectively, p = 0.0056). Conclusions: Surveillance alone for TC patients with borderline size LN of undetermined significance at diagnosis is a possible option and may help avoid overtreatment in 60% of these patients.

Effect of blue dye guided lymph channel ligation on the surgical morbidity of groin lymphadenectomy for vulval cancer: a feasibility study

Inguinal lymphadenectomy has significant morbidity. Blue dye-guided lymph channel ligation is an effective technique for resolving lymphocele. This was a feasibility study in a preventative setting. Patients with vulval cancer requiring bilateral inguinal lymphadenectomy were recruited. After lymphadenectomy, patent blue V dye was injected and the severed lymph channels leaking blue dye, on the randomly-designated side were ligated. The median age was 72.5 years and the median body mass index was 25. The median lymph node harvest was 18.5. There were no significant surgical procedural differences between the right and the left sides. There was no significant difference between the two arms in terms of the duration or the volume of drainage and post-operative complications. All patients were alive at the follow-up period of 40.5 months. In this feasibility study, blue dye-guided lymph channel ligation did not significantly impact on post-operative outcomes.Impact statementWhat is already known on this subject? Lymph channel ligation with blue dye-guidance is an effective strategy for managing recalcitrant inguinal lymphocyst. This strategy was prospectively-studied in a small series of patients with non-gynaecological cancers. This particular study by Nakamura et al. (2011) revealed that such a strategy might be efficacious in reducing wound drain output.What do the results of this study add? Our study is the first study to assess this technique exclusively in vulval cancer. Blue dye-guided lymph channel ligation at the time of inguinal lymphadenectomy does not appear to reduce wound drainage. However, this study suggests that primary lymphocyst predominantly results from inflammatory exudates, whereas persistent secondary lymphocysts are likely to result from lymphorrhoea.What are the implications of these findings for clinical practice and/or further research? Future studies, which aim to reduce the morbidity of open inguinal lymphadenectomy, should employ a composite strategy to reduce inflammatory secretions. In addition, a biochemical and cytological analysis on lymphocysts at various time points should be performed to characterise the natural history of groin lymphocysts.

Postoperative proton therapy for pancreatic cancer patients enrolled on the Proton Collaborative Group (PCG) registry.

513 Background: The PCG registry is a multicenter registry for patients receiving proton therapy for various malignancies. The current abstract reviews the outcomes for patients receiving postoperative proton therapy for resected pancreatic cancer. Methods: From March, 2013 to August,2016 18 patients with resected pancreatic adenocarcinoma received postoperative proton therapy. The current study reviews the pretreatment characteristics and outcomes of these patients. Results: Median age -70 years (range 52 to 79); Males 12, Females 6; pT Stage -T2–4, T3–13, T4–1; N Stage -N1–12, N0–6; Margin Status -Close-8, Positive-4, Negative-6; Surgical approach -open-16, laparoscopic 2; Operations performed: standard pancreaticoduodenectomy-11, pylorus sparing pancreaticoduodenectomy-4, total pancreatectomy-1; Pancreaticoduodenectomy with portal vein reconstruction –1; Pancreaticoduodenectomy with irreversible electroporation. Median lymph nodes taken-16.50 (range 3 to 72); Median lymph nodes positive-1.5 (range 0 to 7); PNI positive-9, PNI negative-2, PNI unknown-4; LVI positive-7, LVI negative-6, LVI unknown-5; Median tumor size –3.1cm (range 2.2 to 6.2); Median dose delivered –50.51Gy(RBE) (range 27.88 to 54.00); Median treatment duration –38 calendar days (range 25 to 48); One patient died during treatment. One additional patient demonstrated grade 3 toxicity (anorexia, nausea, diarrhea). Only one patient’s treatment was protracted by more than 5 days. Median available follow up is 1.1 years (range 0.07 to 3.4 years); 2 year survival 37%. Conclusions: Postoperative proton therapy after pancreatectomy was well tolerated without treatment interruption or severe toxicity.

A comparison of doublet versus triplet chemotherapy regimens for esophagogastric adenocarcinoma (EGC): Is more always better?

124 Background: Recent data showed that a taxane-containing triplet regimen (FLOT) was superior to an anthracycline-containing regimen (ECX/ECF). However, there is no comparison between more costly and toxic triplet (T) regimens versus doublets (D) in the perioperative setting (periCT) of EGC. Methods: A retrospective analysis of patients (pts) with newly diagnosed EGC was carried out at AC Camargo Cancer Center from 2007 to 2015. Pts received either a D with a fluopyrimidine and platin or T with addition of epirubicin or docetaxel. Variables used in the Cox model were age, site, TNM, Lauren subtype and periCT (T versus D). The selection between T and D was at physician's choice. Endpoints were Relapse Free Survival (RFS) and Overall Survival (OS). Results: A total of 128 pts were included. Median age was 59.5y (56.5y for T and 67y for D, respectively). Male/female ratio was 82/46. Sixty-six received T (DCF 26 pts, EOX 28, ECX 8, 4 others) and 62 received D (FOLFOX 47 pts, CF 13, 2 others). Primary site: gastric in 93 pts and 35 EGJ. Main clinical staging cT3 N = 81 (63.3%), cN+ 84 (65.4%). Lauren subtype: intestinal N = 48, diffuse N = 54. Regarding surgery: 114 pts were resected and median lymph nodes removed 30. Pathologic complete response was seen in N = 9 (14.5%) and N = 4 (6.1%) considering D and T regimens, respectively (p = 0.14). In multivariate analysis there was no advantage of T over D regarding RFS (HR = 1.65, 0.87 – 3.11, p = 0.12) or OS (HR = 1.29, 0.65 – 2.57, p = 0.45). The 3y RFS rate was 63.2% for D and 40.6% for T and the 3y OS was 69.4% for D and 56.1% for T. Conclusions: In our analysis outcomes of pts treated with T regimen was not superior to D. Our main T was DCF and D was FOLFOX. We consider that doublet regimens may still have a role in periCT in EGC and could be an option for frail or elderly pts. Future trials are needed to confirm our data.

Redefining the learning curve for robotic esophagectomy.

132 Background: Minimally invasive esophagectomy(MIE) has demonstrated superior outcomes compared to open approaches. The myriad of techniques has precluded the recommendation of a standard approach. The robotic approach has increased steadily. We have previously published our series defining the learning curve for this approach. The purpose of this study is to redefine the learning curve for robotic-assisted esophagogastrectomy with respect to operative time, conversion rates, and patient safety. Methods: We have prospectively followed all patients undergoing robotic-assisted esophagogastrectomy and compared operations performed at our institutions by a single surgeon in successive cohorts. Our measures of proficiency included: operative times, conversion rates, and complications. Statistical analyses were undertaken utilizing Spearman regression analysis and Mann-Whitney U test. Significance was accepted with 95 % confidence. Results: We identified 203 patients (166 [81.8%] male: 37 [18.2%] female) of median age of 67.2 (30-90) years who underwent robotic-assisted esophagogastrectomies for malignant esophageal disease. One-hundred sixty six were adenocarcinoma, 26 were squamous cell carcinoma and 11 were other. R0 resections was performed in 202 (99.5%) of patients. The median lymph node harvest was 18 (6-63). Neoadjuvant chemoradiation was administered to 157 (77.4%) patients. A significant reduction in operative times (p &lt;0.005) following completion of 20 procedures was identified (514 ± 106 min vs. 415± 91 min compared to subsequent 80 cases and further reduced with the subsequent 100 cases 397 ± 71.9 min) p&lt;0.001. Complications decreased after the initial learning curve of 29 cases, p=0.04. However there was an increase in complications after 90 cases in which there was an increase in the Charleson morbidity index, p&lt;0.01 indicating higher risk patients which tapered after case 115. Conclusions: For surgeons proficient in performing minimally-invasive esophagogastrectomies, the learning curve for a robotic-assisted procedure appears to begin near proficiency after 20 cases however as more complex cases are undertake there appears to be an additional learning curve which is surpassed after 90 cases.

Defining the role of lymphadenectomy for pancreatic neuroendocrine tumors: An eight institution study of 695 patients from the U.S. Neuroendocrine Tumor Study Group.

212 Background: Preoperative factors that reliably predict lymph node (LN) metastases in pancreatic neuroendocrine tumors (PanNETs) are unclear. The number of LNs needed to accurately stage PanNETs has not been defined. Methods: Patients who underwent curative-intent resection of primary non-functional PanNETs at 8 institutions from 2000-2016 were analyzed. Tumors with poor differentiation and Ki-67 &gt; 20% were excluded. Preoperative factors associated with LN metastases were identified. A procedure specific target for LN retrieval to accurately stage patients was determined. Results: Of 2182 pts with GI NETs, 695 underwent resection of PanNETs. 33% of tumors were proximal (head/uncinate), and 67% were distal (neck/body/tail). 26% of pts (n = 158) had LN+ disease, which was associated with worse 5-yr recurrence-free survival (RFS) (60% vs 86%; p &lt; 0.001). Increasing number of +LNs was not associated with worse RFS. Preoperative factors associated with +LNs included tumor size ≥2 cm (OR 6.6; p &lt; 0.001), proximal location (OR 2.5; p &lt; 0.001), moderate vs well differentiation (OR 2.1; p = 0.006), and Ki-67≥3% (OR 3.1; p &lt; 0.001). LN metastases were also present in tumors without these risk factors: &lt; 2cm (9%), distal location (19%), well differentiated (23%), and Ki-67 &lt; 3% (16%). Median LN retrieval was 13 for pancreatoduodenectomy (PD), but only 9 for distal pancreatectomy (DP). Given that PD routinely includes a complete regional lymphadenectomy, a minimum number of LNs to accurately stage pts was not identified. For DP, however, removal of &lt; 7 LNs failed to discriminate 5-yr RFS between LN (+) and (-) pts ( &lt; 7 LNs: 72% vs 83%, p = 0.198; ≥7 LNs: 67% vs 86%, p = 0.002). Conclusions: Tumor size ≥2 cm, proximal location, moderate differentiation, and Ki-67≥3% are preoperative factors that predict LN positivity in resected non-functional PanNETs. Given the 9-23% incidence of LN metastases in patients without such risk factors, routine regional lymphadenectomy should be considered. Pancreatoduodenectomy inherently includes sufficient LN retrieval, while distal pancreatectomy should aim to remove ≥7 LNs for accurate staging.

Extraperitoneal Para-Aortic Lymphadenectomy by Robot-Assisted Laparoscopy

Study ObjectiveTo evaluate the outcomes of extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy. DesignA retrospective study (Canadian Task Force classification III). SettingAn academic institution. PatientsTwenty-three consecutive patients with gynecologic cancer who presented for para-aortic lymphadenectomy between March 2016 and May 2017 were reviewed retrospectively. InterventionsExtraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy was performed. Measurements and Main ResultsOf the 23 patients reviewed retrospectively, 10 had cervical cancer, 7 had endometrial cancer, 5 had adnexal cancer, and 1 had vaginal cancer. Data regarding patient characteristics, indication for para-aortic lymphadenectomy, type of surgery (infrarenal or inframesenteric), operative time, surgical complications, number of nodes retrieved, and postoperative hospital length of stay were collected. Two patients were excluded because of early perforation of the peritoneum. In total, 21 para-aortic lymphadenectomies were performed (16 infrarenal and 5 inframesenteric). The median skin-to-skin operating time of infrarenal extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy was 170 minutes (range, 90–225 minutes), the median lymph node count was 18 (range, 11–38), and the median estimated blood loss was 50 mL (range, 10–600 mL). The median skin-to-skin operating time of inframesenteric extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy was 120 minutes (range, 90–220 minutes), the median lymph node count was 10 (range, 7–19), and the median estimated blood loss was 30 mL (range, 10–100). Intraoperative complications included 1 thermal lesion of the left genitofemoral nerve, 1 thermal lesion of the left mesoureter (a ureteral stent was placed to avoid ureteric necrosis and fistula without after effect), and 1 lesion of the inferior vena cava that was sutured by robot-assisted laparoscopy. There were 2 additional cases of perforation of the peritoneum that occurred in the infrarenal group. The median hospital length of stay was 1 day (range, 0–7 days). Three patients were readmitted for symptomatic lymphocysts. ConclusionExtraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy provides good visualization of the operative field without arm conflict. Still, perforation of the peritoneum and symptomatic lymphocysts are a postoperative concern.

Comparing Outcomes of Robotic and Open Inguinal Lymph Node Dissection in Patients with Carcinoma of the Penis

We compared outcomes between robot-assisted video endoscopic inguinal lymphadenectomy and open inguinal lymph node dissection in patients without bulky nodal metastasis in a tandem contemporary cohort. We retrospectively analyzed a prospectively maintained hospital registry of 51 patients who underwent robot-assisted video endoscopic inguinal lymphadenectomy and 100 treated with open inguinal lymph node dissection from 2012 to 2016 for groins without bulky nodal metastasis and who hada minimum 9-month followup. Complications were graded by the Clavien-Dindo classification, and nodal yield and disease recurrence during followup were assessed. Elastic net regression was used to select variables associated with major complications (Clavien 3a or greater) for multivariable analysis of plausible factors, including patient age, diabetes, body mass index, smoking, nodal stage, surgery type, sartorius transposition, saphenous vein transection and adjuvant radiotherapy. Penalized likelihood logistic regression methods were used for multivariate analysis to ascertain final effect sizes while accounting for sparse data bias. Robot-assisted video endoscopic inguinal lymphadenectomy and open inguinal lymph node dissection had comparable median lymph node yields (13 vs 12.5). No patient experienced recurrence during the median followup of 40 months. Robot-assisted video endoscopic inguinal lymphadenectomy was associated with significantly lower hospital stay, days needing a drain in situ, incidence of major complications, edge necrosis, flap necrosis and severe limb edema. On multivariable analysis pathological nodal stage (OR 2.8, 95% CI 1.1-6.8, p=0.027) and open inguinal lymph node dissection (OR 7.5, 95% CI 1.3-43, p=0.024) emerged as independent risk factors associated with an increased risk of major complications. Robot-assisted video endoscopic inguinal lymphadenectomy is a feasible technique which allows for a similar nodal yield while being associated with lower morbidity than open inguinal lymph node dissection in patients without bulky groin adenopathy.

The technique of laparoscopic hepatic bisegmentectomy with regional lymphadenectomy for gallbladder cancer.

Background:Laparoscopic hepatic bisegmentectomy (s4b and s5) with regional lymphadenectomy (LHBRL) for patients with gallbladder cancer (GBC) is rarely reported.Aims:The aim of the study was to describe the technique of LHBRL in patients with GBC and to present our initial experience.Patients and Methods:This retrospective study was conducted on twenty patients with GBC who were considered for LHBRL by the described technique. These patients either had a suspicion of GBC (SGBC) or had an incidental diagnosis of GBC (IGBC). Appropriate statistical methods were applied.Results:Twelve patients (60%) had SGBC and eight patients (40%) had IGBC. Eighteen patients (90%) were females and median age was 50 (range: 28–70) years. Median (range) surgical blood loss was 120 ml (80–400), operation time was 300 (200–480) min and hospital stay was 5.5 (2–10) days. No patient had iatrogenic complication during LHBRL. Five (25%) patients required conversion to open method. Four patients (20%) who developed complications were managed conservatively. All but three patients (25%) with SGBC had a benign disease on final biopsy. TNM stage of 17 patients (85%) with adenocarcinoma was T1bN0 in 3 (17.6%), T2N0 in 6 (35.3%), T3N0 in 2 (11.7%) and T1-3N1 in 6 (35.3%). The median lymph node count was 10 (range: 4–24) and resection margins were negative (R0) in all. The overall survival was 82.3%. During a median follow-up of 22 months, two patients died due to disease recurrence and one patient died due to myocardial infarction.Conclusion:The described technique of LHBRL is safe and feasible for patients with GBC without extrahepatic involvement.

Robot-assisted radical nephroureterectomy with extended template lymphadenectomy for upper tract urothelial carcinoma: An outcome analysis.

Introduction:Robot-assisted radical nephroureterectomy (RANU) with extended template lymphadenectomy (E-LND) is the leading treatment option for nonmetastatic upper tract urothelial carcinoma. Due to the rarity of this disease, there is a lack of consensus regarding the best approach and the extent of lymphadenectomy. We report our technique and its initial outcomes from the retrospective evaluation of a prospectively maintained database of 11 consecutive cases of RANU + E-LND. To the best of our knowledge, our series represents the first published experience of this procedure from India.Materials and Methods:RANU was performed in 11 patients (including two patients with simultaneous radical cystectomy) with the da Vinci Xi system. Pelvic and upper ureteric tumors were operated without re-docking or repositioning, using the port hopping feature. For the lower ureteric tumors, the patient was repositioned and the robot was re-docked to ensure completeness of pelvic lymphadenectomy. E-LND was performed in all the patients as per the templates described in previous studies.Results:Median age was 67.5 years (range 52–71). Median console time and blood loss were 170 min (range 156–270) and 150 cc (range 25–500), respectively. Median hospital stay was 3 days (range 2–8). One patient developed paralytic ileus in the postoperative period (Clavien Dindo Grade 1). None had a positive surgical margin and the median lymph node yield was 22.5 (range 7–47). Median follow-up was 9 months during which one patient developed metastatic systemic recurrence. All other patients were disease free at the last follow-up.Conclusions:A robotic approach to radical nephroureterectomy with E-LND is feasible and safe and does not appear to compromise the short-term oncological outcomes as defined by lymph node yields and margin positivity. At the same time, it offers the benefits of minimal invasion and results in swifter patient recovery from this extensive surgery.

Comparative effectiveness of robot-assisted vs. open radical cystectomy

ObjectivesOver the past decade, robot-assisted radical cystectomy (RARC) has gained traction as an alternative to the conventional open approach open radical cystectomy (ORC). However, the benefits of RARC over ORC remain unclear. Our objective was to conduct a comparative effectiveness analysis between RARC and ORC using data from the National Cancer Data Base. Materials and methodsWithin the National Cancer Data Base, we identified patients with localized muscle-invasive bladder cancer who underwent RC between 2010 and 2013. Patients were stratified according to surgical approach: ORC vs. RARC. Intraoperative endpoints included: the presence of positive surgical margins, the performance of a pelvic lymph node dissection, and number of lymph nodes (LN) removed. Postoperative endpoints included: length of stay (LOS), 30- and 90-day postoperative mortality (POM) rates, 30-day readmission rate, and overall survival (OS). To minimize selection bias, observed differences in baseline characteristics between RARC vs. ORC patients were controlled for using weighted propensity scores. Binary endpoints and OS were assessed using propensity score-adjusted logistic and Cox regression analyses, respectively. POM was assessed using propensity score weighted Kaplan-Meier survival estimates at 30 and 90 days after RC. ResultsOf 9,561 patients who underwent RC, 2,048 (21.4%) and 7,513 (78.6%) underwent RARC and ORC, respectively. The use of RARC increased over time, from 16.7% in 2010 to 25.3% in 2013. With regard to intraoperative outcomes, RARC was associated with equivalent rates of positive surgical margins (9.3% vs. 10.7%, odds ratio [OR] = 0.86, 95% CI: 0.72–1.03; P = 0.10), higher rates of pelvic lymph node dissection (96.4% vs. 92.0%, OR = 2.30, 95% CI: 1.67–3.16; P<0.001), higher median LN count (17 vs. 12, P<0.001), higher rates of LN count above the median (56.8% vs. 40.4%, OR = 1.94, 95% CI: 1.55–2.42, P<0.001). With regard to postoperative outcomes, receipt of RARC was associated with a shorter median LOS (7 vs. 8, P<0.001), and lower rates of pLOS (45.0% vs. 54.8%, OR = 0.68, 95% CI: 0.58–0.79; P<0.001). The 30- and 90-day POM rates were 2.8%, 6.7% for ORC, and 1.4%, 4.8% for RARC, respectively (hazard ratio [HR] = 0.48, 95% CI: 0.29–0.80, P = 0.005 and HR = 0.71, 95% CI: 0.54–0.93; P = 0.014). Finally, with a mean follow-up of 26.9 months, on IPTW-adjusted Cox regression analysis, RARC vs. ORC was associated with a benefit in OS (HR = 0.79, 95% CI: 0.71–0.88; P<0.001). ConclusionsOur large contemporary study found an increased adoption of RARC between 2010 and 2013, with more than 1 out of 4 patients undergoing RARC by the end of the study period. We found that RARC was associated with higher LN counts, shorter LOS, and lower POM. Our results allude to potential benefits of RARC while we wait for more definitive answers from randomized trials.

An audit of lymph node retrieval and histopathology reporting of pancreaticoduodenctomy specimens undertaken at a tertiary care referral center

Pancreaticoduodenectomy (PD) is currently the main surgical option for malignancies in the ampullary region, which includes ampulla of Vater tumours (AVT), distal bile duct tumours (DBDT), periampullary duodenal tumours (DT) and tumours of the head of the pancreas (PT). Nodal status and many other important pathological features have a significant impact on tumour prognosis and therapy. The aim of this study was to determine the total number of lymph nodes (LNs) retrieved from PD specimens, whether grouping of LNs improves the total yield and to assess the level completeness of histopathology reporting of PD specimens. Forty two PD requests and histopathology reports were assessed to determine the total number of LNs retrieved and whether the LN were grouped (G)or non-grouped (NG). The significance of difference in the number of LNs in the two groups were assessed using the Wilcoxon signed rank test. The tumours were subcategorized as AVT, DBDT, DT and PT and the reports were audited against the respective minimum data sets of the Royal College of Pathologists of United Kingdom to determine the overall completeness and the parameters poorly reported in the reports. The overall median LN yield was 14.5 and the median LN yield was 15 and 10 in G and NG respectively which was statistically significant. The completeness of the histopathology reporting was 63.6%- 77.3% in AVT (n-18), 73.9% - 95.6% in DBDT (n-5), 68.1% - 90.1% in DT (n-8), 70.8% - 83.3% in PT (n-11). The lengths of the bile duct, lesser and greater curvature of the stomach, tumour differentiation, involvement of resection margins and named blood vessels were poorly reported. In conclusion, the total LN retrieval improved by grouping according to the Union of International Cancer Control (UICC) protocol. Histopathology reporting of some of the data items requires improvement. Hence adoption of a pro forma for synoptic reporting and establishment of national guidelines on reporting and handling of specimens is recommended.

Gastrectomy with Extended Lymphadenectomy: a North American Perspective

PurposeDespite evidence of oncologic benefits from extended (D2) lymphadenectomy in gastric cancer from many East Asian studies, there is persistent debate over its use in the West, mainly due to perceived high rates of morbidity and mortality. This study evaluates the safety and efficacy of D2 dissection in a high-volume North American center. MethodsA prospectively entered database of all patients undergoing gastrectomy for cancer at a North American referral center from 2005 to 2016 was reviewed. Wedge resections, thoracoabdominal approach, emergency surgery, palliative operations, and non-adenocarcinoma cases were excluded. ResultsOf 366 non-bariatric gastrectomies over this period, 175 met the inclusion criteria. Median age was 73 years and 69% were male. One hundred forty-one patients (80%) underwent D2 dissection, the rest having D1. There was no difference in postoperative complications (D1 = 44%: D2 = 42%), anastomotic leaks (D1 = 6%: D2 = 5%), and same-admission or 30-day mortality (D1 = 6%: D2 = 2%). D2 dissection was associated with higher pathological stage (72% > stage 1 vs 38% > stage 1; p < 0.05) and median lymph node yield (30 vs 14; p < 0.05), with no difference in complete resection (R0) rate (D1 = 98% vs D2 = 92%). Laparoscopic approach was employed in 34% (45/141) of D2 cases, resulting in shorter median length of stay (6 days vs 9; p < 0.05) and equivalent oncologic outcomes compared to open D2. ConclusionThis study supports the use of D2 lymphadenectomy, by either open or laparoscopic approach, in high-volume North American centers as a safe and effective oncologic procedure for gastric cancer, with equivalent complication rates and superior lymph node yield to traditional D1 dissection.