Median Number Of Positive Nodes Research Articles

Utility of axillary surgery in patients with de novo metastatic breast cancer undergoing surgery of the primary site.

1086 Background: Approximately 6% of patients have de novo metastatic breast cancer (MBC) for whom surgery is reserved for special circumstances since it confers no survival benefit. The prospective studies evaluating surgery of the primary site in MBC recommended standard surgical management of the axilla. However, it is unclear whether axillary surgery is of any utility among these patients. We sought to evaluate the survival benefit of axillary surgery in MBC patients undergoing primary site surgery. Methods: From the National Cancer Database (2012-2020), we identified patients aged 18-79 with MBC undergoing surgery of the primary site and grouped patients according to axillary surgery performed: none, sentinel lymphadenectomy (SLNB), or axillary lymph node dissection (ALND) with or without SLNB. We performed a landmark analysis beginning 12 months after diagnosis to assess overall survival (OS) and used Cox regression to adjust for clinicodemographic characteristics. Results: We identified 7,808 patients, 20.2% of whom had no axillary surgery, 16.3% had SLNB, and 63.5% had ALND. Of the patients who had axillary surgery, 26.3% were pN0. Patients who had no axillary surgery, were older (mean 57.2 vs 60.3 years), more likely to have tumor histology other than ductal or lobular (8% vs. 4%), be cN0 (28% vs. 20%), less likely to have bone-only metastases (36% vs. 44%) and undergo breast-conserving surgery (49% vs. 24%) [all p<0.001]. The mean and median number of positive nodes was 1.3±2.3 in the SLNB, and 5.9±6.8 in the ALND group. 36-month adjusted survival estimates were 71.4%, 66.5%, and 58.0% for SLNB, ALND, and no axillary surgery groups, respectively. On univariate analysis and after adjusting for clinicodemographic features, both SLNB and ALND remained independently associated with improved OS when compared with no surgery (Table). Conclusions: As in prior retrospective analyses of surgery for the primary site, we found that the performance of axillary surgery in MBC patients was associated with improved OS. Selection bias is likely a contributing factor as surgeons are more likely to recommend axillary surgery for patients with a better functional status. Of concern is the number of MBC patients being exposed to the morbidity of ALND who are ultimately pN0, and thus derived no benefit. These findings highlight the need to carefully weigh the risks and benefits before performing axillary surgery. Prospective studies evaluating axillary surgery are needed to validate these results. [Table: see text]

Extended nodal radiotherapy for prostate cancer relapse guided with [11C]-choline PET/CT: ten-year results in patients enrolled in a prospective trial.

To report long-term outcomes of relapsed prostate cancer (PC) patients treated in a prospective single-arm study with extended-nodal radiotherapy (ENRT) and [11C]-choline positron emission tomography (PET)/computed tomography (CT)-guided simultaneous integrated boost (SIB) to positive lymph nodes (LNs). From 12/2009 to 04/2015, 60 PC patients with biochemical relapse and positive LNs only were treated in this study. ENRT at a median total dose (TD) = 51.8Gy/28 fr and PET/CT-guided SIB to positive LNs at a median TD = 65.5Gy was prescribed. Median PSA at relapse was 2.3 (interquartile range, IQR:1.3-4.0) ng/ml. Median number of positive LNs: 2 (range: 1-18). Androgen deprivation therapy (ADT) was prescribed for 48 patients for a median of 30.7 (IQR: 18.5-43.1) months. Median follow-up from the end of salvage treatment was 121.8 (IQR: 116.1, 130.9) months; 3-, 5-, and 10-year BRFS were 45.0%, 36.0%, and 24.0%, respectively; DMFS: 67.9%, 57.2%, and 45.2%; CRFS: 62.9%, 53.9%, and 42.0%; and OS: 88.2%, 76.3%, and 47.9%, respectively. Castration resistance (p < 0.0001) and ≥ 6 positive LN (p = 0.0024) significantly influenced OS at multivariate analysis. Castration resistance (p < 0.0001 for both) influenced DMFS and CRFS in multivariate analysis. In PC relapsed patients treated with ENRT and [11C]-choline-PET/CT-guided SIB for positive LNs, with 10-year follow-up, a median Kaplan-Meier estimate CRFS of 67months and OS of 110months were obtained. These highly favorable results should be confirmed in a prospective, randomized trial.

Primary Retroperitoneal Lymph Node Dissection for Seminoma Metastatic to the Retroperitoneum.

Primary surgical treatment with retroperitoneal lymph node dissection aims to accurately stage and treat patients with node-positive pure seminoma while avoiding long-term risks of chemotherapy or radiation, traditional standard-of-care treatments. We reported the pathologic and oncologic outcomes of patients with pure seminoma treated with primary retroperitoneal lymph node dissection in a retrospective, single-institution case series over 10 years. The primary outcome was 2-year recurrence-free survival stratified by adjuvant management strategy (surveillance vs adjuvant chemotherapy). Forty-five patients treated with primary retroperitoneal lymph node dissection for pure testicular seminoma metastatic to the retroperitoneum were identified. Median size of largest lymph node before surgery was 1.8 cm. Viable germ cell tumor, all of which was pure seminoma, was found in 96% (n=43) of patients. The median number of positive nodes and nodes removed was 2 and 54, respectively. Median positive pathologic node size was 2 cm (IQR 1.4-2.5 cm, range 0.1-5 cm). Four of 29 patients managed with postoperative surveillance experienced relapse; 2-year recurrence-free survival was 81%. Median follow-up for those managed with surveillance who did not relapse was 18.5 months. There were no relapses in the retroperitoneum, visceral recurrences, or deaths. Among the 16 patients who received adjuvant treatment, 1 patient experienced relapse in the pelvis at 19 months. Primary retroperitoneal lymph node dissection for pure seminoma with low-volume metastases to the retroperitoneum is safe and effective, allowing most patients to avoid long-term toxicities from chemotherapy or radiation.

254. THE IMPACT OF D2 VERSUS D1 LYMPHADENECTOMY IN SIEWERT II GASTROESOPHAGEAL JUNCTION (GEJ) CANCER

Abstract Background Though a myriad of multimodal treatment options exist for gastroesophageal junction (GEJ) cancer, surgical resection remains the mainstay for potential cure. Extended nodal dissection with a D2 lymphadenectomy (LAD) beyond the D1 peri-gastric dissection remains controversial for Siewert II GEJ cancer. Though D2 LAD may lead to increased lymph node harvest, its effect on overall survival remains elusive. We hypothesize that additional D2 dissection in Siewert II GEJ cancer does not lead to increased survival. Methods We reviewed Siewert II GEJ cancer patients who received either a D1 or D2 LAD after receiving neoadjuvant chemoradiation or perioperative chemotherapy from 2012 through 2022. Chi-square and Fisher exact tests were used to compare categorical variables and two-sample Wilcoxon rank sum tests for non-normally distributed continuous variables. The main outcomes measured were 1-year mortality from date of diagnosis, number of nodes sampled, and operative time. Results Among the 155 patients identified, 75% of Siewert II underwent a D1 and 25% underwent a D2 LAD. Patients with a D2 LAD more often had &amp;gt;15 lymph nodes harvested than D1 (83% vs 48%, p &amp;lt; 0.001) but had no significant difference in median number of positive nodes (Figure 1). Patients with a D2 LAD had a median operative time approximately 2 hours longer than D1, 362 min vs 244 min (p &amp;lt; 0.001). On multivariable logistic regression adjusting for patient and clinical characteristics, there was no significant difference in 1-year mortality from patients undergoing a D2 vs D1 LAD. Conclusion Despite the associated high mortality associated with gastroesophageal junction (GEJ) cancer, there remains little consensus guidelines regarding the optimal preoperative and operative management. Though D2 LAD may theoretically lead to more lymph node harvest, its role in staging may be unnecessarily excessive as there is no gain in number of positive nodes leading to increased operative morbidity with no significant change in survival.

Characterization of lymph node metastases in prostate cancer.

380 Background: Unlike lymph node (LN) staging in other malignancies, prostate cancer nodal staging does not characterize or quantify the LN tumor burden. Detailed characterization of LN metastases may provide improved prognostic information, which could assist in post-surgical management decisions. Methods: Clinical and pathologic information was retrospectively collected via electronic medical record from 66 patients with pathologically confirmed LN involvement after radical prostatectomy with pelvic lymph node dissection performed by a single surgeon. Tissue slides of all positive LNs were re-evaluated by a single pathologist in accordance with our institutional review board protocol. Poisson regression analyses and Cox proportional-hazard regression were performed to evaluate the association of risk factors with the number of positive nodes and the association of LN characteristics with biochemical recurrence (BCR)-free survival. Results: Median number of positive LNs per patient was 2 (IQR 1-3). Mean % positive LNs per patient was 8.9 (SD10.4). Mean cumulative size of all tumor deposits in all positive LNs per patient was 5.0mm (SD 4.8). Average % surface area of LN involved by tumor was 28%. 48 (73%) patients were alive without disease at median follow-up time of 38 months (IQR 26-50 months). Higher pre-surgery PSA, clinical stage T3-T4 versus T1-2, extraprostatic extension (EPE), seminal vesical involvement (SVI), and lymphovascular invasion (LVI) were significantly associated with higher incidence rate of nodal positivity. Larger mean size of largest LN deposits, mean size of total LN deposits, and mean % surface area of LN involved were significantly associated with worse BCR-free survival. There was no significant association for number of positive nodes, LN anatomical compartments, extranodal extension (ENE), span of ENE, and distance of ENE from LN capsule. Higher pre-surgery PSA and post-surgery Gleason grade were significantly associated with worse BCR-free survival. Conclusions: Our data shows that LN tumor burden is associated with worse BCR-free survival. Anatomical LN compartments and quantification of ENE did not show significant association with BCR. [Table: see text]

Association of lymph node metastases, grade and extent of mesenteric lymph node dissection in locoregional small intestinal neuroendocrine tumors with recurrence-free survival.

We aimed to assess the prognostic impact of tumor- and patient-related parameters in patients with stage I-III small intestinal neuroendocrine tumors (SI-NETs), who underwent locoregional resective surgery (LRS) with curative intent. We included 229 patients with stage I-III SI-NETs diagnosed from June 15, 1993, through March 8, 2021, identified using the SI-NET databases from five European referral centers. Mean ± SD age at baseline was 62.5 ± 13.6 years; 111/229 patients were women (49.3%). All tumors were well-differentiated; 160 were grade 1 (G1) tumors, 51 were G2, two were G3 and 18 tumors were of unspecified grade (median Ki-67: 2%, range 1%-50%). One-hundred and sixty-three patients (71.2%) had lymph node (LN) involvement. The median number of retrieved lymph nodes was 10 (0-63), whereas the median number of positive LNs was 2 (0-43). After a mean ± SD follow-up of 54.1 ± 64.1months, 60 patients experienced disease recurrence at a median (range) of 36.2 (2.5-285.1) months. The 5- and 10-year recurrence-free survival (RFS) rates were 66.6% and 49.3% respectively. In univariable analysis, there was no difference in RFS and overall survival (OS) between LN-positive and LN-negative patients (log-rank, p=.380 and .198, respectively). However, in stage IIIb patients who underwent mesenteric lymph node dissection (MLND) with a minimum of five retrieved LN (n=125), five or more LN metastases were associated with shorter RFS (median RFS [95% CI]=107.4 [0-229.6] vs. 73.7 [35.3-112.1]months; log-rank, p=.048). In addition, patients with G2 tumors exhibited shorter RFS compared to patients with G1 tumors (median RFS [95% confidence interval (CI)]=46.9 [36.4-57.3] vs. 120.7 [82.7-158.8]months; log-rank, p=.001). In multivariable Cox-regression RFS analysis in stage IIIb patients, the Ki-67 proliferation index (hazard ratio=1.08, 95% CI=1.035-1.131; p < .0001) and the number of LN metastases (hazard ratio=1.06, 95% CI=1.001-1.125; p=.047) were independent prognostic factors for RFS. In conclusion, LRS with a meticulous MLND and a minimum number of five harvested LNs appears to be critical in the surgical management of SI-NET patients with locoregional disease. In patients who underwent LRS and MLND, the Ki-67 proliferation index and the LN metastases count were independent predictors of RFS.

Influence of positive margins on tumour recurrence and overall survival after gastrectomy for gastric cancer.

Incidence of positive surgical margins after curative gastrectomy ranges from 1% to 20%. It has been suggested that positive surgical margin is an adverse prognosis factor, with a higher local recurrence and worse overall survival (OS). However, the management of these patients remains unclear. A total of 267 patients who underwent gastrectomy with curative intent between January 2010 and December 2018 in our centre were enrolled in this study. Post-operative histological analysis revealed positive resection margins in 18 patients (8%). Clinicopathological features and outcome of patients undergoing gastrectomy with negative and positive margins were compared. Patients with positive margins were associated with higher American Joint Committee on Cancer (AJCC) stage, T stage, N stage, median number of positive nodes, diffuse Lauren type, whole stomach involved and poorly differentiated tumours. Local recurrence was described in 50% of cases with positive margins. The multivariate analysis demonstrated that the TNM stage was the only independent prognostic factor associated with recurrence. OS for positive margins at 1, 3 and 5 years was 75%, 57% and 26%, respectively. The median survival in patients with positive margins was 38.33 versus 81.17 months for R0 patients (p=0.027). Multivariate analysis showed that age (hazard ratio [HR] 1.041, 95% confidence interval [CI] 1.02-1.07, sex (HR 2.00, 95% CI 1.22-3.30) and TNM stage (p < 0.001) were independent factors of OS. Positive resection margin was an indication of advanced and more aggressive disease rather than an independent prognosis factor for OS or recurrence in gastric cancer.

Prognostic value of lymph node ratio in children and adolescents with papillary thyroid cancer.

Neck lymph node (LN) metastasis is a common feature of paediatric papillary thyroid cancer, and LN ratio (LNR) is defined as the ratio of the number of positive LNs excised to the total number of removed. Unlike in adults, few data are available regarding the clinical implication of LNR in the paediatric population. Our purpose was to investigate the association of LNR with clinical outcomes in paediatric papillary thyroid cancer. The study retrospectively reviewed 136 consecutive children and adolescents with papillary thyroid cancer and LN involvement but no initial distant metastasis. Initial treatment, included in all patients a total thyroidectomy with central and/or lateral neck dissection followed by radioactive iodine ablation. Within the neck dissections, total number of LNs removed, total positive LNs and LN ratios were determined. The effect of clinicopathologic characteristics and intraoperative findings on persistent and recurrent diseases were analysed by univariate and multivariate analyses. Median number of positive LNs was 9, and median LNR was 0.4. During a median follow-up of 49months (range, 12.0-139months), persistent disease occurred in 43 (31.6%) patients. The multivariable analysis showed that age and LNR were the independent factors predictive of persistent disease. Patients with a LNR >0.34 exhibited a threefold higher risk of persistent disease after initial therapy than the counterparts (P=.02). Our findings suggest that LNR was an independent determinant predictive of persistent disease after initial therapy in children and adolescents with papillary thyroid cancer.

Does the Time to Adjuvant Radiotherapy Impact Outcomes in Women With Stage III Uterine Cancer?

Adjuvant radiotherapy (ART) combined with chemotherapy (CT) is an effective adjuvant therapy in women with stage III uterine carcinoma (UC). However, there exists a sparse evidence for the optimal time to start ART. We evaluated the impact of time interval to ART initiation on survival endpoints for surgically staged patients with stage III EC receiving adjuvant multimodality therapy. We queried our prospectively- maintained database for women with FIGO stage III UC who underwent surgical staging at our institution between 12/1990 and 12/2019. All patients in the study received ART and CT with various sequences. CT consisted of 4-6 cycles of paclitaxel-carboplatin combined with ART (external beam RT (EBRT) ± vaginal brachytherapy (VB) boost). Time to RT initiation (TRTI) elapsing between surgical staging and 1st fraction of ART was calculated in weeks for each patient. We studied the influence of TRTI on relapse- free (RFS), disease- specific (DSS) and overall (OS) survival using log-rank test (continuous) and Kaplan-Meier curves to compare outcomes at weekly increments (8-12 weeks). Clinico-pathological and treatment characteristics were dichotomized at the 8 weeks' time-point and compared. Cox regression multivariate analyses (MVA) were performed to determine independent predictors for survival endpoints. 137 patients were identified. Median age was 64 years (range, 38-85), 45% of patients had non-endometrioid histology. Median number of lymph nodes (LN) examined was 23 (range, 1-55) and median number of positive LN was 2 (range, 0-18). Stage IIIC constituted 78% of the study cohort followed by stage IIIA (20%). 51% of the patients received EBRT alone, while 49% received an additional VB boost. 72 cases (52.5%) received ART ≤8 weeks after hysterectomy, and 47.5% (n = 65) received ART > 8 weeks. After a median follow up of 58 months (CI: 42-66), longer TRTI > 8 weeks was associated with worse 5-year RFS (49% (CI:36-62) vs. 71% (CI:55-83); p = 0.01), which persisted at latter time points (9-12 weeks), p<0.05 for all; with a trend when assessed as a continuous variable (p = 0.053). TRTI was neither correlated with 5-year OS or DSS. On MVA for RFS, TRTI (> vs. ≤ 8 weeks) (HR 2.9 (CI:1.4-6.03); p = 0.004), lymphovascular space invasion (HR 4.05; p = 0.009) and advanced stage (HR 3.63; p = 0.04) were all independent prognostic factors. African American race was the only independently predictive for shorter OS (HR 2.44; p = 0.002) and DSS (HR 3.26; p = 0.006). Within the context of multimodality therapy, our study suggests that earlier start of ART within 8 weeks was independently associated with improved recurrence- free survival in women with advanced stage endometrial cancer. Multi-institutional research collaboration is needed to validate our results.

Incidence and Pattern of Nodal Metastasis in Colon and Rectal Cancer: a Study of 1012 Cases from Thailand

Objective: Lymph node (LN) metastasis is a key to determine prognosis and adjuvant treatment for resectable colorectal cancer. This study aimed to determine and compare the incidence and pattern of LN metastasis between colon cancer and rectal cancer.Methods: Medical and pathological reports of patients with stage I-III colorectal adenocarcinoma undergoing oncological resection between 2009 and 2013 at the Faculty of Medicine Siriraj Hospital were reviewed. The incidence and pattern of LN metastasis related to tumor staging between colon cancer and rectal cancer were analyzed.Results: This study included 1012 cases (502 colon cancer and 510 rectal cancer). Compared with rectal specimens, colonic specimens had a larger tumor size (5.8 cm vs 5.0 cm; P&lt;0.001), more T4 lesion (24% vs 6.3%; P&lt;0.001) and more LNs harvested (24 vs 18; P&lt;0.001). Nodal metastases were found in 552 specimens (54.5%). The rate of LN metastasis was 14.3% for T1 tumors, 25.6% for T2 tumors, 61.2% for T3 tumors, and 65.6% for T4 tumors. There was no significant difference in the overall rate of nodal metastasis between colon cancer and rectal cancer (52.6% vs 56.5%; P=0.22), but rectal cancer had more N2 staging (31% vs 22.5%; P=0.002). Rectal cancer yielded more median number of positive LN (4 vs 3; P=0.002) with a greater LN ratio (0.22 vs 0.12; P&lt;0.001) than colon cancer. Based on the depth of tumor invasion, T3 rectal cancer had a significantly higher rate of LN metastasis (66.8% vs 55.7%; P=0.004) and a greater LN ratio (0.23 vs 0.10; P&lt;0.001) than T3 colon cancer.Conclusion: Although colon cancer had a larger tumor size and a higher percentage of deeper invasion, rectal cancer were associated with a higher number of positive LN, more N2 status and a greater LN ratio - especially T3 lesion.

MP74-02 LONG-TERM OUTCOMES OF CLINICALLY NODE-POSITIVE PROSTATE CANCER PATIENTS TREATED WITH RADICAL PROSTATECTOMY AS PART OF A MULTIMODAL TREATMENT: PATTERNS OF RECURRENCE AND IMPACT ON COMPETING-RISK MORTALITY

INTRODUCTION AND OBJECTIVE:Curative intent therapies such as radical prostatectomy (RP) might represent an option in prostate cancer (PCa) patients with enlarged lymph nodes at imaging (cN1), no da...

Does use of axillary ultrasound in clinically node-negative patients receiving neo-adjuvant systemic therapy for breast cancer lead to surgical overtreatment?

Increased use of neo-adjuvant chemotherapy (NAC) for breast cancer has raised uncertainty regarding staging of the axilla, particularly for patients with a clinically negative axillary physical examination (PE). We sought to determine whether axillary ultrasound (AUS) prior to NAC to identify occult nodal disease is beneficial in patients with a clinically negative examination by evaluating the difference in nodal burden on final pathology in those with abnormal vs normal AUS. A retrospective review of an institutional cancer registry identified patients who underwent NAC for breast cancer and had a pretreatment AUS. Differences in the number of positive lymph nodes (PLN) in patients with a normal axillary PE and abnormal vs normal AUS prior to NAC were determined. A total of 120 patients who received NAC had a negative axillary PE prior to treatment. Fifty-three had an abnormal AUS and biopsy-proven lymph node (LN) involvement. In patients with an abnormal AUS, median number of PLNs at surgery was 1 vs 0 for those with a normal AUS (mean difference of 2.12, P<.0001). Of those patients with an abnormal AUS and biopsy-proven LN involvement, 87% underwent axillary lymph node dissection (ALND) and nearly half had no PLN on final pathology (N=23, 43%). Patients with a clinically negative axilla and an abnormal AUS were more likely to have PLN at the time of surgery. However, almost half of those patients had no residual LN involvement. Routine AUS prior to NAC may lead to more extensive surgical management of the axilla.

Is there any benefit in adding postoperative adjuvant concurrent radiotherapy and chemotherapy for penile cancer with regional lymph node metastasis?

The aim of this study was to evaluate whether there is any benefit in adding postoperative adjuvant concurrent radiotherapy and chemotherapy (RT-CHT) for penile cancer with regional lymph node metastasis (RLNM). A single institution, retrospective study was conducted for a total of 23 patients with RLNM from penile squamous cell carcinoma. All underwent a definitive surgical intervention for both primary tumor and RLNM. Of these, 11 patients received adjuvant concurrent RT and CHT within 3 months after surgery (RT-CHT group), while 12 patients received no additional treatment (Surveillance Group). Overall survival was calculated with the Kaplan-Meier method. The difference in survival between the two groups was tested using the log-rank test. A potential prognostic factor for survival was evaluated using a univariate Cox-proportional hazards model. Median follow-up for the entire group was 15.8 months (17.1 months for the RT-CHT group and 10.7 months for the Surveillance Group). Overall survival at 1 and 2 years were 54.5% and 27.2%, respectively, for the RT-CHT Group, compared to 57.1% and 28.4% for the Surveillance Group (log-rank=0.68). On a univariate analysis, the number of involved lymph nodes and the presence of pN3 disease were associated with poor prognosis (P>0.001 and P=0.049, respectively). The RT-CHT Group had more extensive RLNM with a higher median number of positive nodes (5 vs. 3) and more pN3 disease (72.7% vs. 16.7%) than the Surveillance Group. The rate of complications requiring hospitalization was higher in the RT-CHT Group (63.6% vs. 16.6%; P=0.02), as was the rate of systemic complications (34.7% vs. 0%; P<0.01). Penile cancer with extensive RLNM carries a poor prognosis. Despite having more extensive RLNM, the RT-CHT group had a similar overall survival as the Surveillance Group. This suggests a potential benefit of postoperative adjuvant concurrent RT-CHT for patients with extensive RLNM, although it carries an increased risk of complications. Further study is warranted to assess the benefit-to-risk ratio of this combined adjuvant therapy.

Prospective evaluation of the performance of [68Ga]Ga-PSMA-11 PET/CT(MRI) for lymph node staging in patients undergoing superextended salvage lymph node dissection after radical prostatectomy

PurposeTo assess the accuracy of [68Ga]-PSMA-11 PET/CT or [68Ga]-PSMA-11 PET/MRI (PSMA-11 PET/CT(MRI)) for lymph node (LN) staging using salvage LN dissection (SLND) in patients with biochemical recurrence (BCR) after radical prostatectomy (RP).Patients and methodsIn a prospective study, 65 consecutive patients who developed BCR after RP underwent SLND after PSMA-11 PET/CT(MRI) between 2014 and 2018. Extended SLND up to the inferior mesenteric artery was performed in all patients. Regional and template-based correlations between the presence of LN metastases on histopathology and whole-body PSMA-11 PET/CT(MRI) results were evaluated. The diagnostic accuracy of PSMA-11 PET/CT(MRI) was also evaluated in relation to PSA level at the time of SLND.ResultsThe median age of the patients at the time of SLND was 65 years (IQR 63–69 years) and the median PSA level was 1.4 ng/ml (IQR 0.8–2.9 ng/ml). Before SLND, 50 patients (77%) had additional therapy after RP (26.2% androgen-deprivation therapy and 50.8% radiotherapy). The median number of LNs removed on SLND was 40 (IQR 33–48) and the median number of positive nodes was 4 (IQR 2–6). LN metastases were seen in 13.8% of resected LNs (317 of 2,292). LNs positive on PSMA-11 PET/CT(MRI) had a median diameter of 7.2 mm (IQR 5.3–9 mm). Metastatic LNs in regions negative on PSMA-11 PET had a median diameter of 3.4 mm (IQR 2.1–5.4 mm). In a regional analysis, the sensitivity of PSMA-11 PET/CT(MRI) ranged from 72% to 100%, and the specificity from 96% to 100%. Region-specific positive and negative predictive values ranged from 95% to 100% and 93% to 100%, respectively.ConclusionPSMA-11 PET/CT(MRI) has a very good performance for the identification of LN metastases in patients with BCR after RP. The high diagnostic accuracy in the regional and subregional analyses demonstrates the potential of this approach to enable a region-directed instead of a complete bilateral therapeutic intervention. The performance of PSMA-11 PET/CT(MRI) is dependent on the PSA level and the size of the metastatic deposit.

Robot-assisted esophagogastric reconstruction in minimally invasive Ivor Lewis esophagectomy.

Although the incidence of esophagogastric junction cancer has increased considerably in recent years, the application of minimally invasive Ivor Lewis esophagectomy, especially in East Asia, is still much rarer than the McKeown approach. The reconstruction of the alimentary tract is one of the main technical challenges under traditional endoscopy. The robotic surgical system with high-resolution 3D images and multiarticulate instruments may help simplify this procedure. Here, we describe our experience in the gastric tube and esophagogastric anastomosis construction, and the initial clinical results for Ivor Lewis robot-assisted minimally invasive esophagectomy (RAMIE). A retrospective study of all patients undergoing Ivor Lewis RAMIE with circular stapled anastomosis at a single institution from December 2016 to June 2018 was performed. Operative and postoperative outcomes were recorded. Twenty-four patients [median age, 63 years (range, 49-77 years)] underwent Ivor Lewis RAMIE during the study period with a four-arm robotic platform. Four patients (16.7%) received neoadjuvant therapy. The median estimated blood loss was 120 mL (range, 50-210 mL). The median operating time was 352.5 min (range, 259-485 min). There was no conversion to an open surgical procedure. Postoperative complications occurred in 3 (12.5%) patients. Complications included pneumonia in two patients (8.3%) and mediastinitis in 1 (4.2%). The median stay in the intensive care unit was 1 d (range, 0-8 d) and the median postoperative hospital stay was 11 d (range, 8-30 d). All patients had an R0 resection. The median number of nodes removed was 19 (range, 11-30) and the median number of positive nodes removed was 1 (range, 0-8). Our initial results indicate that Ivor Lewis RAMIE may be a safe and feasible alternative to open and endoscopic Ivor Lewis esophagectomy.

The prognostic significance of nodal disease burden in patients with lymph node metastases from renal cell carcinoma

ObjectivesTo assess the relationship between nodal disease burden and overall survival (OS) among patients with lymph node (LN) metastases from renal cell carcinoma (RCC) MethodsThe National Cancer Data Base was used to identify 2,975 patients with RCC who were treated with radical nephrectomy and were found to have regional LN metastases. Associations between the number of positive and negative LN removed and OS were assessed using Cox proportional hazards regression. The median follow-up time among survivors was 3.6years. ResultsThe median number of positive LN was 1 (interquartile range 1–3). A higher number of positive LN was associated with higher all-cause mortality on multivariable analysis (HR 1.06 per 1 positive LN, 95% CI 1.04, 1.07, P < 0.001). Conversely, higher negative LN counts were associated with better OS (HR 0.97 per 1 negative LN, 95% CI 0.96, 0.99, P < 0.001). The adjusted probability of a patient with 1 LN removed that was positive surviving at least 2 years was 56%, a figure that increased to 64% when 1 out of 10 LN removed was positive and decreased to 38% when 10 out of 10 LN removed were positive. ConclusionsOurs is the first study to show that differences in nodal disease burden translate into clinically significant differences in survival among patients with LN metastases from RCC.

Lymph node ratio has impact on relapse and outcome in patients with stage III melanoma.

Even though both the involvement of regional lymph nodes and the number of metastatic lymph nodes are regarded as major determinants of survival in cutaneous melanoma, the extent of node dissection has been analyzed as an independent prognostic indicator in only a few studies. This study aims to determine how the lymph node ratio (NR) (ratio of positive nodes to total nodes removed) might predict the disease relapse and survival in node-positive melanoma. A total of 317 patients with stage III primary melanoma were included in the study and reviewed retrospectively. All patients had nodal staging (N) by radical lymph node dissection. Patients were divided into three groups based on NR1 ≤ 10%, NR2 10-25%, and NR3 > 25%. The median age was 50years (range 16-86) and men were predominant (59.3%). The majority of the patients had thicker Breslow depth (> 2mm) (83.3%), higher mitotic rate (> 2/mm2) (64.1%) and ulcerated lesions (69.4%). The median number of positive nodes was 1 (range 1-32). The largest group was N1 (52.4%), which was followed by N2 (29.6%) and N3 (18%). The ratios of patients were 37.5%, 35.3%, and 27.1% in NR1, NR2, and NR3, respectively. The median number of excised lymph nodes was 13 (range 1-73). For all patients the estimated 5-and 10-year relapse-free survival (RFS) rates were 41% and 39%, respectively; and the estimated 5-and 10-year overall survival (OS) rates were 51% and 42%, respectively. Nodular histopathology, ulcerated lesions, higher mitotic rates, and higher node substages were the independent variables that were inversely correlated with survival for all patients; and NR was one of the significant prognostic factors and strongest predictors of relapse and survival (p = 0.03 and p = 0.01, respectively). Our results suggest that, apart from the conventional nodal status, NR is an independent prognostic factor-regarding both RFS and OS in stage III cutaneous melanoma.

Abstract P3-12-16: Five year outcomes of a prospective study of proton radiotherapy for breast cancer regional nodal irradiation

Abstract Purpose: Through improved nodal coverage and decreased dose to the heart and lung, proton therapy (PT) may improve the therapeutic ratio for treatment of breast cancer requiring regional nodal irradiation (RNI). The purpose of this study is to report 5 year disease control and toxicity. Methods: From May 2012 to February 2014, 18 women (stage IIA-IIIB) prospectively enrolled on a pilot study. Median age was 52 years (range, 42-73), with equal division between breast-conserving therapy (BCT) and mastectomy and right and left-sided cancers. Median number of positive nodes among the 16 node-positive patients was 2 (range, 1-14). Five patients had ≥ 10 nodes positive on axillary dissection (N3a). Treatment targets (CTVs for breast/chest wall, supraclavicular, axillary, internal mammary nodes (IMNs)) and organs at risk were delineated on CT scans. Double scatter PT alone was used for 10 patients (9 post-mastectomy, 1 after BCT) and combined proton-photon in 8 (all BCT). Toxicity was prospectively recorded using CTCAE v4.0. Results: Median follow-up was 4 years (range, 0.3 – 6). 5 year overall survival was 82% and locoregional control was 100%. 5 year distant metastases-free survival was 82%. No grade 4+ toxicity developed. Four patients developed grade 3 cellulitis, which was the only grade 3 toxicity. One patient had a reconstructive failure associated with a post-surgical cellulitis. A right-sided patient was diagnosed with CHF within 2 months of completion of PT, following diagnosis of a pulmonary embolus 1 month prior. She had an elevated BNP (1101) prior to PT following adriamycin-based chemotherapy. Mean heart dose was 0 Gy and cardiac V5 0%. Atrial fibrillation developed in two patients. One patient developed grade 2 pneumonitis (she received concurrent chemotherapy). One patient, with a history of rib fractures prior to PT, developed an ipsilateral rib fracture 7 months after PT. Conclusion: In a population of women with locally advanced breast cancer, PT for RNI has proven feasible after either mastectomy (with or without reconstruction) or BCT with excellent locoregional control. PT allows for highly conformal radiation delivery without compromise of target coverage or excess exposure of normal tissue. Documentation of the ultimate benefits of PT in this population, freedom from radiation induced cardiac disease and breast cancer recurrence will require prospective study of a larger numbers of patients. Citation Format: Bradley JA, Dagan R, Liang X, Ho MW, Rutenberg M, Mailhot R, Morris C, Mendenhall NP. Five year outcomes of a prospective study of proton radiotherapy for breast cancer regional nodal irradiation [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-12-16.

Axillary ultrasound-guided core biopsy in breast cancer: identifying higher nodal burden and more aggressive clinicopathological characteristics.

Patients with sentinel lymph node (SLN) metastases may not require axillary lymph node dissection (ALND) but it remains unclear if patients with a positive ultrasound-guided axillary core biopsy (ACB) would satisfy such criteria. The aim of this study was to assess if breast cancer patients with a positive pre-operative ACB have more aggressive tumour characteristics/higher axillary nodal burden compared to those with a positive SLN. Data was extracted from a prospectively maintained breast cancer database between 2012 and 2015. Patients who underwent ALND after either positive ACB or SLN were included and tumour characteristics/nodal burden were compared. One hundred eighty patients underwent ALND, 125/180 after positive ACB and 55/180 after positive SLNB. Patients with positive ACB were more likely to undergo mastectomy (chi-square test; p = 0.03) and have higher tumour grades (Mann-Whitney test; p < 0.01) compared to the SLNB group. Median positive nodes excised during ALND were 2 (1-22) and 1 (1-11) for ACB and SLNB groups respectively (p < 0.001). Fifty-six patients received neoadjuvant chemotherapy (NCT). Of 72/125 patients in the ACB group not receiving NCT, the median number of positive nodes was 4 (range, 1-22). Ten patients within the ACB group satisfied ACOSOG Z011 criteria. Breast cancer patients with a positive ACB are more likely to have aggressive tumour characteristics and higher nodal burden compared to those identified as having axillary nodal disease on SLNB, which may affect surgical decision making.

Abstract P3-14-09: Low rates of chronic breast cancer related lymphedema (BCRL) in a cohort of high-Risk patients undergoing prospective surveillance with bioimpedance spectroscopy (BIS)

Abstract Background: We report outcomes using prospective BIS surveillance in a high-risk cohort of patients who all underwent axillary lymph node dissection (ALND). Methods: From 8/2010 through 12/2016, 206 consecutive patients were evaluated with BIS as part of a prospective surveillance program. 30 underwent ALND and constitute the study population. The program included pre-operative BIS measurement as well as post-operative assessments at regular intervals. Patients with L-Dex readings increasing by more than 10 from baseline were considered to have subclinical BCRL and treated with an over-the-counter (OTC) compression sleeve for 4 weeks. For the purpose of this analysis, additional high-risk features were defined as receipt of axillary radiation, a high body mass index (BMI) or the use of taxane based chemotherapy. Chronic BCRL was defined as the need for complex decongestive physiotherapy (CDP). Results: Median follow-up was 36 months (range: 4.8-122.1 months). The median number of nodes removed was 18 (range: 5-32) and the median number of positive nodes was two. The median age for the cohort was 57.5 years old with 70% of patients undergoing mastectomy and the remainder breast conserving therapy. With respect to additional high-risk features, 77% also received taxane-based chemotherapy, 62% axillary irradiation, and 48% had an elevated BMI. Overall, 86% of patients had at least one additional high-risk feature, 70% at least two, and 23% had all three additional high-risk features. Seven patients (23%) had an elevated L-Dex score at some point during follow-up and underwent intervention with an OTC sleeve for 4 weeks. To date, no patients have required CDP at any time. Conclusions: Prospective surveillance with BIS in a high-risk cohort of patients all undergoing ALND (plus additional high-risk features) led to no patients requiring CDP. These excellent findings are consistent with growing data supporting the use of BIS in prospective BCRL surveillance programs. Citation Format: Kaufman D, Shah C, Vicini F. Low rates of chronic breast cancer related lymphedema (BCRL) in a cohort of high-Risk patients undergoing prospective surveillance with bioimpedance spectroscopy (BIS) [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 P3-14-09.