Lymph Node Yield Research Articles

OGC P68 Surgical performance of Minimally Invasive Esophagectomy is associated with patient outcome on a national level - A video assessment study

Abstract Background It is highly likely that suboptimal surgical performance is associated with less favorable patient outcomes in minimally invasive esophagectomy (MIE). Establishing this association can lead to programs that promote better surgical performance of MIE and improve patient outcomes. Methods In this nationwide cohort study, 7 blinded expert MIE surgeons assessed performance of surgical videos of MIE performed in 2022, using a previously developed and validated competency assessment tool (CAT), the MIE-CAT. Hospitals were divided into quartiles based on their MIE-CAT score. Patient outcomes of 2021-2022 registered in the Dutch Upper-GI Clinical Audit were compared between highest (top 25%) and lowest (bottom 25%) performing quartiles. Multilevel logistic regression, with clustering of patients within hospitals was used to analyze associations between performance and outcomes, and to correct for casemix. Primary outcome parameter was severe postoperative complications (Clavien-Dindo≥3) within 30 days after surgery. Results MIE-CAT scores ranged from range 93.9-118.8. In total, 970 patients were included. Severe postoperative complications occurred in 18.7% (n=41/219) in the highest performing quartile versus 39.2% (n=40/102) in the lowest performing quartile (RR=0.50, 95%CI 0.24-0.99). Moreover, there were less conversions (1.8% versus 8.9%, RR=0.21, 95%CI 0.21-0.21), less peroperative complications (2.7% versus 7.8%, RR=0.21, 95%CI 0.04-0.94) and overall less postoperative complications (46.1% versus 65.7%, RR=0.54, 95%CI 0.24-0.96). Oncological outcomes R0 resection and lymph node yield increased with oncologic specific-performance scores (e.g. hiatus dissection/thoracic esophagus dissection and abdominal/thoracic lymph node dissection respectively). ). A strong association between high anastomotic-phase score and a lower anastomotic leakage rate was observed (4.6% versus 17.7%, RR=0.14, 95%CI 0.06-0.31). Conclusions Better surgical performance was associated with decreased perioperative complications and better oncological outcome for esophageal cancer patients undergoing MIE. If surgical performance of MIE can be improved, significantly better patient outcomes may be possible.

Pelvic lymphadenectomy: Evaluating nodal stage migration and will rogers effect in bladder cancer

IntroductionPelvic lymphadenectomy (PLND) alongside radical cystectomy (RC), provides crucial diagnostic and therapeutic value in patients with bladder cancer. With the advent of neoadjuvant chemotherapy and prospective data supporting standard PLND, controversy remains regarding the optimal PLND extent and patient selection. Nearly 40% of patients may not receive adequate PLND, even though 25% of patients have positive lymph nodes (LN) at time of RC. We hypothesized that PLND still remains an important facet of bladder cancer treatment. To clarify the prognostic importance of nodal yield, we performed a retrospective investigation of a heterogenous population (pTanyNx/0M0) of patients undergoing RC. MethodsFrom the Surveillance, Epidemiology, and End Results (SEER) program, we identified pTanyNx/0M0 bladder cancer patients undergoing RC from 2004 to 2015. Kaplan Meier curves and Cox proportional hazards models assessed cancer-specific survival. Patients were analyzed with PLND performed as the primary covariate. Survival analysis then stratified patients undergoing PLND by LN yield, both as a continuous and categorial variable (≤10, 11–20, 21–30, and >30), and T stage. ResultsThe final cohort included pTanyNx/0M0 patients with urothelial bladder cancer (n = 12,096); median follow up was 39 (IQR: 17–77) months. PLND was performed in 81.45% of patients with a median LN yield of 14 (IQR: 7–23). Most commonly, patients had T2 disease (44.68%). After controlling for age and T stage, patients receiving PLND had improved CSS (HR = 0.56, [95% CI: 0.51–0.62]) compared to those that did not receive PLND. When grouping patients by LN yield, survival improved in a “dose dependent” manner (>30 LN: HR = 0.76, [95% CI: 0.66–0.87]). We noted similar results when stratifying patients into non–muscle-invasive (NMIBC) and muscle-invasive bladder cancer (MIBC). ConclusionsIn a large contemporary series of pTanyNx/0M0 bladder cancer patients, we found a significant oncologic benefit to PLND. Higher LN yield correlated to improved CSS in non–muscle-invasive and muscle-invasive disease. Our data support the possibility of occult micrometastasis even in non–muscle-invasive disease. Additionally, in light of recent advances in adjuvant immunotherapy, our results emphasize the importance of adequate nodal yield for accurate staging and optimal treatment.

Robotic versus laparoscopic approach for left-sided colon cancer: a nationwide cohort study.

The use of robot-assisted surgery for left-sided colon cancer is increasing in Denmark; however, it is yet to be established if the robotic approach results in improved clinical outcomes compared with the corresponding laparoscopic approach. The aim of this study was to compare the intraoperative and short-term postoperative outcomes of robot-assisted surgery with laparoscopic surgery for left-sided colon cancer at a national level. The study is a nationwide database study based on data from the Danish Colorectal Cancer Group database. Patients from all colorectal centres in Denmark treated with surgery with curative intent in an elective setting with either robotic or laparoscopic left colectomy or sigmoidectomy during the period 2014-2019 were included. To adjust for confounding, propensity score matching (PSM) was performed and the groups were compared for age, sex, body mass index, American Society of Anesthesiologists classification, performance score, year of diagnosis, neoadjuvant chemotherapy, left colectomy or sigmoidectomy, tumour localization, use of stoma or stenting and pathological T (pT) category. A total of 5532 patients were available for analysis, and after PSM in a ratio of 2:1, 1392 laparoscopic and 696 robotic cases were identified. After matching we found a lower conversion rate and a higher lymph node yield in the robotic group compared with the laparoscopic group (5.8% vs. 11%, p < 0.001 and 27 vs. 24, p < 0.001, respectively). Further, we found a higher proportion of patients with a lymph node yield of 12 or more in the robotic group (97% vs. 94.8%, p = 0.02). Plane of dissection, radicality and pathological disease stages did not differ between the two groups. We found no difference in either overall surgical (13% vs. 11.1%, p = 0.23) or medical (5.6% vs. 6.5%, p = 0.49) postoperative complications and no difference in 30-day (p = 0.369) or 90-day mortality (p = 0.08). Robot-assisted surgery for left-sided colon cancer was associated with a significantly lower conversion rate and a significantly higher lymph node yield than the laparoscopic approach. Postoperative morbidity and mortality were similar in the two groups.

P265 - The role of nodal yield in patients with bladder cancer submitted to neoadjuvant chemotherapy and radical cystectomy

P265 - The role of nodal yield in patients with bladder cancer submitted to neoadjuvant chemotherapy and radical cystectomy

High Ligation of the Inferior Mesenteric Artery in Left-Sided Colon and Rectal Cancer Resection: Rates of Success and Outcomes.

High ligation of the inferior mesenteric artery, defined as ligation before the takeoff of the left colic artery, is often described as the gold standard in low left-sided colon and rectal cancer surgery. The aim of this study is to quantify the rate of ligation at the described level at a single academic center. Additionally, we examined the relationship between level of ligation and cancer-related outcomes. This retrospective cohort study included patients ages 18 and over with low left-sided colon, rectal, and anal cancers undergoing surgical resection. Radiographic evidence of high ligation was defined as ligation of the inferior mesenteric artery before the takeoff of the left colic artery. Patients with and without radiographic evidence of high ligation on CT were compared. Secondary outcomes include lymph node yield and positivity, need for adjuvant therapy, and time from surgery to adjuvant therapy. 169 patients (54% male) were included in the study. 61.5% of operative reports described high ligation of the IMA. There was radiographic evidence of high ligation in 55.6% of total patients and in 70.2% of patients where high ligation was intended. There was no significant difference in surgeon experience, surgical procedure, or surgical approach. There was no difference in lymph node yield, time to adjuvant chemotherapy, or recurrence rates. This study demonstrates good technical success rate of high ligation of the inferior mesenteric artery but shows no difference in short-term patient-measured outcomes between high and low ligation (or successful and unsuccessful high ligation).

Format for safe introduction of robotic esophagectomy

The aim of this study is to review the current literature on the learning curve for robotic-assisted minimally invasive esophagectomy (RAMIE) and explore strategies for introducing and implementing RAMIE. A literature search of electronic databases (Pubmed and Science Direct) was conducted using multiple combinations and synonyms of the keywords “esophageal cancer”, “robotic esophagectomy”, “RAMIE”, and “learning curve” up to March 31, 2023. In total, eighteen studies were included. Fourteen studies reported on surgeons with experience in minimally invasive surgery. Seven studies reported on surgeons with prior robotic experience for benign diseases or experience as observant or assistant in robotic surgery or experience on cadaveric robotic training. Four studies reported on a specific training pathway. The learning curve was mostly analyzed using the cumulative sum control chart (CUSUM). The most commonly used measured variables were the total operation time, the thoracic and abdominal console time, the lymph node yield, and vocal cord palsy rates. Τhe learning curve plateaus for the total operative time, the vocal cord palsy rates, and the lymph node yield varied between 20-80, 15-80, and 18-73 cases, respectively. At present, several centers are increasingly adopting RAMIE for esophageal cancer. Education about the learning curve of RAMIE is crucial for the training pathway in order to safely introduce RAMIE in centers without pre-existing robotic esophagectomy experience.

Radicality and safety of mediastinal lymphadenectomy in lung resection: a comparative analysis of uniportal thoracoscopic, multiportal thoracoscopic, and thoracotomy approaches.

Lung cancer poses a significant challenge with high mortality rates. Minimally invasive surgical approaches, including the uniportal thoracoscopic technique, offer potential benefits in terms of recovery and patient compliance. This study focuses on evaluating the radicality of mediastinal lymphadenectomy during uniportal thoracoscopic lung resection, specifically assessing the reachability of established lymphatic stations. A comparative study was conducted at the University Hospital Ostrava from January 2015 to July 2022, focusing on the evaluation of radicality in mediastinal lymphadenectomy across three patient subgroups: uniportal thoracoscopic approach, multiportal thoracoscopic approach, and thoracotomy approach. The study implemented the routine identification and excision of 8 lymph node stations from the respective hemithorax to assess the radicality of lymph node harvesting. A total of 428 patients were enrolled and evaluated. No significant differences were observed in the number of lymph nodes removed between the subgroups. The mean number of lymph nodes removed was 6.50 in the left hemithorax and 6.49 in the right hemithorax. The 30-day postoperative morbidity rate for the entire patient population was 27.3%, with 17.5% experiencing minor complications and 6.5% experiencing major complications. Statistically significant differences were observed in major complications between the uniportal approach and the thoracotomy approach (3.5% vs 12.0%, p = 0.002). The overall mortality rate in the study population was 3%, with a statistically significant difference in mortality between the uniportal and multiportal approaches (1.0% vs 6.4%, p = 0.020). The uniportal approach demonstrated comparable accessibility and lymph node yield to multiportal and thoracotomy techniques. It is equivalent to established methods in terms of postoperative complications, with fewer major complications compared to thoracotomy. While our study indicates a potential for lower mortality following uniportal lung resection in comparison to multiportal lung resection, and demonstrates comparable outcomes to thoracotomy, it is important to approach these findings cautiously and refrain from drawing definitive conclusions.

Outcomes of Central Neck Dissection for Papillary Thyroid Carcinoma in Primary Versus Revision Setting.

Surgery in the central compartment after previous thyroidectomy involves an increased risk of injury to critical organs, including the parathyroids and recurrent laryngeal nerve. Contrastingly, primary central neck dissection involves a relatively low operative risk. This study aimed to compare the outcomes of central neck dissection in primary versus revision settings with respect to the lymph node yield and complication rates. This single-center prospective study included patients who underwent primary or revision neck dissection surgery for histologically confirmed thyroid malignancy between January 2018 and January 2022. We included 30 patients who underwent total thyroidectomy with primary central neck dissection and 29 patients who underwent central neck dissection following remote thyroidectomy with or without previous central dissection. There was no significant between-group difference in postoperative complications, including permanent hypocalcemia and recurrent laryngeal nerve injury. However, both groups showed a significant postoperative decrease in calcium levels even though calcium and parathyroid hormone levels were within reference range. Although many surgeons fear revision central neck dissection, it appears to have similar therapeutic outcomes and complication rates as primary neck dissection for papillary thyroid cancer. Specifically, there were no between-group differences in the lymph node yield, hypoparathyroidism, or recurrent laryngeal nerve paralysis. Patients with normocalcemia showed a significant postoperative reduction in calcium levels, suggesting subclinical parathyroid insufficiency.

Oncologic Outcome in Advanced Oral Squamous Cell Carcinoma After Refusal of Recommended Adjuvant Therapy

Clinicians may be confronted with patients refusing recommended adjuvant therapy (AT) after the primary resection of an advanced oral squamous cell carcinoma (OSCC). However, for this tumor entity, data are lacking regarding the oncological outcomes and associated factors after refusal of AT. To evaluate the difference in survival and disease recurrence for patients with and without recommended AT after resection of advanced OSCC. In this single-center retrospective matched cohort study, patients with advanced OSCC who refused recommended AT between January 2010 and December 2021 were matched 1:1 according to Union for International Cancer Control tumor staging with patients who completed AT. Patients with advanced OSCC who refused or completed recommended AT between 2010 and 2021. The primary outcome of this study was the comparison of overall survival (OS) and recurrence-free survival (RFS) between the 2 study groups. A total of 82 patients (mean [SD] age at time of surgery, 68.0 [11.3] years; 38 [46.3%] female, 44 [53.7%] male) with and without AT (41 per study group) were included in the analysis. Patients refusing AT developed more frequent disease recurrence than patients who completed AT (61.0% vs 26.8%; difference, 34.2%; odds ratio, 4.26; 95% CI, 1.68-10.84). In addition, patients who refused AT presented with lower 2-year OS (72.7% vs 88.6%; difference, 15.9%; 95% CI, 8.6%-40.6%) and much lower 2-year RFS (39.1% vs 74.2%; difference, 35.1%; 95% CI, 0.2%-70.5%). In the patient cohort who rejected AT, a worse OS was associated with female sex (48.6% vs 90.5%; difference, 41.9%; 95% CI, 0.6%-84.4%), pT1-2 category (57.1% vs 92.3%; difference, 35.2%; 95% CI, 3.3%-73.6%), and pN1 or higher category (61.2% vs 82.6%; difference, 21.4%; 95% CI, 14.1%-56.8%). Lower RFS was associated with female sex (37.9% vs 90.9%; difference, 53.0%; 95% CI, 8.0%-97.9%), advanced T category (pT3-4, 35.3% vs 80.0%; difference, 44.7%; 95% CI, 6.4%-95.3%), lymph node yield of 20 or greater (31.4% vs 80.6%; difference, 49.2%; 95% CI, 4.9%-93.4%), and lymph node ratio of less than 4.6% (36.6% vs 84.4%; difference, 47.8%; 95% CI, 1.8%-93.1%). In this cohort study of patients with advanced OSCC, refusal of AT was associated with worse oncological outcomes. The prevalence of disease recurrence during follow-up was 34% higher in patients who refused AT than in patients who completed AT. The results from this study may assist clinicians in guiding patients who are considering refusal of or withdrawal from AT.

Head and neck continued: a retrospective analysis of neck dissections from a New Zealand oral and maxillofacial surgery unit.

The aim of this study is to analyse the demographics, diagnosis, nodal yield, metastatic rates and outcomes of patients undergoing neck dissections within the Waikato Hospital Oral and Maxillofacial Surgery (OMS) Department. All patients that underwent neck dissections under the care of OMS at Waikato Hospital between January 2016 and December 2021 were included. Data on patient demographics, diagnosis, surgery details, nodal yields, histological results and clinical outcome were collected retrospectively for analysis. One hundred and five patients and 123 neck dissections were included in the final analysis. The median age was 65 years of age. The average nodal yield from a selective neck dissection of levels I-III was 20.1 and I-IV was 25.4. There was no metastatic nodal disease in level IIb, and only 2 neck dissections with nodal disease in level IV. Complications were mostly associated with free flap reconstruction rather than the neck dissection alone. The demographics and outcomes of the study cohort are consistent with both the current population and previously published head and neck data. The OMS unit at Waikato Hospital recommends omission of levels IIb and IV in neck dissections for cN0 cases if deemed oncologically safe to do so.

Long-term oncological and surgical outcomes after Video Endoscopic Inguinal Lymphadenectomy (VEIL) in patients with penile cancer.

To report outcomes from the largest multicenter series of penile cancer patients undergoing video endoscopic inguinal lymphadenectomy (VEIL). Retrospective multicenter analysis. Authors of 21 centers from the Penile Cancer Collaborative Coalition-Latin America (PeC-LA) were included. All centers performed the procedure following the same previously described standardized technique. Inclusion criteria included penile cancer patients with no palpable lymph nodes and intermediate/high-risk disease and those with non-fixed palpable lymph nodes less than 4 cm in diameter. Categorical variables are shown as percentages and frequencies whereas continuous variables as mean and range. From 2006 to 2020, 210 VEIL procedures were performed in 105 patients. Mean age was 58 (45-68) years old. Mean operative time was 90 minutes (60-120). Mean lymph node yield was 10 nodes (6-16). Complication rate was 15.7%, including severe complications in 1.9% of procedures. Lymphatic and skin complications were noted in 8.6 and 4.8% of patients, respectively. Histopathological analysis revealed lymph node involvement in 26.7% of patients with non-palpable nodes. Inguinal recurrence was observed in 2.8% of patients. 10y- overall survival was 74.2% and 10-y cancer specific survival was 84.8%. CSS for pN0, pN1, pN2 and pN3 were 100%, 82.4%, 72.7% and 9.1%, respectively. VEIL seems to offer appropriate long term oncological control with minimal morbidity. In the absence of non-invasive stratification measures such as dynamic sentinel node biopsy, VEIL emerged as the alternative for the management of non-bulky lymph nodes in penile cancer.

Surgeon, Pathologist and Pathology Technician Effects on Nodal Yield after a Neck Dissection

A minimum nodal count of 18 lymph nodes has been associated with improved survival after neck dissection and has been suggested as a head and neck cancer quality metric. Despite its critical importance, factors affecting nodal yield are poorly studied. In particular, the relative contribution of surgeons, pathologists, and pathology technicians has not been evaluated. The purpose of this study was to understand both patient and provider related factors that affect nodal yield after neck dissection for patients with oral cavity squamous cell carcinoma (OCSCC). This retrospective cohort study involved review of all adult patients with OCSCC undergoing primary neck dissection between 2000-2020 at an academic medical center. The outcome of interest was a continuous variable denoting the number of nodes removed per side during neck surgery. Surgeon and pathologist year of experience were calculated and represented in quartiles. A multilevel multivariable linear regression model was used to assess the association of surgeon/pathologist experience quartiles with nodal yield, controlling for patient age, comorbidity index, previous cancer, tumor grade, and clinical nodal status. The 508 patients included in our cohort were treated by 5 surgeons and 6 pathologists and involved 44 pathology technicians. Of these patients, 310 (61.0%) were male with a mean age of 63. Oral tongue primary tumors were 46.7% of the cohort, while 64.4% of patients had cT1-T2 tumors, and 65.2% were cN0. The mean nodal yield was 24.2 nodes. The ANOVA analysis revealed significant difference in mean nodal yield by surgeon (p-value = 0.03), pathologist (p-value<0.01) and pathology technician (p-value = 0.037). After accounting for patient-level characteristics and patient clustering by surgeon, increasing surgeon experience was found to be significantly associated with a higher nodal yield (joint significance of surgeon years of experience quartiles < 0.01). Specifically, when compared to surgeons with the least experience (1st quartile), those whose years of experience fell into the 2nd, 3rd, and 4th quartile removed 4.69 (95% CI: 0.97 to 7.92), 4.47 (95% CI: 0.33 to 7.87), and 7.37 (95% CI: 0.73 to 11.27) more lymph nodes. Meanwhile, there was no association between pathologist experience and nodal yield (joint significance of pathologist years of experience quartiles = 0.27). Additionally, previous cancer diagnosis and cN0 disease were significantly associated with lower nodal yield (all p-values = 0.02). This study demonstrates an independent association between increasing surgeon experience and higher nodal yields. Importantly, it also demonstrates that pathologists and pathology technicians contribute to the variation in nodal yield, and their contribution should not be overlooked in the implementation of a lymph node yield-based quality metric.

Lymph Node Yield in Lung Cancer Resection is Associated With Demographic and Institutional Factors

IntroductionLymphadenectomy is routinely performed during surgical resection of nonsmall cell lung cancer (NSCLC). Lymph node yield and number of nodal stations sampled are important prognostic markers viewed as surrogates of surgical quality. The purpose of this study was to identify factors associated with these quality metrics after resection of NSCLC. Materials and methodsWe identified NSCLC patients undergoing resection at a single institution from 2010 to 2021. Cases were matched to detailed pathologist reports, which included lymph node yield and number of stations sampled. Demographic and clinical characteristics were analyzed individually using unadjusted linear regression to identify factors associated with lymph node yield and number of stations sampled. Multivariable linear regression analyses were performed to evaluate the same end points, using covariates determined through stepwise-backwards selection. ResultsThe study cohort included 836 patients. Multivariable regression demonstrated that male sex, history of cardiothoracic surgery, and individual pathologist were independently associated with lymph node yield. Among 18 pathologists, interpathologist coefficients with respect to lymph node yield varied from −5.61 to 11.25. Multivariable regression demonstrated White race and history of cardiothoracic surgery to be independently associated with number of nodal stations sampled, as well as individual surgeon and pathologist. ConclusionsLymph node yield and number of nodal stations sampled after NSCLC resection may vary based on patient demographic and clinical characteristics, as well as institutional factors. These factors should be accounted for when using these metrics as markers of surgical quality and prognosis of NSCLC.

Three-staged minimally invasive esophagectomy with end-to-end esophago-gastric anastomosis for thoracic esophageal cancers: An experience from a low middle-income country

BackgroundEsophageal cancer is on a steady rise and carries significant mortality and morbidity. Depending upon the clinical stage at presentation, either chemotherapy, radiotherapy with or without surgical resection is the treatments in practice. Traditionally, open esophagectomy was performed but over time, the importance of minimally invasive esophagectomy has been established. In this study, we aimed to report our data of totally minimally invasive esophagectomies performed for thoracic esophageal cancers in last four years. MethodologyA prospective cross-sectional study was conducted at the Department of Upper GI Surgery, Dow University of Health Sciences, Karachi. All diagnosed cases of esophageal carcinoma undergoing minimally invasive esophagectomy, from 2019 to 2022 were included in this study. Outcomes measured were operative time, intra operative complications, conversion rate to open, postoperative complications, number of lymph nodes harvested, margin clearance, in-hospital mortality and 90-days mortality. ResultsA total of 53 cases were included in the study, the most prevalent histological type was squamous cell carcinoma 42(79.2%) as compared to adenocarcinoma 8(15.1%). Most common tumor site was lower thoracic esophagus (30–38 cm) in 20 (56.6%) cases. Neo-adjuvant chemotherapy was given in all 53(100%) cases, whereas neo-adjuvant radiation therapy was offered to 49(92.5%) patients. There was a significant and favorable patient response to the neo-adjuvant treatment in 37(69.8%) cases, leading to a decrease in tumor size. Laparoscopic McKeown Esophagectomies were performed in 44 (83.0%) and 9(17.0%) were Robot-assisted Minimally Invasive esophagectomy (RAMIE). Intraoperative injuries (i.e., lung parenchymal injury and bleeding) were reported in only 2(3.8%) patients. Post-operative complications were recorded in 12(22.6%) patients. Margin clearance was observed in 53 (100%) of the patients. The 90-day mortality rate was 3(5.7%), one due to bleeding and other two mortalities were due to COVID related respiratory complications. ConclusionMinimally invasive esophagectomy was found to be safe and feasible technique with encouraging results in terms of decreased intraoperative and post operative complications as well as achieving the standard oncological surgery with acceptable lymph node yield and margin clearance and in hospital and 90 days mortality.

Lymph node level ratio as a predictor of survival in oral cavity squamous cell carcinoma

ObjectiveTo evaluate whether nodal yields and ratios based on level serves as prognostic indicators in patients with oral cavity squamous cell carcinoma undergoing neck dissection. Materials and MethodsA retrospective analysis of 342 patients with oral cavity squamous cell carcinoma treated surgically between 1998 and 2017 were included.Demographics and clinicopathologic data were collated. Disease specific survival and overall survival were analyzed via Kaplan-Meier method and log-rank test as well as univariable and multivariable Cox models. ResultsTotal nodal yield is associated with improved overall and disease specific survival (p < 0.01). Total positive nodal yield (p < 0.01), positive nodal ratio per level (p < 0.001), and identification of <4 lymph nodes/level (p < 0.001) are associated with worse disease specific survival and overall survival. A ratio of at least 4 lymph nodes/level dissected yields the maximal hazard ratio on for both disease specific and overall survival optimizes the Kaplan-Meier split between survival groups. After controlling for sex, age, margin status, disease stage, extranodal extension, perineural invasion, and lymphovascular invasion as fixed covariates in the Cox models, a nodal level ratio of 4 lymph nodes/level provides hazard ratio (95% CI) of 3.59 (1.69, 7.60); p < 0.0006) for disease free survival and 2.90 (1.54, 5.46; p < 0.001) for overall survival. ConclusionNodal level ratio of < 4 lymph nodes/level is associated with worse disease specific and overall survival in oral cavity squamous cell carcinoma. This level-specific metric may prove useful qualitatively and in predicting survival in oral cavity cancer with broader utility to address variations in levels of neck dissection performed.

The Association between Lymph Node Dissection and Survival in Lymph Node-Negative Upper Urinary Tract Urothelial Cancer.

The benefit of lymph node dissection (LND) during radical nephroureterectomy (RNU) in lymph node (LN)-negative (cN0/pN0) UTUC remains controversial. We aimed to assess the association between LND and its extent and survival in LN-negative UTUC. The Surveillance, Epidemiology, and End Results database was searched to identify patients with non-metastatic chemotherapy-naïve cN0/pNx or pN0 UTUC who underwent RNU +/- LND between 2004 and 2019. Overall, 4649 patients with cN0/pNx or pN0 UTUC were analyzed, including 909 (19.55%) individuals who had LND. Among them, only in 368 patients (7.92%) was LND extended to at least four LNs, and the remaining 541 patients (11.64%) have had < four LNs removed. In the whole cohort, LND contributed to better cancer-specific survival (CSS) and overall survival (OS). Furthermore, a propensity score-matched analysis adjusted for confounders confirmed that improved CSS and OS was achieved only when ≥ four LNs had been removed, especially in muscle-invasive UTUC. A multivariable analysis further confirmed an association between the extent of LND and CSS. To conclude, adequate LND during RNU was associated with improved OS and CSS in LN-negative UTUC, particularly in muscle-invasive stage. This underscores that a sufficient LN yield is required to reveal a therapeutic benefit in patients undergoing RNU.

Intracorporeal Vessel Ligation in Laparoscopic Right Colectomy for Cancer is Associated with Increased Lymph Node Yield.

This study aimed to compare intra- and extracorporeal division of the vascular pedicle in laparoscopic right colectomy regarding pathological outcomes, short-term morbidity, and local recurrence and distant metastases. Retrospective analysis of an IRB-approved database of all patients who underwent laparoscopic right colectomy for cancer between 01/2011 and 08/2021. Main outcome measures were number of harvested lymph nodes, length of resected colon, R1 rate, positive lymph node ratio, short-term post-operative morbidity, local recurrence, and distant metastases. Two-hundred seventy-one consecutive patients (136 males) patients underwent laparoscopic right hemicolectomy for cancer during the study period. Vessel ligation was intracorporeal in 171 (63%) and extracorporeal in 100 patients (37%); groups had similar baseline characteristics except for extent of resection as extended right hemicolectomy was significantly more often performed in the intracorporeal group. When the two groups were matched for theextent of resection (standard versus extended right hemicolectomy),the mean number of harvested lymph nodes (28.61 ± 12.04 versus25.37 ± 10.06, p = 0.04) and median length of theresected colon [26.00 (IQR:21.00, 32.00) versus 23.00 (IQR:19.00, 27.00)cm, p = 0.003] were significantly higher in the intracorporeal than in the extracorporeal group. The intracorporeal group required a significantly longer operative time than didthe extracorporeal group (168.94±57.9 vs. 139.7±41.3mins, p=0.001). No significant differences were noted between the groups in terms of ileus, hemorrhage, surgical site infection, re-operation rates, recurrence, or distant metastases. Intracorporeal vessel ligation in laparoscopic right hemicolectomy was associated with increased lymph node yield and longer specimens, although requiring longer operative times. Postoperative clinical outcomes were similar to outcomes in the extracorporeal ligation group.

The limited value of sentinel lymph node biopsy in lentigo maligna melanoma: A nomogram based on the results of 29 years of the nationwide dutch pathology registry (PALGA)

BackgroundLentigo maligna melanoma (LMM) predominantly presents in the head and neck of the elderly. The value of sentinel lymph node biopsy (SLNB) for LMM patients remains to be determined, as the reported average yield of positive lymph nodes is less than 10%. In this nationwide cohort study, we wanted to identify LMM patients with an increased risk of SLNB-positivity. MethodsLMM with an SLNB indication according to the 8th AJCC melanoma guidelines were retrospectively identified from the nationwide network and registry of histo- and cytopathology in the Netherlands (PALGA). A penalized (LASSO) logistic regression analysis was performed to determine the optimal combination of clinicopathological factors to predict a positive SLNB. ResultsBetween 1991 and 2020, 1989 LMM patients met our inclusion criteria. SLNB was performed in 16.7% (n = 333) and was positive in 7.5% (25/333). The false-negative rate was 21.9%. Clinically detectable regional lymph node (LN) metastases were found in 1.3% (n = 25). Clinicopathological characteristics best predictive for SLNB-positivity (Odds ratio; 95% CI) were age (0.95; 0.91–0.99), ulceration 1.59 (0.44–4.83), T4-stage (1.81; 0.43–6.2), male sex (1.97; 0.79–5.27), (lymph)angioinvasion (5.07; 0.94–23.31), and microsatellites (7.23; 1.56–32.7) (C-statistic 0.75). During follow-up, regional LN recurrences were detected in 4.2% (83/1989) of patients, of which the majority (74/83) had no evidence of regional LN metastases at baseline. ConclusionOur findings confirm the limited SLNB-positivity in LMM patients. Based on the identified high-risk clinicopathological features, a nomogram was developed to predict the risk of a positive SLNB.

Evaluation of the quality of neck dissection in patients with oral cavity squamous cell carcinoma

Oral cavity squamous cell carcinoma is one of the leading localizations in the structure of head and neck cancers in the Russian federation and in the world. Neck metastases are the key criterion which influence to survival, recurrence, and distant metastases in patients with oral squamous cell carcinoma. Neck dissection is a main step in the surgical treatment of oral squamous cell carcinoma. This literature review analyzes data on possible methods for assessing the quality of neck dissection in squamous cell carcinoma of the oral cavity. Evaluation criteria can be conditionally divided into prognostic (lymph node extracapsular extension, the size of the largest neck metastasis, lymph node yield, lymph node ratio, metastasis topography) and qualitative (lymph node yield, lymph node ratio). Nowadays, there are some prognostic factors of surgical specimen after neck dissection which we use in clinical practice except for lymph node yield, lymph node ratio. This paper analyzes the criteria for an objective assessment of the quality of the operation “neck dissection”. The clinical and prognostic significance of these parametrs is considered.

Outcome of Completion Surgery after Endoscopic Submucosal Dissection in Early-Stage Colorectal Cancer Patients.

T1 colorectal cancers (T1CRC) are increasingly being treated by endoscopic submucosal dissection (ESD). After ESD of a T1CRC, completion surgery is indicated in a subgroup of patients. Currently, the influence of ESD on surgical morbidity and mortality is unknown. The aim of this study was to compare 90-day morbidity and mortality of completion surgery after ESD to primary surgery. The completion surgery group consisted of suspected T1CRC patients from a multicenter prospective ESD database (2014-2020). The primary surgery group consisted of pT1CRC patients from a nationwide surgical registry (2017-2019). Patients with rectal or sigmoidal cancers were selected. Patients receiving neoadjuvant therapy were excluded. Propensity score adjustment was used to correct for confounders. In total, 411 patients were included: 54 in the completion surgery group (39 pT1, 15 pT2) and 357 in the primary surgery group with pT1CRC. Adverse event rate was 24.1% after completion surgery and 21.3% after primary surgery. After completion surgery 90-day mortality did not occur, though one patient died in the primary surgery group. After propensity score adjustment, lymph node yield did not differ significantly between the groups. Among other morbidity-related outcomes, stoma rate (OR 1.298 95%-CI 0.587-2.872, p = 0.519) and adverse event rate (OR 1.162; 95%-CI 0.570-2.370, p = 0.679) also did not differ significantly. A subgroup analysis was performed in patients undergoing rectal surgery. In this subgroup (37 completion and 136 primary surgery), these morbidity outcomes also did not differ significantly. In conclusion, this study suggests that ESD does not compromise morbidity or 90-day mortality of completion surgery.