Omission Of Node Dissection Research Articles

Age represents the main driver of surgical decision making in patients candidate to radical cystectomy.

Age might influence the choice of surgical approach, type of urinary diversion (UD) and lymph node dissection (LND) in patients candidate to radical cystectomy (RC) for urothelial bladder cancer (UBC). Similarly, age may enhance surgical morbidity and worsen perioperative outcomes. We tested the impact of age (octogenarian vs. younger patients) on surgical decision making and peri- and postoperative outcomes of RC. Non-metastatic muscle-invasive UBC patients treated with RC at 18 high-volume European institutions between 2006 and 2021 were identified and stratified according to age (≥80 vs. <80 years). Intraoperative Complications Assessment and Reporting with Universal Standards and European Association of Urology guidelines recommendations were accomplished in collection and reporting of, respectively, intraoperative and postoperative complications. Multivariable logistic regression models (MVA) tested the impact of age on outcomes of interest. Sensitivity analyses after 1:3 propensity score matching were performed. Of 1955 overall patients, 251 (13%) were ≥80-year-old. Minimally invasive RC was performed in 18% and 40% of octogenarian and younger patients, respectively (p < 0.001). UD without bowel manipulation (ureterocutaneostomy, UCS) was performed in 31% and 7% of octogenarian and younger patients (p < 0.001). LND was delivered to 81% and 93% of octogenarian and younger patients (p < 0.001). At MVA, age ≥80 years independently predicted open approach (odds ratio [OR]: 1.55), UCS (OR: 3.70), and omission of LND (OR: 0.41; all p ≤ 0.02). Compared to their younger counterparts, octogenarian patients experienced higher rates of intraoperative (8% vs. 4%, p = 0.04) but not of postoperative complications (64% vs. 61%, p = 0.07). At MVA, age ≥80 years was not an independent predictor of length of stay, intraoperative or postoperative transfusions and complications, and readmissions (all p values >0.1). These results were replicated in sensitivity analyses. Age ≥80 years does not independently portend worse surgical outcomes for RC. However, octogenarians are unreasonably more likely to receive open approach and UCS diversion, and less likely to undergo LND.

Factors predicting upstaging from clinical N0 to pN2a/N3a in breast cancer patients.

BACKGROUNDWith sentinel node metastasis in breast cancer (BC) patients, axillary lymph node (ALN) dissection is often omitted from cases with breast-conserving surgery. Omission of lymph node dissection reduces the invasiveness of surgery to the patient, but it also obscures the number of metastases to non-sentinel nodes. The possibility of finding ≥ 4 lymph nodes (pN2a/pN3a) preoperatively is important given the ramifications for postoperative treatment. AIMTo search for clinicopathological factors that predicts upstaging from N0 to pN2a/pN3a.METHODSPatients who were sentinel lymph node (SLN)-positive and underwent ALN dissection between September 2007 and August 2018 were selected by retrospective chart review. All patients had BC diagnosed preoperatively as N0 with axillary evaluation by fluorodeoxyglucose (FDG) positron emission tomography/computed tomography and ultrasound (US) examination. When suspicious FDG accumulation was found in ALN, the presence of metastasis was reevaluated by second US. We examined predictors of upstaging from N0 to pN2a/pN3a. RESULTSAmong 135 patients, we identified 1-3 ALNs (pN1) in 113 patients and ³4 ALNs (pN2a/pN3a) in 22 patients. Multivariate analysis identified the total number of SLN metastasis, the maximal diameter of metastasis in the SLN (SLNDmax), and FDG accumulation of ALN as predictors of upstaging to pN2a/pN3a. CONCLUSIONWe identified factors involved in upstaging from N0 to pN2a/pN3a. The SLNDmax and number of SLN metastasis are predictors of ≥ 4 ALNs (pN2a/pN3a) and predictors of metastasis to non-sentinel nodes, which have been reported in the past. Attention should be given to axillary accumulations of FDG, even when faint.

PD60-02 CAN PELVIC LYMPH NODE DISSECTION BE OMITTED AT THE TIME OF RADICAL PROSTATECTOMY IN PATIENTS WITH A NEGATIVE PREOPERATIVE 68GA-PSMA PET/CT? THE IMPORTANCE OF PATIENT RISK STRATIFICATION ACCORDING TO INDIVIDUAL RISK OF LYMPH NODE METASTASES

You have accessJournal of UrologyCME1 May 2022PD60-02 CAN PELVIC LYMPH NODE DISSECTION BE OMITTED AT THE TIME OF RADICAL PROSTATECTOMY IN PATIENTS WITH A NEGATIVE PREOPERATIVE 68GA-PSMA PET/CT? THE IMPORTANCE OF PATIENT RISK STRATIFICATION ACCORDING TO INDIVIDUAL RISK OF LYMPH NODE METASTASES Elio Mazzone, Daniele Robesti, Giorgio Gandaglia, Armando Stabile, Carlo Andrea Bravi, Andrea Necchi, Daniele Raggi, Laura Marandino, Giuseppe Cirulli, Eleonora Balestrazzi, Stefano Fanti, Vito Cucchiara, Andrea Farolfi, Lorenzo Bianchi, Riccardo Schiavina, Francesco Montorsi, and Alberto Briganti Elio MazzoneElio Mazzone More articles by this author , Daniele RobestiDaniele Robesti More articles by this author , Giorgio GandagliaGiorgio Gandaglia More articles by this author , Armando StabileArmando Stabile More articles by this author , Carlo Andrea BraviCarlo Andrea Bravi More articles by this author , Andrea NecchiAndrea Necchi More articles by this author , Daniele RaggiDaniele Raggi More articles by this author , Laura MarandinoLaura Marandino More articles by this author , Giuseppe CirulliGiuseppe Cirulli More articles by this author , Eleonora BalestrazziEleonora Balestrazzi More articles by this author , Stefano FantiStefano Fanti More articles by this author , Vito CucchiaraVito Cucchiara More articles by this author , Andrea FarolfiAndrea Farolfi More articles by this author , Lorenzo BianchiLorenzo Bianchi More articles by this author , Riccardo SchiavinaRiccardo Schiavina More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , and Alberto BrigantiAlberto Briganti More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002645.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The role of PSMA PET/CT in the primary staging for patients with prostate cancer (PCa) is debated. Although previous studies suggested a high negative predictive value (NPV) in intermediate risk patients, the variation of false negative (FN) rate according to the prevalence of lymph node invasion (LNI) based on preoperative LNI risk has never been tested. We explored the variation of FN rates in a consecutive cohort of men receiving preoperative PSMA PET. METHODS: We identified 92 patients evaluated with 68Ga-PSMA PET/CT before RP and extended lymph node dissection (LND) between 2019 and 2021 at two referral centers. The main outcome was FN rate, defined as presence of LNI at pathology in patients with negative preoperative scan. To test the correlation between LNI prevalence and FN rate, individual preoperative LNI risk was calculated based on the Briganti nomogram. We investigated the association between the preoperative LNI risk and FN using logistic regression. Thereafter, the relationship between preoperative LNI risk and FN rate was graphically explored using the Lowess function. RESULTS: Overall, 30 patients had positive spots at preoperative scan. Median LNI risk was 31% (IQR 17-52%). Overall, 13 patients (22%) had FN findings. On a patient-based analysis, PSMA PET/CT showed 59% sensitivity, 81% specificity, 78% NPV and 63% positive predictive value in the detection of LNI. At logistic regression, higher LNI risk was significantly associated with increased risk of missing positive nodes at PSMA PET (HR 1.36, p=0.02). At Lowess analysis, the FN rate progressively increased with higher LNI risk, with rates ranging from 7 to 35% between a preoperative LNI risk of 5 and 90%. Notably, FN rates remained equal or lower 10% in patients with a low risk of LNI (<15%) (Fig. 1). CONCLUSIONS: We confirmed that the NPV of preoperative PSMA PET/CT is strongly correlated with LNI prevalence. Notably, in patients with low LNI risk at nomograms and negative PSMA PET, the omission of LND could be considered in the light of the very low rate of FN. This evidence reinforces the need to prospectively explore the diagnostic role of PSMA PET compared to LND in patients with intermediate risk disease. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1024 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elio Mazzone More articles by this author Daniele Robesti More articles by this author Giorgio Gandaglia More articles by this author Armando Stabile More articles by this author Carlo Andrea Bravi More articles by this author Andrea Necchi More articles by this author Daniele Raggi More articles by this author Laura Marandino More articles by this author Giuseppe Cirulli More articles by this author Eleonora Balestrazzi More articles by this author Stefano Fanti More articles by this author Vito Cucchiara More articles by this author Andrea Farolfi More articles by this author Lorenzo Bianchi More articles by this author Riccardo Schiavina More articles by this author Francesco Montorsi More articles by this author Alberto Briganti More articles by this author Expand All Advertisement PDF DownloadLoading ...

Status of the Sentinel Lymph Node in Patients with Endometrial Cancer Stage I-II.

Endometrial cancer (EC) is the most common gynecological cancer in developed countries. In literature, there are discordant data regarding the therapeutic value of systematic lymphadenectomy whereas the importance of lymph node status for determining prognosis and the need for adjuvant treatment is undoubted. Given the low risk of lymph node metastases in stage I-II of EC and the significant surgical and postoperative risks when performing a complete pelvic lymphadenectomy, the surgical approach in these patients is controversial, ranging from no nodal evaluation to comprehensive pelvic and aortic lymphadenectomy. The recent introduction of sentinel node detection represents the mid-way between the execution and omission of node dissection in EC patients. Indeed, the sentinel node mapping has rapidly emerged as an alternative to complete lymphadenectomy to reduce morbidity. In the present research, we discuss the role of sentinel node mapping in the surgical management of EC in early stage. Results of study on SLN in EC in early stages seem to be promising, but only a small series have been published so far.

Sentinel lymph node biopsy in endometrial cancer: state of the art.

Endometrial cancer (EC) is the most common gynecological neoplasm in developed countries. In literature, there are discordant data regarding the therapeutic value of systematic lymphadenectomy whereas the importance of lymph node status for determining prognosis and the need for adjuvant treatment is undoubted. Given the low risk of lymph-node metastases in the apparent early-stage disease and the significant surgical and postoperative risks when performing a complete pelvic lymphadenectomy, the surgical approach in these patients is controversial, ranging from no nodal evaluation to comprehensive pelvic and aortic lymphadenectomy. The recent introduction of sentinel node mapping represents the mid-way between the execution and omission of node dissection in EC patients. Indeed, the sentinel node mapping has rapidly emerged as an alternative to complete lymphadenectomy to reduce morbidity. In the present review, we discuss the role of sentinel node mapping in the surgical management of EC evaluating all aspects of this procedure.

Current Role and Benefits of Sentinel Lymph Node Mapping in Endometrial Cancer

Endometrial cancer (EC) is one of the three major malignant tumors of the female reproductive system in developed countries. In recent years, the incidence of EC ranks first in gynecological malignancy and the mainstay of treatment is Surgery. Although EC has a high prevalence, its several features associated with management are still unclear. Endometrial cancer lymph node status is the most important predictor of survival and also guides postoperative treatment planning but in gynecologic oncology, lymphadenectomy, as a part of initial surgical management remains controversial. The current introduction of sentinel lymph node mapping in EC patients represents a midway between the execution and omission of node dissection. Sentinel lymph node (SLN) mapping has emerged as an alternative staging strategy hence, the role of SLN mapping is currently being evaluated prospectively in several centers. The objective of this review is to provide an update of the emerging role of sentinel node mapping in EC. In this review, we discussed how several different techniques, type of tracers utilized and injection sites has been described and used for lymphatic mapping in EC impacting on sentinel lymph node detection rates. In addition, we also discussed another evolving field in EC staging i.e. interpretation of pathologic ultra staging of SLN, which can identify low volume metastasis for which the clinical significance and ideal management remain uncertain. Future perspective regarding EC management is also discussed in this review.

1442P - Wedge resection with omission of lymph node dissection as an optional treatment strategy in octogenarians or older with early stage non-small cell lung cancers

BackgroundIn early stage non-small cell lung cancer (NSCLC), the anatomical resection with lymph node dissection is a standard procedure as a curative intent while wedge resection is considered as a passive treatment. However, optimal treatment strategy for elderly (>= 80 y.o.) patients remains controversial. We attempted to disclose the role of wedge resection without lymph node dissection as a treatment option in octogenarians or older. MethodsAmong 671 patients with clinical stage IA NSCLC with whole tumor size is 2cm or less and consolidation to tumor ratio is more than 0.5 underwent R0 resection in three institutions between 2010 and 2015, 55 octogenarians or older were investigated about clinicopathological findings and prognosis based on surgical procedures and lymph node dissection status. ResultsThe median follow-up time was 35 months. The 3-year overall survival (OS) rate for octogenarians or older was 83.8% (95% confidential interval (CI): 69.7-91.7%). No significant differences for OS were detected among three surgical procedures (3-year OS rate: wedge resection: 88.5% (95%CI: 68.4-96.1%), segmentectomy: 83.3% (95%CI: 27.3-97.5%) , and lobectomy: 78.9% (95%CI: 53.0-91.6%), P=0.72) or lymph node dissection status (3-year OS rate: ND0: 88.9% (95%CI: 69.4-96.3%) and ND1 or 2: 77.0% (95%CI: 50.8-90.4%), P=0.95). The multivariable Cox regression analysis revealed that male gender (Hazard ratio (HR): 4.7 (1.1-20.2), P=0.039) and larger solid tumor size (HR: 5.8 (1.1-29.9), P=0.035) were independent poor prognostic factors whereas surgical procedure (wedge resection vs. segmentectomy or lobectomy) (HR: 0.50 (0.15-1.7), P=0.27) was not. In another model, lymph node dissection status (ND0 vs. ND1 or 2) (HR: 0.51 (0.15-1.8), P=0.28) was not found to be a prognostic factor. ConclusionsIn octogenarians or older with early stage NSCLC, wedge resection without lymph node dissection might be an alternative option to lobectomy or segmentectomy with lymph node dissection. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Current landscape and future perspective of sentinel node mapping in endometrial cancer.

Endometrial cancer (EC) represents the most common gynecological neoplasm in developed countries. Surgery is the mainstay of treatment for EC. Although EC is characterized by a high prevalence several features regarding its management are still unclear. In particular the execution of lymphadenectomy is controversial. The recent introduction of sentinel node mapping represents the mid-way between the execution and omission of node dissection in EC patients. In the present review we discuss the emerging role of sentinel node mapping in EC. In addition, we discussed how type of tracers utilized and site of injection impacted on sentinel node detection rates. Future perspective regarding EC management are also discussed.

Axillary lymph node management in breast cancer with positive sentinel lymph node biopsy.

The surgical treatment of localized breast cancer has become progressively less aggressive over the years. The management of the axillary lymph nodes has been modified by the introduction of sentinel lymph node biopsy. Axillary dissection can be avoided in patients with sentinel lymph node negative biopsies. Based on randomized trials data, it has been proposed that no lymph node dissection should be carried out even in certain patients with sentinel lymph node positive biopsies. This commentary discusses the basis of such recommendations and cautions against a general omission of lymph node dissection in breast cancer patients with positive sentinel lymph node biopsies. Instead, an individualized approach based on axillary tumor burden and biology of the cancer should be considered.

Sentinel node navigation surgery for gastric cancer: Overview and perspective

The sentinel node (SN) technique has been established for the treatment of some types of solid cancers to avoid unnecessary lymphadenectomy. If node disease were diagnosed before surgery, minimal surgery with omission of lymph node dissection would be an option for patients with early gastric cancer. Although SN biopsy has been well ascertained in the treatment of breast cancer and melanoma, SN navigation surgery (SNNS) in gastric cancer has not been yet universal due to the complicated lymphatic flow from the stomach. Satisfactory establishment of SNNS will result in the possible indication of minimally invasive surgery of gastric cancer. However, the results reported in the literature on SN biopsy in gastric cancer are widely divergent and many issues are still to be resolved, such as the collection method of SN, detection of micrometastasis in SN, and clinical benefit. The difference in the procedural technique and learning phase of surgeons is also varied the accuracy of SN mapping. In this review, we outline the current status of application for SNNS in gastric cancer.

Outcomes of patients with low-risk endometrial cancer surgically staged without lymphadenectomy based on intra-operative evaluation

ObjectiveThe objective of the study was to evaluate clinical outcomes in patients with stage I endometrial cancer undergoing surgical management without lymphadenectomy based on intra-operative assessment for low-risk disease. MethodsBetween 2000 and 2009, a total of 179 patients were surgically staged without lymphadenectomy for low-risk stage I endometrial cancer. Low-risk cancer was defined by intra-operative criteria based on both gross and frozen tissue microscopic evaluation: 1) G1 or G2 endometrioid histology; 2) myoinvasion <50%; 3) no cervical disease, and 4) no intra-abdominal metastasis. Records were reviewed for postoperative complications, pathological diagnoses, adjuvant radiation treatment, cancer recurrence, and mortality. ResultsMorbidity, cancer recurrence, and disease-specific mortality were low. Postoperative complications occurred in 5 patients (2.8%). Nine patients (5.0%) were offered adjuvant radiation for higher risk disease diagnosed on final pathology. Radiation morbidity was minimal: grade 1 vaginal toxicity in 2 patients. Three patients (1.7%) experienced recurrent cancer with mean time to recurrence of 43.7months. Five year overall survival was 95.8%. The five year probability of disease-specific death was 1.1%. ConclusionIn an institution with reliable capability of pathological frozen tissue diagnosis, omission of lymph node dissection is a reasonable option in the surgical management of those patients with low-risk disease diagnosed by intra-operative factors.

Hepatic infestation of Echinococcus multilocularis with extension to regional lymph nodes

The objective of this paper is to prove lymph node infestation by Echinococcus multilocularis and provide evidence for systematic lymph node dissection in curative resections for alveolar echinococcosis (AE). Human AE is a life threatening parasitic condition, usually caused by an intrahepatic infiltrative and destructive growth of the larvae E. multilocularis. WHO guidelines provide radical hepatic resection for curative treatment. However, the current norms do not consider dissection of regional lymph nodes. No report to date has visualized concurrent lymph node infestation. Radical excision of infested liver including regional lymph nodes with subsequent histological examination was carried out in a patient suffering from AE. The literature was reviewed and a revised state-of-the-art treatment of AE deduced. Upon inspection the liver displayed macroscopic features of AE, in contrast to the regional lymph nodes which appeared unsuspicious. Further histological analysis confirmed regional lymph node infestation of E. multilocularis. This is the first publication on histological evidence of E. multilocularis in regional hepatic lymph nodes, and thus, demonstrating dissemination from the liver. Since AE can spread through lymphatic drainage, even without causing macroscopic conspicuity, resection should not be resumed to the liver tissue only, but rather to consider the routine removal of regional lymph nodes as well. Omission of lymph node dissection can leave behind parasitic tissue and surgical procedures erroneously judged as curative.

Peut-on se passer d’un curage ganglionnaire dans le cancer du rectum ?

F. Leblanc, C. Laurent E. Rullier Lymph node dissection is a standard part of surgical resection of rectal cancer which helps to avoid local recurrence and allows for accurate staging of the disease. Three types of lymph node dissection have been considered. Mesorectal lymphadenectomy should remove the mesorectum systematically and should extend at least 5cm distal to the tumor. Inferior mesenteric lymphadenectomy should extend at least to the origin of the left colic artery. Lateral lymphadenectomy removing iliac and obturator nodes results in complications and has not been shown to improve survival; it is not routinely recommended. Omission of lymph node dissection is only proposed for the smallest T1 tumors with favorable histology.

Peut-on se passer d’un curage ganglionnaire dans le cancer du rectum ?

F. Leblanc, C. Laurent E. Rullier Lymph node dissection is a standard part of surgical resection of rectal cancer which helps to avoid local recurrence and allows for accurate staging of the disease. Three types of lymph node dissection have been considered. Mesorectal lymphadenectomy should remove the mesorectum systematically and should extend at least 5cm distal to the tumor. Inferior mesenteric lymphadenectomy should extend at least to the origin of the left colic artery. Lateral lymphadenectomy removing iliac and obturator nodes results in complications and has not been shown to improve survival; it is not routinely recommended. Omission of lymph node dissection is only proposed for the smallest T1 tumors with favorable histology.

Le ganglion sentinelle en pathologie digestive : données actuelles et implications à venir

M. Pocard, J.-C. Sabourin In theory, the concept of sentinel lymph node (SLN) biopsy can be applied to cancer surgery for all solid cancers. Yet sentinel lymph node biopsy has not become a standard part of gastrointestinal cancer surgery. It has been of value in the assessment of small early-stage gastric cancers, but has only achieved widespread practice in Japan. Studies of SLN biopsy in colon cancer have not shown it to be a reliable predictor of N+ status and therefore don't permit the omission of lymph node dissection in selected cases. On the other hand, as a form of intra-operative lymph node mapping, dye injection of the SLN may demonstrate aberrant lymphatic drainage and could occasionally permit the sparing of a middle colic artery whose sacrifice would otherwise be dictated by standard drainage patterns. SLN biopsy may have prognostic usefulness by demonstrating micrometastases; careful serial sectioning focussed on the SLN may detect nests of metastatic cells on HE staining, thereby converting a tumor from Stage I (TxN0M0) to Stage II (TxN1M0). This finding has been noted in 10-15% of cases. However, the prognostic value of micrometastases detected only by immunohistochemical staining or PCR has not been demonstrated. For cancers of the anal canal, SLN biopsy of inguinal nodes has been tested as a means of establishing the indications for inguinal lymph node dissection.

PTD classification: proposal for a new classification of gastric cancer location based on physiological lymphatic flow

We propose a new classification for the location of gastric cancer - the PTD classification (i.e., zones P, T, and D; see below), with the zones classified according to the physiological lymphatic flow. Three hundred and thirty-six patients with T1 or small T2 gastric cancer who underwent sentinel node mapping at our hospital were enrolled. The relationship between the location of the gastric cancer and the physiological lymphatic flow derived from sentinel node mapping was investigated. Lymphatic basins were defined as lymphatic zones divided by the stream of stained lymphatic canals. One hundred and forty-six patients underwent standard gastrectomy with more than D2 dissection and the other 190 patients underwent function-preserving gastrectomy with the omission of lymph node dissection outside the lymphatic basin. In the former group, the progression pattern of lymph node metastasis was observed; nodal metastasis occurred in sentinel nodes first, and rarely extended outside the lymphatic basin. In the latter group, none of the patients have had a recurrence. The PTD classification we propose is as follows: the dividing line between the proximal region (zone P) and the transitional region (zone T) is the line that links the point of the watershed between the left gastroepiploic artery and right gastroepiploic artery, to the point that is the inflow point of the first descending branch of the left gastric artery; and the dividing line between zone T and the distal region (zone D) is an arc at a radius of 8 cm from the pylorus. There were no lymphatic basins within the right gastric artery area for tumors located in zone T. The advantage of the PTD classification is that if the PTD classification were to be used as a guide for gastric resection procedures, preservation of the pylorus would become possible without diminishing the prognosis in patients with cT1N0 cancer located in zone T.