Pathological Node Research Articles

Recurrence Risk Score Model for Evaluating the Impact of Postmastectomy Radiotherapy in Breast Cancer Patients with Pathologic Nodal Negative after Neoadjuvant Chemotherapy and Mastectomy

Recurrence risk score model was established to distinguish the recurrent risk of patients with pathologic nodal negative (ypN0) after neoadjuvant chemotherapy (NACT) and mastectomy and determine the impact of postmastectomy radiotherapy (PMRT). This multicenter retrospective study reviewed 766 patients who underwent mastectomy and NACT with ypN0 from 2000 to 2014. Recurrent risk score model was assigned proportionally to the relative contribution of independent prognostic factors in the multivariate Cox model of disease-free survival (DFS). Decision tree analysis was conducted to determine two optimal cutoff points for stratification. The median follow-up time was 74 months. The 5-year locoregional control (LRC), DFS, and overall survival (OS) rates for the entire group were 96.5%, 89.1% and 95.3%, respectively. 353 (46.1%) patients received PMRT and 413 (53.9%) patients did not. Patients with PMRT have more high-risk factors, including age <40 years, clinical stage III, grade III, or ER and PR negative. Chest wall and regional nodal region were irradiated in 307 (87.0%) and chest wall only in 46 (13.0%). The median radiation dose was 50 Gy (range: 36-60 Gy) in 25 fractions (range: 15-30 fractions). There were no significant differences between the PMRT and No-PMRT groups in the LRC, DFS and OS rates. Recurrent risk score model consisted of five factors and used a range of zero to eleven scoring points: age <40 years and clinical N1 stage for one point; clinical N2, NACT ≥4 cycles, lymphovascular invasion and ypT1-2 for two points; ypT3-4 for four points. 456 (59.5%) patients scoring zero to four points, 188 (24.5%) scoring five points and 122 (15.9%) scoring six to eleven points were assigned to the low-, intermediate-, and high-risk group. LRC, DFS and OS rates in three risk groups were significantly distinct from each other (5yr-LRC: 98.6% vs. 95.5% vs. 89.8%, p < .001; 5yr-DFS: 94.4% vs. 87.4% vs. 71.5%, p < .001; 5yr-OS: 97.6% vs. 93.2% vs. 90.0%, p < .001). PMRT had no impact on the LRC, DFS and OS rates in either low-, intermediate-, or high-risk group. The recurrence risk score model can effectively distinguish patients with different recurrent risk stratification. PMRT in patients with ypN0 after NAC and mastectomy cannot improve LRC, DFS or OS. Table 1. Survival outcomes and comparison between PMRT and No-PMRT arms in different groups.

Development of a Screening Nomogram for Regional Lymph Node Metastasis Development in Muscle Invasive Bladder Cancer after Multiagent Systemic Therapy

A reliable method of identifying clinically node negative bladder cancer patients at greater risk of developing lymph node metastasis and may require intensified therapy is needed. The purpose of this study was to create a nomogram to quantify the risk for regional lymphatic involvement in non-metastatic muscle invasive bladder cancer. Usingthe National Cancer Database, patients with clinical T2-4N0M0 urothelial carcinoma of the bladder between the years of 2004 - 2020 were selected. All patients completed multiagent chemotherapy followed by surgery for pathologic nodal staging to determine presence or absence of nodal disease. No neoadjuvant radiation therapy was allowed and patients with history of prior malignancies were excluded. Following a 70:30 training to testing data split, baseline variables were assessed using univariate logistic regression. Variables were selected for inclusion in the multivariate logistic regression model using a combination of previously reported findings in the literature and/or if found to have a p-value < 0.05 on univariate analysis. A nomogram was constructed using this final model with assessment using calibration plots and the area under the receiver operating characteristics curve (AUC), respectively. An empiric cut point was chosen at 95% sensitivity to identify patients at "high" and "low" risk for pathologic nodal disease with overall assessment in both cohorts using chi-square. A total of 6194patients were identified for study with a median age of 65 years (IQR = 58 - 71 years). Most patients were male (68.0%) with T2 disease (81.2%). The final multivariate model included age at time of diagnosis (OR = 0.99; 95% CI = 0.99 - 1.00; p = 0.172), time from diagnosis to initiation of chemotherapy (OR = 1.00; 95% CI = 1.00 - 1.01; p = 0.005), papillary histology (OR = 0.85; 95% CI = 0.72 - 1.01; p = 0.068), and clinical T stage (Table 1). Model calibration demonstrated excellent goodness-of-fit with good discrimination (AUC = 0.644). Within the training data, high risk patients were seen to have a twofold increase in pathologic nodal disease (N = 835/3924, 21.2%) when compared to those identified as low risk (N = 38/347, 9.9%) (p < 0.001). Validation within the testing data set demonstrated similar results with pathologic node rates of 22.8% and 7.8% for high- and low-risk patients, respectively (AUC = 0.645, p < 0.001). This study demonstrates a clinically applicable risk stratification tool for identifying patients at risk for developing lymphadenopathy in T2-4 bladder cancer and may help guide future research in selecting patients eligible for escalation of therapy. Future studies should aim to externally validate this tool within prospective cohorts, and seek to determine if this nomogram may provide further prognostic utility.

Development and Validation of a Recurrence-Free Survival Prediction Model for Locally Advanced Esophageal Squamous Cell Carcinoma with Neoadjuvant Chemoradiotherapy

BackgroundA recurrence-free survival (RFS) prediction model was developed and validated for patients with locally advanced esophageal squamous cell carcinoma treated with neoadjuvant chemoradiotherapy (NCRT) in combination with surgery.Patients and MethodsWe included 282 patients with esophageal squamous cell carcinoma who received neoadjuvant chemoradiotherapy (NCRT) combined with surgery, constructed three models incorporating pathological factors, investigated the discrimination and calibration of each model, and compared the clinical utility of each model using the net reclassification index (NRI) and the integrated discrimination index (IDI).ResultsMultivariable analysis showed that pathologic complete response (pCR) and lymph node tumor regression grading (LN–TRG) (p < 0.05) were independent prognostic factors for RFS. LASSO regression screened six correlates of LN-TRG, vascular invasion, nerve invasion, degree of differentiation, platelet grade, and a total diameter of residual cancer in lymph nodes to build model three, which was consistent in terms of efficacy in the training set and validation set. Kaplan–Meier (K–M) curves showed that all three models were able to distinguish well between high- and low-risk groups (p < 0.01). The NRI and IDI showed that the clinical utility of model 2 was slightly better than that of model 1 (p > 0.05), and model 3 was significantly better than that of model 2 (p < 0.05).ConclusionsClinical prediction models incorporating LN-TRG factors have high predictive efficacy, can help identify patients at high risk of recurrence after neoadjuvant therapy, and can be used as a supplement to the AJCC/TNM staging system while offering a scientific rationale for early postoperative intervention.

Portomesenteric venous contact ≤180° and overall survival in resectable head and body pancreatic adenocarcinoma treated with upfront surgery

IntroductionUpfront surgery is the standard of care for resectable pancreatic cancer, defined as the absence of or ≤180° tumour contact with the portal/superior mesenteric vein. We hypothesized that portomesenteric venous tumour contact is prognostically unfavourable and aimed to assess whether it is associated with poorer survival compared with no venous contact in resectable head and body pancreatic cancer. MethodsThis single-centre retrospective study included patients undergoing upfront surgery for resectable head and body pancreatic cancer in 2010–2020 at Umeå University Hospital, Sweden. No venous contact was compared with portomesenteric venous contact of ≤180° based on preoperative imaging. Overall survival on an intention-to-treat basis was compared with Kaplan-Meier curves, a log-rank test and Cox proportional hazards models. ResultsThe final study cohort included 39 patients with portomesenteric venous tumour contact and 144 patients without venous tumour contact. Patients with venous tumour contact had a median overall survival of 15.3 months compared to 23.0 months (log rank P = 0.059). Portomesenteric venous tumour contact was an independent negative prognostic factor for survival in the multivariable Cox model (HR 1.68; 95% CI 1.11–2.55, P = 0.014) and was associated with higher rates of microscopically non-radical resections (R1) (50% vs 26.1%, P = 0.012) and pathological lymph node metastasis (76.7% vs 56.8%, P = 0.012). There was no difference in adjuvant chemotherapy receipt or postoperative complications between the groups. ConclusionsPortomesenteric venous tumour contact is associated with poorer overall survival and higher rates of R1 resections and lymph node metastasis in patients with resectable head and body pancreatic cancer treated with upfront surgery.

Impact of 18F-FDG PET on TNM Staging and Prognosis in Thymic Epithelial Tumors.

Preoperative fluorine-18-fluorodeoxyglucose positron emission tomography (18F-FDG PET) of thymic epithelial tumors (TETs) is well known for identifying malignant-grade TETs; however, its predictive power for determining locally advanced tumors, lymph node (LN) metastasis, and prognosis remains unknown. We retrospectively evaluated patients with resectable TETs who were preoperatively assessed using 18F-FDG PET from January 2012 to January 2023. The receiver operating characteristic curve was used to evaluate the cutoff value of the maximum standardized uptake value (SUVmax) to predict advanced-stage disease. Recurrence/progression-free survival (RFS/PFS) was analyzed using the Kaplan-Meier method. The staging was classified according to the tumor-node-metastasis system. Our study included 177 patients; 145 (81.9%) had pathological early-stage TET (stage I or II), and 32 (19.1%) had advanced stage (stage III or IV). The area under the curve value for predicting the advanced stage was 0.903, and the cutoff value was 5.6 (sensitivity 81.3%, specificity 84.8%). SUVmax > 5.6 was associated with worse prognosis for RFS/PFS. LN metastasis was preoperatively detected by FDG uptake in 30.8% of patients with pathological LN positivity, whereas LN metastasis was not pathologically detected in patients with SUVmax < 5.9. In patients with advanced-stage TETs, LN recurrence was more frequent in patients who were preoperatively detected by 18F-FDG PET than those who were not (75.0% versus 7.1%). 18F-FDG PET is a potentially valuable tool for predicting advanced stage and poor prognosis of recurrence in patients with TETs. SUVmax can help thoracic surgeons to guide them in selecting appropriate therapeutic strategies for TETs.

Prognostic Significance of the Proposed Residual Tumor Classification in Patients With NSCLC After Sleeve Lobectomy

IntroductionTo validate the residual tumor (R) classification proposed by the International Association for the Study of Lung Cancer (IASLC) in NSCLC after sleeve lobectomy. MethodsA total of 682 patients were analyzed. The R status, on the basis of the Union for International Cancer Control (UICC) criteria, was recategorized according to the IASLC descriptors. Recurrence-free survival (RFS) and overall survival (OS) among different R classifications were assessed for the entire cohort and pathologic node (pN) subgroups. ResultsAll in all, 631 (92.5%), 48 (7.1%), and three patients (0.4%) were classified as R0, R1, and R2, respectively, by the UICC criteria, whereas 489 (71.7%), 110 (16.1%), and 83 patients (12.2%), received R0, uncertain resection (R[un]), and R1/2 resection, respectively, according to the IASLC criteria. There were 96 patients (15.2%) with UICC R0 who were reclassified as R(un), mainly because of the positive highest mediastinal node station (82 of 96, 85.4%). A total of 46 patients (7.3%) were reassigned from UICC R0 to IASLC R1/2 owing to extracapsular extension. For the entire cohort, patients with R(un) and R1/2 exhibited worse RFS (R[un], adjusted p = 0.023; R1/2, adjusted p = 0.001) and OS (R[un], adjusted p = 0.040; R1/2, adjusted p = 0.051) compared with R0. No significant differences were observed between R(un) and R1/2 (RFS, adjusted p = 0.586; OS, adjusted p = 0.781). Furthermore, subgroup analysis revealed a distinct prognostic impact of the IASLC R status—with prognostic significances in the pN1 and pN2 subgroups, but not in the pN0 subgroup. ConclusionsThe IASLC R descriptors helped to stratify the prognosis of NSCLC after sleeve lobectomy, with its prognostic impact varied among pN stages.

Clinical Significance of Radical Prostatectomy in Clinical Lymph Node Metastasis in Prostate Cancer.

This study aimed to investigate the role of radical prostatectomy (RP) among clinical nodal metastasis prostate cancer and whether histological confirmation of lymph node metastasis through surgery can help with treatment. After excluding patients with distant metastatic prostate cancer or neoadjuvant androgen deprivation therapy, 42 patients with clinical nodal metastasis who underwent RP at our institution were included in the study. We classified them as having or not having pathological lymph node metastasis. Clinicopathologic data were analyzed in this retrospective chart review. Kaplan-Meier analysis was used to calculate the estimated castration-resistant prostate cancer (CRPC)-free survival, biochemical recurrence (BCR)-free survival, and cancer-specific survival (CSS). There is no significant difference in age, presence of diabetes mellitus, hypertension, BCR time, CRPC time, overall survival, salvage RT rate, and initial prostate-specific antigen level between the two groups. However, there is a significant difference in the pathology N1 group in terms of pathological T stage, pathologic Gleason score, BCR rate, CRPC rate, and CSS. A multivariate Cox proportional hazard regression analysis was used to identify predictors of CRPC-free survival. Patients with pathological lymph node metastasis had a shorter CRPC-free survival [hazard ratio (HR) 4.87; 95% confidence interval (CI) 1.25-19.00, p = 0.02]. Radical prostatectomy can confirm lymph node metastasis. Although pathologic diagnosis has no effect on time to BCR and CPRC, because it affects BCR rate, CRPC rate, and CSS, an accurate pathological diagnosis obtained through surgery is beneficial in the treatment of clinical lymph node metastasis prostate cancer.

Pathologic Nodal Staging Before SBRT for Early-stage NSCLC Does Not Impact Overall Survival: A Propensity Score-matched NCDB Analysis.

Stereotactic body radiation therapy (SBRT) for early-stage non-small cell carcinoma of the lung (NSCLC) is increasingly utilized. We sought to assess overall survival (OS) for early-stage NSCLC patients receiving SBRT depending on staging method. Early-stage NSCLC patients treated with definitive SBRT were identified in the National Cancer Database (NCDB), and OS was determined based on method of staging. Patient, disease, and treatment characteristics were also analyzed. A total of 12,106 patients were included; 865 (7%) received invasive staging (nodal sampling, NS) and 11,241 (93%) had no nodal sampling (NNS). From this larger dataset, a propensity score matching (1:1 without replacement) was performed, which yielded 839 patients for each group (NNS and NS). With a median follow-up time of 3.12 years, median survival for all patients included in the matched dataset was 2.75 years (95% CI: 2.55-2.93y), with 2- and 5-year OS estimated at 63.9% and 25.7%, respectively. In a multivariable analysis on matched data, there was no difference in mortality risk between the NNS and NS groups (hazard ratio=1.08, 95% CI: 0.94-1.24, P =0.25). Negative prognostic factors identified in the multivariable analysis of the matched data included: age more than 65, male sex, Charlson-Deyo Score ≥1, and tumor size ≥3cm. SBRT use in early-stage NSCLC steadily increased over the study period. Most patients proceeded to SBRT without nodal staging, conflicting with National Comprehensive Cancer Network (NCCN) guidelines which recommend pathologic mediastinal lymph node evaluation for all early-stage NSCLC cases, except stage IA. Our findings suggest similar OS in patients with early-stage NSCLC treated with SBRT irrespective of nodal staging. Furthermore, we highlight patient-related, disease-related, and treatment-related prognostic factors to consider when planning therapy for these patients.

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.

Two Interventions on Pathologic Nodal Staging in a Population-Based Lung Cancer Resection Cohort

BackgroundDespite its prognostic importance, poor pathologic nodal staging of lung cancer prevails. We evaluated the impact of 2 interventions to improve pathologic nodal staging. MethodsWe implemented a lymph node specimen collection kit to improve intraoperative lymph node collection (surgical intervention) and a novel gross dissection method for intrapulmonary node retrieval (pathology intervention) in nonrandomized stepped-wedge fashion, involving 12 hospitals and 7 pathology groups. We used standard statistical methods to compare surgical quality and survival of patients who had neither intervention (group 1), pathology intervention only (group 2), surgical intervention only (group 3), and both interventions (group 4). ResultsOf 4019 patients from 2009 to 2021, 50%, 5%, 21%, and 24%, respectively, were in groups 1 to 4. Rates of nonexamination of lymph nodes were 11%, 9%, 0%, and 0% and rates of nonexamination of mediastinal lymph nodes were 29%, 35%, 2%, and 2%, respectively, in groups 1 to 4 (P < .0001). Rates of attainment of American College of Surgeons Operative Standard 5.8 were 22%, 29%, 72%, and 85%; and rates of International Association for the Study of Lung Cancer complete resection were 14%, 21%, 53%, and 61% (P < .0001).Compared with group 1, adjusted hazard ratios for death were as follows: group 2, 0.93 (95% CI, 0.76-1.15); group 3, 0.91 (0.78-1.03); and group 4, 0.75 (0.64-0.87). Compared with group 2, group 4 adjusted hazard ratio was 0.72 (0.57-0.91); compared with group 3, it was 0.83 (0.69-0.99). These relationships remained after exclusion of wedge resections. ConclusionsCombining a lymph node collection kit with a novel gross dissection method significantly improved pathologic nodal evaluation and survival.

New clinical application of indocyanine green in fluorescence-guided laparoscopic lymph-node biopsy in case of lymphoma. Preliminary results on a case series

BackgroundIndocyanine Green (ICG) fluorescence-guided surgery is widely used for intraoperative visualization of lymphatic structures. To date, there are no reports indicating this dye being used in lymph node biopsies for suspected or relapsed lymphoma.MethodsBetween October 2021 and June 2022, 12 patients underwent a fluorescence-guided laparoscopic lymph node biopsy (FGLLB) using ICG. The following was retrospectively evaluated: the dosage of ICG, the injection site, the number of patients where fluorescence was obtained after ICG administration, and additionally, the parameters indicating the outcome of the surgical procedure.ResultsThe median duration of the surgery was 90 min. A laparotomy conversion was required in one case due to bleeding. Fluorescence was obtained in 10/12 (83.3%) patients by means of subcutaneous/perilesional injection in six of the patients, and intravenously in the other four. Hospitalization had a mean duration of three days. There were no major postoperative complications. FGLLB was used in seven patients to follow lymphoproliferative disease progression, and in five patients to establish a diagnosis. In all cases, FGLLB provided the information necessary for the correct diagnosis.ConclusionsFluorescence with ICG offers a simple and safe method for detecting pathological lymph nodes. FGLLB in suspected intra-abdominal lymphoma can largely benefit from this new opportunity which has not yet been tested to date. Further studies with large case series are needed to confirm its efficacy.

Estimating Treatment Effect of Adjuvant Chemotherapy in Elderly Patients With Stage III Colon Cancer Using Bayesian Networks.

While adjuvant therapy with capecitabine and oxaliplatin (CAPOX) has been proven to be effective in stage III colon cancer, capecitabine monotherapy (CapMono) might be equally effective in elderly patients. Unfortunately, the elderly are under-represented in clinical trials and patients included may not be representative of the routine care population. Observational data might alleviate this problem but is sensitive to biases such as confounding by indication. Here, we build causal models using Bayesian Networks (BNs), identify confounders, and estimate the effect of adjuvant chemotherapy using survival analyses. Patients 70 years and older were selected from the Netherlands Cancer Registry (N = 982). We developed several BNs using constraint-based, score-based, and hybrid algorithms while precluding noncausal relations. In addition, we created models using a limited set of recurrence and survival nodes. Potential confounders were identified through the resulting graphs. Several Cox models were fitted correcting for confounders and for propensity scores. When comparing adjuvant treatment with surgery only, pathological lymph node classification, physical status, and age were identified as potential confounders. Adjuvant treatment was significantly associated with survival in all Cox models, with hazard ratios between 0.39 and 0.45; CIs overlapped. BNs investigating CAPOX versus CapMono did not find any association between the treatment choice and survival and thus no confounders. Analyses using Cox models did not identify significant association either. We were able to successfully leverage BN structure learning algorithms in conjunction with clinical knowledge to create causal models. While confounders differed depending on the algorithm and included nodes, results were not contradictory. We found a strong effect of adjuvant therapy on survival in our cohort. Additional oxaliplatin did not have a marked effect and should be avoided in elderly patients.

Contemporary outcomes of patients undergoing robotic-assisted radical cystectomy: A comparative analysis between intracorporeal ileal conduit and neobladder urinary diversions

ObjectiveWe aimed to compare perioperative and oncologic outcomes for patients undergoing robotic-assisted radical cystectomy (RARC) with intracorporeal ileal conduit (IC) and neobladder (NB) urinary diversion. MethodsPatients undergoing RARC with intracorporeal urinary diversion between January 2017 and January 2022 at the Icahn School of Medicine at Mount Sinai, New York, NY, USA were indexed. Baseline demographics, clinical characteristics, perioperative, and oncologic outcomes were analyzed. Survival was estimated with Kaplan-Meier plots. ResultsOf 261 patients (206 [78.9%] male), 190 (72.8%) received IC while 71 (27.2%) received NB diversion. Median age was greater in the IC group (71 [interquartile range, IQR 65–78] years vs. 64 [IQR 59–67] years, p<0.001) and BMI was 26.6 (IQR 23.2–30.4) kg/m2. IC group was more likely to have prior abdominal or pelvic radiation (15.8% vs. 2.8%, p=0.014). American Association of Anesthesiologists scores were comparable between groups. The IC group had a higher proportion of patients with pathological tumor stage 2 (pT2) tumors (34 [17.9%] vs. 10 [14.1%], p=0.008) and pathological node stages pN2–N3 (28 [14.7%] vs. 3 [4.2%], p<0.001). The IC group had less median operative time (272 [IQR 246–306] min vs. 341 [IQR 303–378] min, p<0.001) and estimated blood loss (250 [150–500] mL vs. 325 [200–575] mL, p=0.002). Thirty- and 90-day complication rates were 44.4% and 50.2%, respectively, and comparable between groups. Clavien-Dindo grades 3–5 complications occurred in 27 (10.3%) and 34 (13.0%) patients within 30 and 90 days, respectively, with comparable rates between groups. Median follow-up was 324 (IQR 167–552) days, and comparable between groups. Kaplan-Meier estimate for overall survival at 24 months was 89% for the IC cohort and 93% for the NB cohort (hazard ratio 1.23, 95% confidence interval 1.05–2.42, p=0.02). Kaplan-Meier estimate for recurrence-free survival at 24 months was 74% for IC and 87% for NB (hazard ratio 1.81, 95% confidence interval 0.82–4.04, p=0.10). ConclusionPatients undergoing intracorporeal IC urinary diversion had higher postoperative cancer stage, increased nodal involvement, similar complications outcomes, decreased overall survival, and similar recurrence-free survival compared to patients undergoing RARC with intracorporeal NB urinary diversion.

A rare tumor cause of ileus: primary intestinal lymphoma

Primary intestinal lymphomas (PBL) are rare tumors and extranodal lymphomas. They constitute 1% of malignant tumors of the gastrointestinal (GI) system. Colorectal lymphomas constitute 10-20% of all GI lymphomas and are most commonly located in the cecum. For a case to have PBL, in addition to the dominant GI symptoms, the clinical and radiological absence of pathological lymph nodes located outside the intestine, mediastinum, abdomen, or peripheral is required. In addition, there should be no findings in favor of lymphoma in the liver, spleen, and bone marrow. In this report, a 59-year-old female patient who was admitted to the emergency department with a clinical diagnosis of obstructive ileus while being investigated for abdominal pain lasting for 1 month, was operated on because of the development of an acute abdomen and an obstructive mass as a result of imaging, and was reported as having diffuse large cell lymphoma as a result of postoperative pathology, lastly as a result of the examinations performed, primary intestinal lymphoma was detected, and the diagnosis of the disease is presented. Since the first presentation of PBL may be intestinal obstruction and/or perforation due to delayed diagnosis, PBL should be kept in mind in patients presenting with obstructive ileus in emergency admissions.

147. CHARACTERISTICS AND PREDICTORS OF EARLY POSTOPERATIVE RECURRENCE OF ESOPHAGEAL CANCER

Abstract Background Recurrence after radical esophageal cancer surgery is known to occur in 30–50% of cases, mostly within 2 years after surgery. This study aimed to clarify the characteristics of patients with early recurrence within 6 months after esophageal cancer surgery and the risk factors for early recurrence. Methods A total of 350 patients who underwent esophagectomy between January 2011 and August 2021 were included in this study. Patient background factors were compared among three groups: the early recurrence group with recurrence within 6 months after surgery, the late recurrence group with recurrence after 6 months after surgery, and the recurrence-free group. Multivariate logistic regression was used to analyze the association between various predictors and early postoperative recurrence. Results Postoperative recurrence occurred in 141 patients (40.1%). Recurrence within 6 months after surgery occurred in 65 patients, and recurrence after 6 months in 76 patients. The proportion of advanced clinical stage increased in patients with early postoperative recurrence. Significant differences between the three groups were found for CRP, SCC, Neutrophil, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio. Prognostic nutrition index、advanced lung cancer inflammation (BMI × Alb/NLR) were significantly less in patients with early postoperative recurrence. Multivariate analysis showed that clinical stage, pathological lymph node metastasis, and NLR were independent prognostic factors for early postoperative recurrence. Conclusions Preoperative NLR may be a valuable early postoperative recurrence factor for patients with esophageal cancer undergoing esophagectomy.

Postoperative Radiation Therapy Is Indicated for “Low-Risk” Pathologic Stage I Merkel Cell Carcinoma of the Head and Neck Region but Not for Other Locations

The role of postoperative radiation therapy (PORT) in early stage Merkel cell carcinoma (MCC) is controversial. We analyzed the roleof PORT in preventinglocal recurrences (LR)among patients withlow-risk,pathologicstage IMCCbased on the location of the primary tumors: head/neck (HN) versus non-HN sites. One hundred forty-seven patients with MCC were identified that had "low risk" disease (pathologic T1primary tumor, negative microscopic margins, negative pathologic node status,no immunosuppressionorprior systemic therapy).LR was defined as tumor recurrence within 2 cm of the primary surgical bed, andits frequency wasestimated with thecumulative incidencemethod. Seventy-ninepatients receivedPORT (30HN,49non-HN) with a median dose of 50 Gy (range, 8-64 Gy) and68patients were treated with surgery alone (30HN,38non-HN). Overall, PORT was associated with a decreased risk of LR (5-year rate: 0% vs 9.5%; P=.004) with6LRs observed in the surgery alone group. Although the addition of PORT significantly reduced LR rates among patients with HN MCC (0% vs. 21%; P=.034), no LRs were observed in patients with non-HN MCC managed with surgery alone. There was no significant difference inMCC-specific survival comparing HN versus non-HN groups, with or without PORT. Forlow-risk,pathologic stage IMCCoftheextremitiesand trunk, excellent local control rates were achieved with surgery, and PORT is not indicated. However, PORT was associated with a significant reduction in LRs among low-risk MCC of the HN.

Prevalence and Prognostic Significance of PIK3CA Mutation and CNV Status and Phosphorylated AKT Expression in Patients With Cervical Cancer Treated With Primary Surgery.

Currently, there are limited and conflicting reports on the prognostic utility of PIK3CA and associated pathway markers for cervical cancers treated with primary surgical management. Moreover, current studies are lacking complete characterization of adjuvant treatment with RT and/or chemotherapy. We aimed to document the prevalence, clinicopathologic, adjuvant treatment details, and prognostic value of PI3K/AKT pathway mutations and copy number variation and phosphorylated AKT status in patients with cervical cancers treated with primary surgery. A clinicopathologic review was performed on a retrospective cohort of 185 patients with cervical cancer, treated with primary surgery at a single tertiary institution. Next-generation sequencing and digital PCR was used to determine PI3K/AKT pathway mutational status and PIK3CA copy number variation, respectively, and fluorescent immunohistochemistry measured phosphorylated AKT expression. In all, 179 of 185 (96.8%) of tumors were successfully sequenced; 48 (26.8%) were positive for PI3K/AKT pathway mutations-the majority (n=37, 77.1%) PIK3CA mutations. PIK3CA mutation was associated with pathologically positive lymph nodes [12 (32%) vs. 22 (16%); P =0.022] and indication for postoperative chemoradiotherapy [17 (45.9%) vs. 32 (22.5%); P =0.004]. On multivariable analysis, PIK3CA status was not associated with overall survival ( P =0.103) or progression-free survival ( P =0.240) at 5yrs, nor was PIK3CA copy number variation status. phosphorylated AKT ≤ median significantly predicted for progression-free survival [multivariable hazard ratio 0.39 (0.17-0.89; P =0.025)] but not overall survival ( P =0.087). The correlation of PIK3CA with pathologic positive lymph node status yet lack of association with survival outcomes may be due to the use of adjuvant postoperative therapy. PIK3CA assessment before radical hysterectomy may help identify patients with a higher risk of node-positive disease.

Deep learning analysis of mid-infrared microscopic imaging data for the diagnosis and classification of human lymphomas.

The present study presents an alternative analytical workflow that combines mid-infrared (MIR) microscopic imaging and deep learning to diagnose human lymphoma and differentiate between small and large cell lymphoma. We could show that using a deep learning approach to analyze MIR hyperspectral data obtained from benign and malignant lymph node pathology results in high accuracy for correct classification, learning the distinct region of 3900 cm-1 to 850 cm-1 . The accuracy is above 95% for every pair of malignant lymphoid tissue and still above 90% for the distinction between benign and malignant lymphoid tissue for binary classification. These results demonstrate that a preliminary diagnosis and subtyping of human lymphoma could be streamlined by applying a deep learning approach to analyze MIR spectroscopic data. This article is protected by copyright. All rights reserved.

The Ongoing Necessity of Sentinel Lymph Node Biopsy for cT1–2N0 Breast Cancer Patients

Background: Recent clinical trials attempt to determine whether it is appropriate to omit axillary lymph node surgery in patients with cT1–2N0 breast cancer. The study aimed to investigate the true extent of axillary node disease in patients with clinically negative nodes and explore the differences between negative axillary ultrasound (AUS-cN0) and suspicious axillary ultrasound with negative fine-needle aspiration (FNA-cN0). Methods: Pathologically identified T1–2 invasive breast cancer patients with clinically negative nodes were retrospectively analyzed at our center between January 2019 and December 2022. Patients who received any systematic treatment before surgery were excluded from this study. Results: A total of 538 patients were enrolled in this study. 134 (24.9%) patients had pathologically positive nodes, and 404 (75.1%) patients had negative nodes. Univariate analysis revealed that tumor size, T stage, Ki67 level, and vascular invasion (VI) were strongly associated with pathological axillary lymph node positivity. In multivariate analysis, VI was the only independent risk factor for node positivity in patients with cT1–2N0 disease (OR: 3.723, confidence interval [CI]: 2.380–5.824, p < 0.001). Otherwise, pathological node positivity was not significantly different between AUS-cN0 and FNA-cN0 groups (23.4% vs. 28.8%, p = 0.193). However, the rate of high nodal burden (≥3 positive nodes) was significantly higher in FNA-cN0 group. Further investigation revealed that FNA-cN0 and VI were independently associated with a high nodal burden (OR: 2.650, CI: 1.081–6.496, p = 0.033; OR: 3.521, CI: 1.249–9.931, p = 0.017, respectively). Conclusions: cT1–2 breast cancer patients with clinically negative axillary lymph nodes may have pathologically positive lymph nodes and even a high nodal burden. False negatives in AUS and AUS-guided FNA should not be ignored, and sentinel lymph node biopsy remains an ongoing necessity for cT1–2N0 breast cancer patients.

Lymph node ratio is a prognostic indicator for locally advanced esophageal squamous cell carcinoma after neoadjuvant immunochemotherapy.

The lymph node ratio (LNR) is regarded as a prognostic indicator in esophageal cancer (EC), but its applicability to neoadjuvant immunochemotherapy (NICT) in esophageal squamous cell carcinoma (ESCC) remains unexplored. This retrospective study, conducted between 2019 and 2021, analyzed ESCC patients who underwent radical esophagectomy following NICT. Patients were divided into two groups based on their LNR values according to the X-tile software: Low-LNR group (LNR 0-10%) and High-LNR group (LNR 10-100%). The association between LNR and clinical outcomes in ESCC after NICT were analyzed. A total of 212 ESCC patients who underwent surgery after NICT were included in this study, among which, 169 (79.7%) and 43 (20.3%) cases were allocated to the Low- and High-LNR groups, respectively. Pathologic complete response (PCR) was observed in 28.3% (60/212) of the overall cohort. Patients in the Low-LNR group demonstrated a significantly improved 3-year overall survival (OS) (81.7% vs 55.3%; P < 0.001) and disease-free survival (DFS) (79.9% vs 37.4%; P < 0.001). These findings were consistent among those with non-PCR (3-year DFS was 73.7% vs 37.4%; P < 0.001, and the 3-year OS was 78.9% vs 55.3%; P < 0.001, respectively). High LNR was associated with a 4.013-fold increased risk of relapse and a 7.026-fold elevated risk of death. Compared to the post-neoadjuvant therapy pathologic lymph nodes staging (ypN), LNR exhibited similar prognostic capabilities for DFS and OS. To the best of our knowledge, this study is the first to investigate the prognostic value of LNR in ESCC after NICT, suggesting that LNR may serve as a viable alternative to the ypN stage for prognostication in ESCC patients treated with NICT.