Pathologic N2 Disease Research Articles

Oncologic Outcomes After Treatment for MRI Occult Breast Cancer (pT0N+)

Studies assessing outcomes in occult breast cancer have often included women treated before the routine use of magnetic resonance imaging (MRI). This study examined outcomes for patients presenting with axillary adenopathy and no primary breast tumor detectable by MRI or other imaging methods. All patients with axillary nodal metastases consistent with breast carcinoma and no breast primary tumor detectable by physical exam, mammography, or MRI treated between 1 January 1996 and 30 June 2011 were identified from an institutional database. Data were collected on local, regional, and distant recurrences. For the study, 38 patients were identified. Modified radical mastectomy (MRM) was performed for 13 of the patients, whereas 25 of the patients underwent axillary dissection (ALND) and whole-breast radiotherapy (WBRT). Most of the women had pathologic N1 disease [median number of positive nodes, 2 (MRM cohort) and 3 (ALND+WBRT cohort); p=0.38]. All the patients received chemotherapy, and 30 (79%) of the 38 patients received an anthracycline and taxane. Regional nodal radiation was used for 60% of those with ALND+WBRT and for all 46% of the MRM patients who received chest wall radiotherapy. During a median follow-up period of 7years, there were no nodal recurrences. Two patients treated with ALND+WBRT had in-breast recurrences, whereas none in the MRM group experienced a local recurrence. The proportion that experienced distant disease was similar between the MRM cohort (1 of 13) and the ALND+WBRT cohort (2 of 25). Breast cancer presenting as axillary adenopathy with no detectable primary tumor is rare. Breast conservation with WBRT is a viable option for patients with a diagnosis of occult breast cancer and a negative preoperative MRI.

What is the clinical value of a margin negative resection in lymph node positive gallbladder cancer?

Objective: Achieving free surgical margins in gallbladder cancer (GBAC) often requires an operation more morbid than cholecystectomy. There is little data examining the value of a margin negative resection in patients with lymph node positive GBAC and thus high risk for distant disease recurrence. Methods: We queried the National Cancer Database to identify patients undergoing resection for lymph node positive GBAC between 2004 and 2012. Patients receiving neoadjuvant chemoradiotherapy and those with gross residual (R2) disease were excluded. Multivariable and Cox Models adjusted for age, facility type, Charlson index, margin status, tumor grade, pathologic stage, number of nodes examined, procedure type and adjuvant chemoradiotherapy. Results: 826 (78.1%) patients had free microscopic margins on final pathology (R0); 231 (21.9%) had microscopic positive margins (R1). Multivariable regression identified limited (≤2 nodes) lymphadenectomy (OR 2.014, 95% CI [1.366, 2.971]), pathologic N2 (OR 3.100, 95% CI [1.339, 7.178]) and T3 disease (OR 4.670, 95% CI [1.479,14.751]) as independently associated with R1 resection. Cox modeling identified R0 resection (HR 0.639, 95% CI [0.531, 0.769]) and receipt of adjuvant chemoradiotherapy (HR 0.498, 95% CI [0.416, 0.597]) as independently associated with improved overall survival and advanced age (HR 1.432, 95% CI [1.119, 1.834]), T3 disease (HR 1.895, 95% CI [1.176, 3.053]), and Charlson score>2 (HR 1.450, 95% CI [1.092, 1.925]) with poor survival. Patients undergoing R0 resection had median survival of 20.6 months compared to 9.99 months for those undergoing R1 resection (p < 0.0001). Conclusion: For patients with node positive GBAC, operations that carry greater risk of morbidity but achieve negative surgical margins are justifiable.

SC01.01 The Importance of Mediastinal Down-Staging During Induction Therapy of N2 Disease

SC01.01 The Importance of Mediastinal Down-Staging During Induction Therapy of N2 Disease

P2.02-033 The Role of Surgery for Treating Occult N2 Non-Small Cell Lung Cancer

The presence of mediastinal nodal metastasis is one of the most important factors in the treatment of non-small cell lung cancer (NSCLC). The role of surgical intervention for treating N2 disease is controversial, and two randomized trials failed to show an overall survival benefit. Consequently, the purpose here is to elucidate the needs for surgical intervention of resectable N2 NSCLC. Between April 2010 and May 2016, 316 patients with NSCLC underwent pulmonary resection and mediastinal lymph node dissection. Patients with pathologic N2 were 26. Clinical outcomes and risk factors for pathologic N2 disease were retrospectively analyzed for this cohort. Surgical treatment was performed of 26 pathologic N2 disease patients; there were 18 men and 8 women with a mean age of 68.3 years old (range 55-84). Occult pathologic N2 disease was identified in 22 patients (84.6%). The most common type of resection was lobectomy (96.1%). Adjuvant chemotherapy was administered in 21 patients (80.8%). N2 involvement was single-station in 4 (15.4%) and multiple-station in 22 (84.6%). All patients recovered and were discharged home. There was no operative mortality, and no hospital deaths. The 5-year overall and disease-free survival rates were 58.6% and 33.4%, respectively. The 5-year survival rates of single-station and multiple-station N2 were 50% and 73.2%, respectively (p =0.92). Patients with clinical (expected) N2 disease exhibited better survival outcomes compared with those with occult N2 disease (100% vs 59.8%). The group receiving adjuvant chemotherapy had significantly higher the 5-year survival rates. The 5-year survival rate in patients who received 4 or more cycles of adjuvant chemotherapy was 78.1%, as compared with 0% in non-treated patients (p =0.0008). The 5-year overall and disease-free survival rates of N2 disease tend to improve in recent years. The reasons for improved survival are the increasingly successful treatment options for recurrent disease, including chemotherapy, radiotherapy, and/or molecular targeting drugs. It is common knowledge that therapy of N2 disease needs not only surgery but also chemotherapy. The multiple courses of adjuvant chemotherapy may further improve the outcome in N2 disease. However, patients treated with surgery and chemotherapy had significantly better the 5-year survival rates than patients treated with chemotherapy alone. Though surgery might be very important in that way, the role of surgery for treating N2 disease remains an open question. Because we acknowledge that as a single-institution and retrospective analysis, our sample size was limited. We consider that large-scale, multicenter clinical trials are needed.

P1.03-073 Predictors for Pathological N1 and N2 Disease in Clinical N1 Non-Small-Cell Lung Cancer

Patients with clinical N1 (cN1) non-small-cell lung cancer (NSCLC) is usually considered to be candidates for curative resection. However, they sometimes have unexpected mediastinal nodal involvement (pN2). To avoid futile pulmonary resection, accurate preoperative evaluation of nodal status would be necessary. The purpose of this study was to identify predictors for lymph node metastasis in cN1 NSCLC patients. We retrospectively reviewed data on the clinicopathological and radiological features of 170 patients with cN1 NSCLC who had undergone complete resection at Nagoya University Hospital between 2004 and 2015. Hilar and/or intrapulmonary lymph nodes with ≥ 1.0 cm in the short axis on computed tomography or with high accumulation of [18F] Fluorodeoxyglucose (FDG) in positron emission tomography compared with that of the adjacent mediastinal tissue were considered as cN1 in our institution. The association between clinicoradiological variables and nodal status was analyzed to identify predictors for lymph node metastasis. The cohort consisted of 125 males and 45 females, ranging in age 39 to 84 years. There were 62 (36%) adenocarcinomas, 82 (48%) squamous-cell carcinomas, 10 (6%) large-cell carcinomas, and 16 (10%) other types of cancers. The breakdown by pathological N category was 61 (36%) pN0, 72 (42%) pN1, and 37 (22%) pN2 patients. Among pN2 patients, only three showed negative N1 lymph nodes (skip pN2 metastasis). Female gender, adenocarcinoma histology, middle or lower lobe origin and positive N1 lymph node (pN1) were significantly associated with pN2 by univariate analysis. Logistic regression analysis showed that the female and pN1 were significant predictor for pN2 with the odds ratio of 3.0 and 13.1, respectively (P = 0.02 and 0.0001, respectively). In addition, using the 63 patients extracted from our cohort of this study, we sought the predictor of pN1. The maximum size of the lymph node and standardized uptake value of the FDG were significant factor for pN1 with the cut-off value of 1.3 cm and 4.28, respectively. Female gender and pN1 was significantly associated with pN2 in cN1 NSCLC patients of our cohort. The large size and a high accumulation of FDG of hilar or intrapulmonary lymph node might predict the pN1.

Lymph node ratio as a prognostic factor in patients with pathological N2 non-small cell lung cancer.

BackgroundThe aim of this study was to investigate whether the lymph node ratio (LNR) was associated with the prognosis of patients, who underwent surgery for pathological N2 non-small cell lung cancer (NSCLC).MethodsA total of 182 patients were diagnosed with pathological N2 disease and underwent complete resection surgeries with systematic lymphadenectomies. We counted the number of positives and removed lymph nodes to calculate a ratio between them (LNR). We also investigated the association between skip mediastinal lymph node metastasis and survival.ResultsUnivariate analysis of survival in patients with N2 NSCLC showed that the T factor, clinical N factor, and LNR were significant prognostic factors. Multivariate analyses showed that the clinical N stage and LNR were significant independent prognostic factors for patients with pathological N2 NSCLC. Patients with a clinical lymph node status of 0 (cN0) and LNR ≤0.22 showed a significantly higher survival rate than patients with a cN1-2 and LNR ≥0.22 and 5-year survival rates were 47.1 and 10.3%, respectively (p < 0.0001).ConclusionsLNR is an important prognostic factor for poor outcome following surgery in patients with N2 disease. The combination of the LNR and cN status provides a valuable prognostic tool.

Regional Nodal Irradiation in Breast Cancer Patients With Clinical N1 and Pathologic N0 Disease After Neoadjuvant Chemotherapy: An Analysis of the National Cancer Data Base

Regional Nodal Irradiation in Breast Cancer Patients With Clinical N1 and Pathologic N0 Disease After Neoadjuvant Chemotherapy: An Analysis of the National Cancer Data Base

Risk of Pathological Upgrading and Up Staging among Men with Low Risk Prostate Cancer Varies by Race: Results from the National Cancer Database

The impact of African-American race on oncologic outcomes for low risk prostate cancer is unclear due to conflicting data. We investigated the effect of African-American race on pathological upgrading and/or up staging at prostatectomy in men with clinically low risk prostate cancer. We queried the National Cancer Database for men with low risk prostate cancer (clinical stage T2a or less, Gleason score 6 or less, prostate specific antigen less than 10 ng/ml) treated with radical prostatectomy between 2010 and 2013. The outcomes were pathological upgrading to Gleason score greater than 6 (primary) or Gleason score greater than 3+4=7 (secondary) and/or up staging (pathological T3-4 or N1 disease). The association between race and the end points was assessed using multivariable logistic regression. To further adjust for potential confounders, stratification by urban residence and comorbidity score, and subgroup analyses were performed. With adjustment for age, comorbidity, income, urban residence, T stage, prostate specific antigen and percentage of positive biopsy cores, African-American race conferred 1.2-fold higher odds of pathological upgrading to Gleason score greater than 6 and/or up staging (OR 1.2, 95% CI 1.1-1.3, p<0.01). African-American race also was an independent predictor of pathological upgrading to Gleason score greater than 3+4=7 and/or up staging (p=0.03). African-American men with low risk prostate cancer are more likely to harbor higher risk disease, which may lead to adverse outcomes. This finding alone does not preclude active surveillance. However, race should be considered as men weigh the risks and benefits of active surveillance vs treatment.

Surgical outcome of patients with lung cancer involving the left atrium.

Pulmonary and left atrial resection is not yet an established treatment for patients with primary lung cancer involving the left atrium. We investigated the clinical course of patients with primary lung cancer involving the left atrium who were treated with pulmonary resection and partial atrial resection. From January 1996 to December 2013, 51 patients underwent extended resection for lung cancer that invaded the surrounding organs. Of these, we focused on 12 patients who underwent surgical treatment for lung cancer involving the left atrium. The clinical course of each of these patients was investigated retrospectively. The most common histological subtype was squamous cell carcinoma. Pneumonectomy was performed in nine patients, and right middle and lower lobectomy was performed in three patients. Complete resection was performed in 11 patients (92%). Postoperative complications were observed in four patients (33%)-prolonged air leakage in two patients, broncho-pleural fistula in one patient, and empyema in one patient. There were no surgical deaths. This study involved seven patients with pathological N0-1 disease and five patients with pathological N2 disease. The postoperative 5-year survival rate was 46% in all patients. The 5-year survival rates in patients with pathological N0-1 disease and N2 disease were 67 and 20%, respectively. Because treatment-related death was not observed and outcome was fair in patients with N0-1 disease, surgical resection for primary lung cancer involving the left atrium may be acceptable in selected patients. Further investigations are required to improve the outcome of surgical treatment for patients with primary lung cancer involving the left atrium.

Rebuttal from Dr. Obiols and Dr. Call.

First of all, we would like to congratulate Dr. Decaluwe and Dr. Dooms for their rigorous revision on this topic. As they have commented in their manuscript, following the recommendations of the European Society of Thoracic Surgeons (ESTS) guidelines for preoperative mediastinal nodal staging, high negative predictive values (91–95%) and low rates of unsuspected pathologic (p) N2 disease (5.1–5.5%) are achieved (1,2). The majority of patients with unsuspected pN2 have single station involvement and better survival compared with the global cohort of pN2 (2).

Lobe-Specific Nodal Dissection for Clinical Stage I and II NSCLC: Japanese Multi-Institutional Retrospective Study Using a Propensity Score Analysis

ObjectivesThe purpose of this study was to assess the surgical outcomes according to the extent of mediastinal lymph node dissection for patients with NSCLC by using a nationwide registry database. MethodsFrom among 11,663 patients in a Japanese lung cancer registry study for 2004, 5392 patients with clinical stage (c-stage) I or II NSCLC that was completely resected by lobectomy and either systematic (SND) or lobe-specific nodal dissection (LSD) were enrolled. Patients who received preoperative therapy or had middle lobe tumor were excluded. In the LSD group, inferior mediastinal (subcarinal) nodes were not dissected for upper lobe tumors, and superior mediastinal nodes were not dissected for lower lobe tumors. To reduce the selection bias, an inverse probability of treatment weighting method using a propensity score was implemented. ResultsLSD and SND were performed in 1268 patients (23.5%) and 4124 patients (76.5%), respectively. The LSD group included more upper lobe and c-stage I tumors and less pathological N2 disease than the SND group. Extended pathological N2 disease outside LSD area was found in 3.2% of the SND group. The 5-year overall survival was 81.5% in the LSD group and 75.9% in the SND group. An inverse probability of treatment weighting–adjusted Cox model showed that LSD did not have a negative prognostic impact and instead was associated with favorable survival (hazard ratio = 0.68, 95% confidence interval: 0.60−0.77). ConclusionsThis retrospective registry study suggested that LSD is an alternative to SND for selected patients with c-stage I or II NSCLC. Future prospective studies are warranted to determine whether LSD is applicable and provides clinical benefit for the general population of patients with c-stage I or II NSCLC.

Variation in Pulmonary Resection Practices Between The Society of Thoracic Surgeons and the European Society of Thoracic Surgeons General Thoracic Surgery Databases

Clinical guidelines are created to reduce variation in care practices, with the goal of improving patient outcomes. There is currently no international consensus on best practices for pulmonary resection. Our aim was to evaluate variation in treatment patterns and outcomes for pulmonary resection by comparing The Society of Thoracic Surgeons (STS) and the European Society of Thoracic Surgery (ESTS) general thoracic surgery databases (GTSDs). An international collaboration was established between the STS and ESTS GTSD task forces. Patients who underwent pulmonary resection between 2010 and 2013 were identified from the 2 databases. Data on patient demographics, disease characteristics, treatment strategies, morbidity, and mortality were compared. There were 78,212 lung resections captured in the STS (n= 47,539) and ESTS databases (n= 30,673). Patients from the STS database were more likely to be of the female sex, have no pathologic N2 disease, have had previous cardiothoracic operations, and have received preoperative thoracic irradiation compared with patients from the ESTS database. In addition, patients from the STS database were more likely to have undergone a thoracoscopic operation and have received a sublobar resection. Although there was an increased risk of reintubation, atrial arrhythmias, and return to the operating room in the STS patients, the mean hospital length ofstay was shorter than in patients from the ESTS database, regardless of operation performed. Thirty-day mortality was higher in the STS patients for wedge resection (p < 0.001) but lower for lobectomy (p < 0.001) and pneumonectomy (p < 0.001) compared with the ESTS patients. Differences exists in patient population, procedures performed, and outcomes for pulmonary resections between the STS and ESTS databases, suggesting an opportunity for quality improvement initiatives.

Surgery following neoadjuvant chemotherapy for non-small-cell lung cancer patients with unexpected persistent pathological N2 disease.

Patients with mediastinal lymph node (LN) downstaging following neoadjuvant chemotherapy exhibit improved outcomes compared with patients with persistent N2 disease. The aim of this study was to compare clinicopathological characteristics and survival between patients with unexpected and expected persistent N2 disease following surgery for non-small-cell lung cancer (NSCLC). This retrospective analysis included 348 patients with NSCLC who underwent surgery following chemotherapy at the Shanghai Pulmonary Hospital, Tongji University School of Medicine, between 1995 and 2012. According to the results of the imaging examinations and postoperative pathology, the patients were divided into three groups, namely groups I (nodal downstaging, pN0-1), II (expected persistent N2 disease) and III (unexpected persistent N2 disease). The rates of overall survival (OS) and disease-free survival (DFS) were estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify the independent risk factors for OS and DFS. The mortality rate was 1.1% during the postoperative period. Perioperative complications occurred in 45 patients (12.9%). The 5-year OS rate was 32.2, 6.3 and 25.9% in groups I, II and III, respectively (group I vs. III, P=0.023; and group III vs. II, P<0.001). The 5-year DFS rate was 30.1, 5.1 and 22.4% in groups I, II and III, respectively (group I vs. III, P=0.012; and group III vs. II, P<0.001). Grouping, predicted forced expiratory volume in 1 sec, N downstaging and skip N2 metastasis were identified as independent predictive factors associated with OS, whereas the independent risk factors associated with DFS were grouping and N downstaging. Patients with unexpected persistent N2 disease exhibited better survival compared with those with expected persistent N2 disease. Surgery following chemotherapy remains the optimal approach for a proportion of patients with persistent N2 disease.

Diffusion-weighted imaging can correctly identify false-positive lymph nodes on positron emission tomography in non-small cell lung cancer

One of the limitations of fluorodeoxyglucose-positron emission tomography (PET) for N-staging in non-small cell lung cancer (NSCLC) is false-positive results due to lymphadenitis. This study was performed to examine whether DWI can correctly identify false-positive nodes on PET in NSCLC. Both PET and DWI were performed in 157 patients before surgery, which involved dissection of 1033 nodal stations. Of the 157 patients, 26 patients had pathological N1 or N2 disease. Each nodal station was classified as positive or negative on PET and DWI according to the cutoff value determined by the receiver operating characteristic curve. Short-axis diameters of lymph nodes were measured on computed tomography. While hilar nodes did not show significant differences in the number of false-positives between PET and DWI, DWI showed fewer false-positives than PET in the mediastinum (p=0.011). Of the 43 false-positive mediastinal nodes on PET, 35 (81%) were negative on DWI. The mean size of the 43 false-positive nodes on PET was 9±1mm, which was significantly larger than mean size of 7±3mm of the 24 false-positive nodes on DWI (p=0.002). DWI can correctly identify false-positive nodes on PET in the mediastinum. The larger size of false-positive nodes on PET could be due to enlargement by lymphadenitis.

Postinduction positron emission tomography assessment of N2 nodes is not associated with ypN2 disease or overall survival in stage IIIA non–small cell lung cancer

ObjectiveInduction therapy is often recommended for patients with clinical stage IIIA-N2 (cIIIA/pN2) lung cancer. We examined whether postinduction positron emission tomography (PET) scans were associated with ypN2 disease and survival of patients with cIIIA/pN2 disease. MethodsWe performed a retrospective review of a prospectively maintained database to identify patients with cIIIA/pN2 non–small cell lung cancer treated with induction chemotherapy followed by surgery between January 2007 and December 2012. The primary aim was the association between postinduction PET avidity and ypN2 status; the secondary aims were overall survival, disease-free survival, and recurrence. ResultsPersistent pathologic N2 disease was present in 61% of patients (61 out of 100). PET N2-negative disease increased from 7% (6 out of 92) before induction therapy to 47% (36 out of 77) afterward. The sensitivity, specificity, and accuracy of postinduction PET for identification of ypN2 disease were 59%, 55%, and 57%, respectively. Logistic regression analysis indicated that postinduction PET N2 status was not associated with ypN2 disease. Of the 39 patients with both pre- and postinduction PET N2-avidity, 25 (64%) had ypN2 disease. The 5-year overall survival was 40% for ypN2 disease versus 38% for N2-persistent disease (P = .936); the 5-year overall survival was 43% for postinduction PET N2-negative disease versus 39% for N2-avid disease (P = .251). The 5-year disease-free survival was 34% for ypN2-negative disease versus 9% for N2-persistent disease (P = .079). ConclusionsPostinduction PET avidity for N2 nodes is not associated with ypN2 disease, overall survival, or disease-free survival in patients undergoing induction chemotherapy for stage IIIA/pN2 disease.

The relationship between pathologic nodal disease and residual tumor viability after induction chemotherapy in patients with locally advanced esophageal adenocarcinoma receiving a tri-modality regimen.

A complete pathologic response to induction chemo-radiotherapy (CRT) has been identified as a favorable prognostic factor for patients with loco-regionally advanced (LRA) adenocarcinoma (ACA) of the esophagus and gastro-esophageal junction (E/GEJ). Nodal involvement at the time of surgery has been found to be prognostically unfavorable. Less is known, however, about the prognostic import of less than complete pathologic regression and its relationship to residual nodal disease after induction chemotherapy. Between February 2008 and January 2012, 60 evaluable patients with ACA of the E/GEJ enrolled in a phase II trial of induction chemotherapy, surgery, and post-operative CRT. Eligibility required a clinical stage of T3-T4 or N1 or M1a (AJCC 6(th)). Induction chemotherapy with epirubicin 50 mg/m(2) d1, oxaliplatin 130 mg/m(2) d1, and fluorouracil 200 mg/m(2)/day continuous infusion for 3 weeks, was given every 21 days for three courses and was followed by surgical resection. Adjuvant CRT consisted of 50-55 Gy at 1.8-2.0 Gy/d and two courses of cisplatin (20 mg/m(2)/d) and fluorouracil (1,000 mg/m(2)/d) over 4 days during weeks 1 and 4 of radiotherapy. Residual viability (RV) was defined as the amount of remaining tumor in relation to acellular mucin pools and scarring. Of the 60 evaluable patients, 54 completed induction therapy and underwent curative intent surgery. The Kaplan-Meier projected 3-year overall survival (OS) for patients with pathologic N0 (n=20), N1 (n=12), N2 (n=13), and N3 (n=9) disease is 73%, 57%, 35%, and 0% respectively (P<0.001). The Kaplan-Meier projected 3-year OS of patients with low (0-25%, n=19), intermediate (26-75%, n=26), and high (>75%, n=9) residual tumor viability was 67%, 42%, and 17% respectively (P=0.004). On multivariable analysis (MVA), both the pN descriptor and RV were independently prognostic for OS. In patients with less nodal dissemination (N0/N1), RV was prognostic for OS [3-year OS 85% (0-25% viable) vs. 51% (>25% viable), P=0.028]. Outcomes were poor, however, for patients with advanced nodal disease (N2/N3) regardless of RV [3-year OS 20% (0-25% viable) vs. 21% (>25% viable), P=0.55]. RV and the pN descriptor after induction chemotherapy are independent pathologic prognostic factors for OS in patients with LRA ACA of the E/GEJ. Patients with extensive nodal disease, however, have poor outcomes irrespective of residual tumor viability.

Analysis of Patients Unable to Undergo Adjuvant Chemotherapy after Surgery in Stage IIIA/B Non-Small Cell Lung Cancer: Will They Benefit from Mediastinal Radiotherapy?

Objectives The role of postoperative mediastinal radiotherapy in completely resected non-small cell lung cancer (NSCLC) and pathological N2 disease is controversial. In clinical practice, not all lung cancer patients with histologically confirmed N2 disease and a high risk for local recurrence are able to undergo postoperative concurrent radio/chemotherapy due to their physical condition or postoperative morbidities. Mediastinal radiotherapy is less compromising than a combination of radio/chemotherapy and seems likely to be tolerable for limited patients to achieve better local tumor control. Materials and Methods All patients included in this retrospective analysis were excluded from postoperative adjuvant combination chemo/radiotherapy due to their comorbidity, advanced age, or a complicated postoperative course. Three-dimensional conformal radiotherapy of the mediastinal lymph node stations (mean dose: 50 Gy; range: 50-54 Gy) in patients with R0 resection, additional boost of 10 Gy in patients with R1 or R2 resection, was performed postoperatively. Results A total of 110 patients were included in this analysis. Mean survival was 25.5 ± 19.2 months. The 1-, 3-, and 5-year survival was 75.4, 38.7, and 26.2%, respectively. Postoperative complications and the development of distant metastases did not correlate (p = 0.7). Distant metastases proved to be a significant prognostic factor of survival (p < 0.0001). Local recurrence was seen in a total of three patients (2.7%). Five-year survival of patients developing major postoperative complications was significantly inferior (p = 0.04) to those without postoperative complications. The extent of surgery had a significant impact on survival-5-year survival after lobectomy was significantly longer than after pneumonectomy (p = 0.029). R1 resection had no significant impact on the survival rates (p = 0.67). Discussion Stage III-N2 NSCLC patients with multiple comorbidities or a complicated postoperative course after surgery may benefit from modern mediastinal radiotherapy. Surgery and postoperative mediastinal radiotherapy can achieve local tumor control. Distant metastases have the highest impact on the prognosis. Pneumonectomy, however, should be avoided in stage III NSCLC, when possible.

Underlying Problems in Surgical Treatment of cT1-2N1 Non-Small Cell Lung Cancer.

Background Obtaining an accurate preoperative diagnosis of N1 in non-small cell lung cancer (NSCLC) is a major difficulty. The aim of this retrospective study was to evaluate the pathological and long-term outcomes of NSCLC patients clinically staged with N1 disease, to aid in the search for better treatment strategies. Materials and Methods We retrospectively reviewed the clinical records of 1,180 consecutive patients with NSCLC who underwent surgery for curative intent from 1991 to 2011 in our department. Data on 96 (8.1%) patients who had cT1-2N1 disease and underwent lobectomy or more extensive surgery were available. Results Only 32% of patients (n = 31) were confirmed to have pathological N1 disease, and 34 and 33% of patients were proven to have pN0 and pN2 disease, respectively. Female gender, ≤ 30 pack-year tobacco smoking history, adenocarcinoma, and left-sided disease were significantly associated with pathological upstaging (χ2 test). Multivariate analysis using logistic regression revealed left-sided disease to be independently associated with upstaging (relative risk 4.00, p = 0.015). Left-sided disease was more likely to be underestimated by clinical N staging than right-sided disease (χ2 test, p = 0.0001). Univariate and multivariate survival analyses demonstrated that left-sided disease was an independent prognostic factor associated with poor outcomes (Cox proportional hazards regression: hazard ratio 2.27, p = 0.037). Conclusion The diagnostic accuracy of clinical N1 status was poor. Left-sided disease appeared to be understaged by the preoperative assessment of N status, and therefore, patients who might benefit from preoperative induction treatment would not receive it.

Oncologic outcomes in men with metastasis to the prostatic anterior fat pad lymph nodes: a multi-institution international study.

BackgroundThe presence of lymph nodes (LN) within the prostatic anterior fat pad (PAFP) has been reported in several recent reports. These PAFP LNs rarely harbor metastatic disease, and the characteristics of patients with PAFP LN metastasis are not well-described in the literature. Our previous study suggested that metastatic disease to the PAFP LN was associated with less severe oncologic outcomes than those that involve the pelvic lymph node (PLN). Therefore, the objective of this study is to assess the oncologic outcome of prostate cancer (PCa) patients with PAFP LN metastasis in a larger patient population.MethodsData were analyzed on 8800 patients from eleven international centers in three countries. Eighty-eight patients were found to have metastatic disease to the PAFP LNs (PAFP+) and 206 men had isolated metastasis to the pelvic LNs (PLN+). Clinicopathologic features were compared using ANOVA and Chi square tests. The Kaplan-Meier method was used to calculate the time to biochemical recurrence (BCR).ResultsOf the eighty-eight patients with PAFP LN metastasis, sixty-three (71.6 %) were up-staged based on the pathologic analysis of PAFP and eight (9.1 %) had a low-risk disease. Patients with LNs present in the PAFP had a higher incidence of biopsy Gleason score (GS) 8–10, pathologic N1 disease, and positive surgical margin in prostatectomy specimens than those with no LNs detected in the PAFP. Men who were PAFP+ with or without PLN involvement had more aggressive pathologic features than those with PLN disease only. However, there was no significant difference in BCR-free survival regardless of adjuvant therapy. In 300 patients who underwent PAFP LN mapping, 65 LNs were detected. It was also found that 44 out of 65 (67.7 %) nodes were located in the middle portion of the PAFP.ConclusionsThere was no significant difference in the rate of BCR between the PAFP LN+ and PLN+ groups. The PAFP likely represents a landing zone that is different from the PLNs for PCa metastasis. Therefore, the removal and pathologic analysis of PAFP should be adopted as a standard procedure in all patients undergoing radical prostatectomy.Electronic supplementary materialThe online version of this article (doi:10.1186/s12894-015-0070-1) contains supplementary material, which is available to authorized users.

The Impact of Preoperative Radiation Therapy on Locoregional Recurrence in Patients with Stage IV Rectal Cancer Treated with Definitive Surgical Resection and Contemporary Chemotherapy

PurposeDefinitive resection of primary rectal cancers is frequently incorporated, with or without preoperative radiotherapy and perioperative chemotherapy, in the management of selected patients with metastatic rectal adenocarcinoma. This study reviews the impact of preoperative radiotherapy and perioperative chemotherapy on locoregional recurrence and overall survival in these patients. Methods and MaterialsThis retrospective study with an Institutional Review Board (IRB) waiver included 109 patients with metastatic rectal adenocarcinoma who underwent definitive primary resection between 1998 and 2011. In addition to resection, 64 patients were treated with preoperative radiotherapy and perioperative chemotherapy and 45 patients were treated with perioperative chemotherapy alone. Radiotherapy dose was typically 50.4 Gy. Baseline variables were compared using chi-square and unpaired t tests. Overall survival was calculated using Kaplan-Meier method. Univariate and multivariate analyses were performed using Cox proportional hazards regression. ResultsThere were no significant baseline differences between the two groups. There was no significant difference in locoregional recurrence (10.9 vs. 11.1 %; p = 0.90) or overall survival (34.5 vs. 34.8 months; p = 0.89) for patients treated with preoperative radiotherapy compared to those treated with perioperative chemotherapy alone, respectively. Patients who underwent radiotherapy were less likely to have a positive margin (10.9 vs. 20.0 %; p = 0.19), lymphovascular invasion (32.8 vs. 53.3 %; p = 0.03), and pathologic stage N2 disease (25.0 vs. 42.2 %; p = 0.02). Grade 2 postoperative complications were more common in the preoperative radiotherapy group (32.8 vs. 15.6 %; p = 0.04). Multivariate analysis demonstrated that patients with poorly differentiated tumors (HR 2.19; p = 0.009) and those that did not undergo liver-directed therapy (HR 2.20; p = 0.005) had inferior survival. ConclusionsLocoregional recurrence is modest in patients with metastatic rectal adenocarcinoma receiving definitive primary resection, irrespective of the use of radiotherapy. Preoperative radiotherapy may enhance pathologic downstaging at the expense of increased grade 2 postoperative complications. Its use should be reserved for patients at high risk for locoregional recurrence.