Performance Of Lymph Node Dissection Research Articles

Indeterminate Thyroid Fine-Needle Aspirations in Pediatrics: Exploring Clinicopathologic Features and Utility of Molecular Profiling

Introduction: The diagnostic utility of molecular profiling for the evaluation of indeterminate pediatric thyroid nodules is unclear. We aimed to assess pediatric cases with indeterminate thyroid fine-needle aspiration (FNA) alongside clinicopathologic features and mutational analysis. Methods: A retrospective review of 126 patients with indeterminate cytology who underwent FNA between January 2010 and December 2021 at the Children’s Hospital of Philadelphia was performed. Indeterminate cases defined by The Bethesda System for Reporting Thyroid Cytopathology (AUS/FLUS or TBSRTC III; FN/SFN or TBSRTC IV; SM or TBSRTC V) were correlated to clinicopathologic and genetic characteristics. Results: Of the 114 surgical cases, 48% were malignant, with the majority of malignant cases diagnosed as follicular variant of papillary thyroid carcinoma (28/55). Risk of malignancy increased with TBSRTC category: 23% for AUS/FLUS, 51% for FN/SFN, and 100% for SM nodules. There were significant differences in surgical approach (p < 0.01), performance of lymph node dissection (p < 0.01), histological diagnosis (p < 0.01), primary tumor focality/laterality (p = 0.04), and lymphatic invasion (p = 0.02) based on TBSRTC classification, with resultant differences in post-surgical risk stratification per American Thyroid Association (ATA) Pediatric Guidelines (p = 0.01). Approximately 89% (49/55) of cases were classified as ATA low risk, and 5 of 6 patients with ATA intermediate- or high-risk disease had SM cytology. Somatic molecular testing was performed in 40% (51/126) of tumors; 77% (27/35) of malignant cases and 38% (6/16) of benign cases harbored driver alteration(s). Of the driver-positive malignant cases, 52% (14/27) were associated with low risk (DICER1, PTEN, RAS, and TSHR mutations), 33% (9/27) were associated with high risk (BRAF mutations and ALK, NTRK, and RET fusions), and 15% (4/27) had unreported risk for invasive disease (APC, BLM, and PPM1D mutations and TG-FGFR1 fusion). Incidence of high-risk drivers increased with TBSRTC category. Approximately 23% (8/35) of patients harboring thyroid malignancy did not have an identifiable driver alteration. Conclusions: Molecular analysis is useful to discriminate benign and malignant thyroid nodules with indeterminate cytology. Patients with driver genetic alteration(s) and indeterminate cytology should consider surgical management secondary to the high incidence (82%; 27/33) of thyroid malignancy in these patients.

Uptake and outcomes of sentinel lymph node mapping in women undergoing minimally invasive surgery for endometrial cancer.

To examine the patterns and outcomes of sentinel lymph node (SLN) assessment in women with endometrial cancer. Retrospective cohort study. United States inpatient and outpatient hospital services. Women with endometrial cancer who underwent a laparoscopic or robotic-assisted hysterectomy. The Perspective Database from 2012 to 2018 was used. Performance of lymph node dissection was classified as SLN mapping, lymph node dissection or no nodal evaluation. Adjusted regression models were developed to examine the association between SLN mapping and morbidity and cost. Utilisation rates, morbidity and cost of both lymph node dissection and SLN mapping. Among 45381 patients, SLN mapping was performed for 7768 patients (17.1%), lymph node dissection was performed for 23214 patients (51.2%) and no lymphatic evaluation was performed for 14399 patients (31.7%). SLN mapping increased from 1.8% in 2012 to 35.3% in 2018, whereas the rate of lymph node dissection decreased from 63.5% to 39.1% (p<0.001). Among women who underwent nodal evaluation, residence in the west, White race and use of robotic-assisted hysterectomy were associated with SLN mapping (p<0.05 for all). The complication rate was 5.9% for SLN mapping, compared with 7.3% in those that underwent lymph node dissection (aRR0.85, 95%CI 0.77-0.95). The median hospital costs for women who underwent SLN mapping ($10479) and lymph node dissection ($10747) were higher than for those who did not undergo nodal assessment ($9149) (p<0.001). The performance of SLN mapping is increasing for endometrial cancer. Compared with lymph node dissection, SLN mapping is associated with lower morbidity. SLN mapping significantly increases the costs compared with hysterectomy alone. SLN mapping is increasing rapidly for endometrial cancer and is associated with decreased perioperative morbidity.

Perioperative outcomes in obese women with uterine cancer

Objectives: Obesity is a known independent risk factor for endometrial cancer that is continuing to increase in incidence throughout the United States. There is limited data on perioperative outcomes among women with endometrial cancer and obesity, especially in the era of increasing prevalence of minimally invasive surgery. We examined the association between obesity and perioperative outcomes in patients who underwent hysterectomy for uterine cancer. Methods: The National Surgical Quality Improvement Program (NSQIP) database was utilized to identify women with uterine cancer who underwent hysterectomy between the years of 2007 and 2018. Patients were classified into body mass index (BMI) groups: normal (<25), overweight (25-29.9), and obese (≥30). Analyses were also performed that stratified the obese BMI group into 30-39.9, 40-49.9, and ≥50. Multivariable logistic regression models were developed to determine clinical and demographic factors associated with perioperative morbidity and mortality. The associations between BMI group and route of hysterectomy and performance of lymph node dissection were examined using log-linear regression models. Results: A total of 42,075 endometrial cancer patients including 15.2% who were normal weight, 20.1% who were overweight and 64.8% who were obese were identified. Compared to normal BMI and overweight patients, obese patients were more likely to undergo minimally invasive hysterectomy (73.7% for obese, 72.0% for overweight, 71.6% for normal BMI; P=0.0018) and were less likely to have a lymph node dissection during surgery (53.3% for obese, 60.0% for overweight, 58.9% for normal BMI; P<0.0001). There were no differences in perioperative outcomes based on three BMI groups (normal, overweight, and obese with BMI ≥30). However, compared to women with normal BMI, those with BMI ≥50 were more likely to have any complications (6.8% vs 4.4%; aRR 1.30; 95% CI, 1.07-1.58), severe (Clavian IV) complications (3.3% vs. 1.8%; aRR 1.53; 95% CI, 1.15-2.04), readmission (6.8% vs. 4.4%; aRR 1.37; 95% CI, 1.12-1.66), and reoperation (2.4% vs 1.2%; aRR 1.76; 95% CI, 1.24-2.49). Perioperative mortality was not statistically different among any of the obese cohorts compared to those with normal BMI. Conclusions: Obese women with endometrial cancer who undergo hysterectomy are more likely to have minimally invasive procedures and less likely to have lymph node dissections. Those with BMI ≥50 are at higher risk for severe perioperative complications and reoperation. Obesity is a known independent risk factor for endometrial cancer that is continuing to increase in incidence throughout the United States. There is limited data on perioperative outcomes among women with endometrial cancer and obesity, especially in the era of increasing prevalence of minimally invasive surgery. We examined the association between obesity and perioperative outcomes in patients who underwent hysterectomy for uterine cancer. The National Surgical Quality Improvement Program (NSQIP) database was utilized to identify women with uterine cancer who underwent hysterectomy between the years of 2007 and 2018. Patients were classified into body mass index (BMI) groups: normal (<25), overweight (25-29.9), and obese (≥30). Analyses were also performed that stratified the obese BMI group into 30-39.9, 40-49.9, and ≥50. Multivariable logistic regression models were developed to determine clinical and demographic factors associated with perioperative morbidity and mortality. The associations between BMI group and route of hysterectomy and performance of lymph node dissection were examined using log-linear regression models. A total of 42,075 endometrial cancer patients including 15.2% who were normal weight, 20.1% who were overweight and 64.8% who were obese were identified. Compared to normal BMI and overweight patients, obese patients were more likely to undergo minimally invasive hysterectomy (73.7% for obese, 72.0% for overweight, 71.6% for normal BMI; P=0.0018) and were less likely to have a lymph node dissection during surgery (53.3% for obese, 60.0% for overweight, 58.9% for normal BMI; P<0.0001). There were no differences in perioperative outcomes based on three BMI groups (normal, overweight, and obese with BMI ≥30). However, compared to women with normal BMI, those with BMI ≥50 were more likely to have any complications (6.8% vs 4.4%; aRR 1.30; 95% CI, 1.07-1.58), severe (Clavian IV) complications (3.3% vs. 1.8%; aRR 1.53; 95% CI, 1.15-2.04), readmission (6.8% vs. 4.4%; aRR 1.37; 95% CI, 1.12-1.66), and reoperation (2.4% vs 1.2%; aRR 1.76; 95% CI, 1.24-2.49). Perioperative mortality was not statistically different among any of the obese cohorts compared to those with normal BMI. Obese women with endometrial cancer who undergo hysterectomy are more likely to have minimally invasive procedures and less likely to have lymph node dissections. Those with BMI ≥50 are at higher risk for severe perioperative complications and reoperation.

Uptake and outcomes of sentinel lymph node mapping in women with endometrial cancer

<h3>Objectives:</h3> The role of nodal evaluation for endometrial cancer (EmCa) remains controversial. Sentinel lymph node (SLN) mapping has been introduced as an alternative to lymph node dissection (LND) and may be associated with decreased morbidity. Little is known about the uptake and outcomes of SLN mapping. We examined trends in use and perioperative morbidity, mortality and complications for SLN mapping compared to LND for endometrial cancer. <h3>Methods:</h3> Women with EmCa who underwent a laparoscopic or robotic-assisted hysterectomy from 2012-2018 in the Premier Healthcare Database were examined. Performance of lymph node dissection was classified as SLN mapping, LND or no nodal evaluation based on procedural billing codes and CPT codes. Adjusted regression models were developed to examine the association between SLN mapping and perioperative morbidity, mortality and cost. <h3>Results:</h3> Among 45,381 patients, SLN mapping was performed in 7,768 (17.1%), LND in 23,214 (51.2%) and no lymphatic evaluation in 14,399 (31.7%). Performance of SLN mapping increased from 1.8% in 2012 to 35.3% in 2018 (19.6-fold increase), while the rate of LND decreased from 63.5% to 39.1% (1.6-fold decrease) (P<0.001) (Figure 1). Lymph node (LND or SLN mapping) evaluation increased from 65.2% in 2012 to 74.4% in 2018 (P<0.001). In a multivariable model, residence in the west, surgery at teaching hospitals, treatment at high-volume hospitals, BlackBlack race and use of robotic-assisted hysterectomy were associated with lymph node (LND or SLN mapping) evaluation (P<0.05 for all). Among women who underwent nodal evaluation, residence in the west, White race, and use of robotic-assisted hysterectomy were associated with performance of SLN mapping (P<0.05 for all). The overall complication rate was 5.9% in those who underwent SLN mapping compared to 7.3% in those that underwent LND (aRR=0.85; 95% CI 0.77-0.95). The median hospital cost in women who underwent SLN mapping ($10,479) and LND ($10,747) were substantially higher than in those who did not undergo nodal assessment ($9,149) (P<0.001). In an adjusted regression model, this difference in cost remained significant for SLN mapping ($805; 95% CI $689 to $922) and for those who underwent LND ($1,474; 95% CI $1,384 to $1,563). <h3>Conclusions:</h3> Performance of SLN mapping is increasing rapidly for women with endometrial cancer. Compared to LND, SLN mapping is associated with lower perioperative morbidity and lower cost.

Uptake and outcomes of sentinel lymph node mapping in women with atypical endometrial hyperplasia

<h3>Objectives:</h3> The role of nodal evaluation for endometrial cancer (EmCa) remains controversial. Sentinel lymph node (SLN) mapping has been introduced as an alternative to lymph node dissection (LND) and may be associated with decreased morbidity. Little is known about the uptake and outcomes of SLN mapping. We examined trends in use and perioperative morbidity, mortality and complications for SLN mapping compared to LND for endometrial cancer. <h3>Methods:</h3> Women with EmCa who underwent a laparoscopic or robotic-assisted hysterectomy from 2012-2018 in the Premier Healthcare Database were examined. Performance of lymph node dissection was classified as SLN mapping, LND or no nodal evaluation based on procedural billing codes and CPT codes. Adjusted regression models were developed to examine the association between SLN mapping and perioperative morbidity, mortality and cost. <h3>Results:</h3> Among 45,381 patients, SLN mapping was performed in 7,768 (17.1%), LND in 23,214 (51.2%) and no lymphatic evaluation in 14,399 (31.7%). Performance of SLN mapping increased from 1.8% in 2012 to 35.3% in 2018 (19.6-fold increase), while the rate of LND decreased from 63.5% to 39.1% (1.6-fold decrease) (P<0.001) (Figure 1). Lymph node (LND or SLN mapping) evaluation increased from 65.2% in 2012 to 74.4% in 2018 (P<0.001). In a multivariable model, residence in the west, surgery at teaching hospitals, treatment at high-volume hospitals, black race and use of robotic-assisted hysterectomy were associated with lymph node (LND or SLN mapping) evaluation (P<0.05 for all). Among women who underwent nodal evaluation, residence in the west, white race, and use of robotic-assisted hysterectomy were associated with performance of SLN mapping (P<0.05 for all). The overall complication rate was 5.9% in those who underwent SLN mapping compared to 7.3% in those that underwent LND (aRR=0.85; 95% CI 0.77-0.95). The median hospital cost in women who underwent SLN mapping ($10,479) and LND ($10,747) were substantially higher than in those who did not undergo nodal assessment ($9,149) (P<0.001). In an adjusted regression model, this difference in cost remained significant for SLN mapping ($805; 95% CI $689 to $922) and for those who underwent LND ($1,474; 95% CI $1,384 to $1,563). <h3>Conclusions:</h3> Performance of SLN mapping is increasing rapidly for women with endometrial cancer. Compared to LND, SLN mapping is associated with lower perioperative morbidity and lower cost.

Fertility preserving surgery for high-grade epithelial ovarian carcinoma confined to the ovary

ObjectiveTo investigate the safety of uterine preservation in patients with high-grade epithelial ovarian carcinoma (EOC). Study designThe Surveillance, Epidemiology, and End Results database was accessed (1988–2014) and patients aged < = 45 years, diagnosed with an unilateral high-grade non-clear cell EOC confined to the ovary were selected. Based on surgery codes we determined whether hysterectomy was performed. Overall (OS) and cancer-specific survival (CSS) was estimated calculated following generation of Kaplan-Meier curves and compared using the log-rank test. Cox hazard model was constructed to control for possible confounders. ResultsA total of 1039 patients with a median follow-up of 119 months were identified. Rate of uterine preservation was 31.8 %. Patients who had hysterectomy were older (median 41 vs 32 yrs, p < 0.001). Patients with mucinous tumors were less likely to undergo hysterectomy (58.9 %) compared to those with endometrioid (73.9 %) and serous (75.9 %) carcinoma, p < 0.001. There was no difference in CSS between patients who did and did not have hysterectomy, p = 0.70 (5-yr rates were 93.9 % vs 92.2 %, respectively). After controlling for year of diagnosis, tumor histology (serous vs non-serous), disease stage, performance of lymph node dissection (LND) and tumor grade, uterine preservation was not associated with a worse cancer-specific (HR: 1.08, 95 % CI:0.69,1.71) and overall (HR:0.88, 95 % CI: 0.59, 1.32) mortality. ConclusionIn this retrospective cohort of patients with unilateral high-grade non-clear cell EOC confined to the ovary, uterine preservation was not associated with a worse prognosis.

Disparities in performance of lymph node dissection for women with early stage cervical cancer in Louisiana

Objectives: Racial and socioeconomic disparities in the delivery of cervical cancer (CC) care have been well established. Current guidelines recommend lymph node dissection (LND) as part of the primary surgical treatment of stage IA to IB CC, with the exception of IA1 without LVI. LND is also a consideration when imaging prior to radiation reveals bulky lymphadenopathy. The goal of this study was to evaluate whether age, race or socioeconomic status was associated with disparities in the performance of LND for women with Stage IA and IB CC in Louisiana.

International and Multi-institutional Assessment of Factors Associated With Performance and Quality of Lymph Node Dissection During Radical Nephrectomy

ObjectiveTo determine factors associated with performance and quality of lymph node dissection during radical nephrectomy. Materials and MethodsUsing an International Data Registry, we performed multilevel logistic regression to determine the association of surgical approach (open surgery vs minimally invasive surgery), institutional experience (low, moderate, and high tertiles), and institutional preference (minimally invasive surgery, balanced, and open surgery tertiles) with the performance of lymph node dissection in subgroups by clinical stage and nodal status. ResultsAmong 1,742 patients undergoing radical nephrectomy, 312 (18%) underwent lymph node dissection, which was associated with stage (28% for ≥cT2 vs 9.3% for cT1), and nodal status (68% for ≥cN1 vs 13% for cN0). Open surgery was significantly associated with performing lymph node dissection in all subgroups. Institutional experience and institutional preference had no association with performing lymph node dissection in the ≥cN1 group. The number of nodes removed was greater for open surgery (mean 5.9) vs minimally invasive surgery (mean 3.4); this held true even when stratified by stage and nodal status. ConclusionIn this large dataset, open surgical radical nephrectomy is associated with more frequent performance and higher quality of lymph node dissection, which may owe to selection bias but also could reflect technical concerns. In the patient population in whom lymph node dissection is recommended (≥cN1), this is not explained by institutional experience or preference. Lymph node dissection may be under-utilized for ≥cN1 disease and over-utilized for cN0 disease, at least according to practice guidelines.

Disparities in the use of fertility-sparing surgery for early stage cervical cancer

Women with early stage cervical cancer who are of reproductive age and wish to preserve fertility may be candidates for fertility-sparing surgery (FSS). The goal of this study was to examine the presence of disparities in the use of fertility-preserving surgery (FSS) and to investigate outcomes in this group. Retrospective cohort study. The National Cancer Database was used to identify patients aged <=35 years diagnosed with cervical cancer between 2004-2015. Those with stage IA2 or IB1 squamous cell carcinoma (SCC) or adenocarcinoma (AC) who underwent definitive treatment by hysterectomy (HYST) versus cone resection or trachelectomy (FSS) were identified. Univariate analysis was performed with chi-square and Mann-Whitney tests. Overall survival (OS) was evaluated for cases diagnosed between 2004-2014 after generation of Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for confounders. A total of 2623 patients met the inclusion criteria. Median patient age at the time of diagnosis was 31 years (IQR:5). The majority had squamous cell carcinoma (62.4%) and stage IB1 disease (84.1%). The rate of FSS was 13.6%. Compared to patients who underwent HYST, those who received FSS were younger (median 30 vs 32 yrs, p<0.001), had fewer co-morbidities (3.6% vs 7.6%, p=0.007), were more likely to reside in large metropolitan areas (61.1% vs 49.5%, p<0.001), have private insurance (75.8% vs 62.9%, p<0.001), higher median income (p<0.001), present with stage IA2 disease (25.2% vs 14.4%, p<0.001) and adenocarcinoma (45.4% vs 36.3%, p=0.001). No differences were noted based on patient race (p=0.14). After controlling for clinical stage, histology, age, presence of co-morbidities, and area of residence, private insurance and higher income were associated with the receipt of FSS. There was no difference in OS between patients who received HYST (n=2036) and FSS (n=305), p=0.37; 5-yr OS rates were 93.5% and 94.5%, respectively. After controlling for age, clinical stage, histology, presence of medical comorbidities and performance of lymph node dissection, receipt of FSS was not associated with a worse survival (HR: 0.75, 95% CI: 0.42, 1.37). Socio-economic disparities exist in the utilization of FSS for early stage cervical cancer. For this selected population no difference in OS was found. This is critical information for patients referred for oncofertility consultation.

The association of lymph node dissection with 30-day perioperative morbidity among men undergoing minimally invasive radical prostatectomy: analysis of the National Surgical Quality Improvement Program (NSQIP).

The incremental morbidityof lymph node dissection (LND) among men undergoingradical prostatectomy remains uncertain. We therefore evaluated the association of LND with perioperative morbidity among men undergoing minimally invasive radical prostatectomy (MIRP). We identified 29,012 men aged 35-89 who underwent MIRP from 2010-2015 in the National Surgical Quality Improvement Program (NSQIP) database, of whom 47% underwent concomitant LND. The associations of LND with 30-day perioperative morbidity and mortality were evaluated using logistic regression, adjusted for patient features. Median age at surgery was 63 (IQR57, 67) years. There were statistically significant, but clinically insignificant, differences in several baseline characteristics stratified by performance of LND, including older age at surgery (p < 0.001), higher American Society of Anesthesiology (ASA) class (p < 0.001), and longer operative time (p < 0.001) for men who underwent LND. Overall, 30-day complications occurred in 4.3% of patients. There were no statistically significant differences in rates of 30-day complications (4.2 vs. 4.4%, p = 0.44), perioperative blood transfusion (1.7 vs. 1.7%, p = 0.99), hospital readmission (3.6 vs. 4.0%, p = 0.09), reoperation (1.1 vs. 1.1%, p = 0.80), or 30-day mortality (0.1 vs. 0.2%, p = 0.56) between patients who underwent MIRP alone or MIRP with LND, respectively. On multivariable analysis, LND was not significantly associated with an increased risk of perioperative morbidity or 30-day mortality. LND at the time of MIRP does not appear to be associated with an increased risk of perioperative morbidity.

Differences in Survival Associated with Performance of Lymph Node Dissection in Patients with Invasive Penile Cancer: Results from the National Cancer Database

Inguinal lymphadenectomy remains under performed in patients with invasive penile cancer. Using a large national cancer registry we assessed temporal trends in inguinal lymphadenectomy performance and evaluated the impact of the procedure on survival in patients in whom inguinal lymphadenectomy was an absolute indication (T1b-4 N0/x-1) according to NCCN® (National Comprehensive Cancer Network®) Guidelines®. We queried the National Cancer Database for all cases of nonmetastatic, T1b-4 N0/x-1 squamous cell carcinoma of the penis from 2004to 2014. Multivariable logistic regression models adjusting for patient, demographic, and clinicopathological characteristics were used to examine the association between available covariates and receipt of inguinal lymphadenectomy. Cox proportional hazards regression analysis was then done to assess the impact of clinical and pathological variables on overall survival. Propensity score weighted analysis was performed to assess the effect of inguinal lymphadenectomy on overall survival. A total of 2,224 patients met analysis criteria, of whom 606 (27.2%) underwent inguinal lymphadenectomy. Following adjustment the procedure was more likely in younger patients, those who presented with palpable adenopathy (cN1), those treated at an academic facility and those with a more contemporary diagnosis. On survival analysis controlling for all known and measured confounders inguinal lymphadenectomy was associated with improved overall survival (HR 0.79, 95% CI 0.74-0.84, p <0.001). At hospitals that report to the National Cancer Database the overall rate of inguinal lymphadenectomy in patients with invasive penile cancer was only 27.2%. Inguinal lymphadenectomy was associated with increased overall survival, justifying the procedure as an important quality metric for performance reporting in patients with invasive penile cancer.

Role of surgical approach on lymph node dissection yield and survival in patients with upper tract urothelial carcinoma

ObjectivesWith increasing utilization of robot-assisted surgery in urologic oncology, robotic nephroureterectomy (RNU) is becoming the surgical modality of choice for patients with upper tract urothelial carcinoma (UTUC). The role of surgical approach on lymph node dissection (LND) and lymph node (LN) yield is unclear, and potential therapeutic effects are unknown. Here we analyze the effects of surgical approach on LN yield, performance of LND, and overall survival (OS). Methods and materialsPatients with UTUC who underwent nephroureterectomy from 2010 to 2013 were identified in the National Cancer Database. Outcomes of interest included rate of LND, LN yield, and OS. Logistic regression analyses were used to predict performance of LND. Negative binomial regression was used to derive incidence rate ratios for LN yield. Cox proportional hazards models were used to quantify survival outcomes. ResultsA total of 3,116 patients met inclusion criteria. LND was performed in 41% (314/762) of RNU, 27% (380/1385) of LNU cases, and 35% (340/969) of ONU (P<0.001). Compared with an ONU, patients who underwent a LNU had significantly lower odds of receiving a LND (OR = 0.70, 95% CI: 0.55–0.87) and had fewer LNs removed (IRR = 0.69, 95% CI: 0.60–0.80), while RNU trended toward increased LN yield (IRR = 1.14, 95% CI: 0.98–1.33). In a Cox proportional hazards model, increasing LN yield was associated with improved OS in patients with pN0 disease (HR = 0.97 per 1 unit increase in LN yield, 95% CI: 0.95–0.99). ConclusionsCompared with an ONU, RNU does not compromise performance of a LND and may be associated with improved LN yield. LNU is associated with the lowest rates of LND and LN yield. Increasing LN yield is associated with improved OS in patients with pN0 disease. Despite differential rates of LND and LN yield, surgical approach did not independently affect OS.

Does lymph node dissection during nephroureterectomy affect oncological outcomes in upper tract urothelial carcinoma patients without suspicious lymph node metastasis on preoperative imaging studies?

This study aimed to investigate the effects of lymph node dissection (LND) on upper tract urothelial carcinoma (UTUC) without suspicious lymph node (LN) metastasis on preoperative imaging studies. From 1998 to 2012, 418 UTUC patients without suspicious LN metastasis on preoperative imaging studies were included. Patients were divided into two groups according to the performance of LND. The effects of LND on oncological outcomes were assessed after adjusting other variables. The mean follow-up duration was 69months. Among the 132 patients who underwent LND, LN metastasis was pathologically identified in 16 patients (12.1%). The median number of resected LNs for patients who underwent LND was 7. On multivariate analysis, the number of resected LNs and pathologic T stage was significant predictors of LN metastasis. The 5-year recurrence-free survival was 76.4% for patients without LND and 65.4% for patients with LND (p=0.126). In addition, there was no difference in 5-year overall survival between the 2 groups (without LND; 71.7% vs. with LND; 72.1%, p=0.756). Multivariate analysis showed that pathologic T stage, tumor grade, and lymphovascular invasion were risk factors for recurrence. Age at surgery, tumor size, pathologic T stage, tumor grade, and lymphovascular invasion were significantly associated with overall survival. However, performance of LND was not associated with recurrence and survival. LND could be selectively performed in patients with clinically LN-negative UTUC based on patient/tumor characteristics and operative findings although sufficient LNs should be removed if LND is to be performed.

The effect of minimally invasive prostatectomy on practice patterns of American urologists

Introduction and objectivesTo determine how robotic prostatectomy affects practice patterns of urologists, we examined the case volume characteristics among certifying urologists for the surgical treatment of prostate cancer. We hypothesized that the utilization of open and robotic prostatectomy as well as lymph node dissection changed dynamically over the last 10 years. MethodsA total of 6-month case log data of certifying urologists from 2003 to 2013 were obtained for the American Board of Urology. Cases were identified using Current Procedural Terminology codes for open radical prostatectomy (ORP) and laparoscopic or robotic-assisted laparoscopic prostatectomy (RALP) with a corresponding diagnosis of prostate cancer as defined by ICD-9 code 185.0. Results obtainedA total of 6,563 urologists submitted case logs, of which 68% (4,470/6,563) reported performing at least one radical prostatectomy (RP), totaling 46,030 RPs logged. There was a 376% increase in the performance of RALP over the study period with robotic volume increasing from 22% of all RP in 2003 to 85% in 2013.Among surgeons performing ORP, the median number performed was 2; of surgeons who performed RALP, the median number performed was 8 (P<0.001). Overall, 39% of surgeons logging ORP performed 2 or fewer RP, whereas 19% of surgeons who performed RALP performed 2 or less RP (P<0.001). The highest volume robotic surgeons (top 10% surgical volume) performed 41% of all RALP with the highest performing robotic surgeon recording 658 prostatectomies over 6 months. Oncologists represented 4.1% of all surgeons performing RP and performed 15.1% of all RP (P<0.001); general urologists performed the majority of RP (57.8%). When performed open, there was no influence of surgeon specialty on the performance of lymph node dissection (LND); if performed robotically, oncologists were significantly more likely to perform LND compared with general surgeons (47% vs. 25.9%, respectively, P<0.001). ConclusionsRobotic prostatectomies are performed 5 times more commonly than open prostatectomy and represent 85% of all RP performed by board-certified urologists in 2013. Compared to RALP, ORP are significantly more likely to be performed by lower volume surgeons. Oncologists perform a higher relative percentage of RPs and are significantly more likely to perform LND if performed robotically when compared with general urologists.

Extent of lymph node dissection and overall survival in patients with uterine carcinosarcoma, papillary serous and endometrioid adenocarcinoma: A retrospective cohort study

ObjectiveTo evaluate the interaction between extent of lymph node dissection (LND) and overall survival (OS) in patients with various histologic types of uterine cancer. MethodsWe retrospectively identified 834 patients who had primary surgery in our institution for uterine carcinosarcoma (CS), papillary serous (UPSC) and endometrioid adenocarcinoma between 1984 and 2009. Stage, grade, total lymph node count (LNC), positive LNC, adjuvant therapy, age, race and OS were collected. OS was calculated using the Kaplan–Meier method. Predictive factors were compared with the log rank test and Cox regression analysis. ResultsOur cohort included 158 patients with CS, 115 patients with UPSC and 561 patients with endometrioid adenocarcinoma. Of the cohort, 38% of the patients had Stage III or IV disease. LND was performed in 73% of patients with CS, 68% of patients with UPSC and 79% of patients with endometrioid adenocarcinoma. LND was performed in 82% of Stage I–II and in 68% of Stage III–IV cases. The median total LNC was 13 (range 1–75) and there was no significant difference in the total LNC between the different histologies. Median OS was 21 months for CS, 18 months for UPSC and 200 months for patients with endometrioid adenocarcinoma. A positive association between the total and positive LNC was present in all three histologic types (Spearman coefficient, p < 0.001). The cohort was divided in quartiles based on the total LNC and a Kaplan–Meier survival analysis was performed. A continuum of improved OS was noted in correlation with increased LNC. OS was 27 months for the group with 0 nodes, 112 months for the group with 1–8 nodes, 117 months for the group with 9–16 nodes and 196 months for the group with >17 nodes. Doubling the total LNC was associated with 28% risk of death reduction (HR 0.724, CI 0.66–0.794, p < 0.001) for the first year and 14% risk reduction (HR 0.858, CI 0.761–0.967, p = 0.012) for the second year. ConclusionsIn our cohort, the performance of LND is associated with improved OS. This effect appears to be uniform across pathology types. The extent of the LND is inversely correlated with the risk of death for the first 2 years.

MP9-20 BASELINE CLINICAL CARACHTERISTICS AND PATHOLOGICAL OUTCOMES FOLLOWING ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY (RALP): A POPULATION BASED PROSPECTIVE SERIES.

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes II1 Apr 2015MP9-20 BASELINE CLINICAL CARACHTERISTICS AND PATHOLOGICAL OUTCOMES FOLLOWING ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY (RALP): A POPULATION BASED PROSPECTIVE SERIES. Lorenzo Tosco, Filip Ameye, Simone Albisinni, Peter Dekuyper, David Jegou, Thierry Quackels, Thierry Roumeguere, Ben Van Cleynenbreugel, Nancy Van Damme, Liesbet Van Eycken, and Steven Joniau Lorenzo ToscoLorenzo Tosco More articles by this author , Filip AmeyeFilip Ameye More articles by this author , Simone AlbisinniSimone Albisinni More articles by this author , Peter DekuyperPeter Dekuyper More articles by this author , David JegouDavid Jegou More articles by this author , Thierry QuackelsThierry Quackels More articles by this author , Thierry RoumeguereThierry Roumeguere More articles by this author , Ben Van CleynenbreugelBen Van Cleynenbreugel More articles by this author , Nancy Van DammeNancy Van Damme More articles by this author , Liesbet Van EyckenLiesbet Van Eycken More articles by this author , and Steven JoniauSteven Joniau More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.380AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Since robotic surgery has been implemented in the urological field many series have published, the majority of which are single-center retrospective case series. The aim of this study is to present a prospective nation-wide series of robotic assisted laparoscopic radical prostatectomy (RALP) and to describe baseline clinical characteristics and pathological outcomes. METHODS Since September 2009, a nation-wide prospective RALP registration has been implemented. Until July 2014, 6032 RALP cases were registered in 24 urological centers with a median number of 187 cases (IQR 84–323) per center. Pre- and postoperative clinico-pathological features, nerve sparing approach, performance of lymph node dissection and peri-postoperative complications are described. RESULTS Mean age was 63.1 years (range 34–84). Median PSA was 6.3 ng/ml (IQR 4.5-9-2). 94.2% (n=5863) of prostate cancers were staged as cT1-2 and 4.6 % (n=275) as cT3. The majority of biopsy Gleason score (bGS) consisted of bGS 6, 45.7% (n=2,757) and bGS7, 29.5% (n=1,781); while 8.9% (n=535) biopsies showed GS8-10. bG8 increased from 5% to 8.8% and bGS9 from 2.1 to 3.8% respectively from 2009 to 2014. The same increasing trend was observed for iPSA≥20ng/mL which passed from 4.1% at the beginning of the registration to 5.9% in 2014.69.1% (n=4169) of the procedures were performed with nerve-sparing technique of which the majority (68.8%) underwent bilateral nerve-sparing surgery. In 70.7%, lymph node dissection was not performed. However, there was a positive trend in PLND uptake over time, ranging from 21.3% in 2009 to 35% in 2014. Intraoperative complications were observed in 2.7% of cases (n=165); in these, a conversion rate of 7.3% (12 cases) mostly for hemorrhagic complications. Pathological stage was pT2 in 71.4% (n=4307), pT3a 18.4% (n=1108), pT3b 8.6% (n=519) and pT4 in 0.9% of cases. 88.5% of pathological Gleason score were pGS<8, and 11.5% pGS8-10. Positive surgical margins (PSM) were observed in 23.6% of cases and they increased from 23.5% to 27.0% during the registration period; PSM increased in parallel with pTstage. CONCLUSIONS The majority of cases in this population based study were cT1-2, cGS 6–7 disease treated by nerve sparing surgery and limited use of lymph node dissection. An increased trend to more clinically aggressive disease during last years was observed. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e109 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lorenzo Tosco More articles by this author Filip Ameye More articles by this author Simone Albisinni More articles by this author Peter Dekuyper More articles by this author David Jegou More articles by this author Thierry Quackels More articles by this author Thierry Roumeguere More articles by this author Ben Van Cleynenbreugel More articles by this author Nancy Van Damme More articles by this author Liesbet Van Eycken More articles by this author Steven Joniau More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Prostate-specific antigen density as a parameter for the prediction of positive lymph nodes at radical prostatectomy.

Objective:The aim was to determine the prognostic ability of Partin's tables for a patient collective undergoing radical prostatectomy (RP) and to evaluate the association of prostate-specific antigen (PSA) density (PSAD) and postoperative lymph node status.Methods:From 1999 to 2006, 393 consecutive patients underwent RP at our Urology department. Patients with Gleason scores < 6, clinical stages >T2c or neoadjuvant hormonal therapy were excluded. Preoperative PSA, biopsy results, digital rectal examination, and prostate size at transrectal ultrasound were recorded. Risk stratification according to the Partin scoring system was performed. Postoperative results were compared with preoperative risk estimation. Univariate and multivariate statistical analysis about prediction of postoperative lymph node status was performed.Results:Lymph node invasion (LNI) was found in 36 patients (9.16%). Kendall's rank correlation analysis revealed a significant association between the number of removed LN and LNI (P = 0.016). Patients with LNI had a significantly higher preoperative PSA and PSAD. Preoperative Gleason score was a significant predictor of LNI. The Partin tables' prediction of organ confined stages, extraprostatic extension, and seminal vesicle invasion was in line with the pathological findings in our collective. PSAD was a significant predictor of LNI in univariate and multivariate analysis.Conclusion:The most widely used nomogram is of high value in therapy decision-making, although it remains an auxiliary means. Considering the performance of lymph node dissection, surgeons should be aware of the specifics of the applied nomogram. PSAD appears as a useful adjunctive parameter for preoperative prostate risk estimation and warrants further evaluation.

Regional variation in surgical assessment of lymph nodes for staging among women with early-stage epithelial ovarian cancer

ObjectiveTo investigate geographical and socioeconomic variations in performance of lymph node dissection for the evaluation of patients with early-stage epithelial ovarian cancer. MethodsA population-based, retrospective cohort study was conducted using data from the National Cancer Institute's SEER Program for 15 geographic registries and county-level measures. Women with early-stage epithelial ovarian cancer registered between 2000 and 2008 with known lymph node assessment status were studied. A multiple logistic regression analysis was used to evaluate the differences in the likelihood of lymph node assessment according to geographic SEER region. ResultsAfter adjusting for tumor characteristics, demographics, and area-based socioeconomic measures, a significant relationship between SEER region and lymph node dissection remained. Compared to the region with the highest proportion of lymph node dissection, there is a significantly lower probability of surgical assessment of lymph nodes in 8 of the remaining 14 geographical regions. ConclusionsThe variation in ovarian cancer surgical care by region reported in this study has implications for access and outcomes for patients with early-stage disease. Study findings merit further investigation and should be characterized to permit targeted interventions aimed at reducing the observed disparities.

Extent of lymphadenectomy does not improve the survival of patients with renal cell carcinoma and nodal metastases: biases associated with the handling of missing data

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: A recent population-based analysis suggested a potential survival benefit with respect to performing lymph node dissection at nephrectomy in node-positive patients with RCC. The findings of the present study failed to corroborate the association of a survival benefit with the performance of lymph node dissection at nephrectomy. Previous studies showed no survival benefit with respect to performing lymph node dissection (LND) at nephrectomy, whereas a recent population-based analysis suggested otherwise, although the latter relied on imputation. To reconcile the findings of that study by critically evaluating the handling of missing data. Study participants comprised patients diagnosed with non-metastatic renal cell carcinoma (RCC) of all stages who underwent LND at nephrectomy (n = 10 596). Multivariable Cox regression models were performed to predict cancer-specific mortality (CSM), where the primary variable of interest was the extent of LND. To examine differences in approaches with respect to handling missing data, separate analyses were performed: (i) imputed population; (ii) exclusion of patients with missing data; and (iii) inclusion of patients with missing data as a sub-category. Overall, 2916 (28%) patients had missing tumour grade. In multivariable analyses, our findings showed that increasing the extent of LND was associated with a significant protective effect on CSM in patients with pN1 after imputation (hazard ratio [HR], 0.82; P = 0.04). By contrast, the extent of LND was no longer significantly associated with a lower risk of CSM after excluding patients with a missing tumour grade (HR, 0.83; P = 0.1) or when including patients with missing tumour grade as a sub-category (HR, 0.82; P = 0.05). The findings of the present study failed to corroborate the association of a survival benefit with increasing extent of LND at nephrectomy. The different methodologies employed to account for missing data may introduce important biases. Such considerations are non-negligible with respect to the interpretation of results for investigators who rely on administrative cohorts.

Does Heparin Prophylaxis Reduce the Risk of Venous Thromboembolism in Patients Undergoing Robot-Assisted Prostatectomy?

Venous thromboembolism (VTE) is a major complication of urologic surgery. Data are limited regarding the benefits of heparin prophylaxis for patients undergoing minimally invasive urologic surgery. The American Urological Association recommends sequential compression devices (SCDs) for urologic laparoscopic and robot-assisted procedures but provides no clear recommendations for the use of pharmacologic prophylaxis. We compare the rates of postoperative VTE in two groups of patients undergoing robot-assisted prostatectomy (RP) by two surgeons-one who consistently used heparin with SCDs (group 1) and the other who used SCDs alone (group 2) for prophylaxis. An Institutional Review Board approved, prospectively managed database was analyzed. Group 1 received SCDs just before induction and 5000 units of heparin subcutaneously just after induction. SCDs were continued postoperatively, and heparin was administered twice a day until discharge. VTE rate, patient age, body mass index (BMI), operative time, lymphocele rate, length of stay (LOS), estimated blood loss (EBL), Gleason score, and pathologic stage were compared. Categorical variables were analyzed with the chi square test of proportions and continuous variables with t test using SPSS v 14 software. There were 1486 consecutive patients who underwent RP between August 2007 and December 30, 2011. Of these, 922 patients received heparin/SCDs and 564 received SCDs alone. Age, BMI, EBL, medial LOS, Gleason score, and pathologic stage were the same in the two groups. There was a higher rate of positive nodes in group 2 (1.3% vs 3.5%). There was one lymphocele in each group. Although operative times were longer in group 2 (229 vs 170 min, P<0.001), the incidence of VTE was not statistically different (1.0% vs 0.7%, P=0.78). BMI, operative time, EBL, and the performance of lymph node dissection were not associated with VTE. The risk of VTE in patients undergoing RP is low and not significantly reduced with the administration of prophylactic heparin/SCDs compared with SCDs alone.