pN1 Disease Research Articles

Pathologic N0 Status in Clinical T1N0M0 Lung Adenocarcinoma is Predictable by the Solid Component Proportion with Quantitative CT Number Analysis

Correctly predicting pathologic regional node-negative (pN0) disease in patients with lung cancer before operation may avoid unnecessary mediastinal lymph node dissection (MLND). In this study, we analyze the value of the radiographic and histopathological features of primary tumors for predicting pN0 status in cT1N0M0 lung adenocarcinoma and to establish an optimal surgical strategy for avoiding MLND in cT1N0M0 lung adenocarcinoma patients. We retrospectively investigated the histopathological and radiographic data of 348 surgically resected cT1N0M0 lung adenocarcinoma patients with systematic lymph node dissection from January 2005 to December 2012. Histopathological features and radiographic features were analyzed. Multivariable analysis was used to identify significant predictors of pN0 disease. Our results showed that pN0 disease was detected in 306 patients (87.9%) among the 348 patients with cT1N0M0 lung adenocarcinoma. A decreasing trend of the pN0 disease proportion was observed with both increasing histological grade and decreased differentiation (P < 0.001). In multivariable analysis, the solid component proportion was a significant predictor of pN0 disease. Among 110 patients with a solid component proportion of no more than 21.3%, mediastinal lymph node involvement was not observed. Patients who meet this criterion may be successfully managed with lung resection without MLND.

Post-operative radiotherapy is associated with improved survival in esophageal cancer with positive surgical margins.

The optimal treatment for early-stage esophageal cancer with positive surgical margins after an upfront esophagectomy is not well-defined. This study investigates the effect of post-operative radiotherapy (PORT) on overall survival (OS) in clinical stage I-II patients with positive margins. We identified patients diagnosed between 2004 and 2012 with clinical stage I-II esophageal carcinoma from the National Cancer Data Base (NCDB) who underwent an upfront esophagectomy. For those patients with positive margins, administration of PORT was recorded, and OS was compared by the Kaplan-Meier estimator and log-rank test. Multivariable Cox regression analysis was performed to identify variables associated with improved survival. Among the 3,490 patients identified, 209 (5.8%) had positive margins. One hundred forty-two (67.9%) patients did not receive PORT while 67 (32.1%) did receive PORT. Compared to those receiving PORT, patients who did not receive PORT were significantly older (68.5 vs. 64.0 years, P=0.003), more likely to have pN0 disease (50.7% vs. 35.4%, P=0.026), and less likely to receive postoperative chemotherapy (21.1% vs. 86.6%, P<0.001). On multivariable logistic regression, only receipt of chemotherapy predicted for receipt of PORT (OR: 25.6, 95% CI: 9.9-65.8, P<0.001). OS was significantly higher for patients receiving PORT compared to those who did not (median OS: 32.2 vs. 16.9 months, log-rank P=0.008). Multivariable analysis confirmed an association with PORT and improved OS (HR: 0.39, 95% CI: 0.27-0.60, P<0.001). Subset analysis demonstrated that the OS benefit of PORT persisted in those patients who received adjuvant chemotherapy (HR: 0.33, 95% CI: 0.19-0.57, P<0.001). PORT is associated with improved OS in clinical stage I-II esophageal cancer patients after an upfront esophagectomy with positive margins. In the absence of prospective randomized data, our findings suggest that PORT should be strongly considered in the setting of early-stage esophageal cancer resected with positive margins.

Postoperative radiotherapy with or without concurrent chemotherapy for oral squamous cell carcinoma in patients with three or more minor risk factors: a propensity score matching analysis

BackgroundTo investigate the advantage of concurrent chemotherapy with postoperative radiotherapy (RT) of oral squamous cell carcinoma (OSCC) in patients with three or more minor risk factors.MethodsMinor risk factors included pT4 disease, pN1 disease, margin ≤ 4 mm, poor differentiation, perineural invasion, vessel or lymphatic invasion, and tumor invasion depth ≥ 11 mm. Surgery was the primary treatment, followed by RT or concurrent chemoradiation (CCRT). After propensity score matching, 34 patients in each treatment group were selected for comparison.ResultsThe median follow-up for living patients was 86.4 months (range: 47–189 months). The 5-year overall survival of the RT and CCRT groups was 35.3% and 67.2% (p = 0.018), respectively. The 5-year recurrence-free survival of the RT group and CCRT group was 42.6% and 75.4% (p < 0.01).ConclusionPostoperative CCRT for patients with three or more minor risk factors increased recurrence-free and overall survival.

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.

A Comprehensive Assessment of Accurate Lymph Node Staging and Preoperative Detection in Resected Pancreatic Cancer

BackgroundThe current (seventh edition) American Joint Commission on Cancer (AJCC) Staging System for pancreatic ductal adenocarcinoma (PDAC) dichotomizes pathologic lymph node (LN) involvement into absence (pN0) or presence (pN1) of disease. The recently announced eighth edition also includes stratification on the number of positive nodes. Furthermore, LNs detected on preoperative imaging (CT, MRI, or endoscopic ultrasound—EUS) are considered to be pathologically involved in other gastrointestinal cancers. However, this is less well defined for PDAC. Therefore, the three aims of this study were to determine (1) whether the new AJCC staging system led to more accurate staging, (2) the number of nodes needed to be examined to detect pathologic involvement, and (3) if pN disease could be reliably detected on preoperative imaging in PDAC. MethodsA retrospective review of all patients undergoing pancreatectomy at a single US academic center from January 1990 to September 2015. Pathology reports of resected specimens were reviewed to determine the total number of LNs examined and those positive for metastasis. CT, MRI, and/or EUS reports were used to determine the presence or absence of preoperatively detectable LN enlargement. ResultsOf the 490 surgical resections for PDAC, pN1 disease was detected in 59.4% (n = 291) and was positively correlated with the number of LNs pathologically examined (P < 0.001). Patients with pN1 disease had a shorter overall survival (OS) than those without nodal involvement (25.1 vs. 44.0 months; P < 0.001); however, OS was not different when stratifying by the number of nodes as on the eighth AJCC system. Pathologic examination of > 20 LNs in treatment naïve patients was optimal to detect pN1 disease and predict longer OS for those without nodal involvement (median survival > 41.1 months, P = 0.03 when compared to < 15 or 15–19 LNs examined). LNs were detected by CT, MRI, or EUS in 30.7% (103/335) of patients. The positive predictive value (PPV) of preoperative LN detection for pathologic involvement was 77.3% for treatment naïve patients and 84.2% for those without biliary obstruction. ConclusionsAlthough the LN scoring in the seventh PDAC AJCC Staging System was sufficient to predict OS of our patients, more LNs than previously considered (20 vs. 15) were optimal to detect pathologic involvement. Preoperative LN detection was an accurate predictor of pN1 disease for treatment naïve patients without biliary obstruction.

Rate and Extent of Pelvic Lymph Node Dissection in the US Prostate Cancer Patients Treated With Radical Prostatectomy.

To evaluate the utilization of pelvic lymph node dissection (PLND) and its extent in contemporary US patients, and to correlate it to the detection of pN1 disease. A total of 328,710 individuals who received radical prostatectomy between the years 2004 and 2013 were identified within the National Cancer Data Base. The Cochran-Armitage test was used to assess the statistical significance of temporal trends. Logistic regression analysis tested the relationship between the number of lymph nodes removed (LNR) and pN1 rate. Most patients had T2 disease (76.7%) and a Gleason score of 7 (55.9%). Overall, 63.5% of the patients received PLND; this ranged between 58.9% and 72.1% over the study period (P= .8). In patients receiving PLND, mean LNR increased from 6.1 nodes in 2004 to 7.2 nodes in 2013 (P< .001). When stratified by tumor risk, utilization and extent of PLND increased in intermediate- and high-risk tumors, while it decreased in low-risk tumors. Overall pN1 rate was 3.73%, and it increased from 2.9% to 5.3% between 2004 and 2013 (P< .001). In multivariable analysis, LNR was an independent predictor of pN1 (P< .001). The utilization patterns of PLND in the United States have improved, with an increased focus on patients with intermediate- and high-risk disease. Likewise, the extent of PLND has improved to include more lymph nodes. This seems to translate into more accurate tumor, node, metastasis classification system staging, as more patients are being appropriately diagnosed with pN1 disease.

Invited Commentary

Invited Commentary

Appraisal of the AJCC 8th edition pathologic staging modifications for HPV−positive oropharyngeal cancer, a study of the National Cancer Data Base

BackgroundThe American Joint Commission on Cancer (AJCC) recently created new staging for human papillomavirus associated oropharyngeal cancer (HPV+ OPSCC) for its 8th edition. These proposals have not yet been validated in a national registry. MethodsReview of National Cancer Database (NCDB) for surgically-treated HPV+ OPSCC for years 2010–2014 to validate the new staging system using the Kaplan Meier method to explore survival outcomes. Results3745 cases were analyzed. Median follow-up was 31.3months. Most patients were Caucasian males with tonsillar cancer. Distribution of stage I disease increased from 3.7% to 80.2% in AJCC 8th. pN1 disease shifted from 17.3% to 75.9%. Treatment and distribution of T-stage varied by pathologic nodal (pN) staging. Extranodal extension (ENE) was positive in 41% cases. Four-year overall survival (OS) for AJCC 8th stages I (92%), II (81%), and stage III (62%) showed excellent hazard discrimination (all pairwise p<0.001). Only 4-year OS by pN staging showed significantly different curves when comparing pN2 (79%) with others (pN0 88%; pN1 91%, p=0.01 and <0.001 respectively). Presence of ENE confers a negative effect on overall survival (92% ENE− vs. 85% ENE+, p<0.001). ConclusionThe NCDB shows improved hazard discrimination and outcome prediction in the AJCC 8th edition staging for HPV+ OPSCC. While overall staging had excellent hazard discrimination, this accounted for poorer discrimination between pN0 and pN1. The majority of patients are reclassified as overall stage I. Presence of extranodal extension demonstrated a statistically significant but modest negative effect on overall survival. Condensed abstract (2 sentences)Using NCDB data for validation, the AJCC 8th ed. pathologic staging system offers much improved hazard discrimination and prognostication in HPV oropharyngeal cancer, with the majority of cases reclassified as pStage I. Of note, only pN2 offered hazard discrimination within nodal staging and presence of pathologic extranodal extension has a modest negative effect on survival.

Rate of Symptomatic Lymphocele Formation After Extraperitoneal vs Transperitoneal Robot-Assisted Radical Prostatectomy and Bilateral Pelvic Lymphadenectomy.

With the peritoneum acting as a natural surface for lymphatic reabsorption, transperitoneal robot-assisted radical prostatectomy (tRARP) is thought to be associated with a lower incidence of symptomatic lymphoceles (SLs) compared with its extraperitoneal counterpart (eRARP) when bilateral pelvic lymph node dissection (BPLND) is performed. In this study, we aim to determine if there is a difference in SL formation and characteristics between the two approaches. We retrospectively reviewed the records of patients who underwent eRARP or tRARP and BPLND by a single surgeon at a tertiary care academic center from July 1, 2003, to May 31, 2016. Patients with a history of prior pelvic radiotherapy, concomitant inguinal hernia repair, RARP without BPLND, or nonadenocarcinoma of the prostate were excluded. The resulting eRARP and tRARP groups were propensity matched for age, body mass index (BMI), American Association of Anesthesiologists (ASA) score, D'Amico risk classification, and pathological lymph node (LN) count. A total of 3183 RARPs were performed during this time period. After applying exclusion criteria and propensity score matching, 671 patients remained in each group. No statistically significant differences were noted between the groups with regard to age, BMI, ASA, pre-RARP prostate-specific antigen, D'Amico risk classification, biopsy and pathological Gleason sum score, pathological T stage, or margin status. The tRARP group had a higher clinical T stage (p = 0.0015), length of stay (LOS; p = 0.005), pathological N stage (4.92% vs 1.36%, p = 0.0002), and high total LN count (7.22 ± 5.54 vs 5.78 ± 4.18 LNs, p < 0.0001). The eRARP group had higher operating room times (197.4 ± 48.96 minutes vs 192.2 ± 44.12 minutes, p = 0.04) and estimated blood loss (218.4 ± 152.0 mL vs 179.9 ± 119.4 mL, p < 0.0001). No differences were noted in the frequency of SL formation [eRARP: 19/671 (2.83%) vs tRARP: 10/671 (1.49%), p = 0.09] or any clinical characteristics of the SL. Logistic regression analysis showed no effect of LN count (p = 0.071), pathological N stage (p = 0.111), or both combined (p = 0.085) on SL formation. In this cohort, the rate and clinical characteristics of SL were similar among patients treated with eRARP or tRARP and BPLND. The low event rate of SL in each group and trends favoring higher SL with LN yield and pN1 disease in the tRAPR group may deem the study underpowered to make definitive conclusions.

Quality Indicators for Sentinel Lymph Node Biopsy in Breast Cancer: Applicability and Clinical Relevance in a Non-screened Population.

Quality Indicators for Sentinel Lymph Node Biopsy in Breast Cancer: Applicability and Clinical Relevance in a Non-screened Population: sentinel lymph node biopsy (SLNB) has replaced axillary lymph node dissection (ALND) as standard of care for management of early breast cancer. This study assessed our SLNB program against 11 published quality indicators (QIs). All breast cancer patients who underwent SLNB in our centre from June 2013-Dec 2015 were included. Clinical, pathological and follow-up data were extracted from the institutional REDCap data system. Analysis was done with SPSS 23. Following validation, 234 patients had SLNB, always performed along with primary surgery. Identification rate was 95.3% and >1 SLN was identified in 72% of patients. SLNB positivity was 33%, of these, 100% underwent ALND. Overall 91% of QI eligible patients underwent SLNB. No ineligible patients (T4) underwent SLNB. For the patients who had radio colloid, injection criteria were met for 100%. Pathological evaluation and reporting criteria were met for 100% of patients. There were no axillary recurrences in a median follow-up of 2years. 7.6% patients had SLN negative on frozen section but positive on final histology. 7.2% of patients with clinical negative nodes had pN2 disease in final histopathology report after surgery. Sixty percent of patients who had completion ALND had only positive SLN. This study supports the applicability of published QI of SLNB in a non-screened cohort of early breast cancer patients. Although QI were useful, modification based on patient characteristics and resource availability may be needed. These indicators can be used as audit tools to improve the overall accuracy of the procedure.

Adequacy of Intraoperative Nodal Staging during Surgical Resection of NSCLC: Influencing Factors and Its Relationship to Survival.

Adequate intraoperative lymph node sampling is a fundamental part of lung cancer surgery, but adherence to standards is not well known. This study sought to measure the adequacy of intraoperative lymph node sampling at a regional Thoracic Surgery Centre and a tertiary lung cancer center in the United Kingdom. This retrospective study analyzed the pathological reports from NSCLC resections over the 4-year period 2011-2014. Adequacy of sampling was assessed against International Association for the Study of Lung Cancer recommendations of at least three mediastinal lymph node stations: station 7 in all patients, station 5 or 6 in left upper lobe tumors, and station 9 in lower lobe tumors. The influence of clinical variables (age, tumor T stage, type of surgery, and laterality) on adequacy of sampling and the effect of adequacy on overall survival were also assessed. A total of 1301 NSCLC resections were performed from January 11, 2011, to December 31, 2014. Adequate intraoperative lymph node sampling increased significantly from 14% (22 of 160) in 2011 to 53% (206 of 390) in 2014 (p= 0.001). Secondary analysis of clinical variables also revealed that patients with T1a or T4 tumors, those undergoing sublobar resections, those undergoing video-assisted thoracic surgery resections, and those undergoing left-sided resections have significantly higher rates of inadequate lymph node sampling. Overall, there was no statistically significant difference in survival between patients with adequate versus inadequate intraoperative lymph node sampling or when survival was stratified according to overall stage. There was worse survival in inadequate sampling for patients with pN2 disease than for patients with pN2 disease and adequate sampling. This study provides a much-needed benchmark of current thoracic surgical practice in lung cancer in the United Kingdom and important granularity to facilitate changes to improve adequacy of staging.

Adjuvant Chemotherapy Does Not Confer Superior Survival in Patients With Atypical Carcinoid Tumors

Although the use of adjuvant chemotherapy in patients with pathologically node-positive (pN+) atypical carcinoid tumor of the lung is an accepted practice, controversy exists about its use in pathologically node-negative (pN0) patients. Our aim was to determine whether a survival advantage exists in patients receiving chemotherapy postoperatively for pN0 or pN+ atypical carcinoid tumors of the lung. Adult patients treated with lobectomy or pneumonectomy for pulmonary atypical carcinoid tumor were identified using the National Cancer Data Base, 2006 to 2011. Propensity scoring (4:1 nearest neighbor algorithm) and survival analysis were used to examine the association between adjuvant chemotherapy and pN+ versus pN0 atypical carcinoid tumors. Of the total 581 patients identified with a diagnosis of atypical carcinoid of the lung, 363 (62.5%) were found to be node negative at the time of operation and 218 (37.5%) had node-positive disease. Adjuvant chemotherapy was used in 15 patients (4.1%) with pN0 disease and 89 patients (40.8%) with pN+ disease. Unadjusted survival, at 12 and 60 months, was similar between pN+ patients who were treated with adjuvant chemotherapy versus patients who received operation alone (adjuvant chemotherapy: 98.9% at 12 months and 47.9% at 60 months versus operation alone: 98.4% and 12 months and 67.1% at 60 months, p= 0.46) and for propensity-matched pN0 (adjuvant chemotherapy: 86.7% at 12 months and 73.3% at 60 months versus operation alone: 87.9% at 12 months and 72.3% at 60 months, p= 0.54). In a national-level analysis, the use of adjuvant chemotherapy postoperatively in patients with pN+ and pN0 disease conferred no survival advantage; further study is needed to determine proper chemotherapy use for these patients.

Does oncogenic mutation status influence tumor spread in resectable lung cancer?

Skip N2 metastasis of lung cancer is known to involve the mediastinum, but not the hilar lymph nodes. This phenomenon itself is not especially rare, as the incidence in resected pN2 disease is reported to range from 17.6% to 40.4% ( Table 1 ) (1-13). Prognosis after resection is favorable for skip N2 cases compared with that of pN2 cases accompanied with hilar disease. Based on data from the International Association for the Study of Lung Cancer, Asamura et al . (15) documented no significant survival differences between the skip N2 phenotype and multistation pN1 disease, and thus recommend that physicians record N categories using new descriptors for further testing. With regard to factors predictive of skip N2 metastasis, several authors suggested that the histological type and tumor-containing lobe are predictive of skip pN2. An investigation on resected non-small-cell lung cancer cases conducted by Misthos et al . (3) reported that skip N2 occurred more frequently in squamous cell carcinoma than in adenocarcinoma. Li et al . (13) documented that acinar adenocarcinoma was more frequently associated with skip N2 metastasis in pN2 cases. In terms of the tumor-containing lobe, Riquet et al . (5) actually revealed a higher incidence of skip N2 metastasis involving tumors of the upper lobe and suggested potential contributions of lymph drainage patterns and visceral pleural invasion (VPI) to the spread patterns. In a study of 422 cases of cStage IA adenocarcinoma, Gorai et al . (12) identified 21 instances of skip N2 in 52 pN2 cases and found a significant association between skip pN2 and VPI and concluded that lymph node dissection was essential in cN0 VPI cases.

Abstract 3920: Tumor volume as a predictor of lymph node metastases in prostate cancer

Abstract Introduction: Pelvic lymph node dissection (PLND) is recommended during radical prostatectomy (RP) in patients with high risk prostate cancer (PCa). Guidelines recommend extended PLND in patients who have &amp;gt;5% probability of lymph node involvement, calculated from pre-operative parameters. PLND increases procedure time and potential morbidity to patients. Tumour size has been reported to be predictive of biochemical recurrence after RP. We analysed the utility of several parameters including tumour size in predicting lymph node metastases in order to further refine the population who require PLND during RP. Materials &amp; Methods: We maintained a prospective database of Robotic Assisted Radical Prostatectomy (RARP) from July 2012 to August 2016 consisting of a cohort of 531 patients. Patients with &amp;gt;5% calculated probability of lymph node metastasis had PLND during RARP. We performed multiple linear regression using age, PSA, D’Amico risk score, ISUP prognostic group, clinical T-stage, radiological T-stage, tumour volume, tumour volume relative to prostate size (relative tumour volume), and number of nodes excised during PLND to determine if any of these parameters could predict the presence of lymph node metastases. Results: Of the cohort of 531 patients, 154 had PLND during RARP. Of the PLND cohort, 15 (10%) had pN1 disease. Tumour volume (r2 0.044, p= 0.0098), relative tumour volume (r2 0.033, p=0.026) and number of lymph nodes excised (r2 0.046, p=0.0075) were independent predictors of pN1 disease. D’Amico risk score (r2 0.019, p=0.089) approached but did not reach statistical significance. Patients with pN1 disease all had primary tumours ≥6cc. Conclusions: In our cohort of PLND patients, tumour volume was an independent risk factor for pN1 disease. With the increasing availability of multi-parametric MRI, tumour volume can be measured pre-operatively as an adjunct to PIRADS scoring. The role of tumour volume and relative tumour volume in predicting lymph node metastasis in conjunction with other pre-operative parameters requires further investigation. The use of tumour volume in determining the need for PLND in patients undergoing RP may help to further refine the population at highest risk for pN1 disease and avoid the additional morbidity of PLND in those at low risk. In addition, our findings support the recommendation of performing an extended PLND to maximise regional lymph node clearance. Citation Format: Chidi N. Molokwu, Keith Yuen, Sanjay Addla, Rajindra Singh, Rohit Chahal. Tumor volume as a predictor of lymph node metastases in prostate cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3920. doi:10.1158/1538-7445.AM2017-3920

Clinical Outcomes in pT4 Tongue Carcinoma are Worse than in pT3 Disease: How Extrinsic Muscle Invasion Should be Considered?

The identification of extrinsic tongue muscle invasion in oral cavity cancer remains challenging. Notably, the most recent American Joint Committee on Cancer (AJCC 2017, 8th edition) staging manual indicates that extrinsic muscle invasion does not lead to the diagnosis of a T4 tumor. Because this approach carries the risk of tumor downstaging, we compared the clinical outcomes of patients with oral tongue squamous cell carcinoma (SCC) staged as pT3 vs. pT4 according to the AJCC 2010, 7th edition criteria. We retrospectively examined the records of consecutive patients with pT3 (n=135) and pT4 (n=68) tongue SCC who underwent radical surgery. Of the 68 pT4 tongue SCC, 63 (93%) had extrinsic muscle involvement alone. The 5-year locoregional control (LRC), distant metastasis (DM), and disease-free survival (DFS) rates served as outcome measures. Compared with pT3 tongue SCC, pT4 patients presented significantly more frequently with pN2 disease, extranodal extension, poor tumor differentiation, tumor depth >15 and >20mm, margin status ≤4mm, perineural invasion, vascular invasion, and were more frequently treated with surgery plus concurrent chemoradiotherapy. Less favorable 5-year outcomes were observed in patients with pT4 than pT3 tumors (LRC 50 vs. 75%, p<0.001; DM 27 vs. 14%, p=0.013; DFS 43 vs. 69%, respectively, p<0.001). We identified pT4 disease (vs. pT3) as an independent adverse prognostic factor for LRC and DFS. We suggest classifying patients with tongue SCC and extrinsic muscle invasion as having pT4 disease.

Nodal upstaging: effects of instrumentation and three-dimensional view in clinical stage I lung cancer.

Nodal upstaging after surgical intervention for non-small cell lung cancer (NSCLC) is defined as the presence of unsuspected pathologic hilar (pN1) or mediastinal (pN2) disease detected during the final histopathologic evaluation of surgical specimens. The prevalence of pathologic nodal upstaging is used as a quality measure for the definition of the completeness of the nodal dissection. Risk factors for nodal upstaging may be patient-related (history of tuberculosis, rheumatoid arthritis, and diabetes mellitus), or tumor-related (central tumor, higher T stage, higher SUVmax value, or adenocarcinoma). Actually, the theorical superiority of a minimally invasive resections is the lymph node dissection. Studies may suggest that, expert video-assisted thoracoscopic surgery (VATS) surgeon could do similar lymph node dissection as it is done in open. Robotic surgeons may replicate the results of lymph node dissection in the open techniques. The possible reason for this is the instrumental superiority provided by the higher technology.

How many lymph nodes is enough? Defining the optimal lymph node dissection in stage I-III gastric cancer using the National Cancer Database.

4034 Background: Gastric cancer is one of the most causes of cancer-related death worldwide. Surgical resection with lymph node dissection is the primary therapeutic modality. However, the appropriate extent of lymph node dissection remains controversial. Herein, the National Cancer Database (NCDB) was used to determine the optimal number of lymph nodes (LNs) to be dissected for resectable gastric cancer. Methods: The NCDB was queried from 2004-2013 for patients with invasive gastric cancer who underwent surgical resection with negative margins. The optimal number of LNs dissected was determined using a univariate χ2 cut-point analysis. Actuarial survival was determined using the Kaplan Meier method, and comparisons of survival estimates were completed with log-rank tests. Multiple sensitivity analyses were utilized to decrease bias. Results: 17,851 patients were included. The mean (±SD) number of LNs examined was 16 ± 11. For all patients, the optimal number of LNs needed to be examined was 20+ nodes. When correcting for stage migration ( &lt; 7 LNs removed), the optimal cut-off value was 20+ LNs. When stratifying by pathologic nodal stage, the cutpoint was 10+ LNs for pN1 and pN2. The 5-year survival was 30.6 ± 1.6% for 0-9 removed LNs compared to 48.2 ± 1.2% for 10+ removed LNs (p &lt; 0.001) in pN1 disease and 18.3 ± 1.7% for 0-9 removed LNs compared to 32.6 ± 1.2% for 10+ removed LNs (p &lt; 0.001) in pN2 disease. For pN3 disease, the optimal cut-off point was 20+ LNs; the 5-year survival was 17.2 ± 1.3% for 0-19 removed LNs compared to 28.5 ± 1.7% for 20+ removed LNs (p &lt; 0.001). Moreover, the outcome was inferior among patients who had &gt; 10% positive dissected LNs (p &lt; 0.05). Conclusions: The optimal number of dissected LNs of 20+ LNs was associated with superior survival. Extended LN dissection is to be considered especially in patients with &gt; 10% positive dissected LNs.

Selective versus routine lymphadenectomy in the treatment of liver metastasis from colorectal cancer: a retrospective cohort study

BackgroundLimited data are available on the importance of routine lymphadenectomy of the hepatoduodenal ligament in the treatment of liver metastasis from colorectal cancer in the literature.MethodsA single center retrospective cohort study was conducted to evaluate morbidity and long-term survival in patients who had undergone selective versus routine lymphadenectomy during surgery for colorectal liver metastasis. From January 2006 to December 2009, eighty-one patients undergoing radical resection due to liver metastasis from colorectal cancer were included. The combination of two surgical teams with different approaches to hepatoduodenal ligament lymphadenectomy at our institution allowed us to select two cohorts of patients undergoing selective or routine lymphadenectomy.ResultsNo significant differences between the cohorts were found in age, American Society of Anesthesiology score or Fong’s prognostic criteria. Patients with pN+ disease had significantly inferior survival compared to patients with pN0 disease (hazard ratio [HR] = 6.33, 95% CI 2.16–18.57, p = 0.0001). No significant difference in postoperative morbidity was observed in the group undergoing routine opposed to selective lymphadenectomy (13.63% vs. 8.69%, p = 0.36). There was no difference in long-term survival between the groups (HR = 0.90, 95% CI 0.52–1.58, p = 0.70). There were also no significant differences in the subgroup of patients with pN0 stage (HR = 1.17, 95% CI 0.6–2.11, p = 0.60).ConclusionsThese data suggest that there is no survival benefit from the use of routine lymphadenectomy during surgery for colorectal liver metastasis, but these data should be confirmed in a prospective randomized study.

PD51-10 SURVIVAL AFTER RADICAL PROSTATECTOMY IN PATIENTS WITH PSA PERSISTENCE: THE IMPACT OF COMPETING CAUSES OF MORTALITY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy VI1 Apr 2017PD51-10 SURVIVAL AFTER RADICAL PROSTATECTOMY IN PATIENTS WITH PSA PERSISTENCE: THE IMPACT OF COMPETING CAUSES OF MORTALITY Giorgio Gandaglia, William Parker, Nicola Fossati, Paolo Dell'Oglio, Armando Stabile, Carlo Andrea Bravi, Luigi Nocera, Francesco Pellegrino, Emanuele Zaffuto, Nazareno Suardi, Francesco Montorsi, R. Jeffrey Karnes, Stephen Boorjian, and Alberto Briganti Giorgio GandagliaGiorgio Gandaglia More articles by this author , William ParkerWilliam Parker More articles by this author , Nicola FossatiNicola Fossati More articles by this author , Paolo Dell'OglioPaolo Dell'Oglio More articles by this author , Armando StabileArmando Stabile More articles by this author , Carlo Andrea BraviCarlo Andrea Bravi More articles by this author , Luigi NoceraLuigi Nocera More articles by this author , Francesco PellegrinoFrancesco Pellegrino More articles by this author , Emanuele ZaffutoEmanuele Zaffuto More articles by this author , Nazareno SuardiNazareno Suardi More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , R. Jeffrey KarnesR. Jeffrey Karnes More articles by this author , Stephen BoorjianStephen Boorjian More articles by this author , and Alberto BrigantiAlberto Briganti More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2210AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We aimed to assess the risk of cancer-specific mortality (CSM) in patients with PSA persistence after radical prostatectomy (RP) after accounting for other-cause mortality (OCM). We hypothesized that a non-negligible proportion of patients is at risk of dying from other causes and would not benefit from additional cancer therapies. METHODS We included 829 patients with localized PCa undergoing RP at two referral centers between 1994 and 2014. All patients had PSA persistence after RP defined as a PSA ≥0.1 ng/ml at 8 weeks after surgery. A graphical illustration of the 10-year CSM and OCM rates was generated using competing-risks Poisson regression analyses. Patients were stratified according to age (<65 vs. ≥65 years) and according to their probability of dying from PCa at 10-years (stratified as <10% vs. 10-30% vs. >30%), which was developed from a Cox regression model based on pathologic characteristics and first PSA after surgery. For each strata, survival estimates were calculated. Competing-risks regression models were used to test the effect of age and disease characteristics on CSM after accounting for OCM. RESULTS Overall, 223 (26.9%), 331 (39.9%), and 275 (33.2%) patients had pathologic Gleason score ≤6, 7, and ≥8, and 400 (48.3%), 215 (25.9%), 214 (25.8%), and 172 (20.7%) patients had pT2, pT3a, pT3b/4, and pN1 disease. The median first PSA after surgery was 0.33 ng/ml. Median follow-up was 107 months, during which time 90 and 136 patients died from PCa and from OCM. The 10-year CSM and OCM rates were 12.6% and 11.9%. When considering men with a risk of dying from PCa <10%, the 10-year rate of OCM was higher as compared to the CSM rate (8 vs. 1.6%), regardless of age. The proportion of patients who died from OCM at 10-year was 4.2% in men <65 years with a probability of dying from PCa >30% vs. 18.2% in patients ≥65 years with a probability of CSM between 10 and 30%. In men with a calculated risk of dying from PCa >30% the 10-year CSM rates were 43.7 vs. 34.1% for those aged <65 vs. ≥65 years old. At multivariable regression analyses, the number of positive nodes, first PSA after surgery, and pathologic Gleason score 8-10 (all p<0.001) were associated with the risk of CSM after accounting for the risk of dying from other causes. CONCLUSIONS Up to 20% of men with PSA persistence after RP will ultimately die from other causes. Conversely, patients with Gleason score 8-10, higher PSA after surgery, and a higher number of positive nodes are at increased risk of CSM. These patients might benefit from additional cancer therapies, while men less likely to die from PCa may be spared such treatments. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e987-e988 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Giorgio Gandaglia More articles by this author William Parker More articles by this author Nicola Fossati More articles by this author Paolo Dell'Oglio More articles by this author Armando Stabile More articles by this author Carlo Andrea Bravi More articles by this author Luigi Nocera More articles by this author Francesco Pellegrino More articles by this author Emanuele Zaffuto More articles by this author Nazareno Suardi More articles by this author Francesco Montorsi More articles by this author R. Jeffrey Karnes More articles by this author Stephen Boorjian More articles by this author Alberto Briganti More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Are all grade group 4 prostate cancers created equal? Implications for the applicability of the novel grade grouping

BackgroundAccording to the novel prostate cancer (PCa) grade grouping, men with Gleason score 8 should be included in the grade group 4 regardless of primary and secondary scores. We aimed at evaluating the effect of Gleason patterns on the risk of recurrence in men with grade group 4 PCa. Patients and methodsOverall, 1,089 patients treated with radical prostatectomy with grade group 4 PCa at final pathology were identified. Biochemical recurrence (BCR) was defined as 2 consecutive prostate-specific antigen values≥0.2ng/ml and rising. Clinical recurrence (CR) was defined as positive imaging after BCR. Kaplan-Meier analyses assessed time to BCR and CR. Multivariable Cox regression analyses assessed the impact of Gleason patterns on the risk of BCR and CR. ResultsOverall, 295 (27.1%), 651 (59.8%), and 143 (13.1%) patients had pathologic Gleason pattern 3+5, 4+4, and 5+3. Overall, 435 (39.9%) patients had positive margins and 439 (30.2%), 300 (27.5%), 350 (32.1%), and 216 (19.8%) had pT2, pT3a, pT3b/4, and pN1 disease. Median follow-up was 83 months. Overall, 536 and 221 patients experienced BCR and CR. The 10-year BCR- and CR-free survival rates were 42.9% and 67.5% vs. 38.3% and 59.7% vs. 40.6% and 50.4% for patients with pathologic Gleason pattern 3+5 vs. 4+4 vs. 5+3, respectively (all P≤0.005). In multivariable analyses, patients with Gleason pattern 3+5 were at lower risk of BCR compared to those with 4+4 (P = 0.002). Men with Gleason pattern 3+5 were at lower risk of CR compared to those with 4+4 and 5+3 (all P≤ 0.01). ConclusionsPatients with a primary Gleason score 3 are at reduced risk of recurrence as compared to their counterparts with 4 or 5. Primary and secondary Gleason scores should be considered to stratify the risk of recurrence after surgery in patients with grade group 4 PCa.