Positive Lymph Node Yield Research Articles

354. NEOADJUVANT CHEMORADIOTHERAPY FOLLOWED BY SURGERY VERSUS UPFRONT SURGERY FOR ESOPHAGEAL CANCER: LONG-TERM OUTCOMES IN A CROSS TRIAL STUDY CENTER

Abstract Background Since the publication of the CROSS-trial, showing improved survival following neoadjuvant chemoradiotherapy + surgery (CRT-S) compared to upfront surgery (U-S) for esophageal cancer, this neoadjuvant regimen has become standard care in the Netherlands. Given the relatively low R0 rate in the U-S arm (69%) and lymph node yield (LNY) in both arms (15 U-S, 18 CRT-S) observed in the CROSS-trial, the present study aimed to compare survival of patients who underwent CRT-S versus U-S in a tertiary referral center that participated in the CROSS-trial, within the era that the trial was performed. Methods This retrospective study included patients, who underwent an esophagectomy between 2004-2010, and met the CROSS-trial inclusion criteria. Primary outcome was 10-year overall survival (OS), and patients with CRT-S and U-S were compared. Secondary outcomes were R0-resection rate, LNY and positive LNY. Subgroup analyses were performed for histology (adenocarcinoma [AC] and squamous cell carcinoma [SCC] and for surgical approach (transthoracic [TTE] and transhiatal [THE] esophagectomy). Results We included 288 patients: 144 after CRT-S, 144 after U-S. 112 (39%) participated in the CROSS-trial. 10-year OS was not significantly better for CRT-S (40%) versus U-S (34%; p=0.183). In SSC, OS following CRT-S was 49% and after U-S 35% (p=0.228), versus 38% and 34% in AC (p=0.396). Following TTE, OS was better compared to THE in both CRT-S and U-S groups: 44% and 39% (p=0.369) versus 32% and 29% (p=0.590). R0-rates were 96% (CRT-S) and 86% (U-S). Median LNY was equal: 23. 55 (38%) and 100 (69%) patients had positive lymph nodes after respectively CRT-S and U-S. Conclusion This study showed that, with a radical TTE, comparable OS results can be achieved, and therefore CRT may not be indicated in all patients. Further analyses are necessary to identify patients who may benefit from the additional local treatment that CRT is (e.g SCC or involved circumferential resection margin). Additionally, surgical techniques have improved since the CROSS-trial, with less surgical trauma in minimally invasive esophagectomy. This may result in better outcomes for surgery nowadays, indicating the need for further studies in the current era.

Microscopic tumor mapping of post-neoadjuvant therapy pancreatic cancer specimens to predict post-surgical recurrence: A prospective cohort study

BackgroundAlthough various pathological grading systems are available for evaluating the response of pancreatic ductal adenocarcinoma (PDAC) to neoadjuvant therapy (NAT), their prognostic value has not been thoroughly validated. This study examined whether microscopic tumor mapping of post-NAT specimens could predict tumor recurrence. MethodsThis prospective study enrolled 52 patients who underwent pancreaticoduodenectomy after NAT for PDAC between 2019 and 2021. Microscopic mapping was performed to identify residual tumor loci within the tumor bed using 4 mm2 pixels. Patients were divided into small extent (SE; n = 26) and large extent (LE; n = 26) groups using a cutoff value of 226 mm2. The diagnostic performance for predicting tumor recurrence was evaluated using receiver operating characteristic (ROC) curves. ResultsCarbohydrate antigen 19-9 levels were normalised after NAT in more patients in the SE group (SE 21 [80.8%] vs. LE 13 [50.0%]; P = 0.041). Tumor size (P < 0.001), T stage (P < 0.001), positive lymph node yield (P = 0.024), and perineural invasion rate (P = 0.018) were significantly greater in the LE group. The 3-year disease-free survival rate was significantly lower in the LE group (SE 83.3% vs. LE 50.0%, P = 0.004). The area under the ROC curve for mapping extent was 0.743, which was greater than that of the other tumor response scoring systems. ConclusionsMicroscopic tumor mapping of the residual tumor in post-NAT specimens is a significant predictor of post-surgical recurrence, and offers better prognostic performance than the current grading systems.

Robotic-assisted versus laparoscopic nephroureterectomy; a systematic review and meta-analysis.

Upper tract urothelial carcinoma (UTUC) is the malignant transformation of urothelial cells, from the renal calyces to the ureteral orifices. While the benefits of minimally invasive nephroureterectomy over their open counterpart have been established, the optimal technique remains a debate. We aimed to assess current evidence in the literature and compare outcomes between robotic-assisted (RANU) and laparoscopic nephroureterectomy (LNU). A systematic review of the literature was performed for studies comparing RANU and LNU for bladder cancer. Outcome measurements were recurrence rates (local and distal), positive margins, positive lymph node yield and perioperative outcomes. Meta-analysis was performed using Review Manager 5. Our results demonstrate a significantly higher mortality rate in patients undergoing laparoscopic nephroureterectomy when compared with the robotic-assisted approach for the treatment of UTUC (1.8% vs. 1.1%, p = 0.008); however, these results were inconsistent on sensitivity analysis and should therefore be interpreted with caution. No significant difference was observed for other outcomes. The ideal approach to minimally invasive radical nephroureterectomy remains undetermined. Future research, ideally prospective randomised studies, should focus on long-term outcomes, in particular recurrence, recurrence-free survival, overall survival and the correlation between surgical technique and survival.

Efficacy and safety of camrelizumab combined with FOLFOX as neoadjuvant therapy for patients with resectable locally advanced gastric and gastroesophageal junction adenocarcinoma who received D2 radical gastrectomy.

e16549 Background: Neoadjuvant chemotherapy for patients with locally advanced gastric and gastroesophageal junction adenocarcinoma (GC/GEJC) can improve the overall survival without increasing operation risk. Nowadays, immunotherapy has become a new promising neoadjuvant treatment. Therefore, we intended to evaluate the safety and efficacy of camrelizumab (anti-PD-1 antibody) combined with FOLFOX as the neoadjuvant therapy for patients with locally advanced GC/GEJC who received D2 radical gastrectomy. Methods: Patients who were diagnosed as resectable locally advanced GC/GEJC received the neoadjuvant treatment of camrelizumab and FOLFOX every 2 weeks for 4 cycles. Imaging evaluation was performed in 2-4 weeks after neoadjuvant therapy. Patients who had no progression disease (PD) were recruited. Eligible patients underwent gastrectomy with D2 lymph node dissection through laparotomy or laparoscopic surgery. The primary end points were safety and R0 resection rate. Results: From July 24 2019 to January 31 2020, 15 patients were recruited. The mean age was 57 years. A total of 10(67%) were males and 5(33%) were females. According to AJCC 8th, cT3 and cT4 were confirmed in 7(47%) patients and 8(53%) patients, N1 and N2 in 7(47%) patients and 8(53%) patients, respectively. During operation, intraperitoneal metastases were found in 2 patients. Of the 13 surgeries, only 2 were laparoscopic and the others were laparotomy. The surgical procedures included Roux-en-Y (9, 69.2%), Billroth II (1, 7.7%) and jejunum interposition (3, 23.1%). Thirteen patients underwent gastrectomy with D2 lymph node dissection and all of them were confirmed R0 resection by postoperative pathology results. The mean lymph node yield was 44.1±13.2 nodes, positive lymph node yield was 1.8±2.8 nodes. Duration time of surgery was 186.5±45.5 minutes, mean blood loss was 219.2±109 ml during the operation. Mean hospital stays were 13.2±2.4 days. Only 1 patient experienced grade 3 pneumonia. Neither serious intraoperative complications nor immune-related adverse events both prior and post operation were observed. There was no treatment-related death. Conclusions: Camrelizumab combined with FLOFOX as neoadjuvant treatment for patients with locally advanced GC/GEJC showed acceptable toxicity and promising efficacy with low complications and mortality. Clinical trial information: NCT03939962 .

Rectal cancer in young Indians—Are these cancers different compared to their older counterparts?

The incidence of rectal cancer in young Indians is increasing. Recent evidence suggests a probable existence of noncanonical tumorigenesis pathways in early-onset colorectal cancer patients in India. The aim of the study was to evaluate rectal cancer outcomes in patients ≤40 years with those >40 years. An analysis of a prospective database of surgically treated rectal cancer patients ≤40 years (group 1) and those >40 years (group 2) over 2 years was performed. Clinicopathological features, perioperative outcomes, and disease-free survival (DFS) were analyzed. Of the 512 patients with colorectal cancer treated surgically, 237 patients (group 1-57 patients; group 2-180 patients) were diagnosed with nonmetastatic rectal adenocarcinoma. Patients in group 1 were more likely to present with locally advanced (stage III) disease (p < 0.005) resulting in a higher proportion of them receiving neoadjuvant chemoradiotherapy (NACT-RT). There was no difference in morbidity and mortality between the two groups. Younger patients had a significantly higher median total and positive lymph node yield (p < 0.003). Patients in group 1 had a significantly lower overall DFS (p < 0.005). Stage-specific DFS also demonstrated a significantly lower trend in stage III patients in group 1. Young rectal cancer patients in India tended to present more frequently with locally advanced tumors resulting in a higher proportion being treated with NACT-RT. Stapled rectal anastomoses could be performed safely in young patients even after NACT-RT. The significantly poorer DFS in young Indian patients with stage III disease was a novel finding and merits further investigation into tumor biology.

Improving the standard of lymph node retrieval after gastric cancer surgery

To examine factors that influence lymph node count and to study the relationship between nodal size and metastatic involvement in gastric cancer. Observational study comparing lymph node retrieval by manual nodal dissection (MND) and systematic fat blocking (SFB) from 114 gastrectomy specimens. The influence of lymph node retrieval method, patient characteristics, oncological factors and surgical approach on lymph node count were examined using regression models. The risk-adjusted cumulative sum chart method was also used to analyse lymph node count. The lymph node count increased during the course of this study (P < 0.005). Both pathologist and lymph node retrieval method were independent predictors for lymph node count. MND yielded lower lymph node counts than SFB (58 versus 66, P < 0.05). The pathologist influenced lymph node retrieval by MND (R(2) : 0.297-0.518, P < 0.0001), but not SFB (R(2) : 0.340-0.344, P > 0.05). The percentage of positive lymph nodes below 5 mm was 24.2% and 44.1% for MND and SFB, respectively, resulting in cancer upstaging (P = 0.037). Systematic fat blocking is associated with a higher total and positive lymph node yield compared to MND and is independent of the pathologist. Ignoring small lymph nodes can be a major cause for missing positive nodes, leading in turn to cancer down-staging.

The influence of surgeon and pathologist in obtaining high median lymph node yields after colorectal resection for adenocarcinoma

<h3>Introduction</h3> The number of lymph nodes evaluated in resected colorectal adenocarcinoma specimens is associated with patient survival and therefore used as a marker of quality in colon cancer care.1 The aim of this study was to assess whether individual surgeons and pathologists retrieving and analysing colorectal resection specimens at our centre differed in their lymph node yields (LNY). <h3>Methods</h3> Casenotes for all elective Right Hemicolectomies (RHC) and Anterior Resections (AR) performed at our centre for adenocarcinoma between 2008–2009 were identified using hospital coding and histology reports were assessed for LNYs. Total and positive LNYs were compared between surgeons and pathologists using GnuPSPP statistical software. <h3>Results</h3> Two dedicated colorectal surgeons and 5 pathologists produced 77 RHC and 125 AR (of which 62 were Total Mesorectal Excisions (TME)) specimens. Median total LNYs for each of our surgeons were: 22(16.5–28.6) and 23(17–31) p = 0.95 for RHC; 21(12–28) and 16(12.5–27) p = 0.37 for all ARs; and 19(9.5–25) and 15(12–24) p = 0.13 for TMEs. Positive LNYs from RHC (p = 0.5), AR (p = 0.80) and TME (p = 0.23) were also similar between the surgeons. Of the 5 pathologists the highest and lowest median total LNYs for RHC, AR and TME specimens were: 28(21–32) to 16.5(14.5–18.5); 28(21–35) to 14.5(10–19.72); and 25(16.5–34) to 9(8.5–16.5), respectively. Oneway ANOVA testing of the 5 pathologists total LNYs for RHC, AR and TME gave p values of 0.02, 0.00 and 0.01, respectively. The pathologist with the lowest LNY after TME had significantly more specimens (57%) treated with neoadjuvant radiotherapy than the other pathologists. Comparison of positive LNYs between pathologists showed no differences in yields with p = 0.05 for RHC, p = 0.80 for AR and p = 0.23 for TME. <h3>Conclusion</h3> Lymph node yields following colorectal resection at our centre are far higher than published yields from other centres.2 No difference was seen in the LNYs delivered by the 2 surgeons studied; however, there was a significant difference in total LNYs between our 5 pathologists; with some pathologists consistently producing huge yields. This did not, however, translate to a difference in positive LNYs produced by our pathologists although our study is underpowered to demonstrate equivalence.

The number of lymph nodes identified in a simple pancreatoduodenectomy specimen: comparison of conventional vs orange-peeling approach in pathologic assessment

Lymph node status is one of the most important predictors of survival in resectable pancreatic ductal adenocarcinoma; therefore, thorough lymph node evaluation is a critical assessment in pancreatoduodenectomy specimens. There is considerable variability in pancreatoduodenectomy specimens processed histologically. This study compares two approaches of lymph node dissection and evaluation (standard vs orange peeling) of pancreatoduodenectomy specimens. A different approach to dissection of pancreatoduodenectomy specimens was designed to optimize lymph node harvesting: All peripancreatic soft tissues were removed in an orange-peeling manner before further dissection of the pancreatic head. This approach was applied to 52 consecutive pancreatoduodenectomy specimens performed for ductal adenocarcinoma at two institutions. Specimen dissection was otherwise performed routinely. Overall number of lymph nodes harvested, number of positive lymph nodes, and their anatomic distribution were analyzed and compared with cases that had been dissected by the conventional approach. The mean number of lymph nodes identified by the orange-peeling approach was 14.1 (by institution, 13.8 and 14.4), as opposed to 6.1 (by institution, 7 and 5.3) in cases processed by conventional approach (P=0.0001). The number of lymph node-positive cases also increased substantially from 50% (by institution, 54 and 46%) in the conventional method to 73% (by institution, 88 and 58%) in the orange-peeling method (P=0.02). The orange-peeling method of lymph node harvest in pancreatoduodenectomy specimens for ductal adenocarcinoma enhances overall and positive lymph node yield and optimizes ductal adenocarcinoma staging. Therefore, lymph node harvest by the orange-peeling method should be performed routinely before specimen sectioning in assessment of pancreatoduodenectomy for ductal adenocarcinoma.

Is the number of metastatic nodes in neck dissections influenced by total nodal yield?

Introduction: The presence or absence of lymph node metastases is the most important prognostic factor in patients with squamous cell carcinoma (SCC) of the head and neck. If a high total yield is related to a higher probability of recovering positive nodes then meticulous surgery and specimen analysis might determine the need for adjuvant therapies and could therefore influence survival. The aim of this study was to determine the total lymph node yield in consecutive neck dissections and to investigate whether any association between positive and total nodal yield existed in patients presenting with oral SCC. Methods: A retrospective analysis of 68 neck dissections (mean age 65 years, male:female ratio 2:1) was undertaken to identify the total and positive lymph node yield for each level of the neck dissection. Results: The mean number of nodes examined for comprehensive neck dissections was 40.4. The probability of recovering positive nodes was only increased in cases with a total nodal yield above the mean for levels 1, 2a and 3. This was significant for levels 1 (P < 0.05) and 2a (P < 0.01). Discussion: A higher total nodal yield may be associated with an increased probability of positive nodal recovery in levels 1, 2a and 3 of neck dissections in patients with oral SCC.