Presumed Stage Research Articles

Imaging as a guide to tissue sampling

When assessing a patient with lung cancer, it is important to stage the tumor in order to determine prognosis and direct appropriate therapy. Although imaging findings, particularly with CT and PET, can suggest the correct tumor stage, imaging is imperfect in this regard; enlarged and/or hypermetabolic lymph nodes may require sampling for confirmation of presumed tumor stage. A major role for imaging is to direct the most optimal method of tissue sampling in order to establish the highest possible tumor stage, so that proper therapy may be instituted [1]. Lymph node biopsies may be performed using mediastinoscopy for lymph nodes that are adjacent to the trachea or carina; bronchoscopy with endobronchial ultrasound for lymph nodes adjacent to the trachea, carina, mainstem bronchi and more peripheral airways; video assisted thoracoscopic surgery (VATS) for lesions adjacent to the pleural surfaces; Chamberlain procedure for lymph nodes in the aortopulmonary window and anterior paraaortic regions; endoscopic ultrasound (EUS) for nodes adjacent to the esophagus; ultrasonography for nodes in the neck and supraclavicular regions; and CT biopsy for large, accessible nodes. Selection of the best method for obtaining a tissue sample necessitates consideration of various factors, including the location of the lesion, the need for sampling of single vs. multiple lymph node stations, the amount of tissue that is necessary to make a confident diagnosis, the expected diagnostic yield and accuracy of the technique, the cost and availability of the procedure at the patient’s institution, the expertise of the physicians, and the safety and risks involved.

Occult Nodal Disease in Patients With Non–Small-Cell Lung Cancer Who are Suitable for Stereotactic Ablative Body Radiation

IntroductionStereotactic ablative body radiotherapy is a therapeutic option for patients with peripheral stage I NSCLC in whom surgical resection is considered high risk. Patients receiving SABR do not undergo systematic nodal dissection and any occult nodal metastases will therefore go undetected. Our aim was to determine what proportion of cases this might represent. Materials and MethodsWe retrospectively studied patients who underwent lung resections for presumed stage I NSCLC between 2008 and 2011 at a United Kingdom teaching hospital. We reviewed postoperative pathological lymph node staging and analyzed a subset of these patients in whom SABR would have been be technically possible. ResultsWe reviewed 128 cases of presumed NSCLC preoperatively staged as T1/2a N0 M0. Of 89 cases with peripheral tumor location, 8 patients (8.9%) had nodal involvement at surgical resection. ConclusionOur data show that approximately 1 in 11 patients with peripheral stage I NSCLC will have occult mediastinal/hilar nodal involvement. Although this is a relatively small proportion, routine use of EBUS-TBNA for nodal staging in patients undergoing SABR might identify a greater proportion of patients with nodal disease compared with a strategy of nodal staging directed according to positron emission tomography-computed tomography findings.

Efficacies and pregnant outcomes of fertility-sparing treatment with medroxyprogesterone acetate for endometrioid adenocarcinoma and complex atypical hyperplasia: our experience and a review of the literature.

We retrospectively analyzed oncologic and reproductive outcomes of fertility-seeking premenopausal women with complex atypical hyperplasia (CAH) or Grade 1 endometrial adenocarcinoma (G1EA) who underwent medical management with high-dose medroxyprogesterone acetate (MPA) therapy. Patients were given a dose of 400-600 mg of MPA orally on a daily basis. They had histologically confirmed CAH or G1EA at presumed stage IA and wished to preserve fertility. Endometrial tissue sampling was carried out by dilation and curettage before and after the treatment and the pathologic response to MPA treatment was assessed. A total of 27 premenopausal patients received MPA therapy. The median follow-up time was 39.2 months (3.4-153.8 months). Complete response was achieved in 81.8 % (9/11) of CAH cases and 68.8 % (11/16) of G1EA. Although no recurrences were found in CAH patients, nine G1EA patients (81.8 %) eventually recurred and underwent total hysterectomy. Neither therapeutic death nor irreversible toxicities were observed during the follow-up periods. Five patients (4 CAH and 1 G1EA) became pregnant and had nine live births. The high efficacy of fertility-sparing treatment with MPA was shown demonstrated. MPA therapy can be considered acceptable for the purpose of enabling patients to preserve their fertility. However, the rate of recurrence was high in patients with G1EA. Even in responders, close follow-up is required and a total hysterectomy needs to be considered without delay. Patients should be aware of the risks and limitations of this conservative treatment.

Fertility-Preserving Treatment in Young Women With Endometrial Adenocarcinoma: A Long-Term Cohort Study

Growing evidence suggests that fertility-preserving treatment is feasible for young women with early-stage, low-grade endometrial carcinoma. However, published data on their long-term outcomes and prognostic factors remain scanty. We aimed to investigate the outcomes of young women receiving fertility-preserving treatment. Between 1991 and 2010, the outcomes of young women with grade 1 endometrioid endometrial carcinoma at presumed stage IA (without myometrial invasion) who underwent fertility-preserving treatment of megestrol acetate 160 mg/d with or without other hormonal agents were retrospectively analyzed. We identified 37 eligible patients (median age, 32 years; range, 18-40 years). The median follow-up time was 78.6 months (range, 19.1-252.8 months). Complete response (CR) lasting more than 6 months was achieved in 30 (81.1%) women. Responders were significantly younger than nonresponders (P = 0.032). Of the 30 women who had a CR, 15 (50.0%) had disease recurrence. The 5-, 10-, and 15-year cumulative recurrence-free survival rates were 51.0%, 51.0%, and 34.0%, respectively. Notably, those recurred were significantly older (P = 0.003), and the time to CR was significantly longer (P = 0.043) than those without recurrence. One patient developed late recurrences at 156 months, and 2 patients developed ovarian metastasis (6 and 137 months from diagnosis). All the patients are currently alive. This study demonstrates the feasibility of high-dose megestrol acetate-based therapy for fertility preservation. The substantial risk of late recurrences highlights the need for long-term follow-up studies of large sample sizes with in-depth tumor and host molecular signatures.

Mirror-Image Lymph Node in FDG PET/CT and SPECT/CT for Sentinel Node Detection

We report a case of a patient with presumed stage IB1 squamous cell carcinoma of the cervix in which FDG PET/CT scan revealed 1 hypermetabolic left iliac node suggestive to be malignant. Lymphoscintigraphy and SPECT/CT studies previous to sentinel node (SLN) biopsy revealed unilateral drainage in the right pelvis. Intraoperative pathological assessment of the SLN showed no tumoral involvement, and the hypermetabolic node revealed macrometastasis. Tumor node invasion can lead to a lymphatic blockage and become false-negative for SLN technique. Although FDG PET/CT has lower sensitivity than surgical staging, this case shows its value as a preoperative imaging technique.

Oocyte retrieval timing based on spontaneous luteinizing hormone surge during natural cycle in vitro fertilization treatment

To determine the efficiency of oocyte retrieval (OR) timing based on the occurrence of spontaneous LH surge during natural cycle IVF (ncIVF) treatment. Retrospective cohort study. The cohort was divided into five subgroups according to the presumed stage of spontaneous LH surge on scheduling day (1A: before onset; 1B: surge start; 2: ascending slope; 3: peak; and 4: descending slope). Private infertility clinic. Three hundred sixty-five infertile patients who underwent 1,138 ncIVF treatment cycles during 2008-2011. Drug-free ncIVF treatment. Rate of successfully retrieved, fertilized oocytes, cleaved embryos, and live births per scheduled oocyte retrieval. In 61% of the cycles OR was scheduled before or just at the start of the LH surge (groups 1A-1B), whereas in the remaining cases it was scheduled after the surge had already started (groups 2-4). The proportion of cycles with successfully recovered (range, 71%-86%), inseminated (range, 61%-78%), fertilized oocytes (range, 47%-68%), cleaved embryos (range, 45%-66%), and live births (range, 4.1%-9.2%) was not significantly different among subgroups. In ncIVF treatment OR timing based on the occurrence of spontaneous LH surge is feasible, yielding acceptable oocyte recovery, fertilization, and embryo cleavage rates. This strategy combined with a rapid and low-risk OR procedure permits the management of a large ncIVF program on a 7-days-per-week basis within working hours.

Será uma refeição ligeira fator de erro na avaliação da dureza hepática por elastografia hepática transitória? Um estudo prospetivo

IntroductionTransient Elastography (TE) is a noninvasive method widely used to evaluate hepatic fibrosis in patients with liver disease, especially in chronic hepatitis C. It has excellent accuracy in identifying patients with advanced fibrosis or cirrhosis. However, some factors can interfere with liver stiffness (LS) measurement. The food intake may be one of those confounding factors and there are no defined conditions under which the examination should be performed. ObjectivesTo evaluate the influence of food intake in LS and its potential interference with the clinical management of patients with chronic hepatitis B and chronic hepatitis C. Patients & MethodsObservational prospective study in which TE was performed in two physiological conditions – fasting and after (30-60minutes) a standard meal – in a sample of 42 patients with chronic hepatitis B, 26 chronic hepatitis C and 42 controls. The analysis was complemented by the division into subgroups according to the presumed stage of fibrosis. ResultsDespite the LS variation in all groups with food intake, a significant increase was only seen in individuals with chronic hepatitis B without suspected fibrosis (low LS) (p=0,001). This variation could influence the clinical orientation in 11.8% of cases. ConclusionIn our study, a meal altered LS value in chronic hepatitis B without suspected fibrosis (low LS). As it does not seem to interfere significantly with the clinical management of our patients, we can not, at this point, make any suggestion about the usefulness of performing this exam in the fasting condition.

The value of re-exploration in patients with inadvertently morcellated uterine sarcoma

ObjectiveTo describe the role of immediate re-exploration in patients with inadvertently morcellated uterine leiomyosarcoma (ULMS) and smooth muscle tumors of uncertain malignant potential (STUMP). MethodsAll patients with ULMS/STUMP who were managed or referred to the participating institutions from January 2005 to January 2012 following minimally invasive gynecology surgery with morcellation were detected through the pathology database. The diagnosis was confirmed by gynecologic-pathologists following post-surgery pathology review. ResultsTwenty-one patients with the diagnosis of ULMS (N=15) and STUMP (N=6) after morcellation were identified. The median age of occurrence was 46years (range, 25–58years). Median follow-up duration was 27months (range, 1.8–93.1months). None of the 21 patients had documented evidence of extra-uterine disease at the time of original surgery. Ultimately 12 patients were immediately re-explored to complete staging. The median time to the staging surgery was 33days (range 15–118days). Two (28.5%) out of seven patients with presumed stage I ULMS and one (25%) out of four patients with presumed stage I STUMP had significant findings of disseminated intraperitoneal disease detected at immediate surgical re-exploration. One of the 8 patients with confined early ULMS and STUMP at the second surgery had intraperitoneal recurrence, while the remaining 7 patients have had no recurrence and remain disease free. ConclusionSurgical re-exploration is likely to show findings of disseminated peritoneal sarcomatosis in a significant number of patients diagnosed with ULMS after a morcellation procedure. Findings from re-exploration can contribute to the knowledge of natural history of morcellated ULMS/STUMP and allow for accurate prognostication.

Is pre-operative risk-assessment in laparoscopic treatment of presumed low-risk endometrial cancer effective?

In endometrial (pre)malignancy the pre-operative work-up is primarily based on the histopathological specimen obtained. Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy (TLH + BSO) in presumed low-risk clinical stage I endometrioid endometrial carcinoma (EEC) or atypical hyperplasia (AH), is nowadays considered preferred and sufficient treatment in the Netherlands. To test the effectiveness of this pre-operative work-up, a retrospective cohort analysis was performed. Revised pre- and post-operative histopathology was compared and intra- and post-operative complications registered. In 116 consecutive patients with a pre-operative diagnosis of AH or presumed stage I, grade I or II EEC planned for TLH + BSO. In 24.1 % (28/116) revised endometrial histopathology was upgraded on the definitive hysterectomy specimen. In 3.5 % (4/116) upgrading to high-risk grade III endometrial cancer (EC) was observed. In 9.9 % (8/81) of EC cases a post-operative FIGO stage IG3, II, or III was diagnosed. The major and minor short-term complication rates of TLH + BSO were 12.1 and 7.8 %. In 13.8 % (16/116) of cases conversion to laparotomy was necessary, with a significant higher percentage of obese (68.8 %) patients in the conversion versus the successful TLH + BSO group (42 %). Clinical relevant inconsistency between pre- and post-operative histopathology or FIGO stage was observed in 9.9 % of EC cases. More extensive pre-operative risk analysis of presumed low-risk EEC may be indicated, especially for the morbid obese, harboring a substantial risk for conversion to laparotomy and complications.

Total laparoscopic modified radical hysterectomy with lymphadenectomy for endometrial cancer compared with laparotomy

This is the first report to determine the feasibility and safety of total laparoscopic modified radical hysterectomy (TLMRH) in the treatment of presumed stage I endometrial cancer. This was a retrospective study of 132 consecutive patients who underwent surgery for early endometrial cancer. Thirty-nine patients underwent TLMRH and bilateral salpingo-oophorectomy (BSO), and 93 had a total abdominal extrafascial hysterectomy and BSO. Lymphadenectomy was performed in 87 patients. The groups were compared for epidemiological and clinical characteristics, surgical outcomes, hospital stay, lymph nodes harvested, and intraoperative and postoperative complications. The patients in the TLMRH group had less blood loss (42.9 ± 76.3 vs 236.8 ± 186.6 mL, P < 0.0001), a similar number of lymph nodes removed (32.3 ± 13.1 vs 28.0 ± 11.9, P = 0.15), less need for analgesia and a shorter hospital stay (9.3 ± 2.5 vs 14.6 ± 12.6 days, P = 0.009) but longer operations (321.1 ± 65.9 vs 262.6 ± 75.0 min, P < 0.0001) than those treated by laparotomy. In our study, we had no conversions from laparoscopy to laparotomy. No major complications occurred in the TLMRH group. The patients who underwent TLMRH had less intense postoperative pain than patients treated by laparotomy. The median length of vaginal cuff removed was 12.0 ± 4.1 mm in the TLMRH group, and was 5.6 ± 6.6 mm in the laparotomy group (P < 0.0001). No patients demonstrated recurrence in either of the groups after a median follow-up of 48.5 months (range, 1-84). TLMRH is a safe and reliable alternative to open surgery in the management of early endometrial carcinoma, with a significantly reduced hospital stay and complications.

Impact of lymphovascular space invasion on a nomogram for predicting lymph node metastasis in endometrial cancer

ObjectiveThe aim of this study was to evaluate the impact of lymphovascular space invasion (LVSI) on nomogram-based predictions of lymph node (LN) metastasis in endometrial cancer. MethodsThe data from 485 patients with presumed stage I or II endometrial cancer who underwent hysterectomy and lymphadenectomy were analyzed. Calibration curves were designed and compared for three different subgroups: LVSI-positive tumors (n=113), LVSI-negative tumors (n=213) and LVSI-undetermined tumors (n=159). ResultsIn the entire population, the nomogram showed good discrimination with an area under the receiver operating characteristic curve (AUC) of 0.80 and was well calibrated. In the subgroup analyses, in LVSI-positive, LVSI-negative and LVSI-undetermined patients, the nomogram was not well calibrated (p of the U index of 0.028, 0.087 and 0.011, respectively) with underestimation in LVSI-positive patients and overestimation in LVSI-negative and LVSI-undetermined patients of LN metastasis. In the univariate analysis and after adjusting for the LN metastasis probability provided by the nomogram, LVSI-positive tumors were associated with an increased risk for LN metastasis compared with LVSI-negative tumors (RR=7.29 [3.87–13.7] and 5.04 [2.30–11.08], respectively). In contrast, the univariate analysis and after adjusting for the LN metastasis probability provided by the nomogram showed that LVSI-undetermined tumors were not associated with an increased risk for LN metastasis compared with LVSI-negative tumors (RR=0.73 [0.32–1.69] and 1.26 [0.47–3.37], respectively). ConclusionsOur results suggested that LVSI should be considered to be an independent risk factor for LN metastasis. In this multicenter study, the risk for LN metastasis is similar when the LVSI is negative or is not detailed in the pathological report.

Progestin re-treatment in patients with recurrent endometrial adenocarcinoma after successful fertility-sparing management using progestin

ObjectiveTo analyze the outcomes of second round of fertility-sparing management using progestin in patients with recurrent endometrial cancer after successful fertility-sparing management using progestin. MethodsWe reviewed 45 patients who had recurrence after achieving complete remission by fertility-sparing management using progestin for presumed stage IA, grade 1, endometrioid adenocarcinoma of the uterus. Of 45 patients, 33 tried progestin re-treatment at recurrence and were included in this study. ResultsRecurrent disease was atypical hyperplasia in 13 patients (39%) and grade 1 endometrioid adenocarcinoma in 20 patients (61%) which were confined to the endometrium. Thirty patients (91%) received medroxyprogesterone acetate (dose range, 80–500mg/day) and three patients (9%) received megestrol acetate (dose range, 80–160mg/day), with 29 patients receiving a dose of 500mg/day of medroxyprogesterone acetate. The median duration of treatment was 6months (range, 3–19months). Five patients failed to respond to progestin re-treatment and underwent definitive surgical treatment including hysterectomy. Twenty eight patients (85%) showed complete response to progestin re-treatment. The median follow-up time after progestin re-treatment in 28 patients who achieved complete remission was 51months (range, 24–160months). During follow-up, five patients had second recurrence after median time interval of 14months (range, 4–82months). All patients who tried progestin re-treatment are alive without evidence of disease. ConclusionProgestin re-treatment in patients with recurrent endometrial cancer was effective and safe. Therefore, this can be recommended for young women who still want to preserve fertility at recurrence after complete response to progestin.

A nomogram for predicting lymph node metastasis of presumed stage I and II endometrial cancer

Our objective was to develop a nomogram based on pathological hysterectomy characteristics to provide a more individualized and accurate estimation of lymph node metastasis in endometrial cancer. Data from the Surveillance, Epidemiology, and End Results database for 18,294 patients who underwent hysterectomy and lymphadenectomy were analyzed. A multivariate logistic regression analysis of selected prognostic features was performed, and a nomogram to predict lymph node metastasis was constructed. A cohort of 434 patients was used for the external validation. The nomogram showed good discrimination with an area under the receiver operating characteristic curve of 0.80 (95% confidence interval, 0.79-0.81) in the training set and 0.79 (95% confidence interval, 0.78-0.80) in the validation set. The nomogram was well calibrated. We developed a nomogram based on 5 clinical and pathological characteristics to predict lymph node metastasis with a high concordance probability.

The survival impact of systematic lymphadenectomy in endometrial cancer with the use of propensity score matching analysis

We sought to evaluate whether patients with endometrial cancer in the Surveillance, Epidemiology, and End Results database who underwent lymphadenectomy demonstrate improved survival. The study population comprised 50,969 patients. The 3-year cause-specific survival was tested by using propensity score matching (PSM) analysis. The PSM analysis generated a balanced, matched cohort in which baseline characteristics were not significantly different. The benefit of systematic lymphadenectomy appears to be significant for presumed stage I International Federation of Gynecology and Obstetrics grade 3 cancers and presumed stages II-III cancer. The omission of lymphadenectomy in stage I did not appear to show a deleterious survival consequence if the differentiation grade was moderate (grade 2) or well (grade 1). Using PSM analysis, our results show no evidence of benefit in terms of survival for systematic lymphadenectomy in women with stage I endometrial cancer, except for grade 3 cancers.

Laparoscopic-assisted cytoreduction for primary advanced ovarian cancer: Success, morbidity and survival

Objective The purpose of this paper is to evaluate laparoscopic-assisted cytoreduction for primary advanced ovarian cancer: feasibility, morbidity, response to chemotherapy and survival. Methods All patients with presumed stage 3/4 primary ovarian cancer underwent attempted laparoscopic cytoreduction. All patients had CT evidence of omental metastasis and ascites. A five port (5-mm) transperitoneal approach was used. A bilateral salpingo-oophorectomy, supracervical hysterectomy and omentectomy were performed with the PlasmaKinetic (PK) cutting forceps. A laparoscopic 5-mm Argon-Beam Coagulator was used to coagulate tumor in the pelvis, abdominal peritoneum, intestinal mesentery, and diaphragm. Results Twenty-three cases (92%) were successfully cytoreduced laparoscopically without conversion to laparotomy. Median operative time was 2.3 h and median blood loss was 340 cc. All tumors were debulked to less than 2 cm and 36% had no residual disease. Median length of stay was 1 day. Median VAS pain score was 4—discomforting. Six patients (24%) had post-operative complications, none grades 3–4. Median overall survival is 3.5 years. Conclusion Laparoscopic-assisted cytoreduction for primary advanced ovarian cancer was successful, resulting in minimal morbidity, and acceptable survival.

Coexistence of Intracranial Meningioma, Pulmonary Meningiomas, and Lung Cancer

Pulmonary metastases from a benign meningioma are rare occurrence, and the possible coexistence with other malignancies may be neglected in clinical practice. We report a patient with presumed stage IV lung cancer and a parietal meningioma. The patient underwent meningioma resection and a salvage operation for lung cancer. Palliative chemotherapy resulted in a partial response of the main tumor. Pathologic examination confirmed the rare coexistence of pulmonary squamous cell carcinoma and benign metastatic meningiomas. Although distant metastases from meningiomas are infrequent clinically, the possibility of pulmonary involvement should not be ignored in patients with aberrant responses of separate lesions after chemotherapy.

Incidence of benign pathologic lesions at nephrectomy for renal masses presumed to be stage I renal cell carcinoma in Japanese patients: Impact of sex, age, and tumor size.

374 Background: The widespread use of modern imaging techniques has resulted in the increased detection of small, asymptomatic renal tumors. Some recent studies from Western countries have reported that the incidence of benign lesions is approximately 15% in patients undergoing definitive surgery for renal masses presumed to be clinical stage I renal cell carcinoma (RCC). The high level of noncancerous lesions is, to some extent, due to the fact that no imaging feature can accurately distinguish either oncocytoma or lipid-poor angiomyolipma (AML) from RCC. This study attempts to determine the incidence of benign pathologic findings for such renal masses in Asian patients. Methods: Between 1991 and 2009, 711 consecutive patients (218 women and 493 men) underwent partial (n=206) or radical (n=505) nephrectomy for renal masses presumed to be stage T1N0M0 (T1a/T1b= 503/208) sporadic RCC on preoperative imaging in two Japanese centers. The mean size of the lesions was 3.3 cm (range 0.3-7.0). The pathologic features were reviewed by an experienced pathologist. Results: Of the 711 masses, 53 (7.5%) revealed benign pathologic findings. Twenty-two (3.1%) were AMLs, 13 (1.8%) were oncocytomas, 8 (1.1%) were complicated cysts, and 10 were others. Twenty-eight (12.8%) of the 218 females and 25 (5.1%) of the 493 males had benign lesions (p=0.0005). Of the 357 patients aged 60 years or younger, 37 (10.4%) had benign lesions while only 16 (4.5%) of the 354 patients over 60 years did (p=0.024). Forty six (9.2%) of the 503 T1a and 7 (3.4%) of the 203 T1b masses were benign (p=0.0071). A multivariate logistic regression model showed that sex, age and tumor size were all independently predictive of benign histology, particularly of AML. Conclusions: The present incidence (7.5%) of benign lesions in presumed clinical stage T1N0M0 RCC masses at nephrectomy was lower than the incidence of approximately 15% previously reported from Western countries, probably because of the low incidence of oncocytomas in Japanese patients. Female gender, young age and small tumor size are all independently predictive of benign lesions, particularly of AML in Japanese patients. No significant financial relationships to disclose.

MRI of localized prostate cancer: coming of age in the PSA era.

Prostate cancer is the most common cancer among American men. It varies widely in aggressiveness, ranging from completely indolent to highly aggressive. Currently, predicting the natural history of a particular tumor and deciding on the appropriate treatment, which might include active surveillance, surgery, radiation or hormonal therapies, are based on the condition and age of the patient as well as the presumed stage of the disease. Imaging plays an important role in staging localized prostate cancer. Magnetic resonance imaging (MRI) best depicts the zonal anatomy, with a superior soft tissue resolution providing better results for tumor localization, monitoring, and local staging. Previously, the major function of prostate MRI has been in staging, and this role remains important. In this article, we introduce the reader to the expanding roles that MRI plays in the management of localized prostate cancer.

Individual Surgeon, Pathologist, and Other Factors Affecting Lymph Node Harvest in Stage II Colon Carcinoma. Is a Minimum of 12 Examined Lymph Nodes Sufficient?

Insufficient lymph node harvest in presumed stage II colon carcinomas can result in understaging and worsened cancer outcomes. The purpose of this study was to evaluate factors affecting the number of lymph node examined, their corresponding impact on cancer outcomes, and the optimal number of examined nodes with reference to the standard of 12. We evaluated all patients undergoing surgery alone for stage II colon cancer included in our colorectal cancer database since 1976. A total of 901 patients were included. Mean follow-up exceeded 8 years. The individual pathologist had no statistically significant association with the number of lymph nodes examined. Harvest of at least 12 nodes was related to surgery after 1991 (85% vs 69%, P < 0.001), right vs left colon carcinomas (85% vs 72%, P < 0.001), individual surgeon (P = 0.018), and length of specimen at different cutoffs of at least 30, 25, and 20 cm (P < 0.001). Increasing age was associated with fewer examined lymph nodes (Spearman correlation = -0.22, P < 0.001). Fewer than 12 nodes and T4N0 staging independently affected overall survival (P = 0.003 and P = 0.022, respectively), disease-free survival (P = 0.010 and P = 0.09, respectively), disease-specific mortality (P = 0.009 and P < 0.001, respectively), and overall recurrence (P = 0.13 and P = 0.023, respectively). A minimal number of more than 12 examined nodes had no significant effect on cancer outcomes. A number of factors influenced lymph node harvest in stage II colon cancer. However, lymph node assessment of at least 12 nodes was the only modifiable factor optimizing cancer outcomes.

Laparoscopically Assisted Vaginal Hysterectomy (LAVH) Versus Total Abdominal Hysterectomy (TAH) in Endometrial Carcinoma

To determine the feasibility and safety of laparoscopically assisted vaginal hysterectomy in the treatment of presumed stage I endometrial cancer. This was a prospective cohort study without randomization of 182 consecutive patients who underwent surgery for early endometrial cancer or atypical hyperplasia at the West Kent Gynaecological Oncology Centre, UK. Seventy-four had laparoscopically assisted vaginal hysterectomy and bilateral salpingo-oophorectomy (BSO), and 108 had a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Lymphadenectomy was performed in 153 patients, and lymph node sampling was performed in 2 patients. Twenty-seven patients with serous papillary endometrial cancer in addition had an omentectomy. The groups were compared for epidemiological and clinical characteristics, surgical outcomes, hospital stay, lymph node harvest, and intraoperative and postoperative complications. The patients in the laparoscopy group had less blood loss, similar number of lymph nodes removed, less need for analgesia, and shorter hospital stay but longer operative time than those treated by laparotomy. In our study, we had 4 conversions (5.4%) from laparoscopy to laparotomy. Twenty-eight (41%) patients who had laparoscopic surgery were obese (body mass index [BMI] >30 kg/m2). Postoperative complications were more common in the laparotomy group (34%) than in the laparoscopy group (6%). No major complications occurred in the laparoscopy group. Wound infection was the most common complication in laparotomy patients, and this invariably happened to obese patients (BMI >30 kg/m2). There were 6 readmissions, all from the laparotomy group. Laparoscopic surgery is a safe and reliable alternative to open surgery in the management of early endometrial cancer patients, with significantly reduced hospital stay and complications, especially in those patients with an elevated BMI.