Rate Of Lymph Node Invasion Research Articles

Editorial Comment on: Impact of Surgical Volume on the Rate of Lymph Node Metastases in Patients Undergoing Radical Prostatectomy and Extended Pelvic Lymph Node Dissection for Clinically Localized Prostate Cancer

Abstract Background Previous trials have shown that the number of procedures done by a single surgeon, that is, surgical volume (SV), is associated with several outcomes after radical prostatectomy (RP). Objective To test the association between SV and the detection of lymph node metastases during extended pelvic lymph node dissection (ePLND). Design, setting, and participants The study cohort consisted of 1020 men surgically treated for clinically localized prostate cancer. Intervention All patients underwent RP and ePLND by a group of six surgeons who were trained by the surgeon with the highest SV. All surgeons performed an anatomically extended PLND, including removal of obturator, external iliac, and hypogastric nodes. Measurements Univariable and multivariable logistic regression models tested the association between SV (either continuously coded or dichotomized according to the most informative cut-off, namely >144 vs ≤144 ePLNDs) and the rate of lymph node invasion (LNI) after accounting for preoperative (baseline prostate-specific antigen [PSA], clinical stage, biopsy Gleason sum) and postoperative (pathologic stages and Gleason score, surgical margin status) patient characteristics. Results and limitations Mean number of nodes removed was 19.1 (median, 16; range, 7–63). Mean overall SV was 227 (range, 87–379). Overall, LNI rate was 11.8% (120/1020). No significant differences were found among patients treated by the different surgeons in terms of clinical and pathologic characteristics (all p ≥0.06). Conversely, the surgeon with the highest SV removed more nodes and found more nodal metastases compared with the other surgeons (21.1 vs 17.9 mean number of nodes removed; p p =0.01, respectively). At univariable logistic regression analysis, either continuously coded or dichotomized SV was a significant predictor of LNI ( p =0.007 and p p =0.04 and p =0.009, respectively) as well as for postoperative variables ( p =0.03 and p =0.002, respectively). Conclusions After adjusting for clinical and pathologic case-mix differences, patients treated by the highest-volume surgeons (>144 ePLNDs) were more likely to have LNI than those treated by low-volume surgeons, even though all surgeons used a similar extended template for node removal.

Impact of Surgical Volume on the Rate of Lymph Node Metastases in Patients Undergoing Radical Prostatectomy and Extended Pelvic Lymph Node Dissection for Clinically Localized Prostate Cancer

BackgroundPrevious trials have shown that the number of procedures done by a single surgeon, that is, surgical volume (SV), is associated with several outcomes after radical prostatectomy (RP). ObjectiveTo test the association between SV and the detection of lymph node metastases during extended pelvic lymph node dissection (ePLND). Design, setting, and participantsThe study cohort consisted of 1020 men surgically treated for clinically localized prostate cancer. InterventionAll patients underwent RP and ePLND by a group of six surgeons who were trained by the surgeon with the highest SV. All surgeons performed an anatomically extended PLND, including removal of obturator, external iliac, and hypogastric nodes. MeasurementsUnivariable and multivariable logistic regression models tested the association between SV (either continuously coded or dichotomized according to the most informative cut-off, namely >144 vs ≤144 ePLNDs) and the rate of lymph node invasion (LNI) after accounting for preoperative (baseline prostate-specific antigen [PSA], clinical stage, biopsy Gleason sum) and postoperative (pathologic stages and Gleason score, surgical margin status) patient characteristics. Results and limitationsMean number of nodes removed was 19.1 (median, 16; range, 7–63). Mean overall SV was 227 (range, 87–379). Overall, LNI rate was 11.8% (120/1020). No significant differences were found among patients treated by the different surgeons in terms of clinical and pathologic characteristics (all p≥0.06). Conversely, the surgeon with the highest SV removed more nodes and found more nodal metastases compared with the other surgeons (21.1 vs 17.9 mean number of nodes removed; p<0.001, and 15 vs 9.8% of LNI; p=0.01, respectively). At univariable logistic regression analysis, either continuously coded or dichotomized SV was a significant predictor of LNI (p=0.007 and p<0.001, respectively). In multivariable models, continuously coded as well as dichotomized SV maintained a significant association with the rate of LNI, after accounting for preoperative (p=0.04 and p=0.009, respectively) as well as for postoperative variables (p=0.03 and p=0.002, respectively). ConclusionsAfter adjusting for clinical and pathologic case-mix differences, patients treated by the highest-volume surgeons (>144 ePLNDs) were more likely to have LNI than those treated by low-volume surgeons, even though all surgeons used a similar extended template for node removal.

Differences in the rate of lymph node invasion in men with clinically localized prostate cancer might be related to the continent of origin

To test whether the rate of lymph node invasion (LNI) differs between patients treated with radical prostatectomy (RP) at a European or a North American centre. In all, 1385 men had RP with bilateral lymphadenectomy for clinically localized prostate cancer (587 from Dallas, Texas and 798 from Milan, Italy). Univariate and multivariate analyses focused on the association between the continent of origin and the rate of LNI, after controlling for prostate-specific antigen (PSA) level, clinical stage, biopsy Gleason sum and the number of examined and removed lymph nodes. European men had higher PSA levels (9.1 vs 7.8 ng/mL), a higher proportion of palpable cancers (44.5 vs 32.8%), more nodes removed (mean 14.9 vs 7.8) and a higher rate of LNI (9.0% vs 1.2%; all differences P < 0.001). In multivariate analyses that controlled for PSA level and clinical variables, European men had an 8.9-fold higher risk of LNI (P < 0.001) than their counterparts from the USA. Among preoperative variables, the continent of origin was the third most informative predictor of LNI (67.5%), after biopsy Gleason sum (74.3%) and the number of examined lymph nodes (71.0%), and improved the ability to predict LNI by 4.7%. Men treated at a European centre had a 7.3-8.9-fold higher rate of LNI, despite adjusting for all clinical and pathological variables. It remains to be shown what predisposes European men to a higher rate of LNI.

Percentage of Positive Biopsy Cores Can Improve the Ability to Predict Lymph Node Invasion in Patients Undergoing Radical Prostatectomy and Extended Pelvic Lymph Node Dissection

ObjectiveWe hypothesized that the information stemming from biopsy cores can enhance the ability to predict the rate of lymph node invasion (LNI) at radical retropubic prostatectomy (RRP) in men subjected to extended pelvic lymphadenectomy (ePLND). Materials and methodsA cohort of 278 consecutive patients (mean age: 66.2 yr) underwent a RRP and an ePLND, in which 10 or more nodes were removed and examined. The median PSA was 7.5ng/ml. Clinical stage was mostly T1c (59.4%) and T2 (37.8%). Biopsy Gleason sum was 2–5 in 26.6%, 6 in 39.2%, 7 in 27%, and 8–10 in 7.2%. The number of positive cores was 1–19 (median: 4), whilst percentage of positive cores was 7.1–100% (median: 37.5%). Logistic regression models tested the association between the above predictors and LNI. Testing of PSA was coded as either a continuous variable (CV) or a cubic spline (CS). Individual variables and combined accuracy were tested in regression-based nomograms, which were subjected to 10,000 bootstrap resamples to reduce overfit bias. ResultsMean number of lymph nodes examined was 17.5 (range: 10–38); 29 patients (10.4%) had LNI. Percentage of positive cores (78.5%) and biopsy Gleason sum (78.4%) were the most informative predictors of LNI. A nomogram based on clinical stage, PSA (CV), and biopsy Gleason sum was 79.7% accurate versus 83% (3.3% gain, p<0.001) when percentage of positive cores was added. A 2.7% gain (83.7% vs. 81%; p<0.001) was recorded after the addition of the percentage of positive cores when PSA was coded as a CS. ConclusionsPercentage of positive biopsy cores should be considered in prediction of LNI at ePLND, because it significantly improves the combined accuracy of established clinical predictors such as PSA, clinical stage, and biopsy Gleason sum.

Critical Assessment of Ideal Nodal Yield at Pelvic Lymphadenectomy to Accurately Diagnose Prostate Cancer Nodal Metastasis in Patients Undergoing Radical Retropubic Prostatectomy

Objectives To study the relation between the number of removed and examined lymph nodes at pelvic lymph node dissection and the rate of lymph node invasion (LNI). Methods A total of 858 patients aged 45 to 85 years were predominantly treated with extended pelvic lymph node dissection before radical retropubic prostatectomy. The pretreatment prostate-specific antigen level was 0.24 to 49.9 ng/mL (median 5.8). Most lesions were Stage T1c (55.2%) or T2 (40.7%), with a biopsy Gleason sum of 6 or less (62.2%) or 7 (25.1%). Receiver operating characteristic curve coordinates were used to determine the probability of finding LNI according to the number of removed and examined lymph nodes. Moreover, the association between the number of removed lymph nodes and LNI was tested in univariate and multivariate logistic regression models. Results From 2 to 40 nodes (mean 15, median 14) were removed and examined, and 88 patients (10.3%) had LNI. The LNI rate increased with the number of removed nodes ( P <0.001): 2 to 10 nodes removed, 5.6% LNI rate; 10 to 14 nodes removed, 8.6% LNI rate; 15 to 19 removed, 10.2% LNI rate; and 20 to 40 removed, 17.6% LNI rate. On multivariate analysis, the number of examined nodes predicted for LNI ( P <0.001), after accounting for prostate-specific antigen level, clinical stage, and biopsy Gleason sum. The receiver operating characteristic coordinate plot indicated that the removal of 28 nodes yielded a 90% ability to detect LNI. Conversely, the assessment of 10 or fewer nodes was associated with a virtually zero probability of finding LNI. Conclusions We have provided a critical assessment of the concept that the nodal yield at pelvic lymph node dissection is closely associated with the rate of LNI.

Validation of a nomogram predicting the probability of lymph node invasion based on the extent of pelvic lymphadenectomy in patients with clinically localized prostate cancer

To develop a multivariate nomogram to predict the rate of lymph node invasion (LNI) in patients with clinically localized prostate cancer according to the extent of extended pelvic lymphadenectomy (PLND), which is associated with significantly higher rate of LNI. The study comprised 781 consecutive patients (median age 66.6 years, range 45-85) treated with PLND and radical retropubic prostatectomy (RRP) for clinically localized prostate cancer. Their median (range) prostate-specific antigen (PSA) level was 7 (1.03-49.91) ng/mL, and their clinical stages were T1c in 433 (55.4%), T2 in 328 (42%) and T3 in 20 (2.6%). Biopsy Gleason sums were <or= 6 in 514 (65.8%), 7 in 204 (26.1%) and 8-10 in 63 (8.1%). Multivariate logistic regression models were used to test the association between predictors including PSA level, biopsy Gleason sum, clinical stage, number of nodes removed and the rate of LNI. Finally, regression coefficients were used to develop a nomogram, which was internally validated with 200 bootstrap re-samples. The median (range) number of lymph nodes removed was 14 (2-40); LNI was detected in 71 patients (9.1%). The univariate predictive accuracy for total PSA level, clinical stage, biopsy Gleason sum and number of total nodes removed and examined was 64.2%, 59.8%, 74% and 62.9%, respectively. Except for PSA (P = 0.2), all variables were statistically significant multivariate predictors of LNI at RRP (P <or= 0.001). A nomogram based on clinical stage, PSA level, biopsy Gleason sum and the number of total lymph nodes removed was 78.6% accurate, and 1.8% more accurate than a nomogram without the number of removed lymph nodes. The extent of PLND is directly related to the probability of LNI. The risk of LNI increases linearly, and is proportional to the number of nodes removed and examined. The effect of the increased probability of LNI is weighted more heavily in men with more advanced clinical stage and grade.

Clinicopathologic features of surgically resected primary gastric lymphoma.

To analyze the clinicopathologic characteristics of surgically resected gastric lymphoma patients. We retrospectively analyzed 57 surgically resected gastric lymphoma patients, dividing them into 2 subgroups: Low grade MALToma (the LG group), High grade MALToma and Diffuse large B cell lymphoma (the HG group). The numbers of patients were: 20 in the LG group, 37 in the HG group. The diagnostic rate of gastroscopy was 34.8% at primary diagnosis and 50% including differential diagnoses. The positive rates of H pylori were similar between the 2 groups (68% vs 77%). Multiple lesions were found in 19.3%. The proportion of mucosal and submucosal lesions was 80.0%(16/20) in the LG group, and 24.3%(9/37) in the HG group (P<0.001). Lymph node invasion rates were 10.5%(2/19) in the LG group and 44.1%(15/34) in the HG group (P=0.031). The numbers of recurred patients were none in the LG group, and 8 in the HG group. By univariant analysis, group (P=0.024) and TNM stage (stage I, II vs stages III, IV, P=0.002) were found to be the significant risk factors. There was a tendency of higher recurrence rate in the subtotal gastrectomy group than in the total gastrectomy group (P=0.05). The HG groups had a more advanced stage and a higher recurrence rate than the LG group. Although there was no difference between subtotal and total gastrectomies, more careful assessments of multiplicities and radical resections with lymph node dissections seem to be needed because of multiplicity and LN invasion even in LG group.

Transhiatal esophagectomy for esophageal cancer.

The two main approaches currently used for surgical treatment of esophageal cancer are transhiatal esophagectomy (THE) and esophagectomy through a right thoracotomy. Among technical variations of THE, wide opening of the diaphragm with ample mediastinal exposure allows resection under direct view with acceptable postoperative morbidity and mortality rates. Transthoracic esophagectomy, associated with extensive mediastinal lymphadenectomy, still offers the best chance of definitive cure in intermediate stages (stages II and III), but does not influence survival in advanced cases (stage IV). In early stages, the lymph node invasion rate is negligible and may be treated by other techniques (THE or endoscopic mucosectomy). THE restores oral ingestion and avoids respiratory complications of thoracotomy, and consequently can be reserved for early cases (mucosal or submucosal lesions) or for patients with poor clinical status. To improve results of surgical treatment, protocols of associated radiochemotherapy are currently under research.