Positive Lymph Node Ratio Research Articles

Robotic or three-dimensional (3D) laparoscopy for right colectomy with complete mesocolic excision (CME) and intracorporeal anastomosis? A propensity score-matching study comparison.

We describe our preliminary experience in complete mesocolic excision (CME) with central vascular ligation (CVL) and intracorporeal anastomosis for right colon cancer, comparing the robotic and the three-dimensional (3D) laparoscopic approach. We performed a retrospective observational clinical cohort study on patients who underwent radical curative surgical resection of right colon cancer with CME from January 2014 to June 2019. Propensity scores were calculated by bivariate logistic regression, including the following variables: age, BMI, and size of tumor. Fifty-five patients underwent CME with CVL: 26 by means of robot-assisted surgery and 29 by means of 3D laparoscopic procedure. There were not statistically significant differences about all the intra- and postoperative outcomes (operative time, length of the specimen, time to bowel canalization, time to soft oral intake, length of hospital stay, postoperative complication, number of retrieved lymph nodes, number of positive lymph nodes and lymph node ratio) between the robotic and the 3D laparoscopic approach. After the matching procedure, 20 patients of the robotic group and 20 patients of the 3D laparoscopic group were selected for the analysis. There were no differences in any of the analyzed variables between the two groups except for longer operative time in the robotic group (p = 0.002). The 3D vision revealed an important advantage in order to achieve the correct identification of surgical anatomy allowing a safe and effective right colectomy with CME, CVL, and intracorporeal anastomosis, either using laparoscopic or with robotic approach, providing similar short-term outcomes. Taking into account the high costs and the longer operative time of robotic procedure, the 3D laparoscopy could be considered in performing right colectomy with CME, while the robotic approach should be considered as a first choice approach for challenging situations (obese patient, complex associated procedures).

Positive lymph node ratio as a novel indicator of prognosis in gastric signet ring cell carcinoma: a population-based retrospective study.

BackgroundLymph node status has a strong predictive effect on the prognosis of all patients with gastric cancer. It is unclear whether the positive lymph node ratio (PLNR) is a reliable prognostic factor for gastric signet ring cell carcinoma (SRCC).MethodsPatients with SRCC were obtained from the Surveillance, Epidemiology and End Results (SEER) database for the years 1998–2013. Cutoff values of positive lymph node ratio (PLNR) were decided using X-tile program. Survival was determined using the Kaplan-Meier method. Univariate and multivariate analyses were used to identify prognosticator of gastric signet ring cell carcinoma.ResultsA total of 1,884 cases were identified. 0.8 as the optimal cutoff value to separate the patients into high and low risk subsets in accordance of cancer-caused survival in SRCC patients (the number as 0.8, P<0.0001). Patients with PLNR >0.8 remained to have a poorer prognosis compared with those with PLNR <0.8 as shown by both OS (HR =2.083, 95% CI: 1.862–2.33, P<0.001) and CSS (HR =2.052, 95% CI: 1.802–2.336, P=0.014) in the multivariate cox regression model.ConclusionsPLNR is of great significance in the evaluation of prognosis for patients with SRCC.

Robotic pancreaticoduodenectomy may offer improved oncologic outcomes over open surgery: a propensity-matched single-institution study.

The robotic platform in pancreatic disease has gained popularity in the hepatobiliary community due to significant advantages it technically offers over conventional open and laparoscopic techniques. Despite promising initial studies, there remains scant literature on operative and oncologic outcomes of robotic pancreaticoduodenectomy (RPD) for pancreatic adenocarcinoma. A retrospective review evaluated all RPD performed for pancreatic adenocarcinoma from 2008 to 2019 in a single tertiary institution. RPD cases were matched to open cases (OPD) by demographic and oncologic characteristics and outcomes compared using Mann-Whitney U test, log rank tests, and Kaplan-Meier methods. Thirty-eight RPD cases were matched to 38 OPD. RPD had significantly higher lymph node (LN) yield (21.5 vs 13.5; p = 0.0036) and no difference in operative time or estimated blood loss (EBL). RPD had significantly lower rate of delayed gastric emptying (DGE) (3% vs 32%; p = 0.0009) but no difference in leaks, infections, hemorrhage, urinary retention ,or ileus. RPD had significantly shorter length of stay (LOS) (7.5 vs. 9; p = 0.0209). There were no differences in 30- or 90-day readmissions or 90-day mortality. There was an equivalent R0 resection rate and LN positivity ratio. There was a trend towards improved median overall survival in RPD (30.4 vs. 23.0months; p = 0.1105) and longer time to recurrence (402 vs. 284days; p = 0.7471). OPD had two times the local recurrent rate (16% vs. 8%) but no difference in distant recurrence. While the feasibility and safety of RPD has been demonstrated, the impact on oncologic outcomes had yet to be investigated. We demonstrate that RPD not only offers similar if not superior immediate post-operative benefit by decreasing DGE but more importantly may offer improved oncologic outcomes. The significantly higher LN yield and decreased inflammatory response demonstrated in robotic surgery may improve overall survival.

Significance of nodal dissection and nodal positivity in gastric cancer.

Lymphadenectomy is a central component of surgery for gastric cancer. However, controversies over the optimal extent of lymphadenectomy in gastric cancer surgery have persisted for several decades. In Eastern countries where the incidence of gastric cancer is high, surgeons have performed extensive lymphadenectomy (D2 lymphadenectomy) with low morbidity and mortality, while most Western surgeons have advocated for more limited lymphadenectomies according to the results of Dutch trial and MRC trial. Initially, these trials had failed to show survival benefit of D2 procedure and instead, found pancreaticosplenectomy performed as part of the D2 procedure associated with high incidence of morbidity and mortality. Subsequently, superiority of D2 lymphadenectomy on survival was demonstrated based on updated results. Moreover, spleen and pancreas preserving D2 lymphadenectomy are being performed safely in Western countries. Today, there is an international consensus on performing D2 lymphadenectomy as the standard procedure for advanced gastric cancer and is widely accepted as the standard procedure for gastric cancer surgery. The significance of the extent of lymphadenectomy is intimately associated with the prognostic importance of nodal metastases as the most powerful indicator of recurrence and survival for patients after curative gastrectomy. Maruyama computer program could be used to estimate the risk of lymph node metastasis in each nodal station. The Maruyama Index could be used to assess the adequacy of lymphadenectomy in gastric cancer. Positive lymph node ratio is calculated as the ratio of positive lymph nodes to all harvested lymph nodes, which might be a more precise predictor of prognosis than the absolute number of positive lymph nodes. While D2 lymphadenectomy enables the accurate staging of the disease, reduces the incidence of locoregional recurrences and thus contribute to an improved overall survival; performing lymphadenectomy beyond D2 is unlikely to improve survival. Therapeutic D2+ lymphadenectomy for advanced gastric cancer requires further evaluations, especially for patients receiving neo-adjuvant or conversion treatments.

Analysis of the relationship between the number of lymph nodes examined and prognosis for curatively resected gallbladder carcinoma: a multi-institutional study

Objective: To examine the role of the number of lymph nodes examined(NLNE) on the prognosis of patients with curatively resected gallbladder carcinoma(GBC). Methods: The clinicopathological data and prognosis of 401 patients with GBC who underwent radical surgery from six institutions of China from January 2013 to December 2017 were analyzed retrospectively. There were 153 males(38.2%) and 248 females(61.8%), with age of (62.0±10.5) years (range: 30-88 years). Fifty-three patients(22.2%) were accompanied by jaundice. All patients underwent radical resection+regional lymphadenectomy.R0 or R1 resection was confirmed by postoperative pathological examination.The different cut-off values of NLNE were determined by the X-tile software, the optimal cut-off values were identified by analyzing the relationship between different cut-off values of NLNE with survival rate. Kaplan-Meier method was used for survival analysis. Univariate and multivariate analysis were implemented respectively using the Log-rank test and Cox proportional hazard model. Results: Among the 401 patients enrolled, 135 cases (33.6%) had lymphatic metastasis, of which 98 cases were in N1 stage(24.4%) and 37 cases were in N2 stage(9.2%).A total of 2 794 NLNE were retrieved, with a median count of 6 (5).The median positive lymph nodes count was 0 (1), and the median positive lymph nodes ratio was 0 (IQR, 0-0.2). Since the 12 and 15 were determined as the cut-off values by X-tile, all patients were divided into three groups of 1-11, 12-15 and ≥16.The 3-year survival rate of the three groups was 45.2%, 74.5%, 12.0% respectively, with statistically significant difference between three groups (χ(2)=10.94, P<0.01). The results of multivariate analysis showed that NLNE was an independent prognostic factor for overall survival (P<0.05). Further analysis was performed specifically for subgroup of T stages. For T1b patients, the prognosis of the NLNE with 1-7 group was significantly better than that of the ≥8 group(χ(2)=4.610, P<0.05). For T2 patients, the prognosis of the TLNE ≥7 group was significantly better than that of 1 -6 group (χ(2)=4.287, P<0.05). For T3 and T4 patients, the prognosis of the TLNE with 12 - 15 group was significantly better than that of 1 -11 group (χ(2)=5.007, P<0.01) and ≥16 group (χ(2)=10.158, P<0.01). Conclusions: The NLNE is an independent factor affecting the prognosis of patients with GBC.For patients with stage T1b,8 lymph nodes should be retrieved; for patients with stage T2,extensive dissection of more than 6 lymph nodes can significantly improve the prognosis.For advanced patients (stages T3 and T4), extensive dissection with 12-15 lymph nodes is recommended. However, it fails to get more survival benefits by dissecting more than 16 lymph nodes.

Log odds of positive lymph nodes predicts survival in patients treated with neoadjuvant therapy followed by esophagectomy.

We aimed to evaluate the efficacy of the log odds of positive lymph nodes (LODDS) in survival prediction of patients with esophageal carcinoma receiving neoadjuvant therapy, compared with N descriptor and positive lymph node ratio (LNR). Patients with esophageal carcinoma receiving neoadjuvant therapy from 2004 to 2015 were reviewed in Surveillance, Epidemiology, and End Results database. The receiver operating characteristics curve and area under the curve (AUC) were used to compare discriminatory power among N descriptor, LNR, and LODDS. The goodness of fit was measured using the -2 log-likelihood ratio (-2LLR). About 2239 patients with a 22 months median follow-up and a 37.8% 5-year overall survival rate were included. LODDS had the best discriminatory power and goodness of fit (LODDS vs N descriptor, AUC 0.666 vs 0.626, -2LLR 15 680.402 vs 15 746.162; LODDS vs LNR, AUC 0.666 vs 0.635, -2LLR 15 680.402 vs 15 712.379; all P < .001). LODDS was the best for fewer than 15 lymph nodes retrieved (LODDS vs N descriptor, AUC 0.652 vs 0.618, P < .001; LODDS vs LNR, AUC 0.652 vs 0.625, P = .005). The prognosis of patients without metastatic nodes could be discriminated by LODDS. LODDS could better predict survival of patients with esophageal carcinoma receiving neoadjuvant therapy.

The ratio and size of positive sentinel lymph nodes predicts the involvement of non-sentinel lymph nodes following completion axillary lymph node dissection

Background: The role of completion axillary lymph node dissection (CALND) following positive sentinel lymph node biopsy (SLNB) is being actively debated. The involvement of our unit in the POSNOC trial (which has a no-treatment arm), has prompted a review of our unit’s CALND results, in order to examine predictors of involvement of non-sentinel lymph nodes (n-SLN). Methods: We retrospectively analyzed our experience of SLNB between July 2008 to 2013. A total of 1,152 breast cancer patients underwent SLNB based on lymphoscintigraphy, intraoperative gamma probe detection, and blue dye mapping using 99mTc-nanocolloid and Patent Blue V injected peri-areola. Results: Out of 1,152 SLNB performed, 224 were positive for metastatic disease; 203 patients were anesthetically capable of progressing to CALND. On univariate analysis, involved n-SLN on CALND could not be predicted by age, size of tumor, procedure performed, lymph vascular invasion, number of positive SLN, receptor status; ER, PR, HER2 or triple negative. There was a trend toward higher incidence of positive n-SLN with increasing grade, and extracapsular spread, but these did not reach statistical significance. Positive n-SLN on CALND was however predicted by macrometastases in SLN and ratio of positive nodes on SLNB. Conclusions: In our series of more than 200 SLNB, a ratio of >0.5 positive SLN yield and presence of macrometastases in positive SLN, were associated with positive n-SLN on CALND.

Risk Factors and Outcomes of Postoperative Recurrent Well-Differentiated Thyroid Cancer: A Single Institution's 15-Year Experience.

Identify risk factors and outcomes of recurrent well-differentiated thyroid cancer. Retrospective case-control analysis. Tertiary care academic center in Nashville, Tennessee. This single-center analysis reviews 478 patients who underwent initial surgical management of well-differentiated thyroid carcinoma between 2002 and 2017. Patients were dichotomized with or without recurrent well-differentiated thyroid cancer. Demographic and clinicopathologic risk factors were carefully reviewed. Univariate, multiple regression, and survival analyses were used to evaluate predictors of recurrence. Thirty-eight patients (7.9%) who received initial surgical intervention for well-differentiated thyroid carcinoma at our institution recurred, with an average time to recurrence of 24 months. Male sex, tumor size, multifocality, extrathyroidal extension, lymphovascular invasion, number of positive lymph nodes, and low lymph node yield were all significantly associated with locoregional recurrence (P < .05). Multiple regression analysis showed that extrathyroidal extension, number of positive lymph nodes, and low lymph node yield were independent factors predictive of posttreatment recurrence (P < .05). Metastatic lymph node ratio, the ratio of positive lymph nodes extracted to lymph node yield, of ≥0.3 is associated with increased risk of recurrence (P < .001) and decreased 5-year recurrence free survival (P < .001). Extrathyroidal extension, number of positive lymph nodes, and low lymph node yield are independent clinicopathologic risk factors for postoperative recurrence of well-differentiated thyroid cancer. Metastatic lymph node ratio is uncommonly used but can be an important prognosticator of recurrence. Patients with metastatic lymph node ratio ≥0.3 should be counseled on their increased risk of recurrence and should undergo close surveillance following surgery.

Role of Lymph Node Resection and Histopathological Evaluation in Accurate Staging of Nonfunctional Pancreatic Neuroendocrine Tumors: How Many Are Enough?

BackgroundNodal involvement has been identified as one of the strongest prognostic factors in patients with nonfunctional pancreatic neuroendocrine tumors (NF-PanNETs). Sufficient lymphadenectomy and evaluation is vital for accurate staging. The purpose of this study was to identify the optimal number of examined lymph nodes (ELN) required for accurate staging. MethodsThe SEER database was used to identify patients with resected NF-PanNETs between 2004 and 2014. The distributions of positive lymph nodes (PLN) ratio and total lymph nodes were used to develop a mathematical model. The sensitivity of detecting nodal disease at each cutoff of ELN was estimated and used to identify the optimal cutoff for ELN. ResultsA total of 1098 patients were included in the study of which 391 patients (35.6%) had nodal disease. The median ELN was 12 (interquartile range [IQR]: 7–19.5), and the median PLN was 2 (IQR: 1–4) for patients with nodal disease. With an increase in ELN, the sensitivity of detecting nodal disease increased from 12.0% (ELN: 1) to 92.2% (ELN: 20), plateauing at 20 ELN (< 1% increase in sensitivity with an additional ELN). This sensitivity increase pattern was similar in subgroup analyses with different T stages. ConclusionsThe sensitivity of detecting nodal disease in patients with NF-PanNETs increases with an increase in the number of ELN. Cutoffs for adequate nodal assessment were defined for all T stages. Utilization of these cutoffs in clinical settings will help with patient prognostication and management.

Tumor downsizing following neoadjuvant therapy for borderline-resectable pancreatic adenocarcinoma.

690 Background: Downstaging of pancreatic adenocarcinoma in patients presenting with nonmetastatic, unresectable disease has proven to be associated with improved clinical outcomes. Efforts at rescuing these patients to become surgical candidates are commonly attempted with a combination of systemic and radiation strategies. In this study, we aimed to determine tumor downsizing in patients that underwent neoadjuvant systemic therapy followed by a curative-intended surgical resection. Methods: A retrospective review of consecutive patients that underwent surgical resection for pancreatic adenocarcinoma following a course of neoadjuvant therapy was performed. Basic demographics, endoscopic ultrasound (EUS) findings, chemotherapy regimens and duration, rates of radiotherapy, type of surgical procedure and pathologic results were recorded. Tumor response to neoadjuvant therapy was established by correlating EUS- to pathologic tumor dimensions. Analysis of the data was done using Mann-Whitney U test, Pearson correlation and Chi-square when indicated. Results: A total of 97 patients were analyzed; 40 underwent neoadjuvant chemotherapy (13 patients also received concurrent radiation therapy). In those 57 patients that were resected upfront, EUS tended to underestimate tumor sizes significantly compared to pathologic dimensions, with an average difference between dimensions of 0.66 cm (p = 0.0004). Within the group treated with neoadjuvant chemotherapy, 90% of patients had downsizing at an average of 8% of tumor size. There were no differences in rates of tumor downsizing between FOLFIRINOX or Gemcitabine/Nac-paclitaxel treated patients. In addition, there were no correlations in margin status (R0) based on chemotherapy used, with both regimens achieving a similar rate of R0 resections (mean 61%). The type of chemotherapy regimen used did not affect the ratio of positive lymph nodes harvested. Conclusions: In patients that present with borderline resectable pancreatic adenocarcinoma, a course of neoadjuvant therapy results in tumor downsizing in a significant number allowing for margin negative resections. These results were seen regardless of the chemotherapeutic regimens utilized.

Lymph Node Ratio Can Better Predict Prognosis than Absolute Number of Positive Lymph Nodes in Operable Cervical Carcinoma

Background: Nodal status is the most important prognostic factor in cervical cancer. However, further risk stratification in node positive cervical cancer patients is warranted for optimal therapeutic decisions. Material and Methods: Nodal positive patients (n = 86) were retrospectively stratified into two groups according to either number of positive nodes (>3 vs. 1–3) or lymph node ratio (LNR) (≥10 vs. <10% and >6.6 vs. ≤6.6%). Univariable log-rank tests and both univariable and adjusted multivariable Cox regression models were used to evaluate the association between number of positive nodes or LNR and disease-free survival (DFS) and overall survival (OS). Results: LNR was significantly associated with worse DFS in adjusted multivariable analysis, both when categorized as ≥10 versus <10% (HR 2.25, 95% CI 1.06–4.76, p = 0.034) and when categorized as >6.6 versus ≤6.6% (HR 2.79, 95% CI 1.23–6.37, p = 0.015). However, we found no significant association between number of positive nodes or LNR and OS. Discussion:In operable node-positive cervical cancer, both number of positive lymph nodes and LNR can be used for further risk stratification with regard to DFS but not OS.

The impact of lymph node ratio on overall survival in patients with colorectal cancer.

Lymph node metastasis is a predominant prognostic indicator in colorectal cancer. Number of lymph nodes removed surgically was demonstrated to correlate with staging accuracy and oncological outcomes. However, number of lymph nodes removed depends on uncontrolled variables. Therefore, a more reliable prognostic indicator is needed. Calculation of ratio of positive lymph nodes to total number of removed lymph nodes may be an appealing solution. We retrospectively analyzed data of 156 Stage III colorectal cancer patients whom underwent surgery between 2008 and 2015. Patients' demographic characteristics, tumor grade, location, vascular-perineural invasion status, number of removed lymph nodes, and ratio of positive lymph nodes to number of removed lymph nodes were recorded. Spearman correlation analysis was used to determine the correlation coefficient while Kaplan-Meier method and Cox proportional hazard regression model were performed for the prediction of survival and multivariate analysis, respectively. Number of removed lymph nodes did not correlate with survival, but it was inversely correlated with number of positive lymph nodes. Multivariate analysis showed that ratio of removed positive lymph nodes to the total number of lymph nodes was a significant prognostic factor for survival for a ratio equal or above 0.31 was a poor prognostic indicator (108 months vs. 34 months, hazard ratio: 4.24 [95% confidence interval: 2.15-8.34]; P < 0.019). Tumor characteristics failed to demonstrate any prognostic value. This study showed that positive lymph node ratio (PLNR) is an important prognostic factor for Stage III colorectal cancer. Although 0.31 can be taken as threshold for "PLNR," prospective trials including larger patient groups are needed to validate its role as a prognostic indicator.

The prognostic value of lymph node ratio in stage IIIC cervical cancer patients triaged to primary treatment by radical hysterectomy with systematic pelvic and para-aortic lymphadenectomy.

ObjectiveThe aim of this study was to determine the prognostic value of lymph node ratio (LNR) in women with 2018 International Federation of Gynecology and Obstetrics stage IIIC cervical cancer.MethodsIn this retrospective dual-institutional study, a total of 185 node-positive cervical cancer patients who had undergone radical hysterectomy with systematic pelvic and para-aortic lymphadenectomy were included. All of the patients received adjuvant chemoradiation after surgery. LNR was defined as the ratio of positive lymph nodes (LNs) to the total number of LNs removed. The patients were categorized into 2 groups according to LNR; LNR <0.05 and LNR ≥0.05. The prognostic value of LNR was evaluated with univariate log-rank tests and multivariate Cox regression models.ResultsA total of 138 patients (74.6%) had stage IIIC1 disease and 47 (25.4%) patients had stage IIIC2 disease. With a median follow-up period of 45.5 months (range 3–135 months), the 5-year disease-free survival (DFS) rate was 62.5% whereas the 5-year overall survival (OS) rate was 70.4% for the entire study population. The 5-year DFS rates for LNR <0.05 and LNR ≥0.05 were 78.2%, and 48.4%, respectively (p<0.001). Additionally, the 5-year OS rates for LNR <0.05 and LNR ≥0.05 were 80.6%, and 61.2%, respectively (p=0.007). On multivariate analysis, LNR ≥0.05 was associated with a worse DFS (hazard ratio [HR]=2.12; 95% confidence interval [CI]=1.15–3.90; p=0.015) and OS (HR=1.95; 95% CI=1.01–3.77; p=0.046) in women with stage IIIC cervical cancer.ConclusionsLNR ≥0.05 seems to be an independent prognostic factor for decreased DFS and OS in stage IIIC cervical carcinoma.

Prognostic significance of pretreatment serum lactate dehydrogenase-to-albumin ratio in gastric cancer.

Aim of the studyTo investigate the prognostic role of lactate dehydrogenase-to-albumin ratio (LAR) in gastric cancer patients undergoing curative resection.Material and methodsA retrospective study was conducted including resectable gastric cancer patients. According to the time-dependent receiver operating characteristics (ROC) analysis, the optimal threshold for pretreatment LAR was 5.5. The Kaplan-Meier method, Cox regression univariate and multivariate analyses were used to analyze the prognostic factors for disease-free survival and overall survival (OS).ResultsThe study cohort consisted of 81 patients, mean age was 60.2 ±13.8 (range, 29–87) years and 55 (67.9%) were male. The median OS time was 34.8 and 45 months in patients with LAR ≥ 5.5 (n = 50) and LAR < 5.5 (n = 31), respectively. Kaplan-Meier curves showed that with the increase in LAR there was reduced survival, but it was not statistically significant (p = 0.278). Multivariate analyses revealed that the positive lymph node ratio above 20% was an independent predictor in resectable gastric cancer patients (OR = 6.281, 95% CI: 1.135–34.767, p = 0.035).ConclusionsWith the increase in LAR survival in gastric cancer decreased, but it was not statistically significant. Studies involving a large patient series are needed.

International validation of the Amsterdam model for survival prediction after resected pancreatic cancer

Background: A recent systematic review identified only two prediction models for survival in resectable pancreatic cancer of high methodological quality. The objective of this study was to validate one of these, the Amsterdam prediction model (including differentiation grade, positive lymph node ratio, margin status and adjuvant therapy), in a large international cohort. Methods: All consecutive patients who underwent pancreatoduodenectomy for pancreatic cancer between 2000-2017 at 10 tertiary hospitals from 8 countries were included. Calibration and model performance for prediction of 3-year and 5-year survival were evaluated and compared to the 8th edition of the TNM staging system, using Uno’s C-statistic, the Receiver Operating Characteristics (ROC) curves and area under the curves (AUC). Results: A total of 2,203 patients were included (mean age 65 years, 54% male), with a median overall survival of 23.6 months. The validation cohort was demographically comparable to the design cohort, but had a higher lymph node yield (median of 19 vs. 8) and more N2 disease (22.0% vs. 40.3%), and a higher use of adjuvant therapy (76.0% vs. 35.1%). Calibration analysis demonstrated that the predictions of 3-year survival did not systematically deviate from the observed survival rates with a slope of 0.85 and an intercept of 0.04. Uno’s C-statistic was 0.65 in the validation cohort, compared to 0.67 in the derivation cohort. ROC-curves showed an AUC of 0.70 and 0.72 for 3- and 5-year survival, compared to 0.65 and 0.68 for the TNM 8, respectively. Analysis of model performance among the different countries demonstrated a robust C-statistic, ranging from 0.61 to 0.67. Conclusions: This international multicenter study validated the previous predictions of the Amsterdam model for 3- and 5-year survival after pancreatoduodenectomy for pancreatic cancer. Model performance was fairly accurate in terms of calibration and discrimination, and the model demonstrated robustness within the different countries.

The effect of positive lymph node ratio logarithm (LODDS) on prognosis after curative resection in patients with ampullary adenocarcinoma

The effect of positive lymph node ratio logarithm (LODDS) on prognosis after curative resection in patients with ampullary adenocarcinoma

The Role of the Lymph Node Ratio in Advanced Gastric Cancer After Neoadjuvant Chemotherapy.

The ratio of positive lymph nodes (LNs) to the total LN harvest is called the LN ratio (LNR). It is an independent prognostic factor in gastric cancer (GC). The aim of the current study was to evaluate the impact of neoadjuvant chemotherapy (NAC) on the LNR (ypLNR) in patients with advanced GC. We retrospectively analyzed the data of patients with advanced GC, who underwent gastrectomy with N1 and N2 (D2) lymphadenectomy between August 2011 and January 2019 in the Department of Surgical Oncology at the Medical University of Lublin. The exclusion criteria were a lack of preoperative NAC administration, suboptimal lymphadenectomy (<D2 and/or removal of less than 15 lymph nodes), and a lack of data on tumor regression grading (TRG) in the final pathological report. A total of 95 patients were eligible for the analysis. A positive correlation was found between the ypLNR and tumor diameter (p < 0.001), post treatment pathological Tumour (ypT) stage (p < 0.001), Laurén histological subtype (p = 0.0001), and the response to NAC (p < 0.0001). A multivariate analysis demonstrated that the ypLNR was an independent prognostic factor in patients with intestinal type GC (p = 0.0465) and in patients with no response to NAC (p = 0.0483). In the resection specimen, tumor diameter and depth of infiltration, Laurén histological subtype, and TRG may reflect the impact of NAC on LN status, as quantified by ypLNR in advanced GC.

Development and validation of a prognostic nomogram for predicting early recurrence after curative resection of stage II/III gastric cancer

BackgroundThe biological behavior of early recurrence is more invasive and the prognosis is worse in gastric cancer (GC). The risk of early recurrence (ER) for GC in stage II/III has not been reported of which the majority of GC patients are in China. Therefore, it is necessary to analyze the ER of gastric cancer in stage II/III.MethodsThe medical records of 1511 consecutive stage II/III GC patients who received resections were retrospectively reviewed. They were randomly classified into either a development or validation group at a ratio of 7:3. The nomogram was constructed based on prognostic factors using logistic regression analysis and was validated by bootstrap resampling and validation dataset, respectively. Concordance index (C-index) values and calibration curves were used to evaluate the predictive accuracy and discriminatory capability.ResultsThree hundred eleven patients experienced ER, accounting for 20.58% of the GC patients investigated. Multivariate logistic regression analysis identified tumors located at upper, middle third, or mixed, a positive lymph node ratio ≥ 0.335, pTNM stage III, lymphocyte count < 1.5 × 109/L, postoperative infection complications and adjuvant chemotherapy < 6 cycles were all independent predictors for ER after curative resection of stage II/III GC. The C-index value obtained for the model was 0.780 (95% CI, 0.747–0.813), and the calibration curves of validation group yielded a C-index value of 0.739 (95% CI, 0.684–0.794), suggesting the practicability of the model.ConclusionsThe nomogram which was developed for predicting ER of stage II/III GC after surgery had good accuracy and was verified through both internal and external validation. The nomogram established can assist clinicians in determining the optimal therapy strategies in counseling, adjuvant treatments, and subsequent follow-up planning.

P163 OUTCOMES OF DISTAL PANCREATECTOMY AND SPLENECTOMY DURING 2-STAGE ESOPHAGECTOMY FOR CANCER

Abstract Aim The aim of the study was to assess safety, feasibility and outcomes of esophagectomy with distal pancreatectomy and splenectomy for T4a esophageal and esophagogastric junction adenocarcinoma. Background &amp; Methods From 01/10/2018 to 01/03/2019, three patients were operated in our Unit for adenocarcinoma of the distal esophagus or esophagogastric junction with 2-stage esophagectomy combined with distal pancreatectomy and splenectomy. Records were reviewed and clinicopathological outcomes presented. Results All patients were males with a mean age of 55 years (Range: 44-64). Two out of three had undergone neoadjuvant chemotherapy. Mean operative time was 420 min. (Range: 360- 480 min.). Mean blood loss was 180 ml (Range: 150-230ml). Mean ICU stay was 2.33 days (Range:1-3 days). Mean length of stay was 20 days (Range: 15-25 days). Postoperative complications observed was pneumonia in n=1. R0 resection was achieved in all patients while positive lymph node ratio was 0.3 (Range: 0- 0.73). Adjuvant chemotherapy was administered in all patients. Conclusion Two-stage esophagectomy for cancer along with distal pancreatectomy and splenectomy may be safely performed in specialized Upper GI Units offering adequate postoperative clinical and oncological outcomes. Further studies with larger sample size are needed to reach reproducible results.

P221 THE ROLE OF SUBCARINAL LYMPH NODE DISSECTION IN ESOPHAGECTOMY - A 5-YEAR SINGLE CENTER EXPERIENCE

Abstract Aim To evaluate the involvement of subcarinal lymph node dissection (SLND) in the surgical treatment of esophageal cancer, as well as its impact on surgical outcomes following esophagectomy. Background &amp; Methods Data on patients that underwent esophagectomy from 01/03/2014 to 01/03/2019 were prospectively collected and retrospectively reviewed. Based on the medical records, the following parameters were collected and analyzed: patient demographics, histopathological parameters, surgical- oncological outcomes. All patients were staged according to the AJCC 8th edition. Results A total of 79 patients underwent Ivor Lewis or McKeown esophagectomy for either squamous cell carcinoma (n= 7 patients) or adenocarcinoma of the esophagus or gastroesophageal junction (n= 72 patients). In 26 cases, esophagectomy was performed without SLND, while 53 cases underwent SLND. Among the 53 patients, 50 (94.3%) were men, and 3 (5.7 %) were women. Mean age was 61.4 years, (range 34-78). Mean nodal harvest was 34.7 lymph nodes per patient. Lymph node invasion was noted in 33 patients (62.2%), with a mean of 9 positive lymph nodes per patient. Subcarinal lymph nodes were involved in 5 out of 53 patients (9.4%). The ratio of positive subcarinal lymph nodes to resected ones was 1/2 (50%), 3/3 (100%), 1/2 (50%), 1/2 (50%) and 1/1 (100%) for each patient. Final histopathological report showed adenocarcinoma of moderate or poor differentiation (G2 2/5, G3 3/5) in all five patients (100%). Four out of 5 patients had not received neoadjuvant treatment and their pathological staging was T3N3M0. One patient had received neoadjuvant chemotherapy and his final staging was ypT3N2M0. Noteworthy, the seven patients diagnosed with squamous carcinoma, were subjected to SLND and were 100% negative for invasion histologically. Conclusion Subcarinal lymph nodes were infiltrated in 9.4% of patients operated for esophageal cancer. In the squamous cell cancer group, the relative infiltration rate was notably 0%. It seems that omission of subcarinal lymph node dissection during transthoracic esophagectomy cannot be justified.