Resected Nodes Research Articles

Preoperative CT radiomics of esophageal squamous cell carcinoma and lymph node to predict nodal disease with a high diagnostic capability

PurposeTo develop CT radiomics models of resectable esophageal squamous cell carcinoma (ESCC) and lymph node (LN) to preoperatively identify LN+. Materials and Methods299 consecutive patients with ESCC were enrolled in the study, 140 of whom were LN+ and 159 were LN-. Of the 299 patients, 249 (from the same hospital) were randomly divided into a training cohort (n = 174) and a test cohort (n = 75). The remaining 50 patients, from a second hospital, were assigned to an external validation cohort. In the training cohort, preoperative contrast-enhanced CT radiomics features of ESCC and LN were extracted, then integrated with clinical features to develop three models: ESCC, LN and combined. The performance of these models was assessed using area under receiver operating characteristic curve (AUC), and F-1 score, which were validated in both the test cohort and external validation cohort. ResultsAn ESCC model was developed for the training cohort utilizing the 8 tumor radiomics features, and an LN model was constructed using 9 nodal radiomics features. A combined model was constructed using both ESCC and LN extracted features, in addition to cT stage and LN+ distribution. This combined model had the highest predictive ability among the three models in the training cohort (AUC = 0.948, F1-score = 0.878). The predictive ability was validated in both the test and external validation cohorts (AUC = 0.885 and 0.867, F1-score = 0.816 and 0.773, respectively). ConclusionTo preoperatively determine LN+, the combined model is superior to models of ESCC and LN alone.

Role of routine lymph node dissection alongside resection of intrahepatic cholangiocarcinoma: Systematic review and meta-analysis

BACKGROUND The global incidence of intrahepatic cholangiocarcinoma (ICCA) is soaring. Due to often delayed presentation, only a narrow spectrum of the disease is usually surgically resectable. To more accurately stage the disease, reduce recurrence, and improve overall survival, surgical teams are increasingly performing intraoperative lymph node dissection (LND) as well. This procedure has its associated morbidity, while there is no consensus or formal guidelines on its role in this setting. Hence, there is a need to better delineate the evidence for performing LND alongside surgical resection of the ICCA. AIM To perform a systematic review and meta-analysis on the role of LND in improving prognostication and survival post-resection of ICCA. METHODS We performed a systematic literature search using Pubmed, Medline, Embase, and the Cochrane Library, for all studies involving LND, ICCA, and surgical resection using several keywords, Medical Subject Headings (MeSH) tags, and appropriate synonyms. All clinical studies comparing curative intent resection of ICCA with LND vs resection without LND were included, while single-arm case series, studies with insufficient data, and duplicates were excluded. We included all English-language studies from the different academic databases up till early December 2022. The primary outcome measures were set for overall survival (OS) and disease-free survival (DFS). RESULTS This systematic review and meta-analysis included 15 studies that fulfilled the selection criteria comprising 11413 patients with surgically-resectable ICCA, of whom 6424 (56.3%) underwent hepatectomy with LND while the remainder underwent hepatectomy only. In patients who underwent LND, on average, 27.7% of the resected lymph nodes were positive for metastatic disease. Overall, the results showed that performing LND did not significantly improve OS or DFS. However, the effect of LND on OS showed a degree of variability by geographical region, in Eastern and Western countries. As LND is increasingly being performed, further time-based analysis was undertaken to identify time-dependent changes in the role of LND. An increasing adoption of LND was not associated with improved OS. Furthermore, no roles were identified for neoadjuvant/adjuvant chemotherapy or increasing lymph node retrieval in improving OS either. CONCLUSION LND might aid in staging, prognosticating, and deciding further management of resected ICCA, but does not improve OS and DFS and is unsuitable for high-risk patients unlikely to benefit from further treatments.

Spatial immune composition of tumor microenvironment in patients with pancreatic cancer

This study examined the composition of the immune microenvironment at different sites within resected pancreas specimens from patients with pancreatic ductal adenocarcinoma (PDAC). Therefore, single-cell suspensions were made from fresh tumor and non-tumorous tissue. Fourteen patients were included from whom twelve PDAC and five non-tumorous samples were obtained. These samples were analyzed with a nineteen marker panel on the Aurora spectral flow cytometer. Furthermore, slides from formalin-fixed paraffine PDACs of eight additional patients were stained with eight markers and analyzed by multispectral imaging. These corresponded to central tumor, periphery of the tumor, i.e., invasive front and resected lymph node and were divided into tumor and adjacent tissue. In the single-cell suspension, a decreased ratio between lymphoid and myeloid cells and between M1 and M2 macrophages was observed in the tumor tissue compared to non-tumorous tissue. Furthermore, an increase in CD169 + macrophages in patients undergoing neoadjuvant therapy was found. Using immunofluorescence, more macrophages compared to T cells were observed, as well as a lower ratio of CD8 to M2 macrophage, a higher ratio of CD4–CD8 T cells and a higher ratio of immune-suppressive cells to pro-inflammatory cells in the PDAC area compared to the adjacent non-tumorous tissue. Finally, there were more immune-suppressive cells in the central tumor area compared to the invasive front. In conclusion, we show a gradient in the immune-suppressive environment in PDAC from most suppressive in the central tumor to least suppressive in distant non-tumorous tissue.Graphical abstract

Analysis of predictive factors of unforeseen nodal metastases in resected clinical stage I NSCLC.

Despite notable advances made in preoperative staging, unexpected nodal metastases after surgery are still significantly detected. In this study we aim to analyze the upstaging rate in patients with clinical stage I NSCLC without evidence of nodal disease in the preoperative staging who underwent lobectomy and radical lymphadenectomy. Patients who underwent lobectomy and systematic lymphadenectomy for clinical stage I NSCLC were evaluated. Exclusion criteria included the neoadjuvant treatment, incomplete resection and no adherence to preoperative guidelines. A total of 297 patients were included in the study. 159 patients were female, and the median age was 68 (61 - 73). The variables that showed a significant correlation with the upstaging rate at the univariate analysis were the number of resected lymph nodes and micropapillar/solid adenocar-cinoma subtype. This result was confirmed in the multivariate analysis with a OR= 2.545 (95%CI 1.136-5.701; p=0.02) for the number of resected lymph nodes and a OR=2.717 (95%CI 1.256-5.875; p=0.01) for the high-grade pattern of adenocarcinoma. Our results showed that in a homogeneous cohort of patients with clinical stage I NSCLC, the number of resected lymph nodes and the histological subtype of adenocarcinoma can significantly be associated with nodal metastasis.

Lymphatic Drainage-Promoting Effects by Engraftment of Artificial Lymphatic Vascular Tissue Based on Human Adipose Tissue-Derived Mesenchymal Stromal Cells in Mice

Regenerative medicine using lymphatic vascular engineering is a promising approach for treating lymphedema. However, its development lags behind that of artificial blood vascular tissue for ischemic diseases. In this study, we constructed artificial 3D lymphatic vascular tissue, termed ASCLT, by co-cultivation of ECM-nanofilm-coated human adipose tissue-derived mesenchymal stromal cells (hASCs) and human dermal lymphatic endothelial cells (HDLECs). The effect of hASCs in lymphatic vessel network formation was evaluated by comparison with the tissue based on fibroblasts, termed FbLT. Our results showed that the density of lymphatic vascular network in ASCLT was higher than that in FbLT, demonstrating a promoting effect of hASCs on lymphatic vascular formation. This result was also supported by higher levels of lymphangiogenesis-promoting factors, such as bFGF, HGF, and VEGF-A in ASCLT than in FbLT. To evaluate the therapeutic effects, FbLTs and ASCLTs were subcutaneously transplanted to mouse hindlimb lymphatic drainage interruption models by removal of popliteal and subiliac lymph nodes. Despite the restricted engraftment of lymphatic vessels, ASCLT promoted regeneration of irregular and diverse lymphatic drainage in the skin, as visualized by indocyanine green imaging. Moreover, transplantation of ASCLT to the popliteal lymph node resection area also resulted in lymphatic drainage regeneration. Histological analysis of the generated drainage visualized by FITC-dextran injection revealed that the drainage was localized in the subcutaneous area shallower than the dermal muscle. These findings demonstrate that ASCLT promotes lymphatic drainage in vivo and that hASCs can serve as an autologous source for treatment of secondary lymphedema by tissue engineering.

Solitary lymph-nodal para-aortic recurrence in a patient with High Grade Serous Ovarian Cancer

Ovarian cancer is the second most common cause of gynecologic cancer death. The most common histologic category of epithelial ovarian cancer is High Grade Serous Ovarian Cancer (HGSOC). The initial management usually involves appropriate staging and debulking surgery. Otherwise, patients with unresectable disease receive neoadjuvant chemotherapy, and then undergo Interval Debulking Surgery (IDS). However, even cases with complete clinical response often experience a recurrence. While the primary debulking surgery is the standard of treatment, the role of secondary debulking surgery for recurrent ovarian cancer is still debatable. The most common sites of recurrences are pelvis and abdomen, whereas recurrence confined solely to lymph node is a rare event. Secondary cytoreductive surgery (SCS) for recurrent ovarian cancer presenting as isolated lymph node metastases has been associated with favorable long-term survival, although the resection of aortic metastatic lymph nodes could be related to severe intraoperative complications. In this article, we report a case of a 72-year-old patient with an isolated lymph-nodal para-aortic recurrence with a history of primary debulking surgery for high grade serous ovarian cancer FIGO stage IV, four years before, followed by received adjuvant chemotherapy, and maintenance therapy. The patient presented with a lymph node relapse down the ileocolic artery and submitted to radical resection of the metastatic lymph nodes.

A novel preoperative image-guided localization for small pulmonary nodule resection using a claw-suture device

Video-assisted thoracoscopic surgery (VATS) provides better option concerning pathological diagnosis and curative intention of small pulmonary nodules (SPNs) that are sometimes challenging to localize. We assess the safety and feasibility of a new localization technique for SPNs, and report experience accumulated over time. A retrospective review of the new claw-suture localization cases between February 2018 and May 2023 was performed. Nodules were localized by a novel system that has an anchor claw and a tri-colored suture, guided by computed tomography (CT). Localization and operative procedure outcomes were then assessed. A total of 590 SPNs were localized from 568 patients before operation. The median nodule size was 0.70 cm (range, 0.3–2.0 cm). The claw-suture localization was successful without dislodgment or device fracture in 574 of 590 lesions (97.3%). Failures included not meeting target distance between claw and lesion (n = 13 [2.2%]), and device displacement (n = 3 [0.5%]). Complications requiring no further medical intervention included asymptomatic pneumothorax (n = 68 [11.5%]), parenchymal hemorrhage (n = 51 [8.6%]), and hemothorax (n = 1 [0.2%]) with the exception of pleural reaction observed in 2 cases (0.3%). Additionally, the depth of pulmonary nodules was significantly associated with the occurrence of pneumothorax (P = 0.036) and parenchymal hemorrhage (P = 0.000). The median duration of the localization was 12 min (range, 7–25 min). No patient complained of remarkable pain during the entire procedure. Retrieve of device after operation was 100%. The new localization technique is a safe, feasible, and well-tolerated method to localize SPNs for VATS resection.

Dissection and resection of the left paratracheal lymph node (station 4L) using a traditional mediastinoscope with a 30-degree, 5 mm lens, connected to the video camera.

Dissection and resection of the left paratracheal lymph node (station 4L) using a traditional mediastinoscope with a 30-degree, 5 mm lens, connected to the video camera.

Characteristics of Real-World Patients with High-Risk BRAFV600E/K-Mutated Melanoma Receiving Adjuvant Treatment with Dabrafenib Plus Trametinib After Surgical Resection, Through the Italian Managed Access Program.

Real-world data from patients with BRAFV600-mutated, resected, stage III melanoma treated with dabrafenib plus trametinib as adjuvant targeted therapy are limited, and it is important to gain an understanding of the characteristics of this patient population, as well as of the patient journey. Here we aimed to describe the characteristics, dosage reductions and discontinuations in patients with BRAFV600E/K-mutated melanoma receiving adjuvant dabrafenib plus trametinib after surgical resection through an Italian managed access program (MAP). Eligible patients had completely resected cutaneous melanoma with confirmed BRAF V600E or V600K mutation, or initially resectable lymph node recurrence after a diagnosis of stage I or II melanoma. The starting dose of dabrafenib and trametinib was 150 mg twice daily and 2 mg once daily, respectively. A total of 557 patients received dabrafenib plus trametinib through the MAP (stage III resected disease at inclusion, 554). Median age was 54.0 years, and 40.2% of patients were female. The proportion of all treated patients who required a dose reduction was low (10.8%) as was the proportion of patients who discontinued treatment (13.5%). The main reason for treatment discontinuation was adverse events (36.0%). New treatments, including BRAF-targeted therapies and immunotherapy, have transformed the natural history of melanoma. This is the largest study to date describing patients treated with dabrafenib plus trametinib in routine clinical practice in Italy between 2018 and 2019. Results highlight the characteristics of the patients treated and their journey, as well as the tolerable safety profile of dabrafenib plus trametinib in a real-world patient population.

Shared-Specific Feature Learning With Bottleneck Fusion Transformer for Multi-Modal Whole Slide Image Analysis.

The fusion of multi-modal medical data is essential to assist medical experts to make treatment decisions for precision medicine. For example, combining the whole slide histopathological images (WSIs) and tabular clinical data can more accurately predict the lymph node metastasis (LNM) of papillary thyroid carcinoma before surgery to avoid unnecessary lymph node resection. However, the huge-sized WSI provides much more high-dimensional information than low-dimensional tabular clinical data, making the information alignment challenging in the multi-modal WSI analysis tasks. This paper presents a novel transformer-guided multi-modal multi-instance learning framework to predict lymph node metastasis from both WSIs and tabular clinical data. We first propose an effective multi-instance grouping scheme, named siamese attention-based feature grouping (SAG), to group high-dimensional WSIs into representative low-dimensional feature embeddings for fusion. We then design a novel bottleneck shared-specific feature transfer module (BSFT) to explore the shared and specific features between different modalities, where a few learnable bottleneck tokens are utilized for knowledge transfer between modalities. Moreover, a modal adaptation and orthogonal projection scheme were incorporated to further encourage BSFT to learn shared and specific features from multi-modal data. Finally, the shared and specific features are dynamically aggregated via an attention mechanism for slide-level prediction. Experimental results on our collected lymph node metastasis dataset demonstrate the efficiency of our proposed components and our framework achieves the best performance with AUC (area under the curve) of 97.34%, outperforming the state-of-the-art methods by over 1.27%.

Should sampling of three N2 stations be a quality metric for curative resection of stage I lung cancer?

ObjectiveIn 2022, the American College of Surgeons Commission on Cancer issued standard 5.8 quality metric for curative lung cancer resections requiring nodal resection from 3 N2 stations. In this report, we compare oncologic outcomes after resection of 3 N2 stations versus 2 N2 stations in stage I non–small cell lung cancer. MethodsA retrospective review from a single institution database was conducted from 2011 to 2020 to identify patients with clinical stage I non–small cell lung cancer. Patients with a history of lung cancer, carcinoid tumors, and ground-glass lesions less than 50% solid component were excluded. The primary outcome was overall survival. Secondary outcomes included disease-free survival, recurrence patterns, and nodal upstaging. ResultsA total of 581 patients were identified and divided into 2 groups based on the number of N2 stations examined: Group A had 2 N2 stations examined (364 patients), and group B had 3 or more N2 stations examined (217 patients). Baseline demographic and clinical characteristics were similar between groups. In group A, N1 and N2 positive nodal stations were present in 8.2% (30/364) and 5.2% (19/364) of patients versus 7.4% (16/217) and 5.5% (12/217), respectively, in group B. Five-year overall survival and disease-free survival were 89% and 74% in group A versus 88% and 78% in group B, respectively. Recurrence occurred in 56 patients (15.4%) in group A (6.6% local and 8.8% distant) and 29 patients (13.4%) in group B (5.1% local and 8.3% distant; P = .73). ConclusionsThere was no significant difference in oncological outcomes in stage I non–small cell lung cancer resections that included 2 N2 stations compared with at least 3 N2 stations examined.

A Review of Laparoscopic Para-aortic Lymphadenectomy for Early-stage Endometrial Cancer: Extraperitoneal Approach May Have the Advantage over Intraperitoneal Approach.

The importance of lymphadenectomy, including para-aortic nodes, for the accurate staging of endometrial cancer, is well established. Although the therapeutic role of lymph node resection in endometrial cancer is still under debate, some studies support its usefulness for survival benefit. To predict the necessity of lymphadenectomy, several preoperative scoring systems have been proposed as being effective. For endometrial cancer, there is a trend towards minimally invasive surgery, including para-aortic lymphadenectomy. For para-aortic lymphadenectomy, there are two different approaches: the extraperitoneal approach and the transperitoneal approach. The extraperitoneal approach has advantages over the transperitoneal approach in terms of better access to the left aortic nodes, no interference of the bowel, and possibly better options for obese or elderly patients. However, the extraperitoneal approach may have a longer learning curve than the transperitoneal approach. Robot-assisted extraperitoneal para-aortic lymphadenectomy is feasible and safe and may be suitable for patients irrespective of their baseline characteristics.

Approach to lymphadenopathy: how to diagnose tuberculosis lymphadenitis

lymphadenopathy is considered as abnormal finding local or generalized that can becaused by neoplasm or infection, as tuberculosis lymphadenitis. Cervical localization has prevalence
 in the variety of disorders, can has a similar kind of clinical presentation and to differentiate them be-comes extremely difficult. We provided a case report of the new onset of extrapulmonary tuberculosis
 lymphadenitis in 42-year-old Indian man. The patient complained of multiply enlarged painful lymphnodes on left anterior neck and was also concerned about sore throat persistent for a year. Objectiveexamination and analysis were without evident inflammatory signs. Previous ultrasound, pulmonaryand abdominal CT-scan investigations also revealed conglomerate of left mediastinal lymph nodes,moderate splenomegaly. The preliminary diagnosis of lymphoma was excluded due to confirmationof typical tuberculosis lymphadenitis with specific testing and morphological changes of the resected
 lymphatic node. Sputum microscopy was found to be negative, which meant that the patient was neg-ative for social transmission of tuberculosis. Affected lymph nodes resolved completely after appro-priate therapy during one-year treatment. This case report of extrapulmonary tuberculosis highlights
 the importance of tissue diagnosis in unclear situations. We used clinical protocol for unspecifiedlymph node enlargement as complete history taking and physical examination that is preliminary fordiagnosis, while laboratory tests, imaging diagnostic methods and tissue samplings are gold standardevaluation for definite lymphadenopathy. Tuberculosis lymphadenitis is popularly known as collarstud abscess and is the most common benign cause of cervical lymphadenopathy in endemic areas.This observation determined the details of the immunocompromised state of the patient, conclusionwas supported by the evidence of Pseudomonas putida associated pharyngitis. The main differentialsigns between lymphoma as immunoproliferative disorder and infectious tuberculosis lymphadenitiswere provided.

Three-dimensional lung reconstructions for the localization of lung nodules to be resected during surgery.

The localization of lung nodules is challenging during thoracoscopy. In this study, we evaluated the use of three-dimensional (3D) lung reconstruction for use in the operating room to guide the identification of lung nodules during thoracoscopy. This was a single-center retrospective study. All consecutive patients undergoing thoracoscopic resection of lung nodules were included in the study. Patients were retrospectively divided into two groups based upon whether the thoracoscopic resection was performed with the assistance (3D group) or not (standard group) of 3D lung reconstruction. The operative time (minutes) to detect lung nodules was statistically compared between the two study groups in relation to the characteristics of lung nodules as size, localization, and distance from the visceral pleura. Our study population consisted of 170 patients: 85 in the 3D group and 85 in the standard group. No intergroup difference differences were found regarding the characteristics and histological diagnosis of lesions. The standard group compared to the 3D group was associated with a significantly longer operative time for the detection of lesions <10 mm (13.87 ± 2.59 vs. 5.52 ± 1.01, p < 0.001), lesions between 10 and 20 mm (5.05 ± 0.84 vs. 3.89 ± 0.92; p = 0.03), lesions localized in complex segments (7.49 ± 4.25 vs. 5.11 ± 0.97; p < 0.001), and deep lesions (9.58 ± 4.82 vs. 5.4 ± 1.01, p < 0.001). Our 3D lung reconstruction model for use in the operating room may be an additional tool for thoracic surgeons to guide the detection of small and deep nodules during thoracoscopy. It is a noninvasive and cost saving procedure and may be widely used.

Janus Kinase Inhibitors Differentially Inhibit Specific Cytokine Signals in the Mesenteric Lymph Node Cells of Inflammatory Bowel Disease Patients.

Janus kinase [JAK] inhibitors [JAKinibs] are effective small molecule therapies for treating Crohn's disease [CD] and ulcerative colitis [UC], collectively known as inflammatory bowel disease [IBD]. By preventing JAKs from phosphorylating signal transducer and activator of transcription proteins, JAKinibs disrupt cytokine signalling pathways that promote inflammation. Despite considerable overlap in the JAKs they target, first- and second-generation JAKinibs display different clinical efficacies in CD and UC. We conducted a comparative phosflow study of four JAKinibs [filgotinib, upadacitinib, tofacitinib, and deucravacitinib] to observe subtle mechanistic differences that may dictate their clinical behaviour. Resected mesenteric lymph node [MLN] cells from 19 patients [9 CD, 10 UC] were analysed by flow cytometry in the presence or absence of different cytokine stimuli and titrated JAKinibs. We found a higher potency of the JAK 1/3-preferential inhibitor, tofacitinib, for JAK 3-dependent cytokine signalling pathways in comparison to filgotinib, but a higher potency of the JAK 1-preferential inhibitors, filgotinib and upadacitinib, for JAK 3-independent cytokine signalling pathways. Deucravacitinib, a TYK2-preferential inhibitor, demonstrated a much narrower selectivity by inhibiting only IL-10 and IFN-β pathways, albeit more potently than the other JAKinibs. Additionally, we found some differences in the sensitivity of immune cells from CD versus UC, and patients with versus without a CD-associated NOD2 polymorphism, to phosphorylate signal transducer and activator of transcriptions in response to specific cytokine stimulation. Despite their similarities, differences exist in the relative potencies of different JAKinibs against distinct cytokine families, to explain their clinical efficacy.

The Role of Carbon Nanoparticles as Lymph Node Tracers in Colorectal Cancer: A Systematic Review and Meta-Analysis.

Colorectal malignancies are the third-most common malignancies worldwide, with a rising incidence. Surgery remains the treatment of choice and adequate lymph node dissection is required for accurate staging. The objective of this study is to assess the use of carbon nanoparticles in lymph node tracing and resection in cases of colorectal cancer. For that purpose, we conducted a systematic review and meta-analysis of studies included in Medline, Scopus, Embase, Cochrane Library, and Google Scholar databases. In the end, ten studies with a total number of 1418 patients were included in the final statistical analysis. The meta-analysis carried out showed that the use of carbon nanoparticles results in an increased number of lymph nodes harvested (WMD 6.15, 95% CI 4.14 to 8.16, p < 0.001) and a higher rate of cases with more than 12 lymph nodes harvested (OR 9.57, 95% CI 2.87 to 31.96, p = 0.0002). As a consequence, we suggest that carbon nanoparticles are used on a wider scale and that future research focuses on assessing the association between their use and overall patient survival. This study is limited by the fact that all included studies originate from China and by the fact that certain oncologic parameters and long-term outcomes have not been taken into account in the analysis.

Retrospective comparative study of robot-assisted surgery, laparoscopic surgery, and laparotomy for endometrial cancer in patients with a low risk of recurrence.

Minimally invasive surgeries for endometrial cancer are increasing worldwide. In Japan, some articles have examined surgical outcomes, but only a few have addressed oncological outcomes. This study aims to compare robot surgery, laparoscopic surgery, and laparotomy in terms of surgical and oncological outcomes within a low-risk group for endometrial cancer recurrence. This study included patients with endometrial cancer deemed to be at low risk of recurrence and who underwent surgery between January 2011 and December 2020. We studied 99 patients who underwent robot surgery, 85 patients who underwent laparotomy, and 77 patients who underwent laparoscopic surgery. Surgical and oncological outcomes were compared retrospectively for these groups of patients. The median follow-up period was 47, 61, and 60 months in the laparotomy, laparoscopy, and robotic groups, respectively. The three groups had similar perioperative and pathological data. No significant differences in overall survival and disease-free survival were observed among the groups. Univariate and multivariate analyses conducted on the overall study population for disease-free survival and overall survival showed that the surgical approach did not have any influence. Minimally invasive surgery groups had longer operating times compared to the laparotomy group, but they had significantly less blood loss. The number of resected pelvic lymph nodes was similar, and the complication rate was not significant. Robot-assisted surgery and laparoscopic surgery were found to be less invasive and showed similar oncologic outcomes compared to laparotomy surgery for endometrial cancer in patients with a low risk of recurrence.

Significance of fusion status, Oberlin risk factors, local and maintenance treatment in pediatric and adolescent patients with metastatic rhabdomyosarcoma: Data of the European Soft Tissue Sarcoma Registry SoTiSaR.

Outcome of primary metastatic rhabdomyosarcoma (RMS) is poor. Certain risk factors as fusion status, Oberlin score, and local treatment of primary tumor are known to influence prognosis. Patients with metastatic RMS were treated according to Cooperative Weichteilsarkom Studiengruppe (CWS) guidance with chemotherapy (CHT), radiotherapy (RT) excluding total lung irradiation (TLI), complete resection of the primary tumor, and metastasectomy if possible. Kaplan-Meier estimators and Cox proportional hazard models were used to examine event-free survival (EFS) and overall survival (OS) involving also landmark analyses. In the European Soft Tissue Sarcoma Registry SoTiSaR (2009-2018), 211 patients were analyzed. Many patients had fusion-positive alveolar RMS (n=83; 39%). Median age was 9.4years [0.1-19.7years]. Treatment primarily consisted of CHT with CEVAIE (carboplatin, epirubicine, vincristine, actinomycin-D, ifosfamide, etoposide: 86%, other regimens: 14%), RT (71%), resection of primary tumor (37%), metastasectomy (19%), and lymph node sampling/dissection (21%). Maintenance treatment (MT) (oral trofosfamide, idarubicin, etoposide) was added in 74% of patients. Oberlin factors, fusion status, and MT were predictive for EFS and OS. MT with O-TIE was not improving outcome when adjusting for the immortal time bias. Local treatment of the primary tumor and radical irradiation (except TLI) improved EFS, not OS, when adjusting for the Oberlin score. Patients with fusion-negative alveolar RMS (n=9) had an excellent outcome with a 5-year EFS and OS of 100%, compared to patients with embryonal RMS (49%/62%), PAX7- (22%/47%) and PAX3/FOXO1-positive ARMS (10/13%), respectively (p<.001). Prognosis of metastatic RMS primarily depends on fusion status and Oberlin score. Fusion status needs to be considered in future trials to optimize treatment outcome. The role of radical irradiation needs further investigation.

The Need for Centralization for Small Intestinal Neuroendocrine Tumor Surgery: A Cohort Study from the GTE-Endocan-RENATEN Network, the CentralChirSINET Study.

The concept of surgical centralization is becoming more and more accepted for specific surgical procedures. The aim of this study was to evaluate the relationship between procedure volume and the outcomes of surgical small intestine (SI) neuroendocrine tumor (NET) resections. We conducted a retrospective national study that included patients who underwent SI-NET resection between 2019 and 2021. A high-volume center (hvC) was defined as a center that performed more than five SI-NET resections per year. The quality of the surgical resections was evaluated between hvCs and low-volume centers (lvCs) by comparing the number of resected lymph nodes (LNs) as the primary endpoint. A total of 157 patients underwent surgery in 33 centers: 90 patients in four hvCs and 67 patients in 29 lvCs. Laparotomy was more often performed in hvCs (85.6% vs. 59.7%; p<0.001), as was right hemicolectomy (64.4% vs. 38.8%; p<0.001), whereas limited ileocolic resection was performed in 18% of patients in lvCs versus none in hvCs. A bi-digital palpation of the entire SI length (95.6% vs. 34.3%, p<0.001), a cholecystectomy (93.3% vs. 14.9%; p<0.001), and a mesenteric mass resection (70% vs. 35.8%; p<0.001) were more often performed in hvCs. The proportion of patients with ≥8 LNs resected was significantly higher (96.3% vs. 65.1%; p<0.001) in hvCs compared with lvCs, as was the proportion of patients with ≥12 LNs resected (87.8% vs. 52.4%). Furthermore, the number of patients with multiple SI-NETs was higher in the hvC group compared with the lvC group (43.3% vs. 25.4%), as were the number of tumors in those patients (median of 7 vs. 2; p<0.001). Optimal SI-NET resection was significantly more often performed in hvCs. Centralization of surgical care of SI-NETs is recommended.

Does increasing the number of resected lymph nodes really improve the prognosis of patients with esophageal squamous cell carcinoma?

Does increasing the number of resected lymph nodes really improve the prognosis of patients with esophageal squamous cell carcinoma?