Standard Lymphadenectomy Research Articles

The optional extent of lymph node dissection for pancreatic head cancer

Abstract Objective The extent of lymph node dissection for pancreatic head cancer (PHC) is uncertain and controversial; therefore, this study evaluated whether PHC patients can benefit from different extents of lymph node dissection. Methods A total of 106 PHC patients underwent standard regional lymphadenectomy (SRLN; n = 56, 52.8%) and extended regional lymphadenectomy (ERLN; n = 50, 47.2%) between September 2015 and September 2019. None of the study participants had distant metastases. The median survival time and complications were compared between the two groups. Results The median survival time in the SRLN and ERLN groups was 27.01 months and 21.17 months, respectively (P = 0.30). The postoperative major morbidity and mortality rates were 37.50% and 1.79% in the SRLN group, and 46.00% and 2.00% in the ERLN group, respectively. Moreover, the tumor differentiation, tumor diameter, lymph node involvement, perineural invasion, vascular invasion, and margin status all correlated with survival (P < 0.05). Conclusion For PHC patients, ERLN cannot provide a significant survival benefit over SRLN. Moreover, ERLN increased morbidity and mortality, although without statistical significance. This indicates that ERLN should not be considered in PHC patients.

Application and outcomes of a standardized lymphadenectomy in laparoscopic right hemicolectomy requiring ligation of the middle colic artery.

Complete mesocolic excision with central vessel ligation may be important for accurate staging and improving the prognosis of right-sided colon cancer. Although the procedure is often performed laparoscopically, approaching the middle colic artery (MCA) is technically demanding, especially when complete ligation of arteries at their roots is desired. We standardized our laparoscopic approach by establishing the dissection boundary along the superior mesenteric artery to achieve D3 lymphadenectomy in the region of the MCA. The aim of the present study was to evaluate, on the basis of perioperative and short-term oncologic outcomes, the feasibility and safety of our technique METHODS: We conducted a retrospective study on consecutive patients with cancer located at the ascending colon and transverse colon who had laparoscopic right hemicolectomy requiring ligation of the MCA. There were 41 patients (22 males, median age 71years [range 49-86] years). The median operation time was 285min, and blood loss volume was 40mL. Conversion to open surgery was required in 1 case. Complications that were Clavien-Dindo grade III or above occurred in 3 patients (7.3%). There was no anastomotic leakage. The median number of lymph nodes harvested was 46. Our technique was shown to be a safe, feasible, and useful strategy for performance of right hemicolectomy requiring ligation of the MCA in cases of colon cancer. The technique facilitates maximal lymph node dissection. Having obtained favorable outcomes, we look forward to investigation into long-term outcomes.

Appraisal of long-time outcomes after curative surgery in elderly patients with gastric cancer: a propensity score matching analysis

BackgroundThis study was conducted to assess the long-term outcomes of elderly patients among propensity-score-matched gastric cancer patients after curative gastrectomy and to propose the proper management of elderly gastric cancer patients.MethodsWe enrolled 626 patients with gastric cancer who underwent curative gastrectomy at our institution between January 2004 and December 2015. To minimize selection bias among 2 groups, propensity score matching was performed.ResultsPatients were divided into an elderly group over 75 years old (EP group; n = 186) and a non-elderly group (NEP group; n = 440). After propensity score matching, patients were divided into EP group (n = 178) and NEP group (n = 175). Five-year overall survival was significantly lower in the EP group than in the NEP group, consistent with a subgroup analysis of each stage. However, the 5-year disease-specific survival among all enrolled patients and those with stage I and II disease did not differ significantly. Moreover, in the subgroup of stage III patients, 5 year disease-specific survival was significantly lower in the EP group (23.0%) than in the NEP group (59.4%; P = 0.004). Because elderly patients with stage III disease had an extremely poor prognosis, we decided to compare the two groups with stage III. The EP group contained significantly fewer patients with D2 lymphadectomy (P = 0.002) and adjuvant chemotherapy (P < 0.001) than the NEP group. C-reactive protein to albumin ratio was significantly higher in patients in the EP group than in the NEP group (P = 0.046), and the prognostic nutritional index was significantly lower in patients in the EP group than in the NEP group (P = 0.045). Multivariate analysis revealed that the prognostic nutritional index and lymphatic invasion were independent prognostic factors.ConclusionsElderly gastric cancer patients with stage III disease showed poorer disease-specific survival compared with non-elderly patients, which may be due to a poorer nutritional and inflammatory background, fewer D2 lymphadenectomies, and a lack of adjuvant chemotherapy. The safe induction of standard lymphadenectomy and adjuvant chemotherapy with perioperative aggressive nutritional support may improve the prognosis of elderly gastric cancer patients with stage III disease.

The efficiency of D1(+) lymphadenectomy in signet ring cell carcinoma: comparison of postoperative early and late outcomes between standard lymphadenectomy and D1(+) lymphadenectomy

ABSTRACT Signet ring cell carcinoma (SRCC) is a poorly cohesive subtype of gastric cancer. It is more aggressive than other types of gastric cancer. There is no special method for its treatment, but gastrectomy and lymphadenectomy is the standard approach. The aim of this study is to investigate postoperative outcomes of D1 lymphadenectomy and D1(+)lymphadenectomy in gastric SRCC. A total of 358 cases whohad a gastrectomy performed forthe diagnosis of gastric cancer between 2013 and 2019 in Ankara University Medical Faculty, Surgical Oncology Department were retrospectively investigated. In all, 128 of the cases had SRCC in the final pathology. We separated the cases into two types,D1 lymphadenectomy and D1(+) lymphadenectomy. The 5-year survival, early mortality, hospital mortality and postoperative complication rates were evaluated. There were 59 patients in the D1 group and 64 patients in the D1(+) group.Metastatic lymph node amount and therefore N stage was found to be significantly higher in the D1(+) group (p=0.00 and p=0.03, respectively). Postoperative chyle fistula was found to be significantly higher in the D1(+) group (p=0.003). There was no statistically significant difference between the groups with regard tomean survival (p=0.065);the 5-year mean survival was 21% in the D1 group and 7% in the D1(+) group.Present findings suggest that extended lymphadenectomy does not provide a benefit in cases of SRCC.

Sentinel Lymph Node Biopsy after Neoadjuvant Treatment for Breast Cancer. The Validation Protocol.

Introduction: The identification and biopsy of the sentinel lymph node (SLNB) in breast cancer patients requiring neoadjuvant cytostatic treatment (NAC), with clinically negative lymph nodes following treatment, may be an effective method of de-escalation of axillary surgery. Materials and methods: This prospective study includes 47 cases of breast cancer stage IIB-IIIA, with NAC treatment and complete axillary clinical and imaging response, surgeries performed at Prof. Dr. Alexandru Trestioreanu Oncological Institute in Bucharest (IOB) by the same team. In all the cases, SLNB was employed using the radioactive tracer method. The SLNB technique with Tc99 radioactive tracer involves: - injection of the radioactive tracer and preoperative lymphoscintigraphy, - intraoperative identification of the sentinel node/ lymph nodes and their excisional biopsy, - intraoperative histopathological examination, in paraffin blocks, and immunohistochemistry of the lymph node (SLN). Results: SLN was identified in 46 of 47 cases. In 19 cases SLN was positive, and in 2 cases we recorded false negative results. All patients underwent standard axillary lymphadenectomy (back-up lymphadenectomy). The correlation between the intraoperative and paraffin histopathological examination of SLN with the paraffin and immunohistochemical examination of the rest of the axillary nodes (N-SLN) led to the following results: sensitivity 91% (19/ 21), specificity 100% (25/ 25), positive predictive value 100% (19/ 19), negative predictive value 93% (25/ 27). The accuracy of the method was 96% (44/ 46). SLN invasion was more common in patients with residual tumor 2 cm (vs T 2 cm) (p = 0.01), positive N-SLN (vs non-invaded N-SLN) (p = 0.003). N-SLNs were more frequently invaded when there was peritumoral lymphocyte invasion (vs. no invasion) (p = 0.01). Conclusions: SLNB in patients with breast cancer who require NAC, with clinically and imaging negative lymph nodes following treatment, has a high rate of specificity and an acceptable number of false negative results. Node invasion is more common in patients with residual tumors 2 cm, with lymphovascular invasion or with multicenter/ multifocal disease.

Pattern of No. 12a lymph node metastasis in gastric cancer.

ObjectiveThe current standard D2 lymphadenectomy for gastric cancer (GC) includes dissection of lymph nodes (LNs) along the proper hepatic artery (No. 12a), however, the survival benefit remains controversial. The purpose of this study was to evaluate the pattern of No. 12a LN metastasis (LNM) in GC and explore the indications for No. 12a LN dissection.MethodsMedical records of 413 consecutive GC patients who underwent curative surgery in Zhongshan Hospital, Fudan University between January 2015 and December 2018 were enrolled and reviewed retrospectively. The correlation between No. 12a LNM and clinicopathologic characteristics of patients was analyzed.ResultsThe overall incidence of No. 12a LNM was 2.67% (11/413). Tumor location (P=0.012), depth of tumor infiltration (P<0.01) and N stage (P=0.018) were significant factors associated with No. 12a LNM. All the tumors with No. 12a LNM involved the lower third of the stomach and were in T3−4 stages. Patients with No. 12a LNM had extensive LNM than those without (20.91±4.25vs. 5.0±0.54, P<0.001). For advanced GC patients (stage III/IV) with tumors involving the lower third of the stomach, the incidence of No. 12a LNM increased to 10.7% (11/103). Patients with No. 12a LNM had a significantly poorer recurrence-free survival (RFS) (P=0.005) and overall survival (OS) (P=0.017). According to the result of multivariable Cox regression, No. 12a LNM was not an independent impact factor on RFS and OS. ConclusionsThe overall incidence of No. 12a LNM was low but it was much higher in GC patients who had very advanced tumors involving the lower third of the stomach. No. 12a LN dissection should be considered for these patients to improve the survival outcomes.

Improved Tissue Processing in Esophageal Adenocarcinoma After Ivor Lewis Esophagectomy Allows Histological Analysis of All Surgically Removed Lymph Nodes with Significant Effects on Nodal UICC Stages

BackgroundIn esophageal carcinoma, the numbers of metastatic and total removed lymph nodes (LN) are well-established variables of long-term prognosis. The overall rate of retrieved LN depends on neoadjuvant treatment, the extent of surgical lymphadenectomy, and the modality of the pathological workup. The question in this study is whether technically extended histopathological preparation can increase the number of detected (metastatic) LN with an impact on nodal UICC staging.Patients and MethodsA cohort of 77 patients with esophageal adenocarcinoma was treated with Ivor Lewis esophagectomy including standardized two-field lymphadenectomy. The specimens were grossed, and all manually detectable LN were retrieved. The remaining tissue was completely embedded by the advanced “acetone compression” retrieval technique. The primary outcome parameter was the total number of detected lymph nodes before and after acetone workup.ResultsA mean number of 23,1 LN was diagnosed after standard manual LN preparation. With complete embedding of the fatty tissue using acetone compression, the number increased to 40.5 lymph nodes (p < 0.0001). The mean number of metastatic LN increased from 3.2 to 4.2 nodal metastases following acetone compression (p < 0.0001). Additional LN metastases which caused a change in the primary (y)pN stage were found in ten patients (13.0%).ConclusionsAdvanced lymph node retrieval by acetone compression allows a reliable statement on the real number of removed LN. Results demonstrate an impact on the nodal UICC stage. A future multicenter study will examine the prognostic impact of improved lymph node retrieval on long-term oncologic outcome.

Three-Field Lymphadenectomy in Minimally Invasive Esophagectomy for Squamous Cell Carcinoma

Minimally invasive esophagectomy (MIE) has been used widely for the treatment of esophageal cancer. However, there is still a lack of consensus on the extent of lymphadenectomy in MIE. The objective of this study was to investigate the safety and efficacy of three-field lymphadenectomy (3-FL) in MIE, compared with the standard two-field lymphadenectomy (2-FL). A single-center randomized controlled trial was conducted, enrolling patients with resectable thoracic esophageal cancer (cT1-3,N0-3,M0) between June 2016 and May 2019. Eligible patients were randomized into two groups to receive either 3-FL or 2-FL during MIE procedures. Perioperative outcomes of the two groups were compared. The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-INR-16007957). Seventy-six eligible patients were randomly assigned to the 3-FL group (n= 38) and the 2-FL group (n= 38). Compared with patients in the 2-FL group, patients in the 3-FL group had more lymph nodes harvested (54.7 ± 16.5vs 30.9 ± 9.6, P < .001) and more metastatic lymph nodes identified (3.5 ± 4.5 vs 1.7 ± 2.0, P= .027). Patients in the 3-FL group were diagnosed with a more advanced final pathologic TNM stage than patients in the 2-FL group. There was no significant difference between the two groups in blood loss, major postoperative complications, or duration of hospital stay, except that the operation time was longer in the 3-FL group than in the 2-FL group (270.5 ± 45.4 minutes vs 236.7 ± 47.0 minutes, P= .002). Three-field lymphadenectomy allowed harvesting of more lymph nodes and more accurate staging without increased surgical risks compared with 2-FL MIE for esophageal cancer.

D2 Lymphadenectomy as an Independent Prognostic Factor in Gastric Cancer

Abstract Background: The last decades have been marked by debates based on the importance of lymphadenectomy in gastric cancer, lymphadenectomy being a topic of controversy between the Western Surgical Societies and the Asian side. Lymphadenectomy is currently a globally accepted standard in the treatment of gastric cancer. Methods: The present study was performed prospectively on a number of 93 patients diagnosed with gastric cancer, who underwent radical gastrectomy with lymphadenectomy in the Surgery Department of the Emergency County Clinical Hospital, Constanta, between January 2012 - December 2016. In 70 cases, an extended D2 or standard D2 lymphadenectomy was performed, and for 23 patients: D1 + lymphadenectomy. The data were statistically analyzed in order to determine the prognostic value of lymphadenectomy in gastric cancer. Results: The average age was 65.88 ± 8.80 years. The mean number of lymph nodes harvested in D2 lymphadenectomy was 22.8 ± 7.60, with limits between 15 and 43, and the number of positive lymph nodes ranged from a minimum of 0 to a maximum of 37. Histopathological exam of specimens showed that only 17.2% of patients with gastric cancers were without lymph node metastases (pN0), while 45.16% were in the pN3 stage. Analysis of survival curves revealed that 5-year survival was significantly higher in D2 lymphadenectomy compared to D1 + lymphadenectomy (23.8% vs. 8.7%). Conclusions: The current study validates D2 lymphadenectomy as a standard technique and the superiority of the prognosis in gastric cancer patients through results obtained in terms of 5-year survival.

Meta-analysis and trial sequential analysis of randomised controlled trials comparing standard versus extended lymphadenectomy in pancreatoduodenectomy for adenocarcinoma of the head of pancreas.

To compare baseline demographics, operative, and survival outcomes of randomised controlled trials (RCTs) comparing standard lymphadenectomy versus extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer METHODS: In compliance with PRISMA standards we performed a meta-analysis of baseline demographics, operative, and survival outcomes of RCTs comparing standard lymphadenectomy versus extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer. The uncertainties associated with varying follow-up periods among the included studies were resolved by analysis of time-to-event outcomes. Moreover, we performed trial sequential analysis (TSA) to determine whether the available evidence is conclusive and to assess the risk of type 1 or type 2 errors. Overall, 724 patients from 5 RCTs were included. The included populations were comparable in terms of baseline characteristics. There was no difference between standard and extended lymphadenectomy in terms of pancreatic fistula (OR 0.64, P = 0.11), delayed gastric emptying (OR 0.68, P = 0.40), bile leak (OR 0.33, P = 0.06), wound infection (OR 0.53, P = 0.06), abscess (OR 0.83, P = 0.63), total complications (OR 0.73, P = 0.27), postoperative mortality (OR 1.01, P = 0.85), and overall survival (HR 1.10, P = 0.46). TSA suggested that meta-analysis was conclusive with low risk of type 2 error. The results remained consistent through subgroup analyses based on lymph node positive or negative status and studies from the West and East. Robust evidence from randomised controlled trials (Level 1) suggests no difference in postoperative and survival outcomes between standard and extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer. The findings were consistent in patients with positive and negative lymph node status and in studies from the West or East.

Role of lymphadenectomy in resectable pancreatic cancer.

Pancreatic cancer (PC) remains one of the most devastating malignant diseases, predicted to become the second leading cause of cancer-related death by 2030. Despite advances in surgical techniques and in systemic therapy, the 5-year relative survival remains a grim 9% for all stages combined. The extent of lymphadenectomy has been discussed intensively for decades, given that even in early stages of PC, lymph node (LN) metastasis can be detected in approximately 80%. The primary objective of this review was to provide an overview of the current literature evaluating the role of lymphadenectomy in resected PC. For this, we evaluated randomized controlled studies (RCTs) assessing the impact of extent of lymphadenectomy on OS and studies evaluating the prognostic impact of anatomical site of LN metastasis and the impact of the number of resected LNs on OS. Lymphadenectomy plays an essential part in the multimodal treatment algorithm of PC and is an additional therapeutic tool to increase the chance for surgical radicality and to ensure correct staging for optimal oncological therapy. Based on the literature from the last decades, standard lymphadenectomy with resection of at least ≥ 15 LNs is associated with an acceptable postoperative complication risk and should be recommended to obtain local radicality and accurate staging of the disease. Although radical surgery including appropriate lymphadenectomy of regional LNs remains the only chance for long-term tumor control, future studies specifically assessing the impact of neoadjuvant therapy on extraregional LNs are warranted.

Gastric cancer: Environmental risk factors, treatment, and prevention

Gastric cancer is a heterogeneous, multifactorial, aggressive disease that has been and remains one of the most common causes of cancer-related deaths and a significant public health issue worldwide. Currently, gastric cancer shows decreasing trends in its incidence and mortality in some geographic areas; however, the disease still shows a poor prognosis and remains difficult to cure. The prognosis for gastric cancer patients depends on the stage at which the gastric cancer is detected, and complete excision of the cancer is the only proven curative option. Gastric cancer prevention remains a priority. Patients at higher risk should be screened for early detection and chemoprophylaxis. Surgical resection enhanced by standardized lymphadenectomy remains the gold standard in the treatment of gastric cancer. Systemic therapy improves long-term disease-free survival compared to surgical treatment alone. Palliative chemotherapy in patients with inoperable gastric cancer prolongs survival and improves the quality of life. Demographic, ecological, environmental, cultural, and genetic variables all contribute to the heterogeneity of gastric cancer; however, environmental risk factors play an important role throughout all the stages of the disease progression, management, and surveillance. In this review, we address the role of important environmental risk factors in the onset of gastric cancer and highlight the current treatment modalities and prevention measures.

The Necessity of Dissection of No. 14 Lymph Nodes to Patients With Pancreatic Ductal Adenocarcinoma Based on the Embryonic Development of the Head of the Pancreas.

Objectives: Pancreaticoduodenectomy (PD) followed by lymphadenectomy is performed for patients with pancreatic ductal adenocarcinoma (PDAC) located in the head of the pancreas. Because the head of the pancreas could be divided into dorsal or ventral primordium in relation to embryonic development, the metastasis of lymph node (LN) may differ. In this retrospective study, we evaluated the impact of extended or standard LN dissection for PDAC located in ventral or dorsal primordia of the pancreatic head.Methods: From February 2016 to November 2018, 178 patients who underwent PD for PDAC were enrolled at the Pancreatic Disease Center, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University. According to the tumor location and the range of LN dissection, all patients were divided into three groups: ventral primordium with extended lymphadenectomy (VE group), ventral primordium with standard lymphadenectomy (VS group), and dorsal primordium with extended lymphadenectomy (DE group). Clinical and pathological features were retrospectively analyzed as were the long-term survival outcomes.Results: More patients in the VE group were detected with metastasis in the lymph nodes around the superior mesenteric artery (LN14) than those in the DE group (LN along the right side of the superior mesenteric artery, LN14ab): 22.9 vs. 5.9%, p = 0.005; (LN along the left side of the superior mesenteric artery, LN14cd): 10.0 vs. 0.0%, p = 0.022. LN14 was involved in more patients in the VE group than in the VS group (22.9 vs. 5.0%, p = 0.015). For IIb-stage patients in the VE group, the overall survival time (18.3 vs. 9.3 months, p < 0.001) and disease-free survival time (12.2 vs. 5.1 months, p = 0.045) were longer in those with LN14cd (–) than those with LN14cd (+).Conclusion: This study suggested that patients with PDAC located in the ventral head of the pancreas had higher risk of LN14 involvement compared with those at dorsal. Thus, a thorough dissection of LN14 in PDAC located in the ventral head of the pancreas is recommended to optimize the regional extended lymphadenectomy.

Fluorescence-guided lymphadenectomy in gastric cancer: a prospective western series.

Indocyanine green (ICG) has been recently introduced in clinical practice as a fluorescent tracer. Lymphadenectomy is particularly challenging in gastric cancer surgery, owing to the complex anatomical drainage. The primary outcomes of this study were the feasibility and usefulness of ICG-guided lymphadenectomy in gastric cancer surgery, considering both the success rate and improved understanding of the surgical anatomy of nodal basins. The secondary outcome was the diagnostic ability of ICG to predict the presence of nodal metastases. We conducted a single-center prospective trial comprising 13 patients with gastric cancer. ICG was injected the afternoon prior to surgery or intraoperatively via the submucosal or subserosal route. Standard lymphadenectomy was performed in all patients, according to patient age and tumor stage, as usual, but after standard lymphadenectomy the residual ICG + nodes were harvested and analyzed. Each nodal station and each dissected node was recorded and classified as ICG + or ICG- (both in vivo and back table evaluation was utilized for classification). After pathological analysis, each nodal station and each dissected node was recorded as metastatic or nonmetastatic (E&E staining). The feasibility rate was 84.6% (11/13). The mean number of dissected lymph nodes per patient was 37.9. Focusing on the 11 patients in whom ICG-guided nodal navigation was successfully performed, 81 lymph node stations were removed, for a total of 417 lymph nodes. Sixty-six stations (81.48%), comprising a total of 336 lymph nodes, exhibited fluorescence. No IC- node was metastatic; all 54 metastatic nodes were ICG + . A total of 282 ICG + nodes were nonmetastatic. In two cases, some nodes outside D2 areas were harvested, being ICG + (1 case of metastatic node). Fluorescence lymphography-guided lymphadenectomy is a promising new technique that combines a high feasibility rate with considerable ease of use. Regarding its diagnostic value, the key finding from this prospective series is that no metastatic nodes were found outside fluorescent lymph node stations. Further studies are needed to investigate whether this technique can help surgeons performing standard lymphadenectomy and selecting cases for D2 + lymphadenectomy.

Number and Station of Lymph Node Metastasis After Curative-intent Resection of Intrahepatic Cholangiocarcinoma Impact Prognosis.

To determine the prognostic implication of the number and station of LNM, and the minimal number of LNs needed for evaluation to accurately stage patients with intrahepatic cholangiocarcinoma (ICC). Impact of the number and station of LNM on long-term survival, and the minimal number of LNs needed for accurate staging of ICC patients remain poorly defined. Data on patients who underwent curative-intent resection for ICC was collected from 15 high-volume centers worldwide. External validation was performed using the SEER registry. Primary outcomes included overall (OS), disease-specific, and recurrence-free survival. Among 603 patients who underwent curative-intent resection, median and 5-year OS were 30.6 months and 30.4%. Patients with 1 or 2 LNM had comparable worse OS versus patients with no nodal disease (median OS, 1 LNM 18.0, 2 LNM 20.0 vs no LNM 45.0 months, both P < 0.001), yet better OS versus patients with 3 or more LNM (median OS, 1-2 LNM 19.8 vs ≥3 LNM 16.0 months, P < 0.01). On multivariable analysis, a proposed new nodal staging with N1 (1-2 LNM) (Ref. N0, HR 2.40, P < 0.001) and N2 (≥3 LNM) [Ref. N0, hazard ratio (HR) 3.85, P < 0.001] categories were independently associated with incrementally worse OS. Patients with no nodal metastasis, 1-2 LNM and ≥3 LNM also had an increasingly worse disease-specific survival, and recurrence-free survival (both P < 0.05). Total number of LNs examined ≥6 had the greatest discriminatory power relative to OS among patients with 1-2 LNM, and patients with ≥3 LNM in both the multi-institutional (area under the curve 0.780) and SEER database (area under the curve 0.820) (n = 1036). Among patients who underwent an adequate regional lymphadenectomy (total number of LNs examined ≥6), LNM beyond the HDL was associated with worse OS versus LNM within the HDL only (median OS, 14.0 vs 24.0 months, HR 2.41, P = 0.003). Standard lymphadenectomy of at least 6 LNs is strongly recommended and should include examination beyond station 12 to have the greatest chance of accurate staging. The proposed new nodal staging of N0, N1, and N2 should be considered to stratify outcomes among patients after curative-intent resection of ICC.

Radiation therapy before radical cystectomy combined with immunotherapy in locally advanced bladder cancer \u2013 study protocol of a prospective, single arm, multicenter phase II trial (RACE IT)

BackgroundPatients with locally advanced bladder cancer (cT3/4 cN0/N+ cM0) have a poor prognosis despite radical surgical therapy and perioperative chemotherapy. Preliminary data suggest that the combination of radiation and immunotherapy does not lead to excess toxicity and may have synergistic (abscopal) anti-tumor effects. We hypothesize that the combined preoperative application of the PD-1 checkpoint-inhibitor Nivolumab with concomitant radiation therapy of the bladder and pelvic region followed by radical cystectomy with standardized lymphadenectomy is safe and feasible and might improve outcome for patients with locally advanced bladder cancer.MethodsStudy design: “RACE IT” (AUO AB 65/18) is an investigator initiated, prospective, multicenter, open, single arm phase II trial sponsored by Technical University Munich. Study drug and funding are provided by the company Bristol-Myers Squibb.Study treatment: Patients will receive Nivolumab 240 mg i.v. every 2 weeks for 4 cycles preoperatively with concomitant radiation therapy of bladder and pelvic region (max. 50.4 Gy). Radical cystectomy with standardized bilateral pelvic lymphadenectomy will be performed between week 11–15.Primary endpoint: Rate of patients with completed treatment consisting of radio-immunotherapy and radical cystectomy at the end of week 15.Secondary endpoints: Acute and late toxicity, therapy response and survival (1 year follow up).Main inclusion criteria: Patients with histologically confirmed, locally advanced bladder cancer (cT3/4, cN0/N+), who are ineligible for neoadjuvant, cisplatin-based chemotherapy or who refuse neoadjuvant chemotherapy.Main exclusion criteria: Patients with metastatic disease (lymph node metastasis outside pelvis or distant metastasis) or previous chemo-, immune- or radiation therapy.Planned sample size: 33 patients, interim analysis after 11 patients.DiscussionThis trial aims to evaluate the safety and feasibility of the combined approach of preoperative PD-1 checkpoint-inhibitor therapy with concomitant radiation of bladder and pelvic region followed by radical cystectomy. The secondary objectives of therapy response and survival are thought to provide preliminary data for further clinical evaluation after successful completion of this trial. Recruitment has started in February 2019.Trial registrationProtocol Code RACE IT: AB 65/18; EudraCT: 2018–001823-38; Clinicaltrials.gov: NCT03529890; Date of registration: 27 June 2018.

Facility-Level Variation in Pelvic Lymphadenectomy During Radical Prostatectomy and Effect on Overall Survival in Men with High-Risk Prostate Cancer.

This study was designed to examine facility-level variation in the extent of pelvic lymphadenectomy and to determine whether more extensive lymphadenectomy is associated with a survival benefit among men with localized high-risk prostate cancer. Using data from the National Cancer Data Base, we identified 13,652 men with a high predicted probability of 10-year survival (≤ 65years of age and Charlson Comorbidity Index score of 0) who underwent radical prostatectomy at 1023 facilities for biopsy-confirmed localized high-risk prostate cancer diagnosed between January 2004 and December 2011. Multilevel, multinomial logistic regression was fitted to predict facility-level probability of receiving different extents of lymphadenectomy. Inverse probability of treatment weighting-adjusted Cox regression model with Bonferroni correction was fitted to compare risk of overall mortality. Overall, 11,284 (82.7%), 1601 (11.7%), and 767 (5.6%) men who underwent radical prostatectomy underwent concomitant none/limited lymphadenectomy (0-9 lymph nodes), standard lymphadenectomy (10-16 lymph nodes), and extended lymphadenectomy (≥ 17 lymph nodes), respectively. Extended lymphadenectomy was not associated with a survival benefit relative to standard lymphadenectomy (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.48-1.23; p = 0.4) nor no/limited lymphadenectomy (HR 0.77, 95% CI 0.87-2.20; p = 0.29) at a median follow-up of 83.3months. Risk-adjusted facility-level predicted probabilities of extended, standard, or no/limited lymphadenectomy ranged from 0.01 to 52.6%, 3.3-53.3%, and 17.8-96.3%, respectively. We found significant facility-level variation in the extent of pelvic lymphadenectomy during radical prostatectomy despite no apparent survival benefit associated with more extensive lymphadenectomy. Further prospective data are needed to reevaluate the role of lymphadenectomy in the management of clinically localized prostate cancer.

\u201cD2 plus\u201d lymphadenectomy is associated with improved survival in distal gastric cancer with clinical serosa invasion: a propensity score analysis

The aim of this study was to elucidate the potential impact of “D2 plus” lymphadenectomy on the long-term survival of distal gastric cancer (GC) patients with clinical serosa invasion. A total of 394 distal GC patients with clinical serosa invasion who underwent at least standard D2 lymphadenectomy were enrolled. Patients were categorized into two groups according to the extent of lymphadenectomy: D2 group and “D2 plus” group. Propensity score matching was used to adjust for the differences in baseline characteristics. In the multivariate analysis for the whole study series, extent of lymphadenectomy was an independent prognostic factor for GC patients (P = 0.011). With the strata analysis, the significant prognostic differences between the two groups were only observed in patients at the IIIa-b or N1-3a stages. After matching, patients in “D2 plus” group still demonstrated a significantly higher 5-year overall survival rate than those in D2 group (55.3% versus 43.9%, P = 0.042). The common therapeutic value index of No. 12b, No. 12p, No. 14v and No. 13 LNs was 4.6, which was close to that of No. 5 LN station. In conclusion, “D2 plus” lymphadenectomy may be associated with improved overall survival in distal GC with clinical serosa invasion.

P101 THE IMPACT OF PARATRACHEAL LYMPHADENECTOMY ON LYMPH NODE YIELD AND SHORT-TERM OUTCOMES IN ESOPHAGECTOMY: A NATIONAL PROPENSITY SCORE MATCHED ANALYSIS

Abstract Aim This study aimed to investigate the impact of paratracheal lymphadenectomy on lymph node yield and short-term outcomes in patients undergoing esophagectomy for cancer. Background &amp; Methods Although the addition of paratracheal lymphadenectomy to a standard two-field lymphadenectomy possibly may provide survival benefits for patients undergoing esophagectomy for esophageal cancer, the required dissection along the recurrent laryngeal nerves might be associated with increased morbidity. To investigate the impact of paratracheal lymphadenectomy on short-term oncological outcomes and postoperative complications, this nation-wide population-based cohort study included esophageal cancer patients who underwent neoadjuvant chemoradiotherapy followed by elective transthoracic esophagectomy with at least subcarinal and para-esophageal lymphadenectomy from the Dutch Upper Gastrointestinal Cancer Audit (DUCA). After propensity score matching Ivor Lewis and McKeown approaches separately, the lymph node yield and clinical outcomes were compared between patients who underwent paratracheal lymphadenectomy versus patients who did not. Results Between 2011-2017, a total of 2128 patients were included. A total of 770 patients (n=385 vs. n=385) and 516 patients (n=258 vs. n=258) were matched for the Ivor Lewis and McKeown approaches, respectively. Paratracheal lymphadenectomy was associated with a higher total lymph node yield in both Ivor Lewis (23 vs. 19 nodes, P&lt;0.001) and McKeown (21 vs. 19 nodes, P=0.015) esophagectomy. In McKeown esophagectomy, paratracheal lymphadenectomy was associated with significantly more advanced pathological nodal staging (pN0; 57% vs. 69%, pN1; 25% vs. 16%, pN2; 12% vs. 11%, pN3; 6% vs. 3%, P=0.006). No significant differences were observed regarding recurrent laryngeal nerve injury, other postoperative complications, and mortality, although a higher re-intervention rate was found after paratracheal lymphadenectomy during McKeown esophagectomy (30% vs. 18%, P=0.002) In patients undergoing Ivor Lewis esophagectomy, paratracheal lymphadenectomy was associated with increased length of stay (12 vs. 11 days, P&lt;0.048). Conclusion In patients undergoing transthoracic esophagectomy for cancer, the addition of paratracheal lymphadenectomy results in a higher lymph node yield with comparable complication and mortality rates.

Is D2 Lymphadenectomy Essential for Cytology-positive Gastric Cancer? A Retrospective Analysis.

The appropriate extent of lymphadenectomy on gastric cancer patients with positive peritoneal cytology (CY1) is uncertain. This study retrospectively compared overall survival (OS) after standard and limited lymphadenectomy. The medical records from four institutions from 2004 to 2018 were reviewed and data for 91 patients with CY1, but no other distant metastases, who underwent gastrectomy were analyzed. D2 or greater lymphadenectomy and less than D2 lymphadenectomy were performed in 51 and 40 patients, respectively. Full cohort analyses showed that patients who underwent D2 or greater lymphadenectomy had better prognostic nutritional indices and more such patients received postoperative chemotherapy. The OS in the group treated with D2 or greater lymphadenectomy was also significantly better (p=0.045). Twenty-seven pairs of patients were generated via propensity score matching, and analysis of their OS showed no significant difference between the groups according to lymphadenectomy (p=0.61). The extent of lymphadenectomy may not affect the prognoses for patients with CY1 gastric cancer.