Disease relapse in relation to lymph node sampling in lung carcinoid patients.

The predictive value of the extent of peri-operative lymph node (LN) sampling in relation to disease relapse in patients with pulmonary carcinoid (PC) is unknown. Furthermore, post-surgery follow-up recommendations rely on institutional retrospective studies with short follow-ups. We aimed to address these shortcomings by examining the relation between LN sampling and relapse in a population-based cohort with long-term follow-up. By combining the Dutch nationwide pathology and cancer registries, all patients with surgically resected PC (2003-2012) were included in this analysis (last update 2020). The extent of surgical LN dissection was scored for the number of LN samples, location (hilar/mediastinal), and completeness of resection according to European Society of Thoracic Surgeons (ESTS) guidelines. Relapse-free interval (RFI) was evaluated using Kaplan Meier and multivariate regression analysis. 662 patients were included. The median follow-up was 87.5 months. Relapse occurred in 10% of patients, mostly liver (51.8%) and locoregional sites (45%). The median RFI was 48.1 months (95% CI 36.8-59.4). Poor prognostic factors were atypical carcinoid, pN1/2, and R1/R2 resection. In 546 patients LN dissection data could be retrieved; at least one N2 LN was examined in 44% and completeness according to ESTS in merely 7%. In 477 cN0 patients, 5.9% had pN1 and 2.5% had pN2 disease. In conclusion, relapse occurred in 10% of PC patients with a median RFI of 48.1 months thereby underscoring the necessity of long-term follow-up. Extended mediastinal LN sampling was rarely performed but systematic nodal evaluation is recommended as it provides prognostic information on distant relapse.

Sublobectomy and lymph node sampling are adequate for patients with invasive lung adenocarcinoma presenting as pure ground glass nodules.

PURPOSE: In this study, we aimed to investigate the prognosis of invasive lung adenocarcinoma that manifests as pure ground glass nodules (pGGNs) and confirm the effectiveness of sublobectomy and lymph node sampling in patients with pGGN-featured invasive adenocarcinoma (IAC). MATERIALS AND METHODS: We retrospectively enrolled 139 patients with pGGN-featured IAC, who underwent complete resection in two medical institutions between January 2011 and May 2022. Stratification analysis was conducted to ensure balanced baseline characteristics among the patients. The 5-year overall survival (OS) and disease-free survival (DFS) rates were compared between the groups using Kaplan-Meier survival curves and log-rank test. RESULTS: The 5-year OS and DFS rates for patients with IAC presenting as pGGNs after surgery were 96.5% and 100%, respectively. No lymph node metastasis or recurrence was observed in any of the enrolled patients. There was no statistically significant difference in the 5-year OS between patients who underwent lobectomy or sublobectomy, along with lymph node resection or sampling. CONCLUSION: IAC presented as pGGNs exhibited low-grade malignancy and had a relatively good prognosis. Therefore, these patients may be treated with sublobectomy and lymph node sampling.

[Risk Factors and Sampling Range Evaluation of Lymph node Metastasis for 
Non-small Cell Lung Cancer with Diameter ≤2 cm].

BACKGROUND: More early-stage non-small cell lung cancer (NSCLC) are diagnosed in time and treated surgically, but systematic lymph node dissection can not bring enough survival benefits for them, and even increase the probability of postoperative complications. This study aims to analyze the risk factors and evaluate mediastinal lymph node metastasis sites in different lung lobes for NSCLC with diameter ≤2 cm, so as to provide reference for surgery. METHODS: We collected 1051 patients with pulmonary nodule diameter ≤2 cm who were treated by pulmonary lobectomy with lymph node sampling/dissection in Department of Thoracic Surgery of the First Affiliated Hospital with Nanjing Medical University from December 2009 to December 2019. SPSS 26.0 statistical software was used for statistical analysis, to explore the risk factors and evaluate mediastinal lymph node metastasis sites in different lung lobes. RESULTS: 95 of 1051 (9.04%) patients presented lymph node metastasis. Male, pathological non-adenocarcinoma, 1 cm0.05). Lymph nodes in group N1 were significantly correlated with lymph node metastasis in groups #2R, #4R, #5, #6, #7 and #9 (P<0.01). CONCLUSIONS: Lobe-specific lymph node dissection (LSND) can be performed for early-stage NSCLC. Male, pathological non-adenocarcinoma, 1 cm

Technical advances in the surgical management of Wilms tumors in children.

Surgery is one of the cornerstones of Wilms tumor treatment. In this article, we present technical advancements that are finding their way into the armamentarium of pediatric cancer surgeons. We discuss the current approaches, challenges, opportunities, and future directions of minimally invasive surgery (laparoscopic and robotics), image-guided surgery, and fluorescence-guided surgery. Furthermore, we discuss the use of intraoperative ultrasonography, as well as the use of new techniques to improve the quality of lymph node sampling.

Lymph node sampling-what are the numbers?

Lung cancer is a deadly disease. Lymph node staging is the most important prognostic factor, and lymphatic drainage of the lung is complex. Major advances have been made in this field over the last several decades, but there is much left to understand and improve upon. Herein, we review the history of the lymphatic system and the creation of lymph node maps, the evolution of tumor, node, and metastasis lung cancer classification, the importance of lung cancer staging, techniques for lymph node dissection, and our recommendations regarding a minimum number of nodes to sample during pulmonary resection.

Laparoscopic Excision of Large Wilms Tumor in Children: A Single-Center Experience from a Resource-Challenged Nation.

Background: In this study, we aim to review the outcomes of children with Wilms tumor (WT) operated through the minimally invasive surgery (MIS) approach at our center. We also intend to highlight essential surgical steps during laparoscopic excision of large WTs. Methods: This retrospective study included children with unilateral WT who had undergone resection for a period of 4 years, w.e.f. July 2013 to July 2017. Simple maneuvers such as tilting the table in different positions and use of blunt metallic cannula to lift the tumor to access the hilar vessels were used to dissect large WT. An extended lumbotomy incision was used for retrieval of tumor and lymph-node sampling. Results: Eleven patients (male:female = 7:4) of WT, all having stage III disease, had undergone laparoscopic tumor resection at our center during the study period. The median age at presentation was 36 months (range = 17 months-5 years) and the median preoperative tumor volume was 1140 (range = 936-1560) cm3. The average length of the lumbotomy incision was 6.3 (range = 5-8.2) cm. The median hospital stay was 6 (range = 5-10) days. Two children developed complications (port-site recurrence and grade III surgical site infection in one each) during the postoperative period. All cases are long-term survivors after a median follow-up of 86 (range = 56-104) months. Conclusion: This study highlights the feasibility and safety of the removal of large WT through the MIS approach. Problems due to large-sized tumors in children can be overcome by simple maneuvers. Also, adequate lymph node sampling is possible with a suitably placed extended lumbotomy incision for tumor removal.

Assessment of Updated Commission on Cancer Guidelines for Intraoperative Lymph Node Sampling in Early Stage NSCLC.

INTRODUCTION: The American College of Surgeons Commission on Cancer recently updated its sampling recommendations for early stage NSCLC from at least 10 lymph nodes to at least one N1 (hilar) and three N2 (mediastinal) lymph node stations. Nevertheless, intraoperative lymph node sampling minimums remain subject to debate. We sought to evaluate these guidelines in patients with early stage NSCLC. METHODS: We performed a cohort study using a uniquely compiled data set from the Veterans Health Administration. We manually abstracted data from operative notes and pathology reports of patients with clinical stage I NSCLC receiving surgery (2006-2016). Adequacy of lymph node sampling was defined using count-based (≥10 lymph nodes) and station-based (≥three N2 and one N1 nodal stations) minimums. Our primary outcome was recurrence-free survival. Secondary outcomes were overall survival and pathologic upstaging. RESULTS: The study included 9749 patients. Count-based and station-based sampling guidelines were achieved in 3302 (33.9%) and 2559 patients (26.3%), respectively, with adherence to either sampling guideline increasing over time from 35.6% (2006) to 49.1% (2016). Adherence to station-based sampling was associated with improved recurrence-free survival (multivariable-adjusted hazard ratio = 0.815, 95% confidence interval: 0.667-0.994, p = 0.04), whereas adherence to count-based sampling was not (adjusted hazard ratio = 0.904, 95% confidence interval: 0.757-1.078, p = 0.26). Adherence to either station-based or count-based guidelines was associated with improved overall survival and higher likelihood of pathologic upstaging. CONCLUSIONS: Our study supports station-based sampling minimums (≥three N2 and one N1 nodal stations) for early stage NSCLC; however, the marginal benefit compared with count-based guidelines is minimal. Further efforts to promote widespread adherence to intraoperative lymph node sampling minimums are critical for improving patient outcomes after curative-intent lung cancer resection.

Para-aortic lymph node involvement should not be a contraindication to resection of pancreatic ductal adenocarcinoma.

BACKGROUND: Para-aortic lymph nodes (PALN) are found in the aortocaval groove and they are staged as metastatic disease if involved by pancreatic ductal adenocarcinoma (PDAC). The data in the literature is conflicting with some studies having associated PALN involvement with poor prognosis, while others not sharing the same results. PALN resection is not included in the standard lymphadenectomy during pancreatic resections as per the International Study Group for Pancreatic Surgery and there is no consensus on the management of these cases. AIM: To investigate the prognostic significance of PALN metastases on the oncological outcomes after resection for PDAC. METHODS: This is a retrospective cohort study of data retrieved from a prospectively maintained database on consecutive patients undergoing pancreatectomies for PDAC where PALN was sampled between 2011 and 2020. Statistical comparison of the data between PALN+ and PALN- subgroups, survival analysis with the Kaplan-Meier method and risk analysis with univariable and multivariable time to event Cox regression analysis were performed, specifically assessing oncological outcomes such as median overall survival (OS) and disease-free survival (DFS). RESULTS: 81 cases had PALN sampling and 17 (21%) were positive. Pathological N stage was significantly different between PALN+ and PALN- patients (P = 0.005), while no difference was observed in any of the other characteristics. Preoperative imaging diagnosed PALN positivity in one case. OS and DFS were comparable between PALN+ and PALN- patients with lymph node positive disease (OS: 13.2 mo vs 18.8 mo, P = 0.161; DFS: 13 mo vs 16.4 mo, P = 0.179). No difference in OS or DFS was identified between PALN positive and negative patients when they received chemotherapy either in the neoadjuvant or in the adjuvant setting (OS: 23.4 mo vs 20.6 mo, P = 0.192; DFS: 23.9 mo vs 20.5 mo, P = 0.718). On the contrary, when patients did not receive chemotherapy, PALN disease had substantially shorter OS (5.5 mo vs 14.2 mo; P = 0.015) and DFS (4.4 mo vs 9.8 mo; P < 0.001). PALN involvement was not identified as an independent predictor for OS after multivariable analysis, while it was for DFS doubling the risk of recurrence. CONCLUSION: PALN involvement does not affect OS when patients complete the indicated treatment pathway for PDAC, surgery and chemotherapy, and should not be considered as a contraindication to resection.

Trends of lymph node sampling and metastasis in pediatric and young adult patients with clear cell, epithelioid, and synovial sarcomas.

BACKGROUND: Clear cell sarcoma of soft tissue (CCS), epithelioid sarcoma, and synovial sarcoma are rare tumors historically identified as high risk for lymph node metastasis. This study investigates incident nodal metastasis and associated survival in children and young adults with these subtypes. PROCEDURE: Using the National Cancer Database (2004-2015), we created a retrospective cohort of 1303 patients (aged ≤25 years) who underwent local control therapy for CCS, epithelioid sarcoma, and synovial sarcoma. Kaplan-Meier curves estimated overall survival (OS) by subtype. Stratifying on subtype, Cox regressions assessed OS by lymph node sampling status and nodal metastasis. RESULTS: There were 103 (7.9%) patients with CCS, 221 (17.0%) with epithelioid sarcoma, and 979 (75.1%) with synovial sarcoma. Lymph node sampling was more frequent in patients with CCS (56.3%) and epithelioid sarcoma (52.5%) versus synovial sarcoma (20.5%, p < .001). Synovial sarcoma metastasized to lymph nodes less frequently than CCS or epithelioid sarcoma (2.1% vs. 14.6% and 14.9%, p < .001). Across all subtypes, lymph node metastasis was associated with inferior OS (HR 2.02, CI 1.38-2.95, p < .001). Lymph node sampling was associated with improved OS in CCS (HR 0.35, CI: 0.15-0.78, p = .010), inferior OS in synovial sarcoma (HR 1.60, CI: 1.13-2.25, p = .007), and no statistical association with OS in epithelioid sarcoma. CONCLUSIONS: Lymph node metastasis is rare in children and young adults with synovial sarcoma. Lymph node sampling procedures were not consistently performed for patients with CCS or epithelioid sarcoma, but improved OS supports routine lymph node sampling in children and young adults with CCS.

Prognostic Role of Lymph Node Sampling in Adolescent and Young Adults With Fibrolamellar Carcinoma.

INTRODUCTION: Hepatocellular carcinoma (HCC) is rare among adolescent and young adult (AYA) patients, and resection or transplant remains the only curative therapy. The role of lymph node (LN) sampling is not well-defined. The aim of this study was to describe practice patterns, as well as investigate the impact of LN sampling on survival outcomes in this population. MATERIALS AND METHODS: A retrospective cohort study using the 2004-2018 National Cancer Database (NCDB) was performed. Patients ≤21 y old with nonmetastatic HCC who underwent liver resection or transplant were evaluated. Clinical features of patients who underwent LN sampling were compared to those who did not, and univariable and multivariable logistic regression was performed to evaluate independent predictive factors of node positivity. Survival analysis was performed using Kaplan-Meier methods and Cox Proportional Hazard Survival Regression. RESULTS: A total of 262 AYA patients with HCC were identified, of whom 137 (52%) underwent LN sampling, 44 patients had positive nodes, 40 (95%) of them had tumors >5 cm; 87 (64%) of patients with sampled nodes had fibrolamellar carcinoma (FLC), which was an independent risk factor for predicting positive nodes (P = 0.001). There was no difference in overall survival between patients who underwent LN sampling and those who did not; however, 5-y overall survival for node-positive patients was 40% versus 79% for node-negative patients (P < 0.0001). CONCLUSIONS: In AYA patients with HCC, LN sampling was not associated with an independent survival benefit. However, FLC was an independent risk factor for LN positivity, suggesting a role for routine LN sampling in these patients.

Adequacy of Mediastinal Lymph Node Sampling in Patients With Lung Cancer Undergoing Lung Resection.

BACKGROUND: Intraoperative mediastinal lymph node sampling (MLNS) is a crucial component of lung cancer surgery. Whilst several sampling strategies have been clearly defined in guidelines from international organizations, reports of adherence to these guidelines are lacking. We aimed to assess our center's adherence to guidelines and determine whether adequacy of sampling is associated with survival. MATERIALS AND METHODS: A single-center retrospective review of consecutive patients undergoing lung resection for primary lung cancer between January 2013 and December 2018 was undertaken. Sampling adequacy was assessed against standards outlined in the International Association for the Study of Lung Cancer 2009 guidelines. Multivariable logistic and Cox proportional hazards regression analyses were used to assess the impact of specific variables on adequacy and of specific variables on overall survival, respectively. RESULTS: A total of 2380 patients were included in the study. Overall adequacy was 72.1% (n= 1717). Adherence improved from 44.8% in 2013 to 85.0% in 2018 (P< 0.001). Undergoing a right-sided resection increased the odds of adequate MLNS on multivariable logistic regression (odds ratio 1.666, 95% confidence interval [CI]: 1.385-2.003, P< 0.001). Inadequate MLNS was not significantly associated with reduced overall survival on log rank analysis (P= 0.340) or after adjustment with multivariable Cox proportional hazards (hazard ratio 0.839, 95% CI 0.643-1.093). CONCLUSIONS: Adherence to standards improved significantly over time and was significantly higher for right-sided resections. We found no evidence of an association between adequate MLNS and overall survival in this cohort. A pressing need remains for the introduction of national guidelines defining acceptable performance.

Pulmonary metastasectomy with lymphadenectomy for colorectal pulmonary metastases: A systematic review.

BACKGROUND: Routine lymphadenectomy during metastasectomy for pulmonary metastases of colorectal cancer has been recommended by several recent expert consensus meetings. However, evidence supporting lymphadenectomy is limited. The aim of this study was to perform a systematic review of the literature on the impact of simultaneous lymph node metastases on patient survival during metastasectomy for colorectal pulmonary metastases (CRPM). METHODS: A systematic review was conducted according to the PRISMA guidelines of studies on lymphadenectomy during pulmonary metastasectomy for CRPM. Articles published between 2000 and 2020 were identified from Medline, Embase and the Cochrane Library without language restriction. Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to assess the risk of bias and applicability of included studies. Survival rates were assessed and compared for the presence and level of nodal involvement. RESULTS: Following review of 8054 studies by paper and abstract, 27 studies comprising 3619 patients were included in the analysis. All patients included in these studies underwent lymphadenectomy during pulmonary metastasectomy for CRPM. A total of 690 patients (19.1%) had simultaneous lymph node metastases. Five-year overall survival for patients with and without lymph node metastases was 18.2% and 51.3%, respectively (p < .001). Median survival for patients with lymph node metastases was 27.9 months compared to 58.9 months in patients without lymph node metastases (p < .001). Five-year overall survival for patients with N1 and N2 lymph node metastases was 40.7% and 10.9%, respectively (p = .064). CONCLUSION: Simultaneous lymph node metastases of CRPM have a detrimental impact on survival and this is most apparent for mediastinal lymph node metastases. Therefore, lymphadenectomy during pulmonary metastasectomy for CRPM can be advised to obtain important prognostic value.

Lymphadenectomy in pulmonary metastasectomy.

Lymph node (LN) removal during pulmonary metastasectomy is a prerequisite to achieve complete resection or at least collect prognostic information, but is not yet generally accepted. On average, the rate of unexpected lymph node involvement (LNI) is less than 10% in sarcoma, 20% in colorectal cancer (CRC) and 30% in renal cell carcinoma (RCC) when radical LN dissection is performed. LNI is a negative prognostic factor and presence of preoperative mediastinal disease usually leads to exclusion of the patient from metastasis surgery. Nonetheless, some authors found excellent prognoses even with mediastinal LNI in colorectal and RCC metastases when radical LN dissection was performed (median survival of 37 and 36 months, respectively). Multiple metastases, central location of the lesion followed by anatomical resections are associated with a higher LNI rate. The real prognostic influence of systematic LN dissection remains unclear. Two positive effects were described after radical lymphadenectomy: a trend for improved survival in RCC patients and a reduction of mediastinal recurrences from 23% to 0% in CRC patients. Unfortunately, there is a great number of studies that do not demonstrate any positive effect of lymphadenectomy during pulmonary metastasectomy except a pseudo stage migration effect. Future studies should not only focus on survival, but also on local and LN recurrence.

Analysis of Lymph Node Sampling Minimums in Early Stage Non-Small-Cell Lung Cancer.

Analyze "number of nodes" as an integer-valued variable to identify possible minimum lymph node (LN) number to sample during lung cancer resection. The National Cancer Database (NCDB) queried 2004-14 for surgically treated clinical stage I/II non-small-cell lung cancer (NSCLC). Overall survival (OS) by number of LN sampled was examined for the complete dataset, by adenocarcinoma, and by degree of resection using number of sampled LN both as integer-valued (0-30 nodes) variable and collapsed into classes. A total of 102,225 patients were analyzed. Median sampled LNs were 7. Median overall survival was 59 months if no LNs were sampled (95% confidence interval [CI]: 57.0-62.4), 74.7 months for 1 sampled LN (95% CI: 69.6-78.1), 80.2 (95% CI: 74.2-85.6) for 2 sampled LN, up to 81.5 mos. for 29 sampled LN. A Cox regression model using "0 LN" as baseline level, showed association with increased overall survival starting at 1 LN (hazard ratio [HR] 0.81, 95% CI 0.76-0.87; P <0.001). A "moving baseline" Cox regression model, showed no additional benefit when sampling additional nodes. We noticed a decreasing, linear association between OS and a number of 0-5 sampled LNs, most pronounced between 0 and 1 LN sampled, using a martingale residual plot from a null Cox model; no association was observed for more sampled LNs. For patients undergoing lobectomy, difference in OS was noted between 0 and 1LN sampled but not between 2 and 30 LN. These differences were not statistically significant until the number of 4 removed LN (respectively 3 for wedge-resections). For segmentectomies, median survival was not statistically associated with number of LN sampled. Based on NCDB data, LN sampling for lung cancer resections is recommended. Lobectomy survival is positively associated with 4 LN sampled, but ideal sampling may lie at 5LN in most cases. NCDB data does not seem to justify the quality metric of minimum 10 LNs.

Is there any therapeutic role of pelvic and para-aortic lymphadenectomy in apparent early stage epithelial ovarian cancer?

OBJECTIVE: The therapeutic role of pelvic and para-aortic lymphadenectomy in surgical staging of apparent early-stage epithelial ovarian cancer (eEOC) is still under debate. The aim of this study was to evaluate the potential therapeutic role of systematic lymphadenectomy in patients with eEOC. METHODS: Multi-center retrospective cohort study, comparing women with apparent eEOC who underwent comprehensive bilateral pelvic and para-aortic lymphadenectomy (defined as ≥20 lymph nodes) versus patients receiving no lymphadenectomy or lymph node sampling, from 05/1985 to 12/2016. Patients with bulky nodes at CT-scan and those without complete intra-peritoneal surgical staging were excluded. Only patients who received at least 3 cycles of platinum-based adjuvant chemotherapy were included. RESULTS: Out of 2559 patients with FIGO stage IA-IIIA1 ovarian cancer, 639 (25.0%) met inclusion criteria. 360 (56.3%) underwent comprehensive lymphadenectomy, 150 (23.5%) lymph node sampling and 129 (20.2%) no lymphadenectomy. Patients who underwent comprehensive lymphadenectomy were younger (p < 0.001), experienced a higher number of severe post-operative complications (p = 0.008) and had a longer time to start chemotherapy (p = 0.034). There was no difference in intra-operative complications. Median follow-up was 63 months (range, 5-342). The 5-year disease-free survival (DFS) was 79.7% vs. 76.5% vs. 68.3% (p = 0.006), and 5-year overall survival (OS) was 92.3% vs. 94.5% vs. 89.8% (p = 0.165) in women who received comprehensive lymphadenectomy vs. lymph node sampling vs. no lymphadenectomy, respectively. Lymphadenectomy represented an independent factor for DFS improvement, HR 0.52 (95%CI 0.37-0.73) (p < 0.001). CONCLUSION: Pelvic and para-aortic lymphadenectomy in surgical staging of eEOC improves DFS for the price of increasing post-operative complications and time to chemotherapy but does not affect OS. Better understanding of tumor biology may help to identify those patients in whom lymphadenectomy should still play a role.

Wilms tumor: a review of current surgical controversies.

Overall survival (OS) for children with Wilms tumor (WT) currently stands at around 90%. This is markedly improved from the survival rates of around 30% reported in the middle of the last century. This improvement is due to the development of multimodal treatment for this disease, based on the evidence yielded through international collaboration on trials conducted by the Société Internationale d'Oncologie Pédiatrique (SIOP) and the Children's Oncology Group (COG). In this article, we review some of the current surgical controversies surrounding the management of WT.

Standardizing lymph nodal sampling for Wilms tumor: A feasibility study with outcomes.

BACKGROUND: Despite being mandated by cooperative groups, omission of nodal sampling is the most frequent protocol deviation in surgery for Wilms tumor. The stations as well as the number of nodes that should be sampled are not clearly defined resulting in a marked variation in practices among surgeons. We propose a systematic method for nodal sampling intending to reduce interoperator variation. In this study, we have assessed the feasibility and yield of systematic lymph node sampling and also evaluated the factors influencing nodal metastasis. METHODS: Prospective evaluation of 113 Wilms tumor patients operated at a single tertiary cancer center between 2015 and 2019. All these patients underwent a systematic 5-station nodal sampling. RESULTS: Median lymph node yield was 8 and 13.2% (15/113) patients harbored a histologically positive nodal disease. Of the patients with positive nodal disease, interaortocaval nodes had metastasis in 46.7% (n = 7). They represented isolated sites of nodal disease (skip metastases) in 28.6% (n = 4) of patients. Right-sided tumors had more frequent involvement of interaortocaval nodes and skip disease. Tumors with high-risk histology had 12.5 times more odds of harboring nodal disease as compared to low and intermediate-risk histology Wilms tumor. CONCLUSIONS: The proposed method of systematic station wise sampling provides a template to guide surgeons in performing lymph node harvesting. Interaortocaval nodes sampling should be performed routinely as the incidence of disease at this station is sufficiently high and metastasis may skip hilar nodes. STUDY OF DIAGNOSTIC TEST: Level III evidence.

The prognostic impact of neoadjuvant chemoradiotherapy on lymph node sampling in patients with locally advanced rectal cancer.

According to the American Joint Committee on Cancer, at least 12 lymph nodes are required to accurately stage locally advanced rectal cancer (LARC). Neoadjuvant chemoradiation therapy (NACRT) reduces the number of lymph nodes retrieved during surgery. In this study, we evaluated the effect of NACRT on lymph node retrieval and prognosis in patients with LARC. We performed an observational study of 142 patients with LARC. Although our analysis was retrospective, data were collected prospectively. Half the patients were treated with NACRT and total mesorectal excision (TME) and the other half underwent TME only. The number of lymph nodes retrieved and the number of metastatic lymph nodes were significantly reduced in the NACRT group (P > 0.001). In the univariate and multivariate analyses, only NACRT and patient age were significantly associated with reduced lymph node retrieval. The number of metastatic lymph nodes and the lymph node ratio (LNR) both had a significant effect on prognosis when the patient population was examined as a whole (P = 0.003 and P = 0.001, respectively). However, the LNR was the only significant, independent prognostic factor in both treatment groups (P = 0.007 for the NACRT group; P = 0.04 for the no-NACRT group). NACRT improves patient prognosis only when the number of metastatic lymph nodes is reduced. The number of metastatic lymph nodes and the LNR are important prognostic factors. Lymph node retrieval remains an indispensable tool for staging and prognostic assessment of patients with rectal carcinoma treated with NACRT.

Impact of Lymph Node Sampling in Stage II and III Epithelial Ovarian Cancer Patients with Clinically Negative Lymph Nodes.

The main surgical treatment of stage II and III epithelial ovarian cancer (EOC) is complete cytoreduction, while the main role of lymph node sampling is to exclude microscopic stage III disease in an apparent stage I EOC. This study aims to evaluate the impact of lymph node sampling in stage II and III EOC patients with clinically negative lymph nodes. This is a retrospective cohort study including 51 stage II and III EOC patients treated and followed up between 2012 and 2016. They were treated by complete cytoreduction. Sixteen cases had lymph node sampling, while it was not done in 35 cases. The study was performed at National Cancer Institute (NCI)-Cairo University. There was no statistically significant difference regarding overall survival (P value 0.649) or disease-free survival (P value 0.372) between the group of patients who had lymph node sampling and the other group of patients who had no lymph node sampling. Lymph node ratio (LNR) was not associated with a statistically significant impact regarding overall survival or disease-free survival. There is no impact of lymph node sampling on stage II and III EOC patients with clinically negative lymph nodes.

Switching from Thoracoscopic to Robotic Platform for Lobectomy: Report of Learning Curve and Outcome.

OBJECTIVE: The optimal minimally invasive surgical management for patients with non-small-cell lung cancer (NSCLC) is unclear. For experienced video-assisted thoracoscopic surgery (VATS) surgeons, the increased costs and learning curve are strong barriers for adoption of robotics. We examined the learning curve and outcome of an experienced VATS lobectomy surgeon switching to a robotic platform. METHODS: We conducted a retrospective review to identify patients who underwent a robotic or VATS lobectomy for NSCLC from 2016 to 2018. Analysis of patient demographics, perioperative data, pathological upstaging rates, and robotic approach (RA) learning curve was performed. RESULTS: This study evaluated 167 lobectomies in total, 118 by RA and 49 by VATS. Patient and tumor characteristics were similar. RA had significantly more lymph node harvested (14 versus 10; P = 0.004), more nodal stations sampled (5 versus 4; P < 0.001), and more N1 nodes (8 versus 6; P = 0.010) and N2 nodes (6 versus 4; P = 0.017) resected. With RA, 22 patients were upstaged (18.6%) compared to 5 patients (10.2%) with VATS (P = 0.26). No differences were found in perioperative outcome. Operative time decreased significantly with a learning curve of 20 cases, along with a steady increase in lymph node yield. CONCLUSIONS: RA can be adopted safely by experienced VATS surgeons. Learning curve is 20 cases, with RA resulting in superior lymph node clearance compared to VATS. The potential improvement in upstaging and oncologic resection for NSCLC may justify the associated investments of robotics even for experienced VATS surgeons.