Lymph node ratio is an independent prognostic factor after resection of periampullary malignancies: data from a tertiary referral center in the middle East.

OBJECTIVE: The prognostic impact of nodal involvement in resected pancreatic carcinoma and biliary malignancy has been relatively well established. It has been suggested that lymph node ratio (LNR) may be a more informative way of stratifying patients with node positive disease. Our retrospective review aimed to investigate the significance of such variables and test for independent prognostic factors for survival. METHODS: One hundred eighty-three pancreatic and periampullary malignancy cases were registered at the American University of Beirut Medical Center from 1990 to 2004. Of those, 80 had complete data on lymph node status. We analyzed the impact of the number of lymph nodes resected, the number of positive lymph nodes retrieved and LNR using Kaplan-Meier and Cox proportional hazard models. The measured outcome in the KM model was the survival probability at 1, 3, and 5 years while the Cox model was used to measure the hazard ratio (HR) of the previously identified predictors on survival. RESULTS: For the 80 patients included in this analysis, overall survival rates were 65% (54 to 78), 32% (18 to 47), and 21% (8 to 34) were alive at 1, 3, and 5 years, respectively. The median number of resected lymph nodes was 9. In the node positive patients, those who had >12 nodes examined were found to have a significantly better survival (HR=0.24; P=0.013). On multivariate analysis, our model showed the following factors to be significant: age 60 years or older (HR=5.92; P=0.018), poorly differentiated tumors (HR=21.87; P=0.018), number of lymph nodes examined <12 LN (HR=6.77; P=0.022), 3 or more metastatic LN (HR=7.21; P=0.028), and LNR≥0.2 (HR=7.12; P=0.007). CONCLUSIONS: After pancreaticodudonectomy for adenocarcinoma of the pancreas and biliary malignancies, ratio-based lymph node staging is an independent and powerful prognostic factor.

Improving the inaccuracies of clinical staging of patients with NSCLC: a prospective trial.

BACKGROUND: Clinical stage affects the care of patients with nonsmall cell lung cancer. METHODS: This is a prospective trial on patients with suspected resectable nonsmall cell lung cancer. All patients underwent integrated positron emission tomographic scanning and computed tomographic scanning, and all suspicious metastatic sites were investigated. A, T, N, and M status was assigned. If N2, N3 and M1 were negative, patients underwent thoracotomy and complete thoracic lymphadenectomy. RESULTS: There were 383 patients. The accuracy of clinical staging using positron emission tomographic scanning and computed tomographic scanning was 68% and 66% for stage I, 84% and 82% for stage II, 74% and 69% for stage III, and 93% and 92% for stage IV, respectively. N2 disease was discovered in 115 patients (30%) and was most common in the subcarinal lymph node (30%). Unsuspected N2 disease occurred in 28 patients (14%) and was most common in the posterior mediastinal lymph nodes (subcarinal, 38%; posterior aortopulmonary, 15%). It was found in 9% of patients who were clinically staged I (58% in the posterior mediastinal lymph nodes) and in 26% of patients clinically staged II (86% in posterior mediastinal lymph nodes). CONCLUSIONS: Despite integrated positron emission tomographic scanning and computed tomographic scanning, clinical staging remains relatively inaccurate for patients with nonsmall cell lung cancer. Recent studies suggest adjuvant therapy for stage Ib and II nonsmall cell lung cancer; thus the impact on preoperative care is to find unsuspected N2 disease. Unsuspected N2 disease is most common in posterior mediastinal lymph nodes inaccessible by mediastinoscopy. Thus one should consider endoscopic ultrasound fine-needle aspiration, especially for patients clinically staged as I and II, even if the nodes are negative on positron emission tomographic scanning and computed tomographic scanning.

New techniques for staging esophageal cancer.

Correct staging is essential for treatment selection, discussion of prognosis, and scientific communication. The CT scan has long been the essential tool for staging esophageal cancer and still remains valuable for initial screening for distant metastases. The development of endoscopic ultrasonography (EUS), with EUS fine-needle aspiration, positron emission tomography, and minimally invasive surgical staging via thoracoscopy and laparoscopy has resulted in more precise staging. These new tools will allow better definition of patient subsets that may benefit from selected therapies and clinical investigations.

Fine needle aspiration biopsy of the islet cell tumor of pancreas: a comparison between computerized axial tomography and endoscopic ultrasound-guided fine needle aspiration biopsy.

The objective of the present study is to compare the cytologic features of islet cell tumor (ICT) of pancreas obtained by endoscopic ultrasound guided fine needle aspiration (EUS-FNA) and computed tomography guided FNA (CT-FNA). We also describe the cytologic features associated with malignant ICT. Eleven cytology samples from 121 CT- FNA and 30 EUS- FNA of the pancreas were obtained from nine patients with ICT. Diff-Quik, Papanicolaou, and immunohistochemical stains to determine neuroendocrine differentiation and the hormonal status were evaluated. Cytologic features and specimen adequacy were compared between the two techniques. Cytologic features noted in both benign and malignant ICT were also compared. Nine patients (5 men, 4 women) ranging in age from 29 to 84 years (mean age, 53.8 years). Diagnoses consisted of benign (4) and malignant (5) ICT. EUS-FNA was superior to CT-FNA in obtaining adequate cells (2/2 v 7/9) for the diagnosis and increased cellularity to perform additional immunohistochemical stains (2/2 v 4/7). Single, plasmacytoid cells with finely granular chromatin distribution characterized ICT on cytology. Mitoses (3/5) and necrosis (1/5) were noted in malignant ICT but not in benign ICT. EUS-FNA is superior to CT- FNA for obtaining cells for the diagnosis of ICT. Detection of mitoses and or necrosis from patients with ICT should initiate a search for metastasis.