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Approximately 1%–2% of patients with colorectal cancer (CRC) develop para‐aortic lymph node (PALN) metastases, which are typically considered markers of systemic disease, and are associated with a poor prognosis. The utility of PALN dissection (PALND) in patients with CRC is of ongoing debate and only small‐scale retrospective studies have been published on this topic to date. This systematic review aimed to determine the utility of resecting PALN metastases with the primary outcome measure being the difference in survival outcomes following either surgical resection or non‐resection of these metastases. A comprehensive systematic search was undertaken to identify all English‐language papers on PALND in the PubMed, Medline, and Google Scholar databases. The search results identified a total of 12 eligible studies for analysis. All studies were either retrospective cohort studies or case series. In this systematic review, PALND was found to be associated with a survival benefit when compared to non‐resection. Metachronous PALND was found to be associated with better overall survival as compared to synchronous PALND, and the number of PALN metastases (2 or fewer) and a pre‐operative carcinoembryonic antigen level of <5 was found to be associated with a better prognosis. No PALND‐specific complications were identified in this review. A large‐scale prospective study needs to be conducted to definitively determine the utility of PALND. For the present, PALND should be considered within a multidisciplinary approach for patients with CRC, in conjunction with already established treatment regimens. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to compare the clinical outcomes of bladder cancer patients treated with extended pelvic lymph node dissection (ePLND) before or after cystectomy under robotic-assisted radical cystectomy (RARC). Methods: A retrospective study to identify 348 patients with bladder cancer who underwent RARC was performed. Of the patients, 152 (42.8%) underwent ePLND before radical cystectomy (RC) (group A) and 196 (56.3%) underwent ePLND after RC (group B). The clinical, pathological, and overall survival were compared. Results: The total and RC operation time in Group A (total: 130.68 ± 29.25 minutes, RC: 59.45 ± 28.63 minutes) were both shorter than Group B (total: 154.17 ± 38.18 minutes, RC: 94.81 ± 41.21 minutes) (P < .05). However, no significant difference in time of ePLND. The estimate blood loss (EBL) of RC part and total operation (RC+ePLND) in group A was less than group B (both P < .05), while the ePLND part did not show significance. The result of vascular and nerve injury and surgical drain withdrawal time were similar in two groups. The total number of lymph nodes in group A was fewer than group B (16 versus 26; P < .05). Moreover, the number of bilateral internal iliac and presacral lymph nodes of group A was fewer than group B significantly, whereas the number of bilateral external iliac, common iliac, and obturator lymph nodes was similar in two groups. The lymph node density of group A was significantly lower than group B. The median follow-up of all patients was 33.0 months. Importantly, the survival of group B was better than group A (hazard ratio: 1.412; 95% confidence interval: 1.004–1.987; P = .048). Conclusions: Performing ePLND before RC reveals better result on operation time and EBL, while, when ePLND after RC, the total number of lymph nodes dissected is more and the survival is better. It recommended ePLND be performed before RC, and it is necessary to recheck the internal iliac and presacral area after cystectomy. [ABSTRACT FROM AUTHOR]

Contemporary pelvic lymph node dissection (PLND) rates at radical cystectomy increased over time in variant histology bladder cancer (VHBC) and urothelial carcinoma of the urinary bladder (UCUB) patients. A potential survival benefit related to more extensive PLND is operational in UCUB patients, but not in VHBC patients. Rates of lymph node invasion increased slightly with extent of PLND. Objective: To test 1) contemporary pelvic lymph node dissection (PLND) trends at radical cystectomy (RC) in variant histology bladder cancer (VHBC) patients and urothelial carcinoma of the urinary bladder (UCUB), as well as 2) to test the effect of PLND extent on cancer specific mortality (CSM) after RC. Methods: Within the Surveillance, Epidemiology and End Results Registry (SEER, 2004-2016), we identified non-metastatic stage T1-2 or T3-4 VHBC and UCUB patients, who underwent RC. CSM and lymph node invasion (LNI) rates were stratified according to PLND extent, as well as coded continuously in multivariate Cox and logistic regression models. Results: Of 19,020 patients, 1736 (9.1%) were coded as having VHBC (46.9% squamous cell carcinoma, 22.5% adenocarcinoma, 18.9% neuroendocrine carcinoma, 11.7% not otherwise specified) vs 17,284 (90.9%) UCUB. PLND was performed in 80.1 of VHBC vs. 83.5% UCUB patients. In both histological groups, PLND rates increased over time (70.9-89.6% and 76.2%-90.1%, both P < .01). PLND extent did not significantly affect CSM in stage T1-2 or T3-4 VHBC patients. Conversely, PLND extent was associated with lower CSM in T1-2, as well as in T3-4 UCUB patients, which was confirmed in multivariate Cox analyses (Hazard ratio [HR] 0.99, P < .001). Rates of LNI increased with extent of PLND in logistic regression analyses in stage T3-4 VHBC (Odds ratio [OR] 1.01, P = .001), stage T1-2 UCUB (OR 1.01, P < .001) and T3-4 UCUB (OR 1.01, P < .001), but not in stage T1-2 VHBC (OR 1.01, P = .3). Conclusion: PLND rates do not differ between VHBC and UCUB patients. A potential survival benefit related to more extensive PLND is operational in UCUB patients, but not in VHBC patients. [ABSTRACT FROM AUTHOR]

Background: Para-aortic lymph node metastasis (PALNM) is a rare occurrence in colorectal cancer (CRC), and the high risk of radical lymphadenectomy leads to persistent debate about the best treatment strategy. This study aims to evaluate the predictor for PALNM and the clinical value of para-aortic lymph node dissection (PALND) in CRC patients with radiologically suspected synchronous PALNM., Methods: Patients who have synchronous radiologically suspected PALNM and underwent primary tumor resection were included. Logistic regression and receiver operating characteristic curve analysis were used to assess the predictive value of lymph node short axis in preoperative CT, identifying the optimal cut-off value. Propensity score matching and Cox regression explored factors affecting overall and disease-free survival, while Kaplan-Meier curves and decision tree models identified patient characteristics suitable for synchronous para-aortic lymph node dissection., Results: A total of 578 patients were enrolled, and 125 patients received synchronous PALND. We found that simultaneous PALND significantly improved overall survival (HR, 0.56; 95% CI, 0.35-0.91; P = .019) in multivariate analysis, while disease-free survival showed no significant difference (P = .41). The short axis diameter of PALN on preoperative CT is a crucial predictor of PALNM (P < .001, AUC = 0.759) with a threshold of > 7 mm. N-stage and distant metastasis were included as independent predictors in the diagnostic model to enhance accuracy. A larger short axis diameter of PALN correlated with advanced tumor stage and poorer prognosis. Subgroup analysis revealed that PALND offers survival benefits for colorectal cancer patients at all stages with a short axis diameter >10 mm on preoperative CT (P = .037) and for stage III patients with a diameter between 7 to10 mm (P < .001, AUC = 0.810)., Conclusion: Synchronous PALND can improve overall survival in CRC patients with suspected PALNM, with the maximum short axis diameter of PALN serving as a key criterion for selecting patients for surgery., Competing Interests: Disclosure No potential conflict of interest was reported by the authors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To investigate clinical factors associated to lymphnodal metastasis load in patients who underwent to radical prostatectomy (RP) and extended pelvic lymph node dissection (ePLND). Materials and methods: Between November 2014 and December 2019, ET was measured in 617 consecutive patients not under androgen deprivation therapy who underwent RP and ePLND. Lymphnode invasion (LNI) was codified as not present (N = 0) or with one (N = 1) or more than one metastatic node (N > 1). The risk of multiple pelvic lymph node metastasis (N > 1, mPLNM) was assessed by comparing it to the other two groups (N > 1 vs. N = 0 and N > 1 vs. N = 1). Then, we assessed the association between ET and lymphnode invasion for standard predictors, such as PSA, percentage of biopsy positive cores (BPC), tumor stage greater than 1 (cT > 1) and tumor grade group greater than two (ISUP > 2). Results: Overall, LNI was detected in 70 patients (11.3%) of whom 39 (6.3%) with N = 1 and 31 (5%) with N > 1. On multivariate analysis, ET was inversely associated with the risk of N > 1 when compared to both N = 0 (odds ratio, OR 0.997; CI 0.994–1; p = 0.027) as well as with N = 1 cases (OR 0.994; 95% CI 0.989–1.000; p = 0.015). Conclusions: In clinical PCa, the risk of mPLNM was increased by low ET levels. As ET decreased, patients had an increased likelihood of mPLNM. Because of the inverse association between ET and mPLNM, higher ET levels were protective against aggressive disease. The influence of locally advanced PCa with high metastatic load on ET levels needs to be explored by controlled trials. [ABSTRACT FROM AUTHOR]

Gastric cancer keeps its position among the top five leaders of oncological mortality. Extended lymph node dissection D2 allows to achieve good long-term results after surgical treatment, however process extension and specific features of a tumor have significant impact on the result.Background. Study influence of various tumor characteristics, volume of LN dissection and operation on recurrence probability in patients with locally-advanced gastric cancer.Material and methods.We performed analysis of long-term results of treatment in 662 patients with gastric cancer with application of minimum admissible lymph node dissection D1 and extended lymphodissection D2 operated by one group of surgeons and also 10 various characteristics of tumor process which had an impact on survival rate.Results. Improved survival in patients with extended LN dissection was observed beginning from stage II disease and was the best in cases with stage III. Main group of patients treated with extended LN dissection showed better results compring to the control group with minimally accepted lymphodissection regarding overall and recurrence-free lifespan. Own effect of an extended LN dissection is shown against the background of any other factor of variability. Effects of tumor characteristics (first of all, its prevalence, i.e. stage of disease, metastatic invasion of regional lymph nodes and histologic structure of tumor) and combined surgical volume have always more effect than extended LN dissection.Conclusions.The observed additional effect of an extended lymph node dissection is universal, that is shown on any clinical background of the disease – histologic structure, gastric localization, form of tumor growth, invasion depth in a gastric wall, invasion of regional lymph nodes and stage of cancer (except stage I). The most significant negative impact on life expectancy in patients after treatment had low differentiated tumors, metastatic invasion of regional lymph nodes, stages of disease, on duration of recurrence-free period – stage of cancer and the combined nature of surgical intervention.

Gastric cancer is one the most serious oncological pathologies and it occupies the third position in the structure of oncological mortality. Latest achievements in surgery for gastric cancer are linked to extended lymph node dissection (D2), still, long-term results depend on carcinoma extension, regional lymph node involvement, tumor invasion depth and differentiation. Background: study survival in the patients treated for locally advanced gastric cancer regarding lymph node dissection volume and specific tumor characteristics. Materials and methods: applying Kaplan-Meier method and variance analysis we studied long-term results of 662 patients with gastric cancer with minimal lymph node dissection (D1) in the control group and extended lymph node dissection (D2) in the main group depending on 10 different features of tumor stage. Results: while analyzing long-term results of treatment we defined authentic advantage in patients in the main group according to their total and non-recurrent 5-year survival rates, and the median in the control group was 32,0 months, and in the main group it was 46,0 months. Inherent effect of extended lymph node dissection (D2) was defined at the level of any tumor characteristics, meanwhile their impacts including stage, metastatic spread and regional lymph node invasion and low tumor differentiation had more massive influence on patient survival rate than extended lymph node dissection. Conclusions: surgery for gastric cancer should be accompanied by extended lymph node dissection (D2), and its impact is seen at any tumor clinic stage. The best observed treatment effect in patients with gastric cancer could be achieved while following therapy standards and diagnosing tumors at early stages.

Optimal management of node-positive prostate cancer patients after prostatectomy remains a challenge. We evaluated clinically localized patients who demonstrated node positivity and identified predictors for secondary treatment. From 2010 to 2015, clinically localized prostate cancer patients who underwent robot prostatectomy with extended lymphadenectomy and node-positive disease on pathologic analysis were identified. Clinical N1, M1 or salvage cases were excluded. Patients were stratified based on secondary treatments. Kaplan-Meier method was used to determine the time to biochemical and metastatic recurrence. Multivariate logistic regression was used to identify predictors for additional treatment. 145 patients (45 no additional therapy, 47 adjuvant, 53 salvage) had a median follow-up of 31.2 months. Salvage patients had higher median pre-operative prostate-specific antigen (10.8 vs. 9.7 vs. 8.2, p = 0.1), higher percentage of pathologic Gleason ≥8 (50.9 vs. 38.3% and 22.2%, p < 0.01), and higher median-positive nodes (3 vs. 1 and 1, p < 0.0001) compared to adjuvant and no treatment groups, respectively. Pathologic Gleason ≥8 (OR = 3.5, p = 0.007) and positive nodes ≥2 (OR = 3.3, p = 0.006) were associated with additional therapy. In the no treatment group, two-year estimated BCRFS was 74.3%. Two-year metastatic recurrence-free rates for no treatment, adjuvant and salvage groups were 100, 87.5, and 80.9%, respectively (p = 0.01). Observation is a viable alternative for low metastatic burden patients. In the largest series of node-positive patients from robotic prostatectomy and extended lymphadenectomy, those with pathologic Gleason ≥8 and positive lymph nodes ≥2 were more likely to receive additional treatment. [ABSTRACT FROM AUTHOR]

Objective: To determine if eliminating the prophylactic placement of a pelvic drain (PD) after robot‐assisted radical prostatectomy (RARP) affects the incidence of early (90‐day) postoperative adverse events. Patients and Methods: In this parallel‐group, blinded, non‐inferiority trial, we randomised patients planning to undergo RARP to one of two arms: no drain placement (ND) or PD placement. Patients with demonstrable intraoperative leakage upon bladder irrigation were excluded. Randomisation sequence was determined a priori using a computer algorithm, and included a stratified design with respect to low vs intermediate/high D'Amico risk classifications. Surgeons remained blinded to the randomisation arm until final eligibility was verified at the end of the RARP. The primary endpoint was overall incidence of 90‐day complications which, based on our standard treatment using PD retrospectively, was estimated at 13%. The non‐inferiority margin was set at 10%, and the planned sample size was 312. An interim analysis was planned and conducted when one‐third of the planned accrual and follow‐up was completed, to rule out futility if the delta margin was in excess of 0.1389. Results: From 2012 to 2016, 189 patients were accrued to the study, with 92 patients allocated to the ND group and 97 to the PD group. Due to lower than expected accrual rates, accrual to the study was halted by regulatory entities, and we did not reach the intended accrual goal. The ND and PD groups were comparable for median PSA level (6.2 vs 5.8 ng/mL, P = 0.5), clinical stage (P = 0.8), D'Amico risk classification (P = 0.4), median lymph nodes dissected (17 vs 18, P = 0.2), and proportion of patients receiving an extended pelvic lymph node dissection (70.7% vs 79.4%, P = 0.3). Incidence of 90‐day overall and major (Clavien–Dindo grade >III) complications in the ND group (17.4% and 5.4%, respectively) was not inferior to the PD group (26.8% and 5.2%, respectively; P < 0.001 and P = 0.007 for difference of proportions <10%, respectively). Symptomatic lymphocoele rates (2.2% in the ND group, 4.1% in the PD group) were comparable between the two arms (P = 0.7). Conclusions: Incidence of adverse events in the ND group was not inferior to the group who received a PD. In properly selected patients, PD placement after RARP can be safely withheld without significant additional morbidity. [ABSTRACT FROM AUTHOR]

Objective To explore the evidence and knowledge gaps in sentinel node biopsy ( SNB) in prostate cancer through a consensus panel of experts. Methods A two-round Delphi survey among experts was followed by a consensus panel meeting of 16 experts in February 2016. Agreement voting was performed using the research and development project/University of California, Los Angeles Appropriateness Methodology on 150 statements in nine domains. The disagreement index based on the interpercentile range, adjusted for symmetry score, was used to assess consensus and non-consensus among panel members. Results Consensus was obtained on 91 of 150 statements (61%). The main outcomes were: (1) the results from an extended lymph node dissection ( eLND) are still considered the 'gold standard', and sentinel node ( SN) detection should be combined with eLND, at least in patients with intermediate- and high-risk prostate cancer; (2) the role of SN detection in low-risk prostate cancer is unclear; and (3) future studies should contain oncological endpoints as number of positive nodes outside the eLND template, false-negative and false-positive SN procedures, and recurrence-free survival. A high rate of consensus was obtained regarding outcome measures of future clinical trials on SNB (89%). Consensus on tracer technology was only obtained in 47% of statements, reflecting a need for further research and standardization in this area. The low-level evidence in the available literature and the composition of mainly SNB users in the panel constitute the major limitations of the study. Conclusions Consensus on a majority of elementary statements on SN detection in prostate cancer was obtained.; therefore, the results from this consensus report will provide a basis for the design of further studies in the field. A group of experts identified evidence and knowledge gaps on SN detection in prostate cancer and its application in daily practice. Information from the consensus statements can be used to direct further studies. [ABSTRACT FROM AUTHOR]

The optimal treatment for high-risk prostate cancer (Pca) remains to be established. The current guidelines recommend extended pelvic lymph node dissection (e-PLND) for selected intermediate- and high-risk patients treated with RP. However, the indications, optimal extent, and therapeutic benefits of e-PLND remain unclear. The aim of this study was to assess whether e-PLND confers an oncological benefit for high-risk Pca compared to neoadjuvant luteinizing hormone-releasing hormone and estramustine (LHRH + EMP). The Michinoku Urological Cancer Study Group database contained the data of 2403 consecutive Pca patients treated with RP at four institutes between March 2000 and December 2014. In the e-PLND group, we identified 238 high-risk Pca patients who underwent RP and e-PLND, with lymphatic tissue removal around the obturator and the external iliac regions, and hypogastric lymph node dissection. The neoadjuvant therapy with limited PLND (l-PLND) group included 280 high-risk Pca patients who underwent RP and removal of the obturator node chain between September 2005 and June 2014 at Hirosaki University. The outcome measure was BRFS. The 5-year biochemical recurrence-free survival rates for the neoadjuvant therapy with l-PLND group and e-PLND group were 84.9 and 54.7%, respectively ( P < 0.0001). The operative time was significantly longer in the e-PLND group compared to that of the neoadjuvant therapy with l-PLND group. Grade 3/4 surgery-related complications were not identified in both groups. Although the present study was not randomized, neoadjuvant LHRH + EMP therapy followed by RP might reduce the risk of biochemical recurrence. [ABSTRACT FROM AUTHOR]

Purpose: To assess continence and erectile function (EF) recovery of extended pelvic lymph node dissection (ePLND) versus limited PLND (lPLND) after bilateral nerve-sparing radical prostatectomy (BNSRP). Methods: Consecutive prostate cancer (PCa) patients undergoing BNSRP were stratified according to D'Amico into two groups: low-risk-PCa lPLND (obturator) and intermediate-/high-risk-PCa ePLND (obturator, external iliac artery, internal iliac artery, common iliac artery). Continence (no pad/one safety pad) and EF (IIEF-5 ≥ 17) recovery were assessed. Patients with phosphodiesterase type 5 inhibitors, neoadjuvant/adjuvant therapy, positive lymph nodes or positive surgical margins were excluded. Results: From January 2007 to May 2012, a total 966 consecutive patients were included. Four hundred and sixty patients met the inclusion/exclusion criteria: 262 patients had ePLND and 198 patients had lPLND. Mean number of lymph nodes was 20.4 (range 10-65) and 4.7 (range 0-10), respectively ( p < 0.001). Continence and spontaneous EF recovery after 12 months were 89.7 versus 93.4 % and 40.4 versus 47.5 %, respectively (all p > 0.05). Patient age at surgery ( p = 0.001), preoperative EF ( p < 0.001) and pathological tumor stage ( p = 0.008), but not ePLND ( p = 0.561), were independent predictors of EF recovery. No association was detected for continence recovery. Seven-year BCR-free survival for pT2 PCa was 100 and 94.8 % in lPLND and ePLND, respectively ( p = 0.011). For pT3 PCa, this was 94.7 and 81.2 %, respectively ( p = 0.287). At 2 years, the trifecta of continence, potency and recurrence freedom was achieved in 47.5 and 44.1 % in lPLND and ePLND, respectively ( p = 0.451). Conclusions: ePLND is not associated with increased risk of postoperative incontinence or erectile dysfunction. Only patient age at surgery, preoperative EF and pathological tumor stage represent predictors of EF recovery. [ABSTRACT FROM AUTHOR]

Purpose: To determine the incidence and significance of lymph nodes found in anterior prostatic fat pad (APFP) and to evaluate the risk factors for the lymph node presence at the APFP according to preoperative and postoperative characteristics during the robot-assisted radical prostatectomy (RARP). Methods: Between January 2011 and December 2014, 100 consecutive patients (47-77) with clinically localized prostate cancer underwent APFP excision during RARP at a single institute. Extended pelvic lymph node dissection was also performed to moderate- and high-risk patients (86 patients). Preoperative and postoperative findings were recorded, and descriptive analyses and multivariable analyses to predict the presence of lymph node within APFP were performed. Results: Lymph nodes within APFP were detected in nine (9 %) patients. None of the patients had metastatic lymph node in APFP. Preoperatively, mean PSA levels (14.22 vs. 8.6, p = 0.0001), biopsy Gleason score ( p = 0.002) and radical prostatectomy pathology Gleason score ( p = 0.001) were higher in patients with lymph nodes at the APFP tissue. Pelvic lymph node metastases were detected in seven of 86 (8 %) patients. Of these seven patients, four (57 %) had lymph nodes at the anterior prostatic fatty pad ( p = 0.0001). Conclusion: APFP dissection must be done regardless of the radical prostatectomy technique chosen. In our opinion, it is not necessary to do pathological examination of the APFP tissue routinely except for the patients with high preoperative PSA values, patients with high prostate biopsy Gleason scores and patients at high risk in order to save time and cost. [ABSTRACT FROM AUTHOR]

Background Nodal metastasis is the strongest risk factor of disease recurrence in patients with localized prostate cancer (PCa) treated with radical prostatectomy (RP). Objective To develop a model that allows quantification of the likelihood that a pathologically node-negative patient is indeed free of nodal metastasis. Design, setting, and participants Data from patients treated with RP and pelvic lymph node dissection (PLND; n=7135) for PCa between 2000 and 2011 were analyzed. For external validation, we used data from patients (n=4209) who underwent an anatomically defined extended PLND. Intervention RP and PLND. Outcome measurements and statistical analysis We developed a novel pathologic (postoperative) nodal staging score (pNSS) that represents the probability that a patient is correctly staged as node negative based on the number of examined nodes and the patient's characteristics. Results and limitations In the development and validation cohorts, the probability of missing a positive node decreases with an increasing number of nodes examined. Whereas in pT2 patients, a 90% pNSS was achieved with one single examined node in both the development and validation cohort, a similar level of nodal staging accuracy was achieved in pT3a patients by examining five and nine nodes, respectively. The pT3b/T4 patients achieved a pNSS of 80% and 70% when 17 and 20 nodes in the development and validation cohort were examined, respectively. This study is limited by its retrospective design and multicenter nature. The number of nodes removed was not directly correlated with the extent/template of PLND. Conclusions Every patient needs PLND for accurate nodal staging. However, a one-size-fits-all approach is too inaccurate. We developed a tool that indicates a node-negative patient is indeed free of lymph node metastasis by evaluating the number of examined nodes, pT stage, RP Gleason score, surgical margins, and prostate-specific antigen. This tool may help in postoperative decision making. [ABSTRACT FROM AUTHOR]

Background: Technical proficiency at laparoscopic D2 lymph node dissection (LND) is essential for extending the use of laparoscopic surgery beyond the treatment of early gastric cancer (EGC). The aim of this study was to evaluate the technical and oncological feasibility of laparoscopic distal gastrectomy (LDG) with D2 LND for distal gastric cancer. Methods: Of 922 patients who underwent open or LDG with D2 LND for gastric carcinoma, 133 treated by LDG and 133 treated by open distal gastrectomy (ODG) were selected using the propensity score matching method. The short-term surgical outcomes and long-term survivals of these matched groups were compared. Results: The two study groups were well matched with respect to age, sex, body mass index, comorbidity, ASA score, abdominal operation history, and tumor stage. The LDG group had a significantly longer mean operating time (227 vs. 161 min, p < 0.001) but showed significantly less intraoperative blood loss (149 vs. 189 ml, p = 0.007). Total numbers of collected lymph nodes were similar in the two groups. Postoperatively, no significant intergroup differences were found for hospital stay, morbidity, or mortality. Furthermore, overall survivals were similar in the two groups ( p = 0.621). Multivariate analysis showed that male gender, age ≥70 years, and intraoperative blood loss of ≥200 ml were independent risk factors of postoperative morbidity. Conclusions: Laparoscopic D2 LND for distal gastric cancer is technically safe and feasible compared with ODG. A prospective randomized trial is warranted to evaluate long-term oncological outcomes in advanced gastric carcinoma. [ABSTRACT FROM AUTHOR]

Background/purpose: The aim of this study was to clarify the prognostic factors of intrahepatic cholangiocarcinoma (ICC) following hepatectomy and to examine the impact of lymph node metastasis on survival. This study was therefore carried out as a Project Study of the Japanese Society of Hepato-Biliary-Pancreatic Surgery. Methods: Three hundred and forty-one patients who underwent hepatectomy for ICC between 1995 and 2004 at the 9 institutions of the Medical University Hospitals were analyzed retrospectively. Multivariate regression analyses and a Kaplan-Meyer analysis were performed to identify prognostic factors. Results: Pathological lymph node metastasis was one of the significant factors affecting overall survival (hazard ratio 2.10, p < 0.001) based on the multivariate analysis. Among the patients who underwent extended lymphadenectomy beyond the hepatoduodenal ligament, the median survival of 121 patients with nodal involvement was 12.2 months. Only seven patients with nodal involvement have survived for more than 4 years. Conclusions: In the present study, preoperative carbohydrate antigen (CA) 19-9, intrahepatic metastasis, and nodal involvement were the significant independent predictors of poor prognosis by multivariate analysis. Further prospective studies may thus be needed to confirm these findings, because this study has a limitation in that it was a retrospective study with multicenter data collection. [ABSTRACT FROM AUTHOR]

BACKGROUND: Diagnostic and therapeutic importance of pelvic lymph node (LN) dissection (PLND) in radical cystectomy (RC) has gained recent attention. A method of pathological analysis of LN affects total number of LN removed, number of LN involved, and LN density. OBJECTIVE: To compare extended lymphadenectomy to standard lymphadenectomy in terms of LN yield, density, and effect on survival. MATERIALS AND METHODS: From Jan 2004 - July 2009, 78 patients underwent RC whose complete histopathological report was available for analysis. All were transitional cell carcinoma. From July 2007 onward extended LN dissection was started and LNs were sent in six packets. Twenty-eight patients of standard PLND kept in group I. Group II had 23 patients of standard PLND (LN sent in four packets), and group III had 23 patients of extended PLND (LN sent in six packets). SPSS 15 software used for statistical calculation. RESULTS: Distribution of T-stage among three groups is not statistically significant. Median number of LN harvested were 5 (range, 1-25) in group I, 9 (range, 3-28) in group II, and 16 (range, 1-25) in group III. Although this is significant, we did not find significant difference in number of positive LN harvested. We did not find any patient with skip metastasis to common iliac LN in group 3. CONCLUSIONS: Separate package LN evaluation significantly increased the total number of LN harvested without increasing the number of positive LN and survival. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: This study was designed to establish whether the number of lymph nodes removed has an effect on prognosis in patients with node-negative gastric cancer. Patients and Methods: We retrospectively analysed data of 114 consecutive patients who underwent gastrectomy and extended lymph node dissection for node-negative adenocarcinoma of the stomach between 2000 and 2005. Standard survival methods and restricted cubic spline multivariable Cox regression models were applied. Results: Median age was 63 years and 67 patients out of 114 (59%) were males. Median number of dissected LNs was 22 (range 2–73). Median follow-up was 76 months. Patients who had ≤15 nodes removed had significantly worse distant disease-free survival, disease-free survival and overall survival at multivariable analysis than other patients. The results did not change when pT1 and pT2-3 cancer patients were analysed separately. The risk of distant metastases decreased as the number of dissected lymph nodes increased (>15). Conclusions: More extended lymph node resection offered survival benefit even in the subgroup of patients with early stage disease. Lymphadenectomy involving more than 15 lymph nodes should be performed for the treatment of node-negative gastric cancer. Synopsis: The impact on survival of the number of lymph nodes removed in patients with node-negative gastric cancer has not been established. This study suggests that more extended lymph node resection offers protection, as patients who had ≤15 nodes removed had significantly worse disease-free survival and overall survival at multivariate analysis than patients in whom >15 nodes were removed. [Copyright &y& Elsevier]

Background: several retrospective studies have sugested a proportion of patients with positive lymph node benefits from lymph node dissection (LND) at the time of radical nephrectomy (RN) for renal cell carcinoma (RCC). Objective: Our aim was to report de clinical and histological features of patients with isolated positive lymph nodes who underwent LND at the time of nephrectomies and the impact of LND on survival rate. Objective: Our aim was to report de clinical and histological features of patients with isolated positive lymph nodes who underwent LND at the time of nephrectomies and the impact of LND on survival rate. Materials and methods: A retrospective study was carried out on all patients with histopathologicaly confirmed renal cell carcinoma with isolated positive lymph nodes metastases between january 2005 and december 2007. Positive lymph nodes were confirmed in 39 patients (10,3% of all nepherectomies asociated with LND).We excluded 18 pacients with sistemic metastases (pulmonary,bone etc) .We evaluated a group of 21 patients withpositive lymph nodes (with no evidence of systemic metastases) who underwent extended lymph node dissection ( from ipsilateral great vessels ,from the crus of the diaphragm to bifurcation of ipsilateral great vessel +/- interaorticocaval region) at the time of RN.All patients were preoperatively evaluated with history, clinical examination, blood samples, abdominal ultrasound , helical abdominal CT scan , chest X-Ray ( thoracic CT). All the specimens were assesed by the same pathologist.Follow-up consisted of history, physical examination ,helical abdominal CT scan, chest X-Ray ( thoracic CT ). We calculated overall survival rate at 3 years. Results: Preoperative CT scan revealed false-negative results in4 cases (19%)(size of lymph node less than 1 cm ).Out of 21 patients, 11 (52,3 %) had clear cell hystology, 5 (23%) papillary, 4 (19%) cromophobe RCC, 5 had sarcomatoid features (23%).Massive tumour necrosis was discovered in 17 cases(80%). Over 80% of pacients have staged T3 and T4 (TNM system) (median tumour size was 9,5 cm); 19 patients(90%) have Fuhrman nuclear grade III and IV. Lymph node size ranges between 0,3 cm and 4,5 cm.We have 8 cancer-free patients at 3 years (38 % and 2,1 % of all LND associated with RN performed in that period). No patient having sarcomatoid component or nuclear grade 4 survived. These pacients have less than 4 lymph node metastases (3 patients with single positive lymph node - size 2 cm, 2,5 cm and respectively 2,8 cm; 2patients had 2 positive lymph nodes - maximum size 0,3 cm, 3 patiens with 3 nodal metastases - maximum size 0,6 cm ). Median survival was 23 months.This study is limited by its retrospective feature. Conclusions: Renal cell carcinoma with isolated positive lymph nodes are agresive cancers with high Fuhrmann nuclear grade, large tumor size. Prognostic is poor.Some benefit may have those with less than 4 isolated positive lymph nodes. [ABSTRACT FROM AUTHOR]

OBJECTIVE To investigate the associations between different overall or topographically restricted lymph node (LN) variables and cancer-specific survival (CSS) after radical cystectomy (RC) and extended LN dissection (LND) with curative intent in patients with LN-positive bladder cancer. PATIENTS AND METHODS Between 2001 and 2006, 152 patients had RC with standardized extended LND for bladder cancer with curative intent. Patients with positive LNs were stratified according to the median of the LN variables (LNs removed, number of positive LNs, LN density). CSS was related to overall and topographically restricted LN variables, e.g. different levels of LND, and relationships were tested by univariate and multivariate analyses. Level 1 LND comprised the regions of the external and internal iliac LNs and of the obturator LNs, level 2 the templates of common iliac and presacral LNs, and level 3 the para-aortic and paracaval LNs up to the inferior mesenteric artery. The mean (range) follow-up was 22 (1–84) months. RESULTS LN metastases were diagnosed in 46 of the 152 patients (30%) with extended LND. In these 46 patients, the median number of removed LNs was 33 (level 1, 15.5; level 2, 9.0; level 3, 7.0), the median number of positive LNs was 3 (1.5, 0.5 and 0.0, respectively) and the median LN density was 0.11 (0.10, 0.02 and 0.0, respectively). The CSS was 76% at 1 year and 23% at 3 years. There were significant correlations between the 3-year CSS and the overall LN density (≤0.11 vs >0.11; 34% vs 8%, P = 0.008), and the total number of positive LNs (≤3 vs >3; 33% vs 8%; P = 0.05). Overall LN density (hazard ratio 0.33, 95% confidence interval 0.15–0.72; P = 0.006) was an independent predictor for CSS in multivariate analysis. CONCLUSIONS Overall LN density is an independent predictor of survival after RC and extended LND with curative intent. Evaluation of topographically restricted LN positivity and density for different regions and levels of LND does not improve the prediction of CSS compared with overall LN positivity and density. A low incidence of level 3 LN positivity questions the clinical relevance of removing para-aortic and paracaval LNs. However, our data need to be confirmed by a prospective randomized trial. [ABSTRACT FROM AUTHOR]

Abstract: Objective: In 1996, the Gastric Cancer Detection Center in Costa Rica (CR) initiated extended lymph node (D2) dissection for gastric cancer patients. We present an analysis of the surgical results compared with those in Japan. Background: D2 dissection for gastric cancer is a standard surgical procedure in Japan, whereas it is still controversial in the West because of its poor survival benefit and high morbidity and mortality. Methods: Between January 1996 and March 2000, 199 gastric cancer patients in Costa Rica underwent gastrectomy with D2 dissection (CR group). A Japanese surgeon performed or assisted on every gastrectomy with Costa Rican surgeons. During the same period, 497 gastric cancer patients underwent D2 dissection at Tokyo Women’s Medical University (TWMU), Tokyo, Japan (TWMU group). Results: The operative morbidity was 39.0% in the CR group and 27.0% in the TWMU group (P < .05). The 30-day postoperative mortality in the CR group and the TWMU group was 5% and 0.2%, respectively (P < .05). The 5-year survival rate in the CR group and the TWMU group was 98.0% and 99.3% in stage IA, 88.6% and 94.4% in stage IB, 77.8% and 76.9% in stage II, 60.1% and 66.4% in stage IIIA, 27.2% and 47.2% in stage IIIB, and 39.7% and 27.6% in stage VI, respectively (not significant in any stage). The overall 5-year survival rate in the CR group and the TWMU group was 72.5% and 69.7%, respectively (not significant). Conclusions: D2 dissection performed at the same level of quality as in Japan consequently produced the same long-term survival in Costa Rica as in Japan. [Copyright &y& Elsevier]

In the USA, the incidence of bladder cancer is three-times higher in men than in women and it is the fourth most common cancer in men after prostate, lung and colorectal cancer. Muscle-invasive urothelial urinary bladder cancer has a very high mortality rate. This is regardless of intensive therapeutic efforts such as radical surgery in combination with oncological treatment options. The development of treatments with better outcomes regarding disease-specific survival and treatment-inflicted morbidity is likely to occur over the next few years. The significance of meta-analyses on the effect of neoadjuvant chemotherapy, the development of sentinel node dissection and the impact of the introduction of robot-assisted surgery on the possibility of performing minimally invasive surgery in advanced bladder cancer patients is discussed. [ABSTRACT FROM AUTHOR]

Background. Chyloperitoneum is the accumulation of lymphatic fluid in the peritoneal cavity. Although uncommon, it has been reported after retroperitoneal lymph node dissection. But the incidence of this complication after radical gastrectomy is unknown. In the present study, we analyzed our patients who underwent D3 dissection for gastric carcinoma and developed chyloperitoneum. Methods. Between June 1999 and June 2002, a total of 134 patients with gastric cancer underwent radical lymph node dissection, performed according to the Japanese Research Society for Gastric Cancer guidelines, as the standard procedure for gastric cancer treatment. Of these patients, 34 underwent D3 lymphadenectomy, and chyloperitoneum was detected in 4 of them. Results. There were three male patients and one female patient. All patients were in stage III according to the International Union Against Cancer (UICC)-TNM classification. In three patient, chyle leakage was noticed during the surgery, and surgical ligation of the duct was performed. Abdominal distension developed in one patient 7 days after the surgery, and chylous ascites was diagnosed. This patient was successfully treated with fasting and total parenteral nutrition, within 2 weeks. Conclusion. The incidence of chyloperitoneum is not low, and may increase with more aggressive surgery. Surgeons should be aware of this complication after retroperitoneal lymph node dissection, and injured lymphatics must be controlled and ligated intraoperatively. [ABSTRACT FROM AUTHOR]

Objective: To examine the efficacy of the Ivor Lewis esophagectomy with extended 2-field lymph node dissection for thoracic esophageal carcinoma we reviewed our experience. Methods: We analyzed the cases of 147 consecutive patients who underwent subtotal esophagectomy with extended 2-field lymph node dissection through Ivor Lewis approach for esophageal cancer from January 1996 through December 2000. Eighty-six patients were operated on for cancer of the midthoracic esophagus, 48 for cancer of the lower thoracic esophagus, and 13 for cancer of the aortal segment of the esophagus. No patient had received chemotherapy or radiotherapy before operation. Results: There were 113 men (76.9%) and 34 women. Median age was 57 years (range 51–65 years). Postsurgical pathological studies revealed squamous cell carcinoma in 139 patients (94.6%), adenocarcinoma in five (3.4%), and adenosquamous carcinoma in three (2%). Positive abdominal and/or mediastinal lymph nodes were found in 122 patients (82.9%). At mean 43 nodes (range from 32 up to 75) were studied for each patient. Even in T1–T2 tumors mediastinal or abdominal lymph nodes are involved in up to 80% of cases. However, in T3–T4 stages the frequency of lymph node involvement is significantly higher (P<0.05). Postsurgical staging was as follows: stage I in three patients (2%), stage IIa in 20 (13.6%), stage IIb in 29 (19.7%), stage III in 54 (36.8%), and stage IV in 41 (27.9%). All distant metastases were lymphogenous. The operative mortality rate was 6.1%, and complications occurred in 62 patients (42.1%). The overall 5-year survive rate was 28.8% (median survival 36.1 months). The 5-year survival rate for patients in stage IIa was 59%; for those in stage IIb, 39.5%; for patients in stage III, 26.7%; and 0% for patients in stage IV. Conclusions: Subtotal esophagectomy with extended 2-field lymph node dissection through Ivor Lewis approach for esophageal cancer is a safe operation. Long-term survival is stage dependent. Effective multimodality treatment may be helpful for patients with advanced disease. [Copyright &y& Elsevier]

A recent Intergroup trial demonstrated a significant survival advantage of postgastrectomy chemoradiation in gastric cancer patients, primarily because of a reduction of a relative locoregional recurrence (LRR) rate exceeding 70% in control patients. Radical gastrectomy with extended lymphadenectomy may reduce LRR, possibly affecting adjuvant treatment strategies. Information on patients undergoing gastrectomy for potentially curable gastric cancer between 1990 and 2000 was reviewed. Patterns of first disease recurrence, survival, and disease-free survival were calculated, and predictors were identified. Gastrectomies were performed in 73 patients, with R0 resections in 82%. The median lymph node count was 24; positive nodes were found in 64% of patients. The median actuarial survival was 27 months, with a 5-year survival of 37%. Disease recurred in 35 patients (48%) after a median interval of 7 months (range, .5–67). Recurrent disease patterns included distant only (37%) peritoneal only (23%), peritoneal/locoregional (17%), all sites combined (14%), locoregional only (6%), and distant/locoregional (3%). Recurrence predictors were N3 category for distant recurrence (hazard ratio [RH], 10.2; P=.005), T3/4 category for peritoneal recurrence (HR, 4.8; P=.008), peritoneal relapse (HR, 40; P=.002), and a prior abdominal operation for LRR (HR, 3.2; P=.01). N2 disease had a distant failure risk similar to N1 status and an intraperitoneal failure risk similar to an N3 category. Isolated LRR of gastric cancer after gastrectomy and extended lymphadenectomy is rare in this series. Most recurrences appeared diffusely at distant or peritoneal sites, and most LRRs occurred in conjunction with relapse at extraregional sites. Pathologic predictors of intraperitoneal (T3/4) or systemic failure (>N1) could be used to guide individualized, risk-oriented, adjuvant treatment. [ABSTRACT FROM AUTHOR]

Background. The prognosis of patients with gastric cancer with invasion to adjacent organs is poor. The prognostic factors of patients with advanced gastric cancer with macroscopic invasion to adjacent organs (T4) who were treated with radical surgery was determined in the present study. Methods. A total of 86 consecutive patients with advanced gastric cancer who underwent radical (potentially curable) gastrectomy with combined resection of other organs for macroscopic invasion to adjacent organs during surgery, were investigated. The organs invaded macroscopically were the pancreas in 43 patients, mesocolon in 29, liver in 7, transverse colon in 5, adrenal gland in 3, spleen in 1, diaphragm in 1, and other organs in 5. The prognostic factors were evaluated by univariate and multivariate analysis. Results. The cumulative 5-year survival rate of the patients treated by radical surgery with the combined resection of invaded organs was 35.0%. Multivariate analysis demonstrated that location of the tumor, lymph node metastasis, histological depth of invasion, and extent of lymph node dissection were significant prognostic factors in advanced gastric cancer patients treated by radical surgery with combined resection of adjacent organs for macroscopic invasion. Conclusion. For patients with macroscopic T4 gastric cancer located in the middle- or lower-third of the stomach, aggressive resection of invaded adjacent organs with extended lymph node dissection should be performed to improve long-term outcome. [ABSTRACT FROM AUTHOR]

A total of 587 cases with gastric cancer was reviewed. Particular emphasis was placed on the comparative studies on the stages of stomach cancer and end-results of the R (with a conventional lymph node dissection) and the R-resections (with an extended lymph node dissection). R-resections were found to be generally associated with higher 5-year survival rates than R-resections. Especially for the positive lymph node cases not having a marked serosal invasion, the 5-year survival rate was considerably higher with R-resections than with R-resections (55.3 percent versus 21.5 percent). Although the differences were not significant statistically, it has been suggested from these results that the end-results might be improved more effectively by performing R resection for cases without a marked serosal invasion. [ABSTRACT FROM AUTHOR]

Background: The inferior mesenteric artery (IMA) is a blood vessel of great importance in left colon and rectal cancer surgery. We aimed to determine the role of surgeons in computed tomography (CT) based vascular anatomy interpretation., Method: Patients with left colon and rectal cancer treated surgically with D3 lymph node dissection and selective vascular ligation were included in this study. All patients ( n =250) underwent preoperative CT with intravenous contrast. The IMA anatomy was schematically depicted by surgeon based on CT interpretation. Intraoperatively anatomy was defined by skeletonisation of the IMA. All patients had segmental resection with selective vascular ligation. The concurrence of prospectively obtained results were evaluated by intraclass correlation and Kendall's tau-b test. Misinterpretation of IMA anatomy was analysed by CT-specialist., Results: The preoperative and intraoperative IMA anatomy features were correctly interpreted in 237 cases (in 94.8%) within skeletonisation extent, which is supported by high level of agreement and concordance of preoperative data regards to intraoperative findings (K=0.926; p <0.001; CC=0.912; p <0.001). As a result of the CT-based evaluation of the IMA, E, K, and H types of branching patterns were proposed. IMV position was mistakenly identified in 2.6% of cases., Conclusion: Surgeons are able to evaluate the IMA anatomy accurately with CT and use it in routine preoperative planning. The E, K, and H branching types may be used when defining approach to skeletonisation and level of vascular ligation.

Background: A prospective randomized trial (LEA AUO AB 25/02) found no survival benefit in extended compared with limited pelvic lymph node dissection (PLND) templates in bladder cancer (BCa) patients treated with radical cystectomy (RC). However, the rate of lymph node invasion (LNI) in the standard and extended templates was lower than estimated., Objective: To assess the accuracy of preoperative clinical and pathological parameters to predict LNI and to develop a model to preoperatively select candidates for the extended PLND templates., Design, Setting, and Participants: A total of 903 BCa patients treated at a single institution were retrospectively identified. The primary outcome was to identify preoperatively the risk of LNI to tailor the type of PLND. The extended PLND templates consisted in the removal of pelvic lymph nodes together with the common iliac, presacral, para-aortocaval, interaortocaval, and paracaval sites up to the inferior mesenteric artery., Intervention: A total of 903 BCa patients were treated with RC and bilateral extended PLND templates., Outcome Measurements and Statistical Analysis: Several models predicting LNI were evaluated using the area under the receiver operating characteristic curve (AUC), calibration plots and decision curve analyses. A nomogram predicting LNI in the extended pattern was developed and validated internally., Results and Limitations: Overall, 55 patients (6.1%) had LNI in the extended PLND templates at RC. The median number of nodes removed was 19 (interquartile range: 13-26). A model including age, clinical T stage, clinical node stage, lymphovascular invasion, and presence of carcinoma in situ at the last transurethral resection before RC was developed. The AUC of this model is 73%. Using a cutoff of 3%, 108 extended PLNDs (12%) would be spared and only two LNIs (3%) would be missed. The main limitations of our model are the retrospective nature of the data, lack of external validation, and low rate of LNI., Conclusions: This is the first proposed model to predict LNI in the extended PLND templates. This model might help urologists identify which patients might benefit from an extended PLND at the time of RC, reserving a standard PLND for all the others., Patient Summary: We developed the first nomogram to predict lymph node invasion (LNI) in the extended pelvic lymph node dissection templates in bladder cancer patients treated with radical cystectomy. The adoption of our model to identify candidates for the extended pelvic lymph node dissection templates could avoid up to 12% of these procedures at the cost of missing only 3% of patients with LNI., (Copyright © 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved.)