Gasless Single-Incision Endoscopic Surgery via Subclavicular Approach for Lateral Neck Dissection in Patients with Papillary Thyroid Cancer.

BACKGROUND: The technical difficulties and trauma of remote access methods in endoscopic surgery (ES) for lateral neck dissection (LND) can be daunting for most patients with papillary thyroid cancer (PTC) and surgeons. The purpose of study was to introduce gasless single-incision ES via a subclavicular approach (ESSA) and to explore its safety and efficacy for LND. METHODS: Between January 2022 and February 2023, we retrospectively reviewed 17 patients with PTC who underwent ESSA for LND. In addition, 22 patients who received video-assisted ES (VAES) and 48 patients who underwent open surgery (OP) for LND during the same period were included. Clinicopathological characteristics, complications, and efficacy of the lymph node yield (LNY) were compared between the ESSA and the other two groups (VAES and OP). RESULTS: The LNY from central and lateral neck dissection by ESSA was comparable to that by VAES (9.2 ± 8.1 vs. 9.5 ± 4.2, P = 0.986, and 33.5 ± 11.6 vs. 30.6 ± 9.2, P = 0.382, respectively) and OP (9.2 ± 8.1 vs. 11.0 ± 5.4, P = 0.420, and 33.5 ± 11.6 vs. 31.5 ± 7.9, P = 0.383, respectively). Swallowing impairment scores at 1 and 3 months were significantly lower after ESSA than those after VAES (1.8 ± 1.0 vs. 3.0 ± 1.2, P = 0.003, and 0.9 ± 0.8 vs. 1.7 ± 0.8, P = 0.006, respectively). The cosmetic satisfaction rate 1 month after surgery was significantly higher in the ESSA group than that in the VAES group (100 vs. 31.8%, P < 0.001). CONCLUSIONS: ESSA is a safe and minimally invasive procedure that provides a scarless cervical appearance and has good efficacy for LND. Therefore, ESSA may be a feasible choice for selected patients with N1b PTC with cervical cosmetic needs.

Assessing the Association Between Endoscopic Tattooing and Lymph Node Yield in Rectal Cancer.

INTRODUCTION: Preoperative endoscopic tattooing is an effective tool for intraoperative tumor localization in colon cancer. Endoscopic tattooing in rectal cancer may have unidentified benefits on lymph node yield, making it easier for pathologists to identify nodes during histopathologic assessment. There remains concern that tattoo ink may alter anatomical planes, increasing surgical difficulty. METHODS: Retrospective chart reviews from 2016 to 2021 of n = 170 patients presenting with rectal cancer were divided into two groups: with (n = 79) and without (n = 91) endoscopic tattoos. Demographics, operative details, tumor characteristics, prior chemoradiation, and pathologic details were collected. Primary outcome was total lymph node yield. Secondary outcomes were rates of adequate (> 12) nodes, margin status, and operative variables including operative time. RESULTS: No differences between pathologic stage, tumor height, high inferior mesenteric artery ligation, operative times, conversion rate, or surgical approach (open versus minimally invasive) were noted between groups. Receipt of neoadjuvant chemoradiation was less frequent in the endoscopic tattooing group (53.2% versus 76.9%, P ≤ 0.001). Total node number and rate of adequate lymph node yield were higher with endoscopic tattooing (20.5 ± 7.6 versus 16.8 ± 6.6 lymph nodes and 100.0% versus 83.5% adequate lymph node harvest, both P ≤ 0.001). Rates of positive circumferential and distal margins and complete total mesorectal excision were also similar. Regression analysis identified endoscopic tattooing (Incidence Risk Ratio 1.17, 95% confidence interval 1.04-1.31) and operative time more than 300 min (Incidence Risk Ratio 0.88, 95% confidence interval 0.77-0.99) had significant effects on lymph node harvest. Removal of patients with inadequate lymph node yield resulted in similar rates of total and positive lymph nodes. CONCLUSIONS: Endoscopic rectal tattooing is associated with increased lymph node yield (including after neoadjuvant chemoradiotherapy) without sacrificing oncologic or perioperative outcomes, although this effect is inconsistent when only considering patients with an adequate lymph node yield.

The Impact of Paratracheal Lymphadenectomy on Lymph Node Yield and Short-Term Outcomes in Esophagectomy for Cancer: A Nation-Wide Propensity Score-Matched Analysis.

INTRODUCTION: The balance between potential oncological merits and surgical risks is unclear for the additional step of performing paratracheal lymphadenectomy during esophagectomy for cancer. This study aimed to investigate the impact of paratracheal lymphadenectomy on lymph node yield and short-term outcomes in patients who underwent this procedure in the Netherlands. METHODS: Patients who underwent neoadjuvant chemoradiotherapy followed by transthoracic esophagectomy were included from the Dutch Upper Gastrointestinal Cancer Audit (DUCA). After propensity score matching Ivor Lewis and McKeown approaches separately, lymph node yield and short-term outcomes were compared between patients who underwent paratracheal lymphadenectomy versus patients who did not. RESULTS: Between 2011 and 2017, 2,128 patients were included. Some 770 patients (n = 385 vs. n = 385) and 516 patients (n = 258 vs. n = 258) were matched for the Ivor Lewis and McKeown approaches, respectively. Paratracheal lymphadenectomy was associated with a higher lymph node yield in Ivor Lewis (23 vs. 19 nodes, p < 0.001) and McKeown (21 vs. 19 nodes, p = 0.015) esophagectomy. There were no significant differences in complications or mortality. After Ivor Lewis esophagectomy, paratracheal lymphadenectomy was associated with longer length of stay (12 vs. 11 days, p < 0.048). After McKeown esophagectomy, paratracheal lymphadenectomy was associated with more re-interventions (30% vs. 18%, p = 0.002). CONCLUSIONS: Paratracheal lymphadenectomy resulted in a higher lymph node yield but also in longer length of stay after Ivor Lewis and more re-interventions following McKeown esophagectomy.

Comparative effectiveness of pathological techniques to improve lymph node yield from colorectal cancer specimens: a systematic review and network meta-analysis.

A number of randomised controlled trials (RCT) have compared different techniques to improve lymph node yield (LNY) in colorectal cancer specimens, but data on comparative effectiveness are sparse. Our aim was to compare the relative effectiveness and rank all available techniques. A systematic search of Embase, Cochrane, PubMed and Scopus was performed for randomised trials. Pairwise was meta-analysis performed if more than two homogeneous studies were available for each comparison. Network meta-analysis was used to rank and compare all available techniques. Fifteen studies fulfilled the inclusion criteria. Techniques that were compared included methylene blue (MB), glacial acetic acid, ethanol, distilled water and formaldehyde (GEWF), Carnoy solution (CS), patent blue (PB), formalin, fat clearing (FC) and their combinations. The overall quality of studies was found to be fair. In pairwise meta-analysis MB had a higher lymph node yield weighted mean difference (WMD) = 13.67 (4.83-22.51), P < 0.01, lower number of specimens with fewer than 12 lymph nodes log odds ratio = -1.88 (-2.8, -0.91), P < 0.01 and higher LNY in patients with prior chemoradiotherapy [WMD = 9.11 (3.15, 15.08), P = 0.02] compared to formalin. Evaluation of the network plot revealed a well-connected network. In network meta-analysis MBFC had a higher LNY with [mean difference (MD) 13 and 95% credible interval (CrI) = 2.09-23.91] compared to formalin. MBFC probability of being the best technique for LNY was 91.4%. In network meta-analysis MB did not have a statistically significant difference when compared to formalin. MBFCS seems to be the most effective technique for LNY. Further studies are required to make safe conclusions for outcomes such positive lymph nodes and upstaging.

Total Neoadjuvant Treatment for Pancreatic Ductal Adenocarcinoma Is Associated With Limited Lymph Node Yield but Improved Ratio.

INTRODUCTION: The lymph node yield (LNY) and lymph node ratio (LNR) of nodal metastases following pancreatoduodenectomy (PD) have been reported as prognostic parameters in patients with pancreatic ductal adenocarcinoma (PDAC). However, they have not been compared in the setting of various neoadjuvant therapy modalities. METHODS: A single institutional retrospective study identified 134 patients diagnosed with resectable, BLR- and LA-PDAC who underwent PD at Fox Chase Cancer Center between 2010 and 2019. Patients were categorized based on first-line treatment as follows: surgery first (SF), total neoadjuvant therapy (TNT), and single modality neoadjuvant therapy (SMNT). The histopathological reports of the surgical specimens were examined to obtain LNY and determine the counts of lymph nodes with metastases. Subsequently, LNR was calculated as the number of positive lymph nodes divided by the number of lymph nodes examined. RESULTS: Overall, 49, 38, 27, 12, and 8 patients underwent SF approach, SMNT, incomplete TNT, induction TNT, and consolidation TNT, respectively. There was no difference in R0 resection and vascular resection between the groups (P = 0.096 and 0.794, respectively). The median counts of LNY were 22, 15, 21, 11.5, and 10, respectively (P < 0.001). The average LNR was 0.16, 0.07, 0.03, 0.02, and 0.02, respectively (P < 0.001). There were statistically significant differences in overall survival in the TNT groups (log-rank test P = 0.030). CONCLUSIONS: PDAC patients who undergo the TNT modality exhibit lower LNY and improved LNR compared with the SF approach and SMNT neoadjuvant therapy groups. This is likely explained by the increased treatment response and lymph node obliteration associated with the TNT approach. Our results question the minimal requirement of 11-18 harvested lymph nodes for PD following TNT.

Risk factors for long-term survival in patients with ypN+ M0 rectal cancer after radical anterior resection.

BACKGROUND: Regional lymph node metastases are the main adverse prognostic factor in patients with rectal cancer without distant metastases. There are discrepancies, however, regarding additional risk factors in the group of ypN + M0 patients. The purpose of the study was to assess clinical and pathological factors affecting long-term oncological outcomes in the group of ypN + M0 patients after radical rectal anterior resection. METHODS: 112 patients with ypN + M0 rectal cancer after neoadjuvant therapy and radical anterior resection were subject to a retrospective analysis. The effect of potential factors on survival was assessed with the use of Kaplan-Meier curves together with a log-rank test and multiple factor Cox proportional hazards model. RESULTS: In the multiple factor Cox analysis, adverse factors affecting disease-free survival (DFS) were: the use of angiotensin-converting enzyme inhibitors (ACEIs) (hazard ratio HR: 3.11, 95% CI 1.01-9.56, p = 0.047), presence of perineural invasion (HR: 7.27, 95% CI 2.74-19.3, p < 0.001) and occurrence of postoperative complications (HR: 6.79, 95% CI 2.09-22.11, p = 0.001), while a positive factor was the negative lymph node (NLN) count > 7 (HR: 0.33, 95% CI 0.12-0.88, p = 0.026). In the disease-specific survival (DSS) analysis, an adverse factor was the use of ACEIs (HR: 4.275, 95% CI 1.44-12.694, p = 0.009), while a positive effect was caused by NLN > 5 (HR: 0.22, 95% CI 0.082-0.586, p = 0.002). CONCLUSIONS: The use of ACEIs may have a negative effect on long-term treatment outcomes in patients with ypN + M0 rectal cancer. In this group of patients, the NLN count seems to be an important prognostic factor, as well.

Inking outside the box: systematic review on the utility of tattooing lesions in rectal cancer.

PURPOSE: Endoscopic tattooing in rectal cancer is infrequently utilized for fear of tattoo ink obscuring anatomical planes, increasing the difficulty of surgical excision. Colon cancer tattooing has demonstrated increased lymph node yields and increased accuracy in establishing adequate margins. Rectal cancer tattooing may be especially helpful after neoadjuvant chemoradiation, where complete clinical responses could limit lesion identification and lymph node yields are typically less robust. We seek to review and identify the effects of tattooing in rectal cancer. METHODS: A systematic literature search was performed in PubMed, Embase, and SCOPUS. Studies on endoscopic tattooing with cohorts consisting of at least ≥ 25% of rectal cancer patients were selected. Studies focusing solely on rectal cancer were also reviewed separately. RESULTS: Of 416 studies identified, 10 studies encompassing 2460 patients were evaluated. Seven studies evaluated lymph node yields; five reported beneficial effects of endoscopic tattooing, while two reported no significant difference. Among four studies reporting lesion localization, successful localization rates were between 63 and 100%. Rates of intraoperative endoscopy performed to reevaluate lesion location ranged from 5.7 to 20%. The distal margin was evaluated in two studies, which reported more accurate placement of the distal resection margin after tattooing. When complications of tattooing were documented (7 studies with 889 patients), only five direct complications of endoscopic tattooing were observed (0.6%). CONCLUSIONS: Although the data is heterogenous, it suggests that endoscopic tattooing in rectal cancer may improve lymph node yields and assist in determining accurate distal margins without high rates of complication. Further research must be completed before practice management guidelines can change. TRIAL REGISTRATION: No. CRD42021271784.

Robotic radical prostatectomy: difficult to start, fast to improve? Influence of surgical experience in robotic and open radical prostatectomy.

PURPOSE: The assistance of robotic systems raises the concern of whether there is an improved learning in robotic-assisted radical prostatectomy (RARP) compared to open retropubic radical prostatectomy (ORP). METHODS: We retrospectively analyzed data from 1438 patients who underwent ORP (n = 735) or RARP (n = 703). For each procedure, the level of experience of three different surgeons was summarized. Perioperative and pathological parameters reflecting surgical performance were compared between both learning curves. RARP data were influenced by new introduction of the robotic system. RESULTS: The median patient age at surgery was 66 years (IQR 42-80). Patients in the RARP group were younger (p < 0.001) and had a lower oncological risk (p < 0.001). Inexperienced RARP surgeons had a higher pT2-PSM rate and lower lymph node yield (13.8 ± 4.7 vs. 14.7 ± 4.8; p = 0.03) than inexperienced ORP surgeons. After 100 procedures, RARP and ORP surgeons had the same pT2-PSM rate (8% vs. 8%; p = 0.8) and lymph node yield (15.4 ± 5.4 vs. 15.4 ± 5.1; p = 1.0). In multivariate analysis for ORP, surgical inexperience (≤ 100 cases) was an independent predictor of a longer operating time (OR 9.0; p < 0.001) and higher amount of blood loss (OR 2.9; p < 0.001). For RARP, surgical inexperience (≤ 100 cases) was a predictor of a longer operating time (OR 3.9; p < 0.001), higher amount of blood loss (OR 1.9; p = 0.004), higher pT2-PSM rate (OR 1.6; p = 0.03), and lower lymph node yield (OR 0.6; p = 0.001). CONCLUSIONS: Surgical experience has a relevant impact on perioperative and pathological parameters RARP has a higher initial pT2-PSM rate and lower lymph node yield than ORP. This is relevant for patient selection for novice teaching in RARP.

Identifying Outlier Hospitals in Gastric Cancer Lymph Node Yield Using the National Cancer Database.

BACKGROUND: Lymph node (LN) yield is a key quality indicator that is associated with improved staging in surgically resected gastric cancer. The National Comprehensive Cancer Network recommends a yield of ≥15 LNs for proper staging, yet most facilities in the United States fail to achieve this number. The present study aimed to identify factors that could affect LN yield on a facility level and identify outlier hospitals. METHODS: This was a retrospective review of adults (aged ≥18 y) with gastric cancer (Tumor-Node-Metastasis Stages I-III) who underwent gastrectomy. Data were analyzed from the National Cancer Database (2004-2016). Multivariate analysis identified patient and tumor characteristics, whereas an observed-to-expected ratio of identified outlier hospitals. Facility factors were compared between high and low outliers. RESULTS: A total of 26,590 patients were included in this study. Of these patients, only 50.3% had an LN yield ≥15. The multivariate model of patient and tumor characteristics demonstrated a concordance index was 0.684. A total of 1245 facilities were included. There were 198 low outlier LN yield hospitals and 135 high outlier LN yield hospitals (observed-to-expected ratio of 0.42 ± 0.24 versus 1.38 ± 0.19, P < 0.0001). There was a difference in facility type between low and high outliers (P < 0.0001). High LN yield hospitals had a larger surgical volume than low LN yield hospitals (median 8.4 [4.9, 13.5] versus 3.5 [2.4, 5.2]; P < 0.0001). CONCLUSIONS: Nearly half of the population exhibited low compliance to National Comprehensive Cancer Network recommendations. Facility-level disparities exist as high yearly surgical volume and academic facility status distinguished high-performing outlier hospitals.

Transition from open to minimally invasive en bloc esophagectomy can be achieved without compromising surgical quality.

BACKGROUND: En bloc esophagectomy results in higher lymph node (LN) retrieval than standard esophagectomy. Minimally invasive esophagectomy (MIE) has gained traction due to improved short-term outcomes, but many large series report LN yields well below the international benchmark of 23. We sought to determine if an established approach to open en bloc resection can be safely transferred to MIE using LN yield as a quality benchmark. METHODS: An open approach to en bloc esophagectomy (OE) was established over 5 years (~ 300 cases) before en bloc MIE was introduced in 2010. Patients undergoing curative-intent en bloc Ivor-Lewis and McKeown esophagectomy for cancer from 2010 to 2019 by a single surgeon with formal minimally invasive surgery training were identified from a prospectively collected database. Mann-Whitney U and χ2 tests and cumulative sum analysis were used for statistical analysis. "Failure" was defined as LN yield less than AJCC's 8th edition guidelines: 10 LNs for pT1 cancers, 20 for pT2 and 30 for pT3-4. RESULTS: A total of 269 esophageal resections met inclusion criteria [193(72%) OE; 76(28%) MIE]. Age, sex, BMI and comorbidities were comparable between groups. Tumors were larger and more often locally advanced in OE. Median LN retrieval was sufficient by international standards in both groups [OE:34(27-46); MIE:28(22-39); p = 0.01]. "Failures" occurred in 33(17%) of OE and 12(16%) MIE cases (p = 0.63). No learning effect was observed for LN yield. R0 resection rate was comparable [OE:191(99%); MIE:73(96%); p = 0.90]. Operative time was longer for MIE [275(246-300)] than OE [240(210-270) minutes], p < 0.0001, while estimated blood loss (OE:350(250-500)mL; MIE:300(200-400)mL; p = 0.02] and length of stay [OE:8(6-13); MIE7(6-9) days; p = 0.02] were higher for OE. Morbidity and mortality were comparable between groups and LN yield did not impact survival. CONCLUSIONS: Under appropriate conditions, an established approach to open en bloc esophagectomy can be safely transferred to MIE without compromising surgical quality.

Lower lymph node yield in axillary lymph node dissection specimens in breast cancer patients receiving neoadjuvant chemotherapy: Quality concern or treatment effect?

Axillary lymph node dissection (ALND) specimens should have at least ten-lymph nodes for examination according to established guidelines. Nonetheless, recent evidence suggests that neoadjuvant chemotherapy (NAC) results in fewer nodes in the specimen. We sought to examine if NAC patients have lower lymph node yield from ALND specimens and whether the number of lymph nodes in the specimen is correlated with pathologic complete response (pCR). Using the National Cancer Database (NCDB), a study cohort of female patients with node-positive, non-metastatic invasive breast cancer diagnosed from 2012 to 2015 was identified. The axillary lymph node retrieval count was compared in NAC and non-NAC patients and then correlated with pCR. A multivariable analysis was performed to identify factors that were associated with less than ten-lymph nodes in the ALND pathologic specimen. Of 56,976 patients identified, 27,197 (48%) received neoadjuvant chemotherapy; 29,779 (52%) did not. NAC patients failed to meet the ten-lymph node minimum in the ALND specimen more often than non-NAC patients (35% vs. 27%, p < 0.001). NAC patients with fewer than ten-lymph nodes were more likely to have a pCR than those with ten or more (22% vs. 16%, p < 0.001). On multivariable analysis, pCR of the primary tumor and receptor status were found to be independent predictors of having fewer than ten-lymph nodes in the ALND specimen. Node-positive breast cancer patients that underwent NAC were more likely to not meet the ten-lymph node standard. However, NAC patients who did not meet the minimum were also more likely to have a pCR compared to NAC patients who did. This suggests lower lymph node yield may not truly be a marker of lower quality surgery but rather a potential marker of NAC treatment effect.

The assessment of risk factors for long-term survival outcome in ypN0 patients with rectal cancer after neoadjuvant therapy and radical anterior resection.

BACKGROUND: The main negative prognostic factors in patients with rectal cancer after radical treatment include regional lymph node involvement, lymphovascular invasion, and perineural invasion. However, some patients still develop cancer recurrence despite the absence of the above risk factors. The aim of the study was to assess clinicopathological factors influencing long-term oncologic outcomes in ypN0M0 rectal cancer patients after neoadjuvant therapy and radical anterior resection. METHODS: A retrospective survival analysis was performed on a group of 195 patients. We assessed clinicopathological factors which included tumor regression grade, number of lymph nodes in the specimen, Charlson comorbidity index (CCI), and colorectal anastomotic leakage (AL). RESULTS: In the univariate analysis, AL and CCI > 3 had a significant negative impact on disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS). After the division of ALs into early and late ALs, it was found that only patients with late ALs had a significantly worse survival. The multivariate Cox regression analysis showed that CCI > 3 was a significant adverse risk factor for DFS (HR 5.78, 95% CI 2.15-15.51, p < 0.001), DSS (HR 7.25, 95% CI 2.25-23.39, p < 0.001), and OS (HR 3.9, 95% CI 1.72-8.85, p = 0.001). Similarly, late ALs had a significant negative impact on the risk of DFS (HR 5.05, 95% CI 1.97-12.93, p < 0.001), DSS (HR 10.84, 95% CI 3.44-34.18, p < 0.001), and OS (HR 4.3, 95% CI 1.94-9.53, p < 0.001). CONCLUSIONS: Late AL and CCI > 3 are the factors that may have an impact on long-term oncologic outcomes. The impact of lymph node yield on understaging was not demonstrated.

Right hemicolectomy with complete mesocolic excision is safe, leads to an increased lymph node yield and to increased survival: results of a systematic review and meta-analysis.

BACKGROUND: The introduction of complete mesocolic excision (CME) for right colon cancer has raised an important discussion in relation to the extent of colic and mesenteric resection, and the impact this may have on lymph node yield. As uncertainty remains regarding the usefulness of and indications for right hemicolectomy with CME and the benefits of CME compared with a traditional approach, the purpose of this meta-analysis is to compare the two procedures in terms of safety, lymph node yield and oncological outcome. METHODS: We performed a systematic review of the literature from 2009 up to March 15th, 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two hundred eighty-one publications were evaluated, and 17 met the inclusion criteria and were included. Primary endpoints analysed were anastomotic leak rate, blood loss, number of harvested lymph nodes, 3- and 5-year oncologic outcomes. Secondary outcomes were operating time, conversion, intraoperative complications, reoperation rate, overall and Clavien-Dindo grade 3-4 postoperative complications. RESULTS: In terms of safety, right hemicolectomy with CME is not inferior to the standard procedure when comparing rates of anastomotic leak (RR 0.82, 95% CI 0.38-1.79), blood loss (MD -32.48, 95% CI -98.54 to -33.58), overall postoperative complications (RR 0.82, 95% CI 0.67-1.00), Clavien-Dindo grade III-IV postoperative complications (RR 1.36, 95% CI 0.82-2.28) and reoperation rate (RR 0.65, 95% CI 0.26-1.75). Traditional surgery is associated with a shorter operating time (MD 16.43, 95% CI 4.27-28.60) and lower conversion from laparoscopic to open approach (RR 1.72, 95% CI 1.00-2.96). In terms of oncologic outcomes, right hemicolectomy with CME leads to a higher lymph node yield than traditional surgery (MD 7.05, 95% CI 4.06-10.04). Results of statistical analysis comparing 3-year overall survival and 5-year disease-free survival were better in the CME group, RR 0.42, 95% CI 0.27-0.66 and RR 0.36, 95% CI 0.17-0.56, respectively. CONCLUSIONS: Right hemicolectomy with CME is not inferior to traditional surgery in terms of safety and has a greater lymph node yield when compared with traditional surgery. Moreover, right-sided CME is associated with better overall and disease-free survival.

Association of a multiple-step action with cervical lymph node yield of oral cancer patients in an Asian country.

BACKGROUND: High quality lymph node (LN) yield could increase survival, however strategies to improve LN yield have been seldom reported. This study aimed to assess the multiple-step action to promote quality of neck dissection in oral cancer. METHODS: A total of 400 patients with oral cancer who underwent primary tumor resection and neck dissection, including elective and radical neck dissection, were recruited after propensity score matching by clinical T and N categories between January 2009 and September 2018. Patients were treated by two independent departments in our institute. A multiple-step action was initiated in October 2015 in one department, and another department was as a control group. The impact of multiple-step action on LN yield and regional recurrence were analyzed using multivariate analysis and difference-in-differences (DID) linear regression analysis. RESULTS: The mean patient age was 55.2 + 11.1 years, and 92% were male. A total of 180 (45%) patients had T3-4 disease, and 129 (32%) patients had N2-3 disease. The multivariate linear regression and DID analyses revealed that multiple-step action had a positive effect on LN yield. A net improvement of LN yield with a coefficient of 13.78 (p < 0.001) after launching multiple-step action (since October 2015) was observed. A borderline protective effect of multiple-step action for cN0 patients with a reduced regional recurrence rate of 11.6% (p = 0.072) through DID analysis was noted. CONCLUSIONS: Multiple-step action was associated with increased LN yield and decreased regional recurrence in patients with oral cancer. The observed activity may promote surgeons to improve the quality of neck dissections, is feasible, and could be applied to a widespread patient population.

Risk probability model for residual metastatic lymph node in patients with papillary thyroid microcarcinoma undergoing cervical central lymph node dissection.

To establish a risk probability model for residual metastatic lymph nodes in patients with papillary thyroid microcarcinoma (PTMC) after cervical central lymph node dissection (CLND). The clinical data of patients with PTMC treated in the First Affiliated Hospital of Kunming Medical University from 2007 to 2020 were retrospectively reviewed. All patients underwent thyroidectomy with CLND, and at least one lymph node was examined. Based on the distribution characteristics of metastatic lymph nodes from this retrospective cohort, a probabilistic model for the risk of residual metastatic lymph node was established. ß-Binomial distribution was used to estimate the probability of residual metastatic lymph node as a function of the number of lymph nodes examined. Among 5399 patients included in the probabilistic model, central lymph node metastases were observed in 1664 cases (30.8%). After model correction, the real lymph node metastasis rate increased from 30.8% to 38.9%. The probability of false negative of central lymph node was estimated to be 31.3% for patients with a single node examined, while decreased to 10.0% and 4.9% when 7 and 12 nodes were examined, respectively. In the sensitivity analysis limited to patients with or without Hashimoto thyroiditis, the performance of probability model was also satisfactory. The established risk probability model in this study quantifies the risk of residual metastatic lymph nodes after CLND in patients with PTMC, which can be used as complementary indicators for the risk of recurrence/persistence disease at postoperative evaluation. The study also provides a new method to evaluate the impact of residual metastatic lymph nodes on the prognosis of tumor patients through retrospective data.

The re-evaluation of optimal lymph node yield in stage II right-sided colon cancer: is a minimum of 12 lymph nodes adequate?

PURPOSE: Adequate lymphadenectomy is critical for accurate nodal staging and planning adjuvant therapy in colon cancer. However, the optimal lymph node (LN) yield for stage II right-sided colon cancer (RSCC) is still unclear. This population-based study aimed to determine the optimal LN yield associated with survival and LN positivity in patients with stage II RSCC. METHODS: All patients with stage II-III RSCC were identified from the Surveillance, Epidemiology, and End Results database over a 10-year interval (2006-2015). The optimal threshold for LN yield was explored using an outcome-oriented approach based on survival and LN positivity. RESULTS: The median number of LNs examined for all 17,385 patients with stage II RSCC was 17 (IQR 12-23). Nineteen LNs were determined as the optimal cut-off point to maximize survival benefit from lymphadenectomy. Increased LN yield was associated with a gradual increase in the risk of node positivity, with no change after 19 nodes. Compared with patients with 19 or more LNs examined, the group with fewer LNs had a significantly poor cancer-specific survival (< 12 nodes: hazard ratio (HR) 2.26, P < 0.001; 12-18 nodes: HR 1.58, P < 0.001) and overall survival (< 12 nodes: HR 1.80, P < 0.001; 12-18 nodes: HR 1.31, P < 0.001). Similar survival results were found in the validation cohort. Patients with older age, small tumor size, and appendix and transverse colon cancer were more likely to receive inadequate LN harvest. CONCLUSION: A minimum of 19 LNs is needed to be examined for optimal survival and adequate node staging in lymph node-negative RSCC.

Preoperative anatomical road mapping reduces variability of operating time, estimated blood loss, and lymph node yield in right colectomy with extended D3 mesenterectomy for cancer.

OBJECTIVE: To assess the impact of individual patient anatomy on operating time, estimated blood loss (EBL), and lymph node yield in right colectomy with extended D3 mesenterectomy, where surgeons have access to a preoperative 3-D reconstruction of the vascular anatomy of patients before surgery. Data on the impact of individual patient vascular anatomy when surgeons have an anatomical road map as a guide at surgery is still missing in the literature. METHOD: Consecutive patients enrolled in an ongoing trial were classified into 4 groups and 2 subgroups using a 3-D vascular anatomy reconstruction derived from the staging CT. Outcome measures are operating time, EBL, vascular events, and D3 volume lymph node yield. SPSS was used for statistical analysis. RESULTS: One hundred seventy-six (77 men) patients included. Mean operating time was 200 ± 50 min. Type 4b required significantly longer operating time (mean, 219 ± 59) compared to type 3 (mean, 188 ± 43) (p = 0.004). Vascular events occurred most often in anatomy type 4b (20.0%) and 3 (19.2%). No difference in EBL and lymph node yield was found (p = 0.102 and p = 0.803, respectively). CONCLUSION: The use of a roadmap at surgery seems to even differences in operating time, EBL, and lymph node yield, independent of the complexity of the individual patient's central mesenteric vascular anatomy. The incidents of vascular events requiring hemostasis do not cause differences in EBL between the anatomy groups, suggesting that preoperative awareness of the anatomy is beneficial at surgery.

Lymph node yield and tumour subsite are associated with survival in stage I-III colon cancer: results from a national cohort study.

BACKGROUND: It has been suggested that apart from tumour and nodal status, a range of patient-related and histopathological factors including lymph node yield and tumour location seems to have prognostic implications in stage I-III colon cancer. We analysed the prognostic implication of lymph node yield and tumour subsite in stage I-III colon cancer. METHODS: Data on patients with stage I to III adenocarcinoma of the colon and treated by curative resection in the period from 2003 to 2011 were extracted from the Danish Colorectal Cancer Group database, merged with information from the Danish National Patient Register and analysed. RESULTS: A total of 13,766 patients were included in the analysis. The 5-year overall survival ranged from 59.3% (95% CI 55.7-62.9%) (lymph node yield 0-5) to 74.0% (95% CI 71.8-76.2%) (lymph node yield ≥ 18) for patients with stage I-II disease (p < 0.0001) and from 36.4% (95% CI 29.8-43.0%) (lymph node yield 0-5) to 59.4% (95% CI 56.6-62.2%) (lymph node yield ≥ 18) for patients with stage III disease (p < 0.0001). The 5-year overall survival for tumour side left/right was 59.3% (95% CI 57.9-60.7%)/64.8% (CI 63.4-66.2%) (p < 0.0001). In the seven colonic tumour subsites, the 5-year overall survival ranged from 56.6% (95% CI 51.8-61.4%) at splenic flexure to 65.8% (95% CI 64.5-67.2%) in the sigmoid colon (p < 0.0001). In a cox regression analysis, lymph node yield and tumour side right/left were found to be prognostic factors. Tumours at the hepatic and splenic flexures had an adverse prognostic outcome. CONCLUSION: For stage I-III colon cancer, a lymph node yield beyond the recommended 12 lymph nodes was associated with improved survival. Both subsite in the right colon, as well as subsite in the left colon, turned out with adverse prognostic outcome questioning a simple classification into right-sided and left-sided colon cancer.

Lymph node yield and lymph node density for elective level II-IV neck dissections in laryngeal squamous cell carcinoma patients.

PURPOSE: To determine the minimum lymph node yield (LNY) in patients with laryngeal squamous cell carcinoma (LSCCs). METHODS: This retrospective study was performed in a tertiary care hospital setting and included 42 LSCC patients aged 39-81 years (females, n = 2; males, n = 40) who underwent a total or partial laryngectomy and elective bilateral level II-IV neck dissections (unilateral neck dissections: n = 84). RESULTS: The average LNY in the unilateral level II-IV lymph node dissections was 25.9 ± 10, and the average metastatic LNY was 0.9 ± 1.9. The unilateral neck dissections were grouped according to the number of lymph nodes. There was no significant difference between the groups in terms of the metastatic LNY (p = 0.5). The metastatic lymph node density (LND) (metastatic lymph node yield/LNY) was 0.043 for unilateral neck level II-IV neck dissections. A Cox regression analysis revealed no significant relationship between survival and the LNY and LND in bilateral neck dissections (p = 0.4 and p = 0.8, respectively). CONCLUSIONS: The results revealed no minimum number of lymph nodes that could reliably detect metastatic lymph nodes in LSCC patients.

Acetone clearance of mesocolic or mesorectal fat increases lymph node yield and may improve detection of high-risk Stage II colorectal cancer patients.

AIM: Lymph node (LN) status is key to determining the need for adjuvant therapy in colorectal cancer (CRC) and for disease which has progressed to Stage II (T3-T4, N0, M0). A yield of fewer than 12 LNs is considered a risk factor similar to high-grade histology and vascular, lymphatic and perineural invasion. The aim of this retrospective study was to investigate the effect of acetone fat clearance of the mesocolon or mesorectum on LN yield and the identification of patients with high-risk Stage II CRC. METHOD: After conventional LN retrieval, fatty tissue derived from the mesocolon or mesorectum of 80 CRC specimens was incubated in acetone for 24 h. A second dissection was then performed by a trained technician. The total number of LNs as well as tumour involvement (LNpositive and LNnegative) were assessed at each stage. In addition, LN morphology was assessed and clinicopathological data were extracted from existing pathology reports. RESULTS: Eighty CRC specimens were available for study. 1548 (94%) LN were negative and 96 (6%) were positive. The median (range) LN yield per specimen was 12 (3-41) LN increasing to 18 (4-48) LN after fat clearance (P < 0.001). After fat clearance, 534 additional LNs were identified in 75 (94%) of the specimens, and all but 10 were negative. The pN stage did not change in six patients who were found to be LN positive after fat clearance. However, the number of high-risk Stage II CRC patients decreased from 11 to 7. Although important for these patients, this downstaging did not reach statistical significance (P = 0.125). CONCLUSION: Acetone clearance of mesocolic or mesorectal fat increases median LN yield and may in a larger study decrease the number of patients classified as having high-risk Stage II CRC.