Brian McKinley

Differential lymph node retrieval in rectal cancer: associated factors and effect on survival

BACKGROUNDnRecent publications have identified positive associations between numbers of lymph nodes pathologically examined and five-year overall survival (5-yr OS) in colon cancer. However, focused examinations of relationships between survival of rectal cancer and lymph node counts are less common. We conducted a single institution, retrospective review of rectal cancer resections to determine whether lymph node counts correlated with 5-yr OS and to explore the relationship between lymph node counts and various clinical and pathologic factors.nnnMETHODSnA retrospective review of our institutional tumor registry identified 159 patients with AJCC Stage 1, 2, or 3 rectal cancers that underwent surgical resection at our institution over eleven years. Univariate analysis was used to explore the relationship between lymph node counts and age, AJCC Stage, time period of diagnosis, preoperative radiotherapy, and performance of TME. Survival analysis was performed by the Kaplan-Meier method and the Cox proportional hazards model.nnnRESULTSnIn univariate analysis, there was an association between increased lymph node counts and age <70, higher stage, and diagnosis during the later portion of the study period [all P-values <0.05]. Lymph node counts were not associated with survival in Kaplan-Meier analysis or in multivariate Cox proportional hazards analysis.nnnCONCLUSIONSnIncreasing lymph node counts improve survival and the accuracy of colorectal cancer staging. The body of literature recommends identical minimum lymph node counts in both colon and rectal cancer. In our study, which exclusively examined rectal cancer, we could not demonstrate that increased lymph node counts were associated with improved survival.

The impact of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial: An institutional review

BACKGROUNDnAxillary dissection (AD) was historically recommended for all patients with breast tumor involvement discovered by sentinel lymph node biopsy (+SLNB). However, after the ACOSOG Z0011 trial, omission of AD became the recommendation for selected patients with axa0+SLNB. We report the impact of ACOSOG Z0011 on the completion AD rate in patients withxa0+SLNB at our institution.nnnMETHODSnWe retrospectively reviewed all patients diagnosed with breast cancer between March 2009 and February 2013 (nxa0=xa01781). This cohort was divided into two groups: 1) those diagnosed BEFORE Z0011 and 2) those diagnosed AFTER Z0011. We calculated both the percentage of patients with axa0+SNLB who underwent AD and, from those patients, the percentage who did and did not meet the Z0011 criteria.nnnRESULTSnThe BEFORE group contained 849 patients; 144 hadxa0+SLNB and from those 113 underwent AD. The AFTER group contained 932 patients: 139 hadxa0+SLNB and from those 73 underwent AD. The completion AD rate in the BEFORE group was 78.5%, compared to 52.5% in the AFTER group (pxa0<xa00.001). From the patients who met the Z0011 criteria, 75.6% of the BEFORE patients underwent AD, compared to only 2.2%% in the AFTER group (pxa0<xa00.001). Among those who did not meet the Z0011 criteria, a similar percentage of patients underwent AD in each group (BEFORE 79.8%, AFTER 74.4%, pxa0=xa00.384).nnnCONCLUSIONnFollowing the publication of the ACOSOG Z0011 trial, we experienced a significant decrease in the completion AD rate among patients with axa0+SLNB who met the Z0011 inclusion criteria.

Management of periampullary adenocarcinoma by pancreaticoduodenectomy at a regional teaching hospital

BACKGROUNDnPeriampullary adenocarcinoma (PA) includes: pancreatic, duodenal and ampullary adenocarcinoma; and cholangiocarcinoma. Pancreaticoduodenectomy (PD) is required for cure of PA. Previous studies demonstrated the likelihood of cure increases when a microscopically negative (R0) margin is achieved. Clearance of the superior mesenteric artery (SMA) margin has been identified as the most critical margin in PD. Some authors have emphasized the importance of certain techniques to clear the SMA margin. Neither the degree to which these techniques have been incorporated nor their impact on margin status and survival has been described. We hypothesized that use of techniques focusing on clearing the SMA margin would result in higher R0 resection rates and improved survival after PD in patients with PA.nnnMETHODSnA retrospective study was performed on patients from 1/1/1985 until 7/31/2007. Data on patient demographics, clinical presentation, preoperative treatment, operative technique, margins, and postoperative outcomes were collected. Ninety-three patients were identified for inclusion in the study. Three approximately equal groups were created for analysis.nnnRESULTSnThe overall survival (OS) for the entire cohort was 19 months and was not different among the groups studied. Margins were microscopically negative in 81% of cases. The percentage of node-positive cases increased during the time period, as did the number of lymph nodes (LNs) examined (P=0.017). The use of pylorus-preserving PD decreased (P=0.001) while resection of the superior mesenteric/portal vein (SMV/PV) increased during the study period. We observed an increase in descriptions of the clearance of the anterior aspect of the aorta and inferior vena cava (IVC), dissection to the right side of the SMA, dissection to the origin of the SMA and intra-operative identification of the SMA margin. Dissecting to the SMA did not change the likelihood of achieving an R0 margin. OS was improved after R0 resections (R0: 21 months vs. R1/2: 10 months) but this difference was not statistically significant (P=0.099). There was no association between margin status and OS. Changes in the pathology reporting of margins were observed, with statistically significant increases in the percentage of cases in which the SMA, common bile duct and pancreatic neck margins were separately reported. However, the SMA margin was separately reported in only 26% of pathology reports.nnnCONCLUSIONSnThe operative techniques used in PD at this institution have changed over time. The increasing frequency of dissection to the SMA and identification of the SMA margin by both surgeon and pathologist suggest an increased attention to the SMA margin. This shift did not result in significant improvements in survival or margin status, but it is consistent with the recognition of the importance of the SMA margin. Our analysis has also identified areas of potential improvement in the ways in which operative and pathology reports for PD are generated.