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The Importance of Lymph Node Yield and the Lymph Node Ratio after Neoadjuvant Chemoradiation in Rectal Cancer
Abstracts / Clinical Oncology 29 (2017) e72ee83 Conclusion: Initial results indicate that radiotherapy with IMRT is feasible in our setting. The 2 Gy per fraction course schedule with a shorter overall treatment time was completed without any treatment breaks. Acute gastrointestinal and groin skin toxicity was low. Disease control was at par with reported literature. Long term data will throw more light on late failures and toxicities.
The Importance of Lymph Node Yield and the Lymph Node Ratio after Neoadjuvant Chemoradiation in Rectal Cancer P. Roy, I. Arun, I. Mallick, S. Banerjee, M. Roy Tata Medical Center, Kolkata, India
Aims: Neoadjuvant chemoradiation (NACRT) is the current standard of care before surgery for rectal adenocarcinoma. Lymph node yield is reported to be poorer after NACRT, but is recognised a quality standard. We aimed to perform a detailed analysis of our institutional experience in reporting pathological lymph nodes, including the importance of the size of metastatic nodes in determining the yield, as well as the importance of the lymph node ratio in determining recurrence. Methods: Pathological data from 114 consecutive patients who underwent NACRT with a course of radiotherapy (RT) and concomitant oral capecitabine, followed by anterior or abdominoperineal resection, were analysed. The lymph node yield was audited. In a substudy on 21 patients, the size and involvement of each dissected node were documented. The influence of patient age on lymph node yield was determined. The prognostic importance of the lymph node ratio on disease recurrence was analysed. Results: In total, 1629 nodes were dissected from 114 patients, with a median yield of 13 nodes/patient (mean 14.3 nodes/patient). Metastatic nodes (ypNþ) were identified in 53 patients (46.5%) with a total of 174 positive nodes. Adequate nodal yield (>12 nodes) was achieved in 69.3% of patients. The yield in patients over the age of 60 years in our cohort was not significantly different from those who were younger (64.1% versus 72%, P ¼ 0.4). In the substudy of nodal size in 21 patients, the average size of dissected nodes was 2.8 mm, with 286/310 (92%) nodes <5 mm and 263/310 (85%) nodes <3 mm. The average size of the nodes showing metastasis was 5 mm and 21/ 32 (66%) nodes <5 mm and 14/32 (44%) nodes <3 mm. The smallest metastatic node was 1 mm in size. None of the positive nodes were >1 cm in size. The lymph node ratio (LNR) ranged from 0 to 0.88, with the proportion of patients with ratios of 0, 0.01 to 0.1 and >0.1 being 65%, 7% and 28%, respectively. The lymph node ratio predicted for disease-free survival (DFS) on univariate analysis, with 30 month DFS of 89.8%, 50.4% and 25.0% in these groups (P < 0.001). Conclusion: Lymph node yield after NACRT is not necessarily low if careful nodal examination is performed, even in older patients. Metastatic nodes after NACRT are often small in size and unless adequate sections of adipose tissue are submitted and diligently scrutinised, the identification of pathological nodes may be compromised. The lymph node ratio is a potentially useful predictor of DFS.
Outcomes of Post-cricoid, Upper Cervical and Thoracic Oesophageal Cancer Treated with Radical Non-surgical Treatment: an Indian Experience S. Laskar *, S. Mishra y, M. Chandre z, J.P. Agarwal *, S. Kumar x, K.R. Prabhash *, V. Noronha *, A. Joshi *, C.S. Pramesh *, G. Karimundackal *, S. Jiwnani * * Tata Memorial Hospital, Parel, Mumbai, India y SGPGI, Lucknow, India z NAMCO Charitable Trust Hospital, Nashik, India x Mazumdar Shaw Cancer Hospital, Bengaluru, India
Aims: Carcinoma of the oesophagus carries a guarded prognosis as clinical silence in early disease leads to most patients presenting in advanced stages. Multimodality protocols continue to emerge in an attempt to improve outcomes. Definitive (chemo)radiotherapy is employed in oesophageal cancer patients as an alternative for patients considered medically unfit for surgery or having unresectable tumours. The aim of this study was to determine the outcomes of radical, non-surgical approaches of (chemo) radiotherapy.
e79
Methods: Between January 2000 and March 2012, 333 consecutive patients diagnosed with post-cricoid, upper cervical and thoracic oesophageal cancer and deemed unsuitable for surgery on the grounds of performance status, bulky local disease or personal choice and received (chemo)radiotherapy were included in this retrospective analysis. Demographic, disease, treatment and outcomes data were extracted from patient case files and hospital medical records. Univariate and multivariate analyses were performed to determine the association between patient and disease factors and prognosis. Results: The median follow-up time was 12 months (range 1e148 months, IQR). The disease-free survival (DFS) and overall survival (OS) at 2 years for the whole group was 43% and 52% with a median DFS and OS of 18 months and 27 months, respectively. At last follow-up, 49% had experienced locoregional relapse. On univariate analysis, dose >60 Gy (P ¼ 0.001), conformal technique (P ¼ 0.013), complete response (P ¼ 0.00001) were favourable prognostic factors for OS, whereas KPS > 70(0.000), T1-2 tumours (P ¼ 0.0008), N0 stage (P ¼ 0.023), squamous histology (P ¼ 0.004) and chemotherapy administration (0.016) were favourable factors for DFS. On multivariate analysis, dose >60 Gy (P ¼ 0.011) and complete treatment response (P ¼ 0.00001) had a positive impact on OS, whereas T stage (0.036), N stage (0.029) and histology (P ¼ 0.032) were independent prognostic factors for DFS. 78% of patients completed their planned treatment without any interruptions, 10% (33) of patients were hospitalised during treatment but completed planned treatment after recovery from electrolyte imbalance or febrile neutropenia; 0.06% (2) of patients died on treatment. Conclusion: Definitive (chemo)radiotherapy for unresectable oesophageal cancer can result in an acceptable locoregional control with acceptable toxicity. T stage, N stage and histology influenced DFS. Response after treatment and total radiation dose are important prognostic factors influencing OS.
Neoadjuvant Radiation and Chemotherapy for Rectal Cancer e Clinicopathological Outcomes T. Kataria, M. Tayal, A. Chowdahry, D. Gautam, S. Krishan, G. Srivastava, S. Sasikumar Medanta, Delhi, India
Aims: To assess clinical and pathological outcomes in patients receiving neoadjuvant chemoradiation for locally advanced rectal adenocarcinoma. Methods: A retrospective review was performed on 65 consecutive patients who received neoadjuvant radiotherapy (RT chemotherapy) for cancer rectum. Surgery was performed 4e8 weeks after the completion of chemoradiation. Standard statistical methods were used to analyse recurrence and survival. Results: The median follow-up was 13 months (0e59 months) and the mean age was 59 years (range 28e81). 4 patients (6%) received short course radiation and 94% received long course radiation. 73% (48 patients) had T3, 11% each had T2 and T4, 55% had lymph-nodes (N) positive and 45% were N0/Nx disease status. 43 patients (66%) underwent surgery, 15% did not report for surgery, 9% were found inoperable and another 9% developed distant metastasis before surgery. On pathological analysis, 79% were down-staged and 21% showed poor pathological response; 28% of specimens were T0. 26% patients developed relapse. 55% of relapses belonged to poor responders, 36% to partial pathological responders and 9% to complete response group. Of the 7 distant relapses, 57% were poor responders and 43% were partial responders. Postoperative pathological response was a predictor of long term outcomes in the cohort under study. Conclusion: Neoadjuvant chemoradiation is safe, effective and well tolerated. Postoperative pathological response is found to have an effect on recurrence pattern.
Role of High Dose Radiotherapy for Locally Advanced Pancreatic Cancer e a Single Centre Experience from Eastern India K. Sarkar, I. Mallick, M. Mallath, D. Dabkara, B. Biswas, S. Banerjee, M. Ray, S. Chatterjee, R.K. Shrimali Tata Medical Center, Kolkata, India
Aims: Pancreatic cancer is the fourth leading cause of cancer-related death. Radical resection is possible in 15e20% of patients. Chemoradiation is used
The Importance of Lymph Node Yield and the Lymph Node Ratio after Neoadjuvant Chemoradiation in Rectal Cancer P. Roy, I. Arun, I. Mallick, S. Banerjee, M. Roy Tata Medical Center, Kolkata, India
Aims: Neoadjuvant chemoradiation (NACRT) is the current standard of care before surgery for rectal adenocarcinoma. Lymph node yield is reported to be poorer after NACRT, but is recognised a quality standard. We aimed to perform a detailed analysis of our institutional experience in reporting pathological lymph nodes, including the importance of the size of metastatic nodes in determining the yield, as well as the importance of the lymph node ratio in determining recurrence. Methods: Pathological data from 114 consecutive patients who underwent NACRT with a course of radiotherapy (RT) and concomitant oral capecitabine, followed by anterior or abdominoperineal resection, were analysed. The lymph node yield was audited. In a substudy on 21 patients, the size and involvement of each dissected node were documented. The influence of patient age on lymph node yield was determined. The prognostic importance of the lymph node ratio on disease recurrence was analysed. Results: In total, 1629 nodes were dissected from 114 patients, with a median yield of 13 nodes/patient (mean 14.3 nodes/patient). Metastatic nodes (ypNþ) were identified in 53 patients (46.5%) with a total of 174 positive nodes. Adequate nodal yield (>12 nodes) was achieved in 69.3% of patients. The yield in patients over the age of 60 years in our cohort was not significantly different from those who were younger (64.1% versus 72%, P ¼ 0.4). In the substudy of nodal size in 21 patients, the average size of dissected nodes was 2.8 mm, with 286/310 (92%) nodes <5 mm and 263/310 (85%) nodes <3 mm. The average size of the nodes showing metastasis was 5 mm and 21/ 32 (66%) nodes <5 mm and 14/32 (44%) nodes <3 mm. The smallest metastatic node was 1 mm in size. None of the positive nodes were >1 cm in size. The lymph node ratio (LNR) ranged from 0 to 0.88, with the proportion of patients with ratios of 0, 0.01 to 0.1 and >0.1 being 65%, 7% and 28%, respectively. The lymph node ratio predicted for disease-free survival (DFS) on univariate analysis, with 30 month DFS of 89.8%, 50.4% and 25.0% in these groups (P < 0.001). Conclusion: Lymph node yield after NACRT is not necessarily low if careful nodal examination is performed, even in older patients. Metastatic nodes after NACRT are often small in size and unless adequate sections of adipose tissue are submitted and diligently scrutinised, the identification of pathological nodes may be compromised. The lymph node ratio is a potentially useful predictor of DFS.
Outcomes of Post-cricoid, Upper Cervical and Thoracic Oesophageal Cancer Treated with Radical Non-surgical Treatment: an Indian Experience S. Laskar *, S. Mishra y, M. Chandre z, J.P. Agarwal *, S. Kumar x, K.R. Prabhash *, V. Noronha *, A. Joshi *, C.S. Pramesh *, G. Karimundackal *, S. Jiwnani * * Tata Memorial Hospital, Parel, Mumbai, India y SGPGI, Lucknow, India z NAMCO Charitable Trust Hospital, Nashik, India x Mazumdar Shaw Cancer Hospital, Bengaluru, India
Aims: Carcinoma of the oesophagus carries a guarded prognosis as clinical silence in early disease leads to most patients presenting in advanced stages. Multimodality protocols continue to emerge in an attempt to improve outcomes. Definitive (chemo)radiotherapy is employed in oesophageal cancer patients as an alternative for patients considered medically unfit for surgery or having unresectable tumours. The aim of this study was to determine the outcomes of radical, non-surgical approaches of (chemo) radiotherapy.
e79
Methods: Between January 2000 and March 2012, 333 consecutive patients diagnosed with post-cricoid, upper cervical and thoracic oesophageal cancer and deemed unsuitable for surgery on the grounds of performance status, bulky local disease or personal choice and received (chemo)radiotherapy were included in this retrospective analysis. Demographic, disease, treatment and outcomes data were extracted from patient case files and hospital medical records. Univariate and multivariate analyses were performed to determine the association between patient and disease factors and prognosis. Results: The median follow-up time was 12 months (range 1e148 months, IQR). The disease-free survival (DFS) and overall survival (OS) at 2 years for the whole group was 43% and 52% with a median DFS and OS of 18 months and 27 months, respectively. At last follow-up, 49% had experienced locoregional relapse. On univariate analysis, dose >60 Gy (P ¼ 0.001), conformal technique (P ¼ 0.013), complete response (P ¼ 0.00001) were favourable prognostic factors for OS, whereas KPS > 70(0.000), T1-2 tumours (P ¼ 0.0008), N0 stage (P ¼ 0.023), squamous histology (P ¼ 0.004) and chemotherapy administration (0.016) were favourable factors for DFS. On multivariate analysis, dose >60 Gy (P ¼ 0.011) and complete treatment response (P ¼ 0.00001) had a positive impact on OS, whereas T stage (0.036), N stage (0.029) and histology (P ¼ 0.032) were independent prognostic factors for DFS. 78% of patients completed their planned treatment without any interruptions, 10% (33) of patients were hospitalised during treatment but completed planned treatment after recovery from electrolyte imbalance or febrile neutropenia; 0.06% (2) of patients died on treatment. Conclusion: Definitive (chemo)radiotherapy for unresectable oesophageal cancer can result in an acceptable locoregional control with acceptable toxicity. T stage, N stage and histology influenced DFS. Response after treatment and total radiation dose are important prognostic factors influencing OS.
Neoadjuvant Radiation and Chemotherapy for Rectal Cancer e Clinicopathological Outcomes T. Kataria, M. Tayal, A. Chowdahry, D. Gautam, S. Krishan, G. Srivastava, S. Sasikumar Medanta, Delhi, India
Aims: To assess clinical and pathological outcomes in patients receiving neoadjuvant chemoradiation for locally advanced rectal adenocarcinoma. Methods: A retrospective review was performed on 65 consecutive patients who received neoadjuvant radiotherapy (RT chemotherapy) for cancer rectum. Surgery was performed 4e8 weeks after the completion of chemoradiation. Standard statistical methods were used to analyse recurrence and survival. Results: The median follow-up was 13 months (0e59 months) and the mean age was 59 years (range 28e81). 4 patients (6%) received short course radiation and 94% received long course radiation. 73% (48 patients) had T3, 11% each had T2 and T4, 55% had lymph-nodes (N) positive and 45% were N0/Nx disease status. 43 patients (66%) underwent surgery, 15% did not report for surgery, 9% were found inoperable and another 9% developed distant metastasis before surgery. On pathological analysis, 79% were down-staged and 21% showed poor pathological response; 28% of specimens were T0. 26% patients developed relapse. 55% of relapses belonged to poor responders, 36% to partial pathological responders and 9% to complete response group. Of the 7 distant relapses, 57% were poor responders and 43% were partial responders. Postoperative pathological response was a predictor of long term outcomes in the cohort under study. Conclusion: Neoadjuvant chemoradiation is safe, effective and well tolerated. Postoperative pathological response is found to have an effect on recurrence pattern.
Role of High Dose Radiotherapy for Locally Advanced Pancreatic Cancer e a Single Centre Experience from Eastern India K. Sarkar, I. Mallick, M. Mallath, D. Dabkara, B. Biswas, S. Banerjee, M. Ray, S. Chatterjee, R.K. Shrimali Tata Medical Center, Kolkata, India
Aims: Pancreatic cancer is the fourth leading cause of cancer-related death. Radical resection is possible in 15e20% of patients. Chemoradiation is used