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Gafeer MM, Arriola AGP. The Hunt for Lymph Nodes: Is Total Submission of Standard-Template and Extended-Template Pelvic Lymph Node Dissections Necessary for Detecting Metastatic Prostate Cancer? Arch Pathol Lab Med 2023; 147:1466-1470. [PMID: 36881767 DOI: 10.5858/arpa.2022-0258-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 03/09/2023]
Abstract
CONTEXT.— There are no consensus guidelines on submission of pelvic lymph node dissection (PLND) specimens for radical prostatectomies. Complete submission is only performed by a minority of laboratories. Our institution has been following this practice for standard-template and extended-template PLND. OBJECTIVE.— To investigate the utility of total submission of PLND specimens for prostate cancer and understand its impact on patients and the laboratory. DESIGN.— Retrospective study examining 733 cases of radical prostatectomies with PLND performed at our institution. Reports and slides with positive lymph nodes (LNs) were reviewed. Data on LN yield, cassette usage, and impact of submission of remaining fat after dissection of grossly identifiable LNs were assessed. RESULTS.— Most cases involved submission of extra cassettes for remaining fat (97.5%, n = 697 of 715). Extended PLND yielded a higher mean number of total and positive LNs versus standard PLND (P < .001). However, extended PLND required significantly more cassettes for remaining fat (mean, 8; range, 0-44). There was poor correlation between number of cassettes submitted for PLND with total and positive LN yield and between remaining fat with LN yield. Most positive LNs were grossly identified (88.5%, n = 139 of 157) and were typically larger than those not. Only 4 cases (0.6%, n = 4 of 697) would have been understaged without complete submission of PLND. CONCLUSIONS.— Total submission of PLND increases detection of metastasis and LN yield yet increases workload significantly with only minimal patient management impact. Hence, we recommend that meticulous gross identification and submission of all LNs be pursued without the need to submit the remaining fat of PLND.
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Affiliation(s)
- Mohamad Mazen Gafeer
- From the Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia (Gafeer)
| | - Aileen Grace P Arriola
- The Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, Pennsylvania, and Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania (Arriola)
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Pucher PH, Allum WH, Bateman AC, Green M, Maynard N, Novelli M, Petty R, Underwood TJ, Gossage J. Consensus recommendations for the standardized histopathological evaluation and reporting after radical oesophago-gastrectomy (HERO consensus). Dis Esophagus 2021; 34:doab033. [PMID: 33969411 DOI: 10.1093/dote/doab033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/12/2021] [Accepted: 04/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Variation in the approach, radicality, and quality of gastroesophageal surgery impacts patient outcomes. Pathological outcomes such as lymph node yield are routinely used as surrogate markers of surgical quality, but are subject to significant variations in histopathological evaluation and reporting. A multi-society consensus group was convened to develop evidence-based recommendations for the standardized assessment of gastroesophageal cancer specimens. METHODS A consensus group comprised of surgeons, pathologists, and oncologists was convened on behalf of the Association of Upper Gastrointestinal Surgery of Great Britain & Ireland. Literature was reviewed for 17 key questions. Draft recommendations were voted upon via an anonymous Delphi process. Consensus was considered achieved where >70% of participants were in agreement. RESULTS Consensus was achieved on 18 statements for all 17 questions. Twelve strong recommendations regarding preparation and assessment of lymph nodes, margins, and reporting methods were made. Importantly, there was 100% agreement that the all specimens should be reported using the Royal College of Pathologists Guidelines as the minimum acceptable dataset. In addition, two weak recommendations regarding method and duration of specimen fixation were made. Four topics lacked sufficient evidence and no recommendation was made. CONCLUSIONS These consensus recommendations provide explicit guidance for gastroesophageal cancer specimen preparation and assessment, to provide maximum benefit for patient care and standardize reporting to allow benchmarking and improvement of surgical quality.
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Affiliation(s)
- Philip H Pucher
- Department of General Surgery, Guys and St Thomas' Hospital NHS Foundation Trust, London, UK
- Department of General Surgery, Portsmouth University Hospital NHS Trust, Portsmouth, UK
| | - William H Allum
- Department of Academic Surgery, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Adrian C Bateman
- Department of Cellular Pathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael Green
- Department of General Surgery, Guys and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Nick Maynard
- Department of General Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Marco Novelli
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Russell Petty
- Department of Medical Oncology, Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, Dundee, UK
| | - Timothy J Underwood
- Royal College of Surgeons of England and Association of Upper Gastrointestinal Surgery of GB&I (AUGIS) Surgical Specialty Lead for Oesophageal Cancer, UK
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James Gossage
- Department of General Surgery, Guys and St Thomas' Hospital NHS Foundation Trust, London, UK
- Oesophagogastric Cancer Lead, AUGIS, UK
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Pucher PH, Green M, Bateman AC, Underwood TJ, Maynard N, Allum WH, Novelli M, Gossage JA. Variation in histopathological assessment and association with surgical quality indicators following oesophagectomy. Br J Surg 2021; 108:74-79. [PMID: 33640940 DOI: 10.1093/bjs/znaa038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/04/2020] [Accepted: 09/15/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Histopathological outcomes, such as lymph node yield and margin positivity, are used to benchmark and assess surgical centre quality, and are reported annually by the National Oesophago-Gastric Cancer Audit (NOGCA) in England and Wales. The variation in pathological specimen assessment and how this affects these outcomes is not known. METHODS A survey of practice was circulated to all tertiary oesophagogastric cancer centres across England and Wales. Questions captured demographic data, and information on how specimens were prepared and analysed. National performance data were retrieved from the NOGCA. Survey results were compared for tertiles of lymph node yield, and circumferential and longitudinal margins. RESULTS Survey responses were received from 32 of 37 units (86 per cent response rate), accounting for 93.1 per cent of the total oesophagectomy volume in England and Wales. Only 5 of 32 units met or exceeded current guidelines on specimen preparation according to the Royal College of Pathologists guidelines. There was wide variation in how centres defined positive (R1) margins, and how margins and lymph nodes were assessed. Centres with the highest nodal yield were more likely to use systematic fat blocking, and to re-examine specimens when the initial load was low. Systematic blocking of lesser curve fat resulted in significantly higher rates of patients with at least 15 lymph nodes examined (91.4 versus 86.5 per cent; P = 0.027). CONCLUSION Preparation and histopathological assessment of specimens varies significantly across institutions. This challenges the validity of currently used surgical quality metrics for oesophageal and other tumours.
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Affiliation(s)
- P H Pucher
- Department of General Surgery, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - M Green
- Department of Histopathology, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - A C Bateman
- Department of Histopathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - T J Underwood
- Department of General Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - N Maynard
- Department of General Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - W H Allum
- Department of General Surgery, Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - M Novelli
- Department of Histopathology, University College London Hospitals NHS Foundation Trust, London, UK
| | - J A Gossage
- Department of General Surgery, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
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Oderda M, Diamand R, Albisinni S, Calleris G, Carbone A, Falcone M, Fiard G, Gandaglia G, Marquis A, Marra G, Parola C, Pastore A, Peltier A, Ploussard G, Roumeguère T, Sanchez-Salas R, Simone G, Smelzo S, Witt JH, Gontero P. Indications for and complications of pelvic lymph node dissection in prostate cancer: accuracy of available nomograms for the prediction of lymph node invasion. BJU Int 2020; 127:318-325. [PMID: 32869940 DOI: 10.1111/bju.15220] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To externally validate the currently available nomograms for predicting lymph node invasion (LNI) in patients with prostate cancer (PCa) and to assess the potential risk of complications of extended pelvic lymph node dissection (ePLND) when using the recommended threshold. METHODS A total of 14 921 patients, who underwent radical prostatectomy with ePLND at eight European tertiary referral centres, were retrospectively identified. After exclusion of patients with incomplete biopsy or pathological data, 12 009 were included. Of these, 609 had undergone multiparametic magnetic resonance imaging-targeted biopsies. Among ePLND-related complications we included lymphocele, lymphoedema, haemorrhage, infection and sepsis. The performances of the Memorial Sloan Kettering Cancer Centre (MSKCC), Briganti 2012, Briganti 2017, Briganti 2019, Partin 2016 and Yale models were evaluated using receiver-operating characteristic curve analysis (area under the curve [AUC]), calibration plots, and decision-curve analysis. RESULTS Overall, 1158 patients (9.6%) had LNI, with a mean of 17.7 and 3.2 resected and positive nodes, respectively. No significant differences in AUCs were observed between the MSKCC (0.79), Briganti 2012 (0.79), Partin 2016 (0.78), Yale (0.80), Briganti 2017 (0.81) and Briganti 2019 (0.76) models. A direct comparison of older models showed that better discrimination was achieved with the MSKCC and Briganti 2012 nomograms. A tendency for underestimation was seen for all the older models, whereas the Briganti 2017 and 2019 nomograms tended to overestimate LNI risk. Decision-curve analysis showed a net benefit for all models, with a lower net benefit for the Partin 2016 and Briganti 2019 models. ePLND-related complications were experienced by 1027 patients (8.9%), and 12.6% of patients with pN1 disease. CONCLUSIONS The currently available nomograms have similar performances and limitations in the prediction of LNI. Miscalibration was present, however, for all nomograms showing a net benefit. In patients with only systematic biopsy, the MSKCC and Briganti 2012 nomograms were superior in the prediction of LNI.
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Affiliation(s)
- Marco Oderda
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Torino, Italy
| | - Romain Diamand
- Urology Department, Hôpital Erasme, University Clinics of Brussels, Université Libre de Bruxelles, Brussels, Belgium
| | - Simone Albisinni
- Urology Department, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Giorgio Calleris
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Torino, Italy
| | - Antonio Carbone
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Marco Falcone
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Torino, Italy
| | - Gaelle Fiard
- Urology Department, CHU de Grenoble, Grenoble, France
| | - Giorgio Gandaglia
- Unit of Urology/Department of Oncology, URI, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alessandro Marquis
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Torino, Italy
| | - Giancarlo Marra
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Torino, Italy.,Department of Urology, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France
| | - Cinzia Parola
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Torino, Italy
| | - Antonio Pastore
- Urology Unit, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Alexandre Peltier
- Urology Department, Hôpital Erasme, University Clinics of Brussels, Université Libre de Bruxelles, Brussels, Belgium
| | - Guillaume Ploussard
- Quint Fonsegrives and Institut Universitaire du Cancer, La Croix du Sud Hospital, Toulouse, France
| | - Thierry Roumeguère
- Urology Department, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Rafael Sanchez-Salas
- Department of Urology, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France
| | - Giuseppe Simone
- Urology Department, Regina Elena National Cancer Institute, Rome, Italy
| | | | - John H Witt
- Department of Urology, St Antonius Hospital Gronau, Gronau, Germany
| | - Paolo Gontero
- Division of Urology, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Torino, Italy
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