Cervical Node Dissection Research Articles

Checkpoint inhibition immunotherapy for advanced local and systemic conjunctival melanoma: a clinical case series

BackgroundHerein, we describe the use of systemic immunotherapy for both locally advanced and metastatic conjunctival melanoma. Current treatments for advanced conjunctival melanoma typically result in poor local control leading to disfiguring orbital exenteration surgery. Locoregional spread of conjunctival malignant melanoma typically requires pre-auricular and cervical lymph node dissection with post-operative adjuvant radiation therapy. In addition, classic systemic chemotherapy has been unsuccessful in the treatment of metastatic disease.MethodsThis is a retrospectively analyzed clinical case series of 5 patients with biopsy proven conjunctival melanoma who were treated with checkpoint inhibition therapy. Of these, 3 patients were treated for residual ocular disease present after failing multiple local therapies and refusing orbital exenteration surgery and two (with local ocular control) for metastatic conjunctival melanoma. Both those with locally advanced disease and patients with metastatic disease received an anti-PD1 agent in combination with another immunotherapeutic agent. All 5 were given multiple cycles of systemic anti-PD1 therapy, 1 was initially treated with single agent ipilimumab (3 mg/kg) prior to approval of anti-PD1 agents and two received interferon eye drops. As part of each ophthalmic examination, photographs of all conjunctival and eyelid surfaces were obtained. Systemic evaluations involved initial staging scans as well as periodic re-imaging.ResultsAll cases have shown responses. Of the 2 complete responses, 1 was a patient with systemic disease. No patients developed ocular toxicity or loss of vision. However, systemic adverse effects included adrenal insufficiency, Grade-III colitis, Grade-II dermatitis, Grade-II hepatotoxicity and Grade-II pneumonitis.ConclusionsThis report suggests that systemic immunotherapy with or without topical interferon is effective in treatment of malignant melanoma of the conjunctiva. Therefore, it can be considered for patients with advanced local conjunctival melanoma, those who refuse orbital exenteration surgery and those with systemic metastasis.

Predictive factors for central lymph node and lateral cervical lymph node metastases in papillary thyroid carcinoma.

Central lymph node metastasis (LNM) in papillary thyroid carcinoma (PTC) is common. But the association between primary tumor characteristics and specific features of metastatic lymph nodes in PTC has not been fully identified. Determining risk factors for LNM may help surgeons determine rational extent of lymph node dissection. Data from 432 patients who underwent thyroidectomy with cervical lymph node dissection for PTC were retrospectively analyzed. The relationships between LNM to central compartment or lateral compartment and clinicopathologic factors were analyzed. Cox regression model was used to determine the risk factors for recurrence-free survival (RFS). Central lymph node metastasis (CLNM) and lateral lymph node metastasis (LLNM) were found in 216 (50.0%) and 65 (15.0%) patients, respectively. In the multivariate analysis for CLNM, patients < 45years of age (OR 2.037, 95% CI 1.388-2.988, P < 0.001), extrathyroidal invasion (OR: 2.144, 95% CI 0.824-5.457, P = 0.011), vascular invasion (OR 13.817, 95% CI 1.694-112.693, P = 0.014), LLNM (OR 2.851, 95% CI 1.196-6.797, P = 0.014) and TNM Stage III-IV (OR 465.307, 95% CI 113.903-1900.826, P < 0.001) were independent predictors for high prevalence of CLNM. In the multivariate analysis for LLNM, tumor size more than 1cm (OR 3.474, 95% CI 1.728-6.985, P < 0.001) and CLNM (OR 5.532, 95% CI 2.679-11.425, P < 0.001) were independent predictors for high prevalence of LLNM. Moreover, tumor with T3-T4 stage, extrathyroidal invasion and CLNM were the significant factors related to the RFS. For patients with pre-operative risk factors of LNM, an accurate preoperative evaluation of central compartment or lateral compartment is needed to find suspicious lymph nodes. And prophylactic lymph node dissection should be performed in patients with high risk of CLNM. Moreover, we suggest performing close follow-up for patients with high risk of RFS.

Influence of Body Mass Index on the Clinicopathologic Features of Papillary Thyroid Carcinoma.

Epidemiologic studies have demonstrated an increased risk for papillary thyroid carcinoma (PTC) with increasing body mass index (BMI). However, the relationships between excess weight and the behavior of PTC are inconsistent. The aim of this study was to evaluate the impact of excess weight on clinicopathologic features of PTC and on patient outcomes. Data from 417 patients with PTC who underwent total thyroidectomy with cervical lymph node dissection were retrospectively analyzed. On the basis of World Health Organization standardized categories of BMI, patients were divided into 4 groups: underweight, normal weight, overweight, and obese. Histopathologic tumor features, stage at diagnosis, and disease status were determined by chart review. Logistic regression models were used to define associations between BMI and clinicopathologic features of PTC. Cox proportional-hazards models were used to assess associations between BMI and locoregional recurrence. Overweight (odds ratio [OR], 3.90; P = .040) and obesity (OR, 9.19; P = .012) were independent predictors of vascular invasion. Furthermore, obesity (OR, 6.14; P = .004) was an independent predictor of extrathyroidal invasion. During follow-up (median, 29 months; range, 5-87 months), 48 patients (11.5%) experienced locoregional recurrence. There were no significant differences in locoregional recurrence of PTC among BMI groups. When adjusted for other confounding factors, extrathyroidal invasion (OR, 8.35; P < .001), vascular invasion (OR, 3.57; P < .001), cervical lymph node metastasis (OR, 3.71; P = .009), and advanced tumor-node-metastasis stage (OR, 3.81; P < .001) were identified as independent factors for locoregional recurrence. Higher BMI was associated with extrathyroidal invasion and vascular invasion in patients with PTC, which suggests that excess weight is associated with aggressive clinicopathologic features of PTC. But patients with higher BMI did not have an increased risk for developing postoperative complications and locoregional recurrence.

Outcome of Cervical Lymph Nodes Dissection for Thyroid Cancer with Nodal Metastases: A Southeast Asian 3-Year Experience.

Introduction Therapeutic nodal dissection is still the mainstay of treatment for patients with lymph node metastases in many centres. The local data, however, on the outcome of therapeutic LND remains limited. Hence, this study aims to inform practice by presenting the outcomes of LND for thyroid cancer patients and our experience in a tertiary referral centre. Methods This is a single-centre retrospective observational study in a Malaysian tertiary endocrine surgery referral centre. Patients who underwent total thyroidectomy with lymph node dissection between years 2013 and 2015 were included and electronic medical records over a 3-year follow-up period were reviewed. The outcomes of different lymph node dissection (LND), including central neck dissection, lateral neck dissection, or both, were compared. Results Of the 43 subjects included, 28 (65.1%) had Stage IV cancer. Among the 43 subjects included, 8 underwent central LND, and 15 had lateral LND while the remaining 20 had dissection of both lateral and central lymph nodes. Locoregional recurrence was found in 16 (37.2%) of our subjects included, with no statistical difference between the central (2/8), lateral (7/15), and both (7/20). Postoperative hypocalcaemia occurred in 7 (16.3%) patients, and vocal cord palsy occurred in 5 (11.6%), whereas 9 patients (20.9%) required reoperation. Death occurred in 4 of our patients. Conclusion High recurrence and reoperative rates were observed in our centre. While the routine prophylactic LND remains controversial, high risk patients may be considered for prophylactic LND. The long-term risk and benefit of prophylactic LND with individualised patient selection in the local setting deserve further studies.

Thoracic recurrent laryngeal nerve lymph node metastasis guides the cervical lymph node dissection of patients with esophageal cancer

Three-field lymph node dissection improved the postoperative survival and accuracy of pathological staging of patients with esophageal cancer, and reduced the postoperative local recurrence rate of esophageal cancer patients. However, this surgical procedure enlarged the trauma, cansed more complications, prolonged postoperative hospital stays, and seriously impaired the postoperative adjuvant therapy. Therefore, selection of patients who are suitable for three-field lymph node dissection is extremely important. The special anatomical location of recurrent laryngeal nerve lymph nodes is potentially suitable for it to serve as sentinel lymph node for the evacuation of cervical lymph nodes dissection in esophageal cancer. The guiding value of recurrent laryngeal nerve lymph node metastasis in cervical lymph node dissection of thoracic esophageal cancer is reviewed.

Determination of risk factors causing hypocalcaemia after thyroid surgery

The most common complication after thyroid surgery is hypocalcaemia and it sometimes leads to problems that are difficult to correct in patients. The present study was aimed to determine the risk factors causing the development of hypocalcaemia after thyroid surgery. 818 adult patients were included in the study. The data were recorded by examining the hospital automation system and patient files retrospectively. Patients' demographic characteristics, radiological imaging findings, serum biochemical parameters, extent of the performed surgery, histopathological diagnoses were recorded. The rate of hypocalcaemia was 28.4% (1.7% permanent). In multivariate analysis: the female gender (p=0.002), heavier thyroid gland (p=0.084), substernal location (p=0.004) and cervical lymph nodes dissection (CLND) (p<0.001) were found to be significantly. Malignant thyroid pathology (p=0.006) and total thyroidectomy (p=0.025) increased the risk of hypocalcaemia significantly in univariate analysis. However, this increase in risk was not found to be statistically significant in regression analysis. Significant statistical result was not found on postoperative hypocalcaemia in terms of advanced age, hyperthyroidism and re-operation. The duration of hospitalization was higher in patients with postoperative hypocalcaemia (m=2 days) (p<0.001). In our analyses CLND, female gender, substernal location and heavier thyroid gland was found to be the independent risk factors in the development of postoperative hypocalcaemia. The development of postoperative hypocalcaemia may be predicted and measures may be taken to prevent clinical findings.

Ameloblastic carcinoma of lower jaw (case report)

The study objectiveis to report a case of mandibular ameloblastoma.Materials and methods. A 30-year-oldfemale patient presented with swelling of the right mandibular region that appeared 8 months ago and has been slowly increasing. The patient had no other symptoms, such as pain, anesthesia, paresthesia, difficulty swallowing, mouth opening, speech disorders, fever, chills, or weight loss. Orthopantomography revealed pronounced bone resorption in the right portion of the mandibular body. Computed tomography showed a cystic cavity in this area. After incisional biopsy, the patient was diagnosed with ameloblastic carcinoma. We performed segmental mandibular resection and installed a reconstructive plate to restore mandibular integrity. We also performed selective cervical lymph node dissection (levels Ia and Ib).Results.One yearpostoperatively, the results were considered aesthetically and functionally satisfactory.Conclusion.We observed an aggressive disease phenotype with extensive localized bone destruction, typical of ameloblastic carcinoma. Extensive excision of the primary tumor and selective cervical lymph node dissection without radiotherapy ensured a relapse-free period during patient’s follow up.

Salvage surgery of hypopharyngeal cancer as a second malignancy post radiotherapy and the possibility of digestive track reconstruction – study of three cases and the literature review

Patients with head and neck cancers have an increased risk of second malignant neoplasm occurrence (25% in long-term follow-up, 4% yearly). Most patients with a primary tumor can be treated with organ-preserving strategies including radiotherapy (RT) or chemoradiotherapy (CRT). Very often after radical surgical excision there are indications for adjuvant radiotherapy. However, if recurrence or second malignancy will develop after definitive primary RT, there are limitation to use therapeutic dose of radiation again for the same area. Salvage surgery is regarded as the only curative option in those cases. In our study we analysed 3 patients, who presented with head and neck second cancer in the area of hypopharynx, within 10-25 years after primary radiotherapy due to oropharyngeal and laryngeal cancer. A total pharyngectomy with larynx preservation and bilateral neck dissection were performed in the first case and the radial forearm free flap (RFFF) was used for reconstruction of the pharynx. Second patient, due to perilaryngeal invasion in radiological images, underwent total pharyngolaryngectomy with selective bilateral cervical lymph nodes dissection and digestive track was restored also with RFFF. The third patient had previously undergone laryngectomy and after total pharyngectomy the free autologous jejunal flap (FAJF) was used for reconstruction. The main goal of reconstruction after salvage surgery due to hypopharyngeal cancer is to reconstruct the digestive tract. The other important aspect is to optimize the anatomy for voice rehabilitation and swallowing. Unfortunately, radiation and chemotherapy impair wound healing, which indicates increased risk of postoperative complications and makes salvage surgery results unpredictable.

Meta-analysis of ultrasound for cervical lymph nodes in papillary thyroid cancer: Diagnosis of central and lateral compartment nodal metastases

PurposeTo evaluate the performance of preoperative ultrasound in the diagnosis of cervical lymph nodes metastases (CLNM) of papillary thyroid cancer (PTC) and its value in assisting cervical lymph node dissection (CLND). MethodsPubMed, EMBASE and Cochrane Library databases were searched to identify relevant studies up to Sep. 2017. Overall sensitivity, specificity, and diagnostic odds ratio (DOR) were used to assess the diagnostic efficacy of ultrasound in detecting central and lateral CLNM of PTC. ResultsNineteen studies comprising 4014 patients were included in the meta-analysis. The pooled sensitivity, specificity, DOR and area under curve (AUC) of ultrasound in detecting central CLNM were 0.33 (95% confidence interval (95% CI): 0.31–0.35), 0.93 (95% CI: 0.92–0.94), 5.63 (95% CI: 3.50–9.04), and 0.69, respectively; and lateral CLNM were 0.70 (95% CI: 0.68–0.72), 0.84 (95% CI: 0.82–0.85), 18.7 (95% CI: 10.3–33.9) and 0.88, respectively. We found that the rate of central CLNM of PTC was 48.0%, and 36.2% of the dissected lymph nodes were metastatic, meanwhile, the rate of lateral CLNM of PTC was 59.2%, and 46.6% of the dissected lymph nodes were metastatic in the meta-analysis. ConclusionsPreoperative ultrasound demonstrates poor sensitivity in the diagnosis of central CLNM, and good diagnostic efficacy for lateral CLNM of PTC. Prophylactic central CLND is recommended to PTC patients due to the high incidence of central CLNM and low diagnostic efficacy of ultrasound.

Prediction of Ipsilateral and Contralateral Cervical Lymph Node Metastasis in Unilateral Papillary Thyroid Carcinoma

Background: Surgical therapy is the cornerstone of treatment in patients with papillary thyroid cancer (PTC). Surgical therapy in PTC includes hemithyroidectomy or total thyroidectomy (TT) and, in cases of lymph node metastases, cervical lymph node dissection (CLND). The inclusion of prophylactic central compartment neck dissection (pCCND) as a new approach in the management of patients with PTC with clinically negative cervical lymph nodes raised controversies among the endocrine surgeons and predictive factors for central lymph node (CLN) metastasis in unilateral PTC cases not well defined. Objectives: To investigate the risk factors associated with CLNM in clinical lateral cervical lymph node?negative (cN0) and analyze the rate of ipsilateral and contralateral CLN metastasis in unilateral PTC casesin Al Azhar University Hospitals in the period from May 2016 tillJune 2018. Patients and Methods: A prospective case-control descriptive study was performed to investigate the research questions during the period from the 1st of May 2016 till the end of June 2018 in Al-Azhar University Hospitals. A total of 40 selected patients suffering from papillary thyroid with clinically negative cervical lymph nodes who have received total thyroidectomy with bilateral CLND. The clinicopathological features of PTC patients with respect to sex, age, observation, tumor diameter, multifocality, extrathyroidal invasion, lymphovascular invasion and capsular invasion. The risk factors of CLNM were analyzed by Chi-squared test and multivariate logistic regression model. Results: Ipsilateral CLN metastasis were present in 47.5% (19/40).Results analysis showed that males patients with tumor size (>1 cm) (P=0.027; OR, 2.153), age <45 years old (P=0.017; OR, 2.009) and capsular invasion (P= 0.018; OR= 0.730) were the predictors of ipsilateral CLN metastasis.Contralateral CLN metastasis were present in 17.5% (7/40) and prelaryngeal lymph node (LN) metastasis (P=0.008; OR, 13.333) and ipsilateral CLN metastasis (P=0.051; OR, 9.231), pretracheal lymph nodes (P=0.051; OR, 9.231), lymphovascular invasion (P=0.043; OR, 5.113) and ETE (P=0.05; OR, 4.901) independently predicted contralateral CLN metastasis. Conclusion: For the high-risk PTC patients with CLNM, prophylactic CLND may be beneficial. Nevertheless, the present data was a single center prospective analysis, and the long-term prognostic factors including recurrence rate and mortality rate were lacking. Therefore, the results of this research may only serve as a tool in predicting CLNM.

THE RELATION BETWEEN THE EXCISED THYROID GLAND WEIGHT AND POSTOPERATIVE COMPLICATIONS IN TOTAL THYROIDECTOMY PATIENTS

Aim: The purpose of this study was to determine the postoperative complications in total thyroidectomy patients based on the weight of the thyroid gland with retrospective screening.Material and Methods: A total of 263 adult patients, who underwent total thyroidectomy were included. The data automation system of the hospital and the files of the patients were examined retrospectively.Results: The total complication incidence was 24.3%, and these were determined as hypocalcemia, vocal cord paralyses (VCP), and hemorrhage and seroma at the surgery area. The rate of temporary hypocalcemia and permanent hypocalcemia rate was 20.1% and 1.5% respectively. The temporary VCP rate was 0.3% (n=1), and no permanent VCP was observed in the patients. The median thyroid weight was measured as 50 gr in patients without postoperative hypocalcemia, and as 40 g in the patients with hypocalcemia (p=0.283). There was no significant relation between the variability in the weight of the thyroid and postoperative hypocalcemia. However, the cervical lymph node dissection (LND) (p=0.006) and cervical dissection site (p=0.031) were significant in terms of postoperative complication development. In the multivariate analyses, it was found that female gender and LND were independent risk factors in the development of postoperative complications.Conclusion: It was determined that cervical LND and female gender were independent risk factors. Consistent with the literature findings, no significant results were found in the risk factors like heavy thyroid gland, presence of thyroid operation history, malignant thyroid pathology, retrosternal localization of the thyroid tissue, and hyperthyroidism.Keywords: Complications; hypocalcemia; thyroid weight; total thyroidectomy.

Risk Factors Analysis of Pathologically Confirmed Cervical Lymph Nodes Metastasis in Oral Squamous Cell Carcinoma Patients with Clinically Negative Cervical Lymph Node: Results from a Cancer Center of Central China.

Objective: To explore the risk factors of cervical lymph node metastasis in oral squamous cell carcinoma (OSCC) patients with clinical negative cervical lymph nodes(cN0) and provide a reference for clinical treatment.Methods: The clinical data of 161 OSCC patients with cN0 were retrospectively analyzed. All patients underwent extended primary resection combined with cervical lymph node dissection. The level and number of cervical lymph node metastasis were confirmed by postoperative pathology. The risk factors of cervical lymph node metastasis in patients were analyzed by univariate and multivariate Logistic regression analysis.Results: Thirty-one out of 161 cases (19%) were confirmed cervical lymph node metastasis. Among them, there were 28 cases of lymph node metastasis in one cervical level and 3 cases in two cervical levels. A total of 42 positive lymph nodes were detected in 34 cervical levels. The level number of positive areas in the IA, IB, IIA, IIB, III, IV and V levels was 2, 15, 12, 1, 4,0, and 0, respectively. The corresponding regional metastasis rates were 5.9%, 44.1%, 35.3%, 2.9%, 11.8%, 0% and 0%, respectively. The number of positive lymph node metastases in the corresponding levels were 2, 17, 17, 1, 5, 0, and 0 respectively. Univariate analysis showed that gender, age, lesion location, T stage, and perineural invasion/lymphvascular invasion (PNI/PVI) had no significant effect on cervical lymph node metastasis (P>0.05). The growth pattern, degree of differentiation, depth of invasion, neutrophil/lymphocyte ratio (NLR) and the short/long axis diameter ratio (S/L ratio) of lymph nodes were important factors influencing the cervical lymph node metastasis in cN0 OSCC patients (P<0.05). Multivariate Logistic regression analysis indicated that the growth pattern, degree of differentiation, depth of invasion, NLR, and the S/L ratio of lymph nodes were independent risk factors for cervical lymph node metastasis (P<0.05).Conclusion: The growth pattern, degree of differentiation, depth of invasion, neutrophil/lymphocyte ratio, and the short/long axis diameter ratio of lymph nodes were the independent risk factors for pathological cervical lymph node metastasis in oral squamous cell carcinoma patients with cN0. If patients with the above risk factors receive nonstandard radical neck dissection or no dissection, it may be necessary for them to receive the corresponding regional postoperative radiotherapy.

Cervical Lymph Node Dissection for Papillary Thyroid Cancers: A Decade Experience of a Single Surgical Team.

Background: All patients undergoing thyroid operations should be subjected to preoperative neck ultrasound (US) followed by fine needle aspiration cytology (FNAC) of suspicious lesions. In Western countries, thyroid surgeons routinely perform neck ultrasound. The role of prophylactic central neck dissection (PCND) remains a topic of debate. For treatment of papillary thyroid carcinoma (PTC), in 2014 we introduced two new adjuncts: PCND based on criteria of the European Society of Endocrine Surgeons (ESES) consensus group and surgeon-performed US (S-US). Methods: In order to better understand the role of these two adjuncts in our shift of strategy we aimed to evaluate the outcomes of our patients in two successive 5-year time periods based on a retrospective analysis of our prospectively maintained database (total of 286 patients were included in this study). Results: The two groups were similar regarding epidemiological and clinical data. FNAC was done in only 21.66% of all PTC cases. PTC diagnosis was done in the majority of suspicious cases by FS. S-US guided the selective lateral node dissections (LND), leading to more lymph node metastases detections and it also surpassed endocrinologist performed US (E-US) in terms of PPV. PCND rate of complications was significantly higher due only to transient hypoparathyroidism. Conclusions: Preoperative surgeon-performed ultrasonography is a useful tool in the arsenal of PTC treatment. The systematic preoperative FNAC diagnosis and intraoperative frozen sections in uncertain cases are mandatory. PCND is a safe method of treatment and staging in PTC.

Oral Mucosal Melanoma: The Natural History of the Disease a Case Report

Oral Mucosal Melanoma is a very aggressive disease that requires early detection by biopsy suspicious lesions, characteristics and surgical treatment resection with wide margins, cervical lymph node dissection and adjuvant therapies aimed at eradicating systemically neoplastic cells. The aim of this report is to show the evolution of this disease in a case where the patient did not accept treatment and thus understanding its earlier stage, the subsequent invasion of adjacent tissues and finally as it spread to the cervical lymph nodes and vital organs remote triggering systemic failure.

Response to Lenvatinib in Children with Papillary Thyroid Carcinoma

Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy in children and adolescents. Infrequently, children with PTC may present with or develop disease not amenable to surgery or radioactive iodine (RAI), and systemic therapy may be an option. Lenvatinib is an oral tyrosine kinase inhibitor that is approved by the Food and Drug Administration for the treatment of adults with locally recurrent or metastatic, progressive, RAI-refractory well-differentiated thyroid carcinoma. The effect of lenvatinib in children with PTC has not been reported. Three children with metastatic PTC not amenable or refractory to RAI who responded to lenvatinib are reported. All of them developed respiratory distress requiring oxygen caused by extensive bilateral metastatic pulmonary disease. The first patient is a 14-year-old female who was initially treated with sorafenib for extensive PTC not amenable to upfront surgery or RAI. She had progressive pulmonary disease after five months, and was subsequently treated with oral lenvatinib (14 mg/m2/day). She was weaned to room air after eight weeks. The second patient is a 15-year-old male who was treated with lenvatinib (14 mg/m2/day) for iodine non-avid diffuse pulmonary disease after initial total thyroidectomy and cervical lymph node dissection. He was weaned off oxygen in six weeks. The third patient is a five-year-old male who was treated with lenvatinib (14 mg/m2/day) for pulmonary disease progression 24 months after treatment with total thyroidectomy, cervical lymph node dissection, and RAI treatment. He was weaned off oxygen one day after starting lenvatinib. Two of the patients required dose adjustments secondary to proteinuria. Otherwise, all patients tolerated lenvatinib well. The first two patients remained clinically stable on lenvatinib 23 months and 11 months after initiation of therapy, respectively, and the third patient transitioned to a tumor-specific targeted therapy after one month. Three pediatric patients are reported with metastatic PTC not amenable or refractory to RAI who achieved a response on lenvatinib. Lenvatinib therapy is well tolerated and demonstrated clinical activity in children with advanced PTC. Lenvatinib should be considered in children with PTC that is refractory or not amenable to conventional management.

PS02.203: CHARACTERISTICS AND RISK FACTORS OF LYMPH NODE METASTASIS IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA PATIENTS WITH PREOPERATIVE COMPUTED TOMOGRAPHY-NEGATIVE LYMPH NODES

Abstract Background Characteristics and risk factors of lymph node metastasis (LNM) in esophageal squamous cell carcinoma (ESCC) patients with preoperative computed tomography (CT)-negative lymph nodes are not well elucidated. This study aimed to identify the characteristics and risk factors of LNM in ESCC patients with preoperative CT-negative lymph nodes. Methods We conducted a retrospective analysis of consecutive ESCC patients who had preoperative CT-negative lymph nodes and received esophagectomies between August 2013 and July 2016. Lymph node with a short-axis diameter ≦10 mm on preoperative CT image was considered as CT-negative lymph node. Eligible patients included those: aged 18∼80, without neoadjuvant therapy, without other malignant tumor history, without distant metastasis, without multiple esophageal lesions, tumor locating in the thoracic esophagus, receiving McKeown esophagectomy, undergoing R0 resection, having number of lymph nodes resection≧15, pathological staging as T1a-4aN0–3. Univariate and multivariate logistic regression analyses were used to identify risk factors of LNM. Results Among 243 ESCC patients identified, 137 had LNM (56.4%). The median number of lymph nodes dissected and LNM were 24 (range 15–79) and 2 (range 1–14), respectively. The rates of LNM of the upper, middle and lower thoracic ESCC were 50.0%, 59.3% and 55.1%, respectively. The rates of LNM with the maximal short-axis diameter of lymph node on preoperative CT of ≦5 mm, 6 mm, 7 mm, 8 mm, 9 mm and 10 mm were 57.4%, 42.9%, 47.4%, 31.8%, 73.9% and 70.8%, respectively (P = 0.034). Univariate analysis showed that age (P = 0.041), maximal short-axis diameter of lymph node on CT (P = 0.034), cervical lymph node dissection (P = 0.031), lymphovascular invasion (P &lt; 0.001) and perineural invasion (P = 0.017) were associated with LNM. Multivariate analysis revealed that cervical lymph node dissection (P = 0.018), lymphovascular invasion (P = 0.007) and perineural invasion (P = 0.025) were independent risk factors of LNM. Conclusion Our study showed that the rates of LNM were also high in ESCC patients with preoperative CT-negative lymph nodes. Standard lymph node dissection is necessary for these patients. Cervical lymph node dissection, lymphovascular invasion and perineural invasion are independent risk factors of LNM in ESCC patients with preoperative CT-negative lymph nodes. Disclosure All authors have declared no conflicts of interest.

PS01.189: A STUDY ON THE UTILITY OF INTRAOPERATIVE NEUROSTIMULATION MONITORING SYSTEM FOR RECURRENT LARYNGEAL NERVE IN ESOPHAGECTOMY

Abstract Background Recurrent laryngeal nerve paralysis in esophagectomy is one of the most concerned complications. In recent years, intraoperative neurostimulation monitoring system (IONM) in thyroid surgery have been widespread for identification of recurrent laryngeal nerve and assessment of soundness. Therefore, IONM is often used during esophagectomy in Japan. In this study, we examined the efficacy of IONM in the patients undergoing esophagectomy. Methods Of 66 patients underwent esophagectomy since April 2015 until December 2017, IONM used in 27 patients in the surgery for the examination of recurrent nerve paralysis. We retrospectively reviewed these cases for intraoperative findings, neurostimulation monitoring findings and their outcomes. Results Of 27 patients, 25 were male and two were female, and the median age at operation was 66 years old. Although IONM was used in cervical lymph node dissection, there were no vocal cord responses in 5 patients (left side in 4 and right side in 1) with stimulation of the vagus nerve. Because all patients had no vocal cord paralysis due to stimulation of the cervical recurrent laryngeal nerve, it was diagnosed that there was the recurrent laryngeal nerve injury due to thoracic para recurrent nerve lymph node dissection. IONM was able to facilitate the identification and preservation of cervical recurrent nerve in all patients. Three out of 5 patients with no vocal cord response by IONM were confirmed recurrent laryngeal nerve paralysis in postoperative endoscope. In patients with vocal cord paralysis by IONM, it was possible to carefully performed postoperative management. On the other hand, in patients without paralysis, extubation on the operation day seemed possible without the concern for aspiration. Conclusion By using IONM in esophagectomy, we were able to evaluate the damage of the recurrent laryngeal nerve in real-time. Confirming the intraoperative recurrent nerve injuries is important for postoperative management or prediction of postoperative aspiration pneumonia. IONM in esophagectomy was useful not only in terms of surgical procedures but also in the evaluation of postoperative management. Disclosure All authors have declared no conflicts of interest.

PS01.142: THE IMPACT OF CERVICAL LYMPH NODE DISSECTION ON ACID AND DUODENOGASTROESOPHAGEAL REFLUX AFTER INTRATHORACIC ESOPHAGOGASTROSTOMY FOLLOWING TRANSTHORACIC ESOPHAGECTOMY

Abstract Background The aim of this study was to evaluate the impact of cervical lymph node dissection on acid and duodenogastroesophageal reflux (DGER) in patients undergoing transthoracic esophagectomy with gastric tube reconstruction and intrathoracic esophagogastrostomy. Methods Thirty one patients receiving transthoracic esophagectomy gastric tube reconstruction by intrathoracic esophagogastrostomy were subjected and divided into two groups: two field lymph node dissection group (the 2F group) and three field lymph node dissection group (the 3F group). All patients underwent 24h pH and bilirubin monitoring and gastrointestinal endoscopy one year after surgery. The results of 24h pH and bilirubin monitoring, endoscopic findings, and reflux symptoms, were compared between two groups. Results No acid reflux was observed in the 2F group, whereas it was observed in 6 (40%) of the 3F group (P = 0.023). DGER was observed in 2 patients (13%) of the 2F groups, whereas it was observed in 8 (53%) of the 3F group (P = 0.007). The percentage time of acid reflux in the 3F group was significant higher than that in the 2F group (median 0.8 vs 0%, P = 0.008). The percentage time of bile reflux in the 3F group was also significantly higher than that in the 2F group (median 2.600 vs 0%, P = 0.027). Four patients (25%) had reflux esophagitis in the 2F group, and nine patients (60%) had reflux esophagitis in the 3F group (P = 0.048). Conclusion Cervical lymph node dissection increases acid reflux and duodenogastroesophageal reflux, and can lead to the increase of the incidence of reflux esophagitis in patient with intrathoracic esophagogastrostomy. Disclosure All authors have declared no conflicts of interest.

PS01.200: OPEN IVOR LEWIS ESOPHAGECTOMY WITH AN AGGRESSIVE UPPER MEDIASTINAL LYMPH NODE DISSECTION

Abstract Background The Ivor Lewis procedure consists of open subtotal esophagectomy and intrathoracic esophago-gastric anastomosis. Though this procedure is open surgery, it can minimize the risk of anastomotic leakage. This procedure combined with aggressive upper mediastinal lymph node dissection could achieve satisfactory short-term and long-term outcomes. Methods The cases with middle or lower thoracic cancer without metastasis at the cervical area are subjected to this Ivor Lewis procedure. To evade the demerit of thoracotomy, we have employed 1) the 3-field lymphadenectomy in selective patients, 2) the vertical muscle-sparing thoracotomy without transection of muscles and ribs, 3) paravertebral block for postoperative pain. Results A total of 246 patients who underwent subtotal esophagectomy (2011.1–2016.12) were analyzed for short-time postoperative outcomes. In 135 patients of the Ivor-Lewis group, prevalence of anastomotic leakage, anastomotic stricture recurrent nerve palsy and the morbidity, defined as Clavien-Dindo classification 2 or further, was 0%, 0.7% and 21% respectively. On the other hand, the incidence of these increased significantly in 111 patients who underwent cervical anastomosis, 10%, 6.3% and 47% respectively. Though Ivor-Lewis was open surgery, 83% patients in the Ivor Lewis group achieved 30 m walking at the ward within postoperative day 2 and the median length of postoperative hospital stay was 16 days (10–83). The survival according to our therapeutic strategy was analyzed in 352 patients who underwent subtotal esophagectomy for thoracic esophageal cancer (2002.1–2012.12). The overall survival was 82.5/83.5/52.1/50.0/32.1% for stage0/I/II/III/IVa (JES10th). The solitary cervical lymph node recurrence was diagnosed in 5 patients of Ivor-Lewis group, but 4 of the patient could be cured by additional cervical lymph node dissection. Conclusion Discussion: Intrathoracic anastomosis could minimize the risk of anastomotic leakage, and consequently the total complication rate could be reduced. The strategy that the cervical lymphadenectomy is performed only through the thoracic cavity in the selected patients was acceptable because of our survival data. Conclusion: Using our Ivor-Lewis procedure for the patients with thoracic esophageal cancer, even the open operation can minimize the risk of complication. Out therapeutic strategy could achieve satisfactory survival results. Disclosure All authors have declared no conflicts of interest.

RA05.02: PRELIMINARY STUDY ON SCOPE OF CERVICAL LYMPHADENECTOMY OF PATIENTS WITH ESOPHAGUS CARCINOMA UNDER THORACOSCOPE

Abstract Background Objective: To explore scope of cervical lymphadenectomy of patients with esophagus carcinoma under thoracoscope. Methods Select patients underwent routine bilateral cervical lymph node dissection under thoracoscope.The highest location of cervical lymphadenectomy was marked by titanium clip and recorded anatomic landmark around it.After surgery, CT scan of neck was contributed to estimate the location. Results The results: The upper boundary of lymph node dissection on right neck located on the upward side of the crosspoint of right inferior thyroid artery and right recurret laryngeal nerve, which was adjacent to the midpoint position between the upper pole and lower pole of right thyroid, the lower side of musculi omohyoideus and the plane of transverse cervical artery. The upper boundary of left scope of cervical lymphadenectomy was adjacent to the upper position of lower pole of left thyroid, which was about the same level as that of right titanium clip. Postoperative CT scan on neck and chest suggested that bilateral titanium clip was located on midpoint between the upper pole and lower pole of thyroid on the same side. Conclusion Bilateral cervical paraesophageal lymph nodes (101 group)under inferior thyroid artery could be finished by thracoscope for radical resection of esophageal carcinoma.But we still need more evidence to discover the difference between the 2.5 field lymph node dissection and the 3 field lymph node dissection. Disclosure All authors have declared no conflicts of interest.