Cervical Lymph Node Levels Research Articles

Target movement according to cervical lymph node level in head and neck cancer and its clinical significance.

To evaluate set-up error for head and neck cancer (HNC) patients according to each neck lymph node (LN) level. And clinical factors affecting set-up error were analyzed. Reference points (RP1, RP2, RP3, and RP4) representing neck LN levels I to IV were designated. These RP were contoured on simulation computed tomography (CT) and cone-beam CT of 89 HNC patients with the same standard. After image registration was performed, movement of each RP was measured. Univariable logistic regression analyses were performed to analyze clinical factors related to measured movements. The mean value of deviation of all axes was 1.6 mm, 1.3 mm, 1.8 mm, and 1.5 mm for RP1, RP2, RP3, and RP4, respectively. Deviation was over 3 mm in 24 patients. Movement of more than 3 mm was observed only in RP1 and RP3. In RP1, it was related to bite block use. Movement exceeding 3 mm was most frequently observed in RP3. Primary tumor and metastatic LN volume change were clinical factors related to the RP3 movement. Planning target volume margin of 4 mm for neck LN level I, 3 mm for neck LN level II, 5 mm for neck LN level III, and 3 mm for neck LN level IV was required to include all movements of each LN level. In patients using bite block, changes in primary tumor volume, and metastatic LN volume were related to significant movement.

Clinical Acceptability of Automatically Generated Elective Lymph Node Volumes for Head and Neck Cancer Patients

Manual contouring of head and neck lymph node levels is a time-intensive process prone to provider-specific variation. The purpose of this work is to generate a clinical segmentation tool while minimizing the amount of manual effort required by physicians to develop training datasets and review contours. Here we investigate an approach to curate, develop, and clinically validate an auto-contouring model for standard cervical lymph node volumes in the head and neck using a publicly available deep learning architecture. This model updates our previously validated tool to reflect modern practices in lymph node segmentation. With the assistance of a resident physician, five radiation oncologists manually contoured individual lymph node levels on CT scans for three separate patients treated definitively with radiation or chemoradiation for oropharynx cancer, resulting in 15 unique ground truth cases. These cases were then used to train an nnUnet deep-learning model to generate automated contours for 32 additional cases. These 32 cases were reviewed, manually edited, and used to create the final model. Finally, the model was used to generate contours on the original 15 CT scans (testing cohort), and providers compared these automated contours with the ground-truth (manual) contours. Two blinded studies were performed. In a double-blinded fashion, providers were first asked to select which set of contours they would prefer to use in clinical practice as a starting point for actual cases. Second, they scored each contour on a Likert scale (1-5) to indicate clinical acceptability, ranging from completely unusable to usable without modification. Across all lymph node levels (IA, IB, II, III, IV, V, RP), average Dice Similarity Coefficient ranged from 0.77 to 0.89 for AI vs manual contours in the testing cohort. These AI and manual lymph node contours were reviewed by 5 physicians each, resulting in 525 preference scores. Across all lymph nodes, the AI contour was superior to or equally preferred to the manual contours at rates ranging from 75% to 91% in the first blinded study. In the second blinded study, physician preference for the manual vs AI contour was statistically different for only the RP contours (p < 0.01). Thus, there was not a significant difference in clinical acceptability for nodal levels I-V for manual versus AI contours. Across all physician-generated contours, 82% were rated as usable with stylistic to no edits, and across all AI-generated contours, 92% were rated as usable with stylistic to no edits. An approach to generate clinically acceptable automated contours for cervical lymph node levels in the head and neck was demonstrated. Furthermore, for nodal levels I-V, there was no significant difference in clinical acceptability in manual vs AI contours. Because we were able to generate and validate a model for each lymph node level individually, the output is applicable to a complete range of disease in which cervical lymph nodes are treated.

Clinical debate on papillary thyroid microcarcinoma-could genetic testing change the decision of papillarythyroid microcarcinoma (mPTC) treatment: A case report

The objective of this case report is to explore whether genetic testing is appropriate to guide the treatment of papillary thyroid microcarcinoma (PTMC). In this case report, we describe a 27-year-old female who had no significant medical history and no tumor detected in the thyroid gland by ultrasound or computed tomography (CT), but had multiple enlarged lymph nodes at the right cervical lymph node levels II, III, IV, and V. The intraoperative frozen section pathology results showed that seven out of 23 right lymph nodes were metastatic from thyroid papillary carcinoma, but no primary lesion was found in the thyroid gland. After multiple post-operative sampling and micro section, only a 1 mm papillary carcinoma in the left thyroid gland was identified. The genetic testing result showed that the patient was positive for CCDC6-exon 1-RET-exon 12 fusion. The final diagnosis of the patient was left thyroid micro-papillary carcinoma (1 mm) with the right lateral cervical lymph node metastasis. She received iodine-131 treatment with nuclide and lifelong levothyroxine therapy in the 3rd month after surgery. Continuous follow-up showed no elevation of thyroglobulin, no recurrence signs on positron emission tomography-CT re-examination, and good self-reported health status. In conclusion, the identification of CCDC6-RET fusion by genetic testing in the PTMC case aided diagnosis and treatment.

Lymph drainage and cervical fascia anatomy-oriented differential nodal CTV delineation at the supraclavicular region for esophageal cancer and nasopharyngeal cancer

PurposeTo determine the differences in supraclavicular lymph node metastasis between esophageal cancer (EC) and nasopharyngeal cancer (NPC) and explore the feasibility of differential supraclavicular clinical target volume (CTV) contouring between these two diseases based on the involvement of different fascial spaces. Materials and methodsOne hundred patients with supraclavicular nodes positive for EC or NPC were enrolled, and their pre-treatment images were reviewed. The distribution patterns of nodes between the two diseases were compared in the context of node levels defined by the 2017 Japanese Esophageal Society and 2013 International Consensus on Cervical Lymph Node Level Classification. Grouping supraclavicular nodes based on sub-compartments formed by the cervical fascia was discussed, and the feasibility of differential CTV contouring based on the differences in the involvement of these sub-compartments between EC and NPC was explored. ResultsThe 2013 Consensus on cervical node levels and 2017 Japanese Esophageal Society node station could not practically guide supraclavicular CTV contouring. We divided the supraclavicular space into six sub-compartments: the para-esophageal space (PES), carotid sheath space (CSS), sub-thyroid pre-trachea space (STPTS), pre-vascular space (PVS), and vascular lateral space (VLS) I and II. EC mainly spread to the PES, STPTS, CSS, and VLS I, whereas NPC tended to spread to the CSS, VLS I, and VLS II. These combinations of sub-compartments may help constitute the supraclavicular CTVs for EC and NPC. ConclusionsThe fascia anatomy-based sub-compartments sufficiently distinguished metastasis to the supraclavicular space between EC and NPC, thus facilitating differential CTV contouring between these two diseases.

Educative Impact of Automatic Delineation Applied to Head and Neck Cancer Patients on Radiation Oncology Residents.

To evaluate the educational impact on radiation oncology residents in training when introducing an automatic segmentation software in head and neck cancer patients regarding organs at risk (OARs) and prophylactic cervical lymph node level (LNL) volumes. Two cases treated by exclusive intensity-modulated radiotherapy were delineated by an expert radiation oncologist and were considered as reference. Then, these cases were delineated by residents divided into two groups: group 1 (control group), experienced residents delineating manually, group 2 (experimental group), young residents on their first rotation trained with automatic delineation, delineating manually first (M -) and then after using the automatic system (M +). The delineation accuracy was assessed using the Overlap Volume (OV). Regarding the OARs, mean OV was 0.62 (SD = 0.05) for group 1, 0.56 (SD = 0.04) for group 2M - , and 0.61 (SD = 0.03) for group 2M + . Mean OV was higher in group 1 compared to group 2M - (p = 0.01). There was no OV difference between group 1 and group 2M + (p = 0.67). Mean OV was higher in the group 2M + compared to group 2M - (p < 0.003). Regarding LNL, mean OV was 0.53 (SD = 0.06) in group 1, 0.54 (SD = 0.03) in group 2M - , and 0.58 (SD = 0.04) in group 2M + . Mean OV was higher in group 2M + for 11 of the 12 analysed structures compared to group 2M - (p = 0.016). Prior use of the automatic delineation software reduced the average contouring time per case by 34 to 40%. Prior use of atlas-based automatic segmentation reduces the delineation duration, and provides reliable OARs and LNL delineations.

Locoregional Extension Patterns of Nasopharyngeal Carcinoma Detected by FDG PET/MR.

PurposeWe sought to define the locoregional extension patterns of nasopharyngeal carcinomas (NPCs) by positron emission tomography (PET)/magnetic resonance imaging (MRI) and to improve clinical target volume (CTV) delineation.MethodsBetween May 2017 and March 2021, 331 consecutive patients with nonmetastatic NPCs who underwent pretreatment, simultaneous whole-body PET/MRI for staging were included in this study.ResultsThe high-risk regions included the base of the sphenoid bone, the prestyloid compartment, prevertebral muscle, foramen lacerum, medial pterygoid plate, sphenoidal sinus, clivus, petrous apex, and foramen ovale. When the high-risk regions were invaded, the incidence rates of tumor invasion into the medium-risk regions increased. In contrast, when the high-risk regions were not involved, the incidence rates of tumor invasion into the medium-risk regions were mostly less than 10%, excluding the post-styloid compartment and oropharynx. According to the updated consensus guidelines of the neck node levels for head and neck tumors from 2013, level IIa (77.3%, 256/331), level IIb (75.8%, 251/331), and level VIIa (71.3%, 236/331) were the most frequently involved levels, followed by levels III (42.6%), Va (13.9%), IVa (8.8%), IVb (3.6%), Ib (3.6%), Vb (2.4%), VIIb (2.4%), VIII (1.8%), Vc (0.9%), and Xa (0.3%). Skip lymph node metastasis occurred in only 1.9% of patients.ConclusionsFor NPCs, primary disease and regional lymph node spread follow an orderly pattern, and a skip pattern of lymph node metastasis was unusual. Involved level radiotherapy might be feasible for cervical lymph node levels below the caudal border of cricoid cartilage and level VIIb.

Cervical lymph node metastasis in squamous cell carcinoma of the buccal mucosa: a retrospective study on pattern of involvement and clinical analysis.

Background The study was performed with an aim to map the pattern of metastasis of squamous cell carcinomas of buccal mucosa to various cervical lymph node levels and analyze its correlation with primary tumor size and histo-pathological grading. Material and Methods 254 patients with squamous cell carcinoma of the buccal mucosa treated with surgery first approach were analyzed retrospectively. The tumor size was noted from pre-operative CT Scans and were divided into early and advanced tumors. The resected specimen was studied to note the histo-pathological grading of the squamous cell carcinoma and the metastatic deposits at various lymph node levels. Results Out of 254 patients (149 females, 105 males), 145 patients showed histo-pathologically proven metastatic deposits in one or more lymph nodes out of which there were 56 patients showing occult metastasis. 78/145 patients showed metastatic involvement of level IB and/or IA lymph nodes, 31 showed involvement of level II and/or I lymph nodes, 27 showed involvement of level III with or without involvement of level I and II and 9 showed metastasis to level IV and V lymph nodes with or without level I, II or III lymph nodes. Cervical lymph node metastasis had statistically significant association with tumor size with advanced tumors showing worse pattern of metastatic spread beyond level I and II lymph nodes. As the degree of differentiation of squamous cell carcinoma reduced, they were more prone for cervical metastasis with moderately and poorly differentiated squamous cell carcinoma showing higher involvement of level III, IV and V lymph nodes. Conclusions The majority of buccal mucosa cases showed metastasis to level I, II and III lymph nodes out of which level IB and/or IA was most frequently involved. Metastasis to level IV and V lymph nodes was rare and was seen especially in patients with advanced primary tumor and poor histo-pathologic differentiation. Key words:Oral squamous cell carcinoma (OSCC), cervical lymph node metastasis, histologic differentiation, locally advanced disease.

Educative Impact Of Automatic Head And Neck Cancer Patients Delineation On Radiation Oncology Residents

To evaluate the educational impact on radiation oncology residents in training when introducing an automatic segmentation software. Were assessed accuracy, consistency and speed of delineation regarding organs at risk (OARs) and prophylactic cervical lymph node levels (LNL) volumes in head and neck cancer patients. Two cases of head and neck cancers patients treated by exclusive intensity-modulated radiotherapy were delineated by an expert radiation oncologist and were considered as reference. Then, these two cases were delineated by residents divided into three groups: Group 1 (control group) composed of more experienced residents had never been exposed to automatic delineation system delineated manually, Group 2 (experimental group) composed of young residents on their first rotation trained with automatic delineation system during their learning period delineating manually prior (M-) and after using the automatic system (M+). The delineation accuracy was assessed using the Overlap Volume (OV) index for the OARs and LNL. The time needed to complete the delineation of the two cases was measured. Regarding the OARs, mean OV was 0.62 (SD = 0.05) for group 1, 0.56 (SD = 0.04) for group 2 M-, and 0.61 (SD = 0.03) for group 2 M+. Mean OV was higher in group 1 compared to group 2 M- (p = 0.01). There were no OV difference between group 1 and group 2 M+ (p = 0.67). The mean OV was higher in the group 2 M+ compared to the group 2 M- after paired analysis (p<0.003). Regarding LNL, mean OV was 0.53 (SD = 0.06) in group 1, 0.54 (SD = 0.03) in group 2 M-, and 0.58 (SD = 0.04) in group 2 M+. There was no significant difference between the groups despite a favorable trend in favor of the group 2 M+ (p = 0.079). Mean OV was higher in group 2 M+ for 11 of the 12 structures analyzed compared to group 2 M- (p = 0.016). Prior use of the automatic delineation software reduced the average contouring time per case by 34 to 40%. In this study of head and neck cancer delineation, prior use of atlas-based automatic segmentation by residents reduced the delineation duration, and led to reliable OARs and LNL delineations.

Incidental thyroid papillary microcarcinoma: survival and follow-up.

The aim was to study the survival of incidental thyroid papillary microcarcinoma patients treated with surgery for benign thyroid disease to validate absence of oncological follow-up and reduce unnecessary health expenses. Retrospective cohort study. We analyzed patient's files and interviewed 252 patients by telephone whose cases were submitted to the multidisciplinary meeting of thyroid pathology in Strasbourg, France, for incidental thyroid papillary microcarcinoma without clinical lymph node involvement, between January 1996 and December 2012. Thirteen patients (5.8%) died while the data were being collected; however, none of the deaths were due to the thyroid pathology, and no patients showed signs of relapse of the thyroidectomy or cervical lymph node level. Our retrospective study shows that patients with incidental localized thyroid papillary microcarcinoma who underwent surgery without radioactive iodine treatment have an identical survival compared to the general population at the same age to validate absence of oncological follow-up and reduce unnecessary health expenses. 3 Laryngoscope, 129:1722-1726, 2019.

Evaluation of Diagnostic Accuracy of Cervical Palpation, Contrast Enhanced Multi-detector Computed Tomography, and Intraoperative Macroscopic Nodal Assessment of Cervical Lymph Node Metastasis of Head and Neck Squamous Cell Carcinoma in Filipinos: A Preli

Objectives. 1) To determine if there is an association between physical examination by cervical palpation, preoperative contrast-enhanced multi-detector computed tomography (MDCT), and intraoperative lymph node assessment, with final histopathology in the evaluation of cervical lymph node metastasis in Filipino patients with squamous cell carcinoma of the head and neck. 2) To determine the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and likelihood ratios of cervical palpation, contrast enhanced MDCT, and intra-operative lymph node assessment compared with final histopathology in the evaluation of cervical lymph node metastasis in Filipino patients with squamous cell carcinoma of the head and neck.&#x0D; Methods. Study Design. Retrospective; Cross-sectional. Setting. Tertiary Government Hospital Charity Section, Department of Otorhinolaryngology, Department of Radiology, Department of Pathology. Participants, Patients or Population. Retrospective chart review of all biopsy proven head and neck squamous cell carcinoma patients admitted at the charity ward of a Otorhinolaryngology Department from 2008-2010 who had documented admission physical examination, a preoperative contrast enhanced multi-detector computed tomography (MDCT) scan of the neck done in the same institution within 20 days or less from date of surgery, and underwent neck dissection with appropriate cervical lymph node level specimen labeling with subsequent post-operative histopathologic evaluation of submitted specimens for neck node metastasis by the Pathology Department of the same institution. After set of exclusion criteria was applied, the analyzed sample included 82 lymph node level samples from 9 patients with head and neck Squamous Cell Carcinoma (SCCA).&#x0D; Results. Pre-operative contrast enhanced MDCT, and intraoperative nodal assessment, were both significantly correlated with the final histopathologic evaluation of neck node metastasis as evaluated with Fisher’s Exact test (p = 0.00). Cervical palpation however was not able to show a significant association (p=0.099).Cervical palpation had a sensitivity of 25.00% (8.3352.59%), specificity of 90.91% (80.61-96.25%), NPV of 83.33 (72.30-90.73%), PPV of 40.00 (13.69-72.63%), accuracy of 78.05%, and a likelihood ratio of 3.33. Preoperative contrast enhanced MDCT had a sensitivity of 43.75% (20.75-69.45%), specificity of 93.94% (84.4498.04%), NPV of 87.32 (76.80-93.69%), , PPV of 63.64 (31.61-87.63%), accuracy of 84.15%, and a likelihood ratio of 12.06. Intraoperative surgical evaluation had a sensitivity of 68.75% (41.48-87.87%), specificity of 93.94% (84.44-98.04%), NPV of 92.54 (82.74-97.22%), PPV of 73.33 (44.83-91.09%), accuracy of 89.02%, and a likelihood ratio of 34.10. Further analysis with McNemar’s Test comparing MDCT and Intraoperative assessment showed no significant difference (p = 0.387).&#x0D; Discussion and Conclusions. In the evaluation of cervical lymph node metastasis for head and neck squamous cell carcinoma in the local setting, the extent of neck dissection, clinical staging and prognosis, as well as adjuvant therapy can be guided by pre-operative contrast enhanced MDCT and intraoperative nodal assessment. Contrast-enhanced MDCT can aid treatment planning in preoperative or non-operative cases; but intraoperative evaluation can be used to guide final extent of surgery. Evaluation solely by physical examination by cervical palpation unfortunately in this study was not able to show a significant association with final histopathology.

A novel N staging system for NPC based on IMRT and RTOG guidelines for lymph node levels: Results of a prospective multicentric clinical study.

The present study aimed to investigate the cervical lymph node metastasis of nasopharyngeal carcinoma (NPC) and to establish a novel N staging standard for NPC, based on intensity modulated radiation therapy (IMRT) via a prospective multicenter clinical trial. Between January 2006 and December 2009, a total of 492 patients with NPC without distant metastasis were included in the present study. All patients were treated with IMRT. According to Radiation Therapy Oncology Group division standards, the present study proposed a novel N staging system following the review of magnetic resonance images in comparison with the 7th edition of Union for International Cancer Control/American Joint Committee on Cancer (UICC/AJCC) staging system. Retropharyngeal lymph nodes, cervical lymph node level and cervical lymph node laterality were independent prognostic factors used in multivariate analyses. According to the results of the risk variety, the present study suggested that the novel N staging system included: N0 (no lymph node metastasis), N1 [retropharyngeal or/and unilateral upper cervical (I, II, III, Va, VIIb, VIII, IX and X regions) lymph node metastasis], N2 [bilateral upper cervical (I, II, III, Va, VIIb, VIII, IX and X regions) lymph node metastasis] and N3 (lymph node metastasis in IVa and Vb regions and their lower regions). The novel N staging system proposed in the present study performs better in risk difference and distribution balance. Furthermore, the differences of 5-year curves of distant metastasis-free survival and overall survival had greater statistically significant differences compared with the 7th edition of the UICC/AJCC staging system. The present study suggested a novel N staging system for cervical lymph node metastasis of NPC, which may predict the prognosis of patients with NPC in a more objective and accurate way.

Location and Causation of Residual Lymph Node Metastasis After Surgical Treatment of Regionally Advanced Differentiated Thyroid Cancer.

After initial surgical treatment of differentiated thyroid cancer (DTC) residual lymph node metastases are often found at the time of radioactive iodine (131I) therapy. Recurrence of DTC is due to persistent disease not removed at initial surgery which also did not respond to 131I treatment. This study aimed at determining locations of, and reasons for, residual nodal metastases detected by 131I scans with single-photon emission computed tomography (SPECT/CT) obtained prior to radioiodine therapy following surgical treatment of DTC. This is a retrospective study of 352 patients with intermediate and high-risk DTC treated with 131I therapy at the University of Michigan from 2007 to 2014. All patients underwent total thyroidectomy with or without lymph node dissection followed by radioiodine therapy. Pre-ablation diagnostic 131I scans with SPECT/CT were used postoperatively to localize nodal metastases, which were then compared with the cervical lymph node basins dissected at the time of surgery to determine the reason for residual nodal metastases: incomplete nodal dissection versus preoperative unrecognized nodal metastases. Of the 352 patients in the study, 146 (41.5%) had residual nodal metastases detected on 131I scans with SPECT/CT following initial surgery but prior to 131I therapy. Among the 146 patients with residual disease, there were a total of 218 distinct nodal metastases. Relative to the primary tumor, 71.6% (n = 156) of metastases were ipsilateral, 22.0% (n = 48) were contralateral, and 6.4% (n = 14) were non-sided in the central neck (level VI/VII). Cervical lymph node levels VI, III, and II had the greatest frequencies of residual metastases (33.9%, 22.9%, 18.8%, respectively). Residual metastases occurred because of incomplete nodal dissection (49.3%), lack of preoperative identification (37.7%), or a combination of both (13%). Residual nodal metastasis following initial surgical treatment for regionally advanced differentiated thyroid cancer is rather common on highly sensitive 131I scans with SPECT/CT and is due to both unrecognized nodal involvement preoperatively and incomplete removal of metastatic lymph nodes during compartment-orientated nodal dissection. The surgical management of high-risk DTC should include preoperative imaging to evaluate for nodal metastases in the central and lateral neck and compartment-orientated nodal dissection of involved compartments. Attention should be given to complete dissection in levels VI, III, and II, particularly when dissecting compartments ipsilateral to the primary tumor.

Incidence and Distribution of Nodal Metastases in Sinonasal Malignancy

Cervical lymph node drainage pathways of sinonasal malignancies (SNM) have not yet been well-established in the literature. We present the largest population-based cohort of SNM to investigate the frequency and pattern of cervical node involvement. The Surveillance, Epidemiology, and End Results registry was queried from 2004 to 2014, identifying patients with sinonasal squamous cell carcinoma (SCC), adenocarcinoma, adenoid cystic carcinoma (ACC), sinonasal undifferentiated carcinoma (SNUC), mucosal melanoma, and esthesioneuroblastoma. Cases were assessed by frequency of cervical lymph node level, distant metastasis, and primary subsite. A total of 4,171 SNM cases were identified, 527 of which presented with cervical nodal disease (12.6%). Level II and level I diseases were most commonly identified (36.1 and 29.5%). This finding was consistent despite histology and primary subsite involved. Regional disease was most commonly seen in SNUC (22.4%) and SCC (15.2%), and least commonly in ACC (4.1%). Malignancies of the maxillary sinus demonstrated the highest rate of nodal disease (19.6%), followed by the sphenoid sinus (15.9%). No cases of nodal disease were identified amongst frontal sinus malignancies. The parotid and level I/level II nodes were least involved in cases with distant metastasis (6% and 10%). Conversely, suboccipital/retroauricular and level VII (mediastinal) nodes most frequently presented with distant metastasis (67% and 33%). Although cervical node involvement in SNM is infrequent compared to other head and neck sites, levels II and I were overwhelmingly involved when present. Knowledge of these sinonasal drainage patterns will ultimately help guide the treatment of the neck in select cases.

Patterns and Prognostic Significance of Cervical Lymph Node Metastasis and the Efficacy of Cervical Node Dissection in Esophageal Cancer.

BackgroundThe clinical value of 3-field lymph node dissection (3FLND) in esophageal squamous cell carcinoma (ESCC) remains controversial. This study aimed to identify the patterns and prognostic significance of cervical lymph node metastasis (CLNM) in ESCC.MethodsA retrospective review of 77 patients with ESCC who underwent esophagectomy and 3FLND between 2002 and 2016 was conducted. For each cervical node level, the efficacy index (EI), overall survival, recurrence rate, and complication rate were compared.ResultsCLNM was identified in 34 patients (44.2%) who underwent 3FLND. Patients with CLNM had a significantly lower overall survival rate (22.7% vs. 58.2%) and a higher recurrence rate (45.9% vs. 16.3%) than patients without CLNM. CLNM was an independent predictor of recurrence in ESCC patients. Moreover, in patients with pathologic N3 tumors, the odds ratio of CLNM was 10.8 (95% confidence interval, 2.0 to 57.5; p= 0.005). Level IV dissection had the highest EI, and level IV metastasis was significantly correlated with overall survival (p=0.012) and recurrence (p=0.001).ConclusionCLNM was a significant prognostic factor for ESCC patients and was more common among patients with advanced nodal stages. Level IV exhibited the highest risk of metastasis, and dissection at level IV may be crucial when performing 3FLND, especially in advanced nodal stage disease.

Lymph node metastasis and prognostic value of NPC based on the UICC lymph node staging for cervical lymph node levels.

e18136 Background: Nasopharyngeal carcinoma (NPC) is the most common cancer originating in the nasopharynx. The neck lymph node (LN) metastasis is very common in NPC; it plays an important role in tumor staging which is guide the choice of treatment. Methods: 324 patients were pathologically diagnosed as non-metastatic NPC from Jan. 2005 to Dec.2010 were recruited retrospectively to analysis. All of them treated with standard IMRT. The clinical data including CT/MRI images, followed up were collected, while the OS, DFS, DMFS and RRFS were calculated. Survival analysis was performed by Kaplan-Meier method, and COX regression model was used for multivariate analysis. Results: The median follow-up time was 66 months (6-134 months). The 5-year LRFS,NRFS,DMFS,DFS and OS was 93.5%, 97.4%, 73.4%, 69.1% and 79.2%,respectively. The most common metastatic LN levels were II level 83.9%, retropharyngeal LN level 69.1%, followed by III level 16.9%, Va level 8% ,IV level 5.2% and Vb level 4%. All the retropharyngeal LNs were involved in the lateral group while no medial ones was found. In cervical LN, necrosis was involved in 40.0% patients with positive nodes and extracapsular invasion was noted in 58.6%. Bilateral positive LN was involved in 66.5%, and there was 11.4% in the lower cervical region. Univariate analysis showed that LN diameter greater than 3 cm, extracapsular invasion, LN necrosis and LN laterality are independent prognostic factors for DMFS and DFS (P &lt; 0.05). T staging and N staging were independent prognostic factors for the DMFS (P = 0.024, 0.012, respectively). Lower cervical involvement had no significant effect on DMFS and DFS. Multivariate analysis showed that T staging, extracapsular invasion and laterality were independent prognostic factors (P &lt; 0.05) for DFS, and extracapsular invasion was an independent prognostic factor (P = 0.048) for DMFS. Conclusions: Our results suggested II level and retropharyngeal LN have the highest metastasis rate. All retropharyngeal LN were involved in the lateral group but not medial one. Laterality, maximum diameter and necrosis are independent prognostic factors for DFS and DMFS. The involvement of the lower cervical region had no significant effect on DFS and DMFS.

Study on N staging system for nasopharyngeal carcinoma based on intensity-modulated radiotherapy and RTOG guidelines for cervical lymph node levels

Objective To propose a new N staging system for nasopharyngeal carcinoma based on intensity-modulated radiotherapy (IMRT) and Radiation Therapy Oncology Group (RTOG) guidelines for cervical lymph node levels. Methods A retrospective analysis was performed in 324 patients with newly diagnosed nasopharyngeal carcinoma who had no distant metastasis confirmed by pathology and received IMRT in the Department of Radiation Oncology in The First Affiliated Hospital of Guangxi Medical University from January 2010 to December 2011.They were restaged according to the 7th edition of UICC/AJCC staging system for nasopharyngeal carcinoma. The survival rates were estimated using the Kaplan-Meier method and the log-rank test was used for univariate prognostic analysis. The Cox proportional hazards model was used for multivariate prognostic analysis. Results Of 324 patients, 269(83.0%) had lymph node metastasis. The median follow-up was 58 months (6-77 months). The 5-year overall survival, disease-free survival, relapse-free survival, and distant metastasis-free survival rates were 84.8%, 77.1%, 92.7%, and 80.5%, respectively. Univariate and multivariate analyses of patients with positive cervical lymph nodes revealed that retropharyngeal lymph node status, cervical lymph node level, and laterality were evaluated as independent prognostic factors for nasopharyngeal carcinoma. According to the hazard ratio calculated, the N staging system was revised as follows: N0: no regional lymph node metastasis; N1: VⅡ a or/and unilateral levels (I, Ⅱ, Ⅲ, Va) involvement; N2: bilateral levels (I, Ⅱ, Ⅲ, Va) involvement; N3: levels IVa, Vb, and IVb+ Vc involvement. Conclusions The proposed N staging system is based on IMRT and RTOG guidelines for lymph node levels and more practical, and can provide highly objective prediction of outcome and guide treatment in nasopharyngeal carcinoma. Key words: Nasopharyngeal neoplasms/intentsity-modulated radiotherapy; N staging system; Node level

Ultrasonographic findings of Kikuchi cervical lymphadenopathy in children.

PurposeThe purpose of this study was to analyze the ultrasonographic (USG) findings of Kikuchi cervical lymphadenopathy in pediatric patients.MethodsBetween April 2007 and September 2016, 84 children (42 male and 42 female; mean±standard deviation age, 12.9±3.2 years; range, 5 to 18 years) confirmed with Kikuchi disease were enrolled. Clinical findings and USG findings of Kikuchi cervical lymphadenopathy were retrospectively reviewed. Localized symptoms, systemic symptoms, and laboratory findings including the white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were analyzed. An analysis of the USG findings included evaluation of the location, size, and presence of intranodal abscess; intranodal calcification; perinodal fat swelling; localized fluid collection; and loss of nodal echogenic hilum.ResultsAmong the patients, 49 (58%) showed localized tenderness at the cervical lymphadenopathy. Fever was present in 55 (66%), while 27 (32%) had prolonged fever. Of 74 with lab results, 54 (73%) had leukopenia but none had leukocytosis. Among the same 74, there was a high ESR (>50 mm/hr) in 10 (14%) and a high CRP level (>5 mg/dL) in seven (9%). The USG findings of most of the patients (n=72, 86%) showed unilateral neck involvement, especially in the left side neck (45 of 72, 63%). The most common site of Kikuchi lymphadenopathy involvement was the area at cervical lymph node level V, at the posterior triangle (n=77, 92%). Conglomerated nodal distribution (n=57, 68%), preserved central nodal echogenic hilum (n=84, 98%), and perinodal fat swelling (n=55, 65%) were common USG findings in the children with Kikuchi. In addition, multiple cervical lymph nodes showed a relatively even size distribution (n=73, 87%).ConclusionThe common USG findings of Kikuchi disease in the pediatric population of our study were multiple conglomerated unilateral cervical lymphadenopathy showing perinodal fat swelling and even size distribution.

"IIb or not IIb" - The necessity of dissection in patients with oral squamous cell carcinoma.

The necessary extent of cervical dissection in oral squamous cell carcinoma (OSCC) is still under discussion. Due to its anatomical properties Robins level IIb has a special role in neck dissection. This study focuses on the lymph node metastatic behaviour of OSCC in level IIb and evaluates its worth of dissection. 183 consecutive patients with OSCC were retrospectively screened for age, gender, TNM classification, cancer stage (after UICC), tumour localization, tumour infiltrations depth, and affected cervical lymph node levels. Associations between lymph node metastases and the above-mentioned characteristics were evaluated using Pearson's chi square test and Spearman's rho correlation analyses. Metastases in level IIb were seen in only 3.3% of all patients, and none of these metastases were an exclusive metastasis. Lymph node metastases most likely occurred in levels I and IIa at ipsilateral sites, and metastases were significantly related to tumour size (p<0.01) and the infiltration of lymph vessels (p<0.001). The locations of primary cancer sites in metastatic disease were the soft palate, alveolar crest of the lower jaw and buccal mucosa. Lymph node metastases of OSCC in level IIb remain rare, especially as exclusive metastases and in clinically N-negative necks. The findings of our study support the hypothesis of sparing neck dissection in level IIb in cases of clinically negative necks.

Clinical Characteristics of Severe Histiocytic Necrotizing Lymphadenitis (Kikuchi-Fujimoto Disease) in Children

To analyze the clinical characteristics of children with Kikuchi-Fujimoto disease focusing on cases with prolonged fever. This was a retrospective study of children diagnosed with Kikuchi-Fujimoto disease from March 2003 to February 2015 in South Korea. Electronic medical records were searched for clinical and laboratory manifestations. Among 86 histopathologically confirmed cases, the mean age was 13.2 (SD ± 3.1) years, and male to female ratio was 1:1.32. Cervical lymph node enlargement, found in 85 of the patients (99%), was predominantly unilateral in 64 (75%), and involved the cervical lymph node level V in 67 (81%). Fever was present in 76% of the cases, with a median duration of 9 days (IQR 0.25-17.0). Multivariate analysis revealed that a high fever peak ≥ 39.0°C (P = .010) and presentation with ≥ 2 systemic symptoms other than fever (P = .027) were factors that were significantly associated with longer fever duration. As the size of the largest lymph node's short diameter increased, the fever duration increased (P = .015). Leukopenia (P = .022) also had a significant association with a longer fever duration. Patients with sonographic findings of conglomerated enlarged lymph nodes had a longer median duration of fever compared with those with separate enlarged lymph nodes (11 vs 4.5 days, P = .019). Patients with high fever, more systemic symptoms, leukopenia, and larger lymph nodes with a conglomerated distribution may benefit from early recognition and selective consideration of corticosteroid therapy.

Is 18F-fluorodeoxyglucose positron emission tomography/computed tomography helpful in the decision-making process for neck dissection in patients with T1-T2 lingual cancer?

Conclusion: The usefulness of addition of positron emission tomography/computed tomography (PET/CT) in decisions as to whether to perform neck dissection in patients with T1-T2 lingual squamous cell carcinoma (SCC) might be limited, but adding the condition of lymph nodes with a maximum standardized uptake value (SUVmax) >4.5 to existing criteria would be helpful. Objectives: The purpose of this study was to investigate the usefulness of PET/CT for performing neck dissection in patients with T1-T2 lingual SCC. Methods: This retrospective review surveyed 19 patients with T1-T2 lingual SCC who underwent neck dissection after meeting one or more of the following criteria: (1) clinically positive nodes; (2) >4 mm thickness; (3) ≥ 3 cm longest diameter of the primary tumor. Focal 18F-fluorodeoxyglucose (FDG) uptake was considered to indicate PET-positive nodes (PET + Ns). The relation between pathologically positive nodes (p + Ns) and PET + Ns was estimated. Results: There were 14 PET + Ns at 12 of 66 levels (18%) in 8 of the 19 (42%) patients. There were also 6 p + Ns (1%) among 412 nodes at 5 cervical lymph node levels (8%) in 5 patients (26%). The sensitivity and specificity for PET/CT were 80% and 64%, respectively. The SUVmax was measured, and receiver operating characteristic (ROC) analysis was undertaken to obtain better accuracy. The sensitivity and specificity were 60% and 100% when the SUVmax cut-off value was set at 4.5.