Clinical Lymphadenopathy Research Articles

NODESAFE Nomogram: A Novel Score System to Predict Lymph Node Involvement at the Time of Nephrectomy or Nodal Recurrence in Nonmetastatic Renal Cell Carcinoma

ObjectiveWe sought to develop a preoperative nomogram called NODESAFE (NODE SAFEty) to predict nodal involvement (NI) at time of surgery or subsequent follow up in localized renal cell carcinoma (RCC), as the role of lymphadenectomy in localized RCC remains controversial. MethodsWe conducted a multicenter retrospective analysis of RCC patients who underwent primary surgical resection. Patients with clinical metastasis at presentation were excluded. NI was defined as presence of histological RCC with lymphadenectomy at time of surgery, or subsequent development histologically proven NI. The dataset was divided into training (70%) and testing subsets to facilitate model evaluation which was constructed through a stepwise multivariable logistic regression (MLR) model. Accuracy was tested with receiver operator characteristic estimated area under the curve (AUC). ResultsTotal 3308 patients (2221 [67.1%] male) met inclusion criteria. During follow-up 25 patients (0.76 %) experienced nodal recurrence, and 22/25 were preoperatively classified as cN0. In our cohort, 112 (3.4%) patients had clinical lymphadenopathy preoperatively (cN1), and 34/112 were pN1. The following covariates were found to be statically significant on a MLR model: hypertension (Odds ratio [OR] 3.35, < 0.001), Charlson Comorbidity Index ≥ 5 (OR 1.93 P = .025), tumor size ≥ 6 cm (OR 2.63, P = .001), tumor necrosis at CT scan (OR 1.83, P = .036), cN1 (OR 5.59, P < .001) and CRP ≥ 8.5 mg/L (1.96, P = .018). Testing the prediction performance of the model in the validation set AUC of the model was 0.89. NODESAFE demonstrated a sensitivity of 83.9%, specificity of 86.1% and 99.1% negative predictive values using a 4% threshold probability. ConclusionCombining clinical features, serum biomarkers and radiographic findings, we developed a model capable of predicting NI with high degree of accuracy. NODESAFE may refine clinical decision making with respect to the performance of lymphadenectomy at the time of surgery, postsurgical surveillance, and spur consideration for adjuvant therapy.

Impact of extra-nodal extension and AJCC lymph node staging in predicting recurrence following lymphadenectomy in patients with melanoma

BackgroundRegional lymphadenectomy (RL) has traditionally been recommended in patients with melanoma found to have clinical lymphadenopathy or a positive sentinel lymph node biopsy (SLNB). Regional control of disease is still a relevant issue for patients, even after undergoing lymphadenectomy. The goal of this study was to identify the clinicopathologic characteristics that predict locoregional recurrence in patients who have undergone either therapeutic lymph node dissection (TLND) or completion lymph node dissection (CLND) following SLNB. MethodsRetrospective review of population-based cohort of patients with melanoma lymph node metastasis from the years 2005–2015. Multivariate, proportional hazards regression analysis was performed to determine factors predicting nodal recurrence. Results586 patients underwent a RL, with a median follow up of 35 months. Overall, in-basin recurrence rates in the axilla, groin, and head/neck were 7.7 ​%, 8.7 ​% and 9.2 ​%, respectively. Higher unadjusted recurrence rates occurred following CLND than TLND of the groin (12.8 ​% vs 4.5 ​%) and neck (10.0 ​% vs 4.7 ​%) but not the axilla (7.5 ​% vs 8.0 ​%). Upon multivariate analysis, ENE (HR 2.77; p=<0.0001) and the AJCC lymph node stage (N3 vs N1) (HR 2.51; p ​= ​0.025) were predictive of regional recurrence. ConclusionThe AJCC nodal stage and the presence of extranodal extension were the only variables impacting regional recurrence following regional lymphadenectomy for melanoma. When considering regional disease control, they should be factored into treatment decisions, and surveillance strategies.

COVID-19 vaccine-associated lymphadenopathy: a review.

Following the introduction of RNA-based vaccines, COVID-19 vaccine-associated clinical lymphadenopathy (C19-LAP) has been reported as a side effect. Moreover, subclinical lymphadenopathy detected on imaging (SLDI) has also been observed, mainly as incidental findings while performing screening tests on oncological patients. In these cases, surgical lymphadenectomy, fine-needle aspiration cytology (FNAC) and core needle biopsy (CNB) have been used as a valuable diagnostic tool for SLDI and C19-LAP. In this review the clinical, histologic and cytologic features of SLDI and C19-LAP have been investigated. A search for studies that reported on C19-LAP and SLDI histopathology and cytopathology was performed on PubMed and Google Scholar, on 11 January 2023. Thirty-one reports on SLDI and C19-LAP were retrieved and included in a pooled analysis. In total, we included 54 patients with a median age of 47 years. In our research, surgical excision, CNB and/or FNAC of C19-LAP or SLDI enlarged lymph nodes have been performed in 54 cases. Of all cases, only two metastases were diagnosed and one case was diagnosed as reactive hyperplasia with atypical follicles. The remaining cases were reactive lymphadenopathy (28 cases), follicular hyperplasia (13 cases), Kikuchi-Fujimoto disease (6 cases), granulomatous lymphadenitis (2 cases), eosinophilic lymph node abscesses (1 case), Langherans cell histiocytosis (1 case), Rosai-Dorfman disease (1 case). SLDI and C19-LAP have represented a diagnostic dilemma, especially in oncologic patients. The role of different diagnostic tools for SLDI and C19-LAP has been discussed.

Prognostic value and predictors of the alteration of the diffusing capacity of the lungs for carbon monoxide in systemic lupus erythematosus.

SLE is a systemic autoimmune disease characterized by heterogeneous manifestations and severity, with frequent lung involvement. Among pulmonary function tests, the measure of the diffusing capacity of the lungs for carbon monoxide (DLCO) is a noninvasive and sensitive tool assessing pulmonary microcirculation. Asymptomatic and isolated DLCO alteration has frequently been reported in SLE, but its clinical relevance has not been established. This retrospective study focused on 232 SLE patients fulfilling the 2019 EULAR/ACR classification criteria for SLE. Data were collected from the patient's medical record, including demographic, clinical and immunological characteristics, while DLCO was measured when performing pulmonary function tests as part of routine patient follow-up. At the end of follow-up, DLCO alteration (<70% of predicted value) was measured at least once in 154 patients (66.4%), and was associated with a history of smoking as well as interstitial lung disease, but was also associated with renal and neurological involvement. History of smoking, detection of anti-nucleosome autoantibodies and clinical lymphadenopathy at diagnosis were independent predictors of DLCO alteration, while early cutaneous involvement with photosensitivity was a protective factor. DLCO alteration, at baseline or any time during follow-up, was predictive of admission in intensive care unit and/or of all-cause death, both mainly due to severe disease flares and premature cardiovascular complications. This study suggests a link between DLCO alteration and disease damage, potentially related to SLE vasculopathy, and a prognostic value of DLCO on death or intensive care unit admission in SLE.

COVID-19 post-vaccination lymphadenopathy: A review of the use of fine needle aspiration cytology.

COVID-19 vaccine-associated clinical lymphadenopathy (C19-LAP) and subclinical lymphadenopathy (SLDI), which are mainly detected by 18F-FDG PET-CT, have been observed after the introduction of RNA-based vaccines during the pandemic. Lymph node (LN) fine needle aspiration cytology (FNAC) has been used to diagnose single cases or small series of SLDI and C19-LAP. In this review, clinical and LN-FNAC features of SLDI and C19-LAP are reported and compared to non-Covid (NC)-LAP. A search for studies on C19-LAP and SLDI histopathology and cytopathology was performed on PubMed and Google Scholar, on 11 January 2023. Reports on LN-FNAC of C19-LAP were retrieved. A total of 14 reports, plus one unpublished case of C19-LAP observed in our institution, diagnosed by LN-FNAC were included in a pooled analysis and compared to the corresponding histopathological reports. In total, 26 cases were included in this review, with a mean age of 50.5 years. Twenty-one lymphadenopathies assessed by LN-FNAC were diagnosed as benign, and three cases as atypical lymphoid hyperplasia; the latter were subsequently confirmed as benign (one by repetition of LN-FNAC, two by histological control). One case of mediastinal lymphadenopathy in a patient suffering from melanoma was reported as reactive granulomatous inflammation, while one unsuspected case was diagnosed as metastasis from melanoma. In all cases, the cytological diagnoses were confirmed by follow-up or excisional biopsy. The high diagnostic value of LN-FNAC in excluding malignant processes was extremely useful in this context and may be particularly valuable when CNB or histological excisions are difficult to perform, as was the case during Covid lockdowns.

Pathological Findings in COVID-19 and Non-COVID-19 Vaccine-Associated Lymphadenopathy: A Systematic Review.

COVID-19 vaccine-associated lymphadenopathy (C19-VAL) is increasingly encountered with the widespread use of the vaccine in controlling the outbreak. We aim to characterize the pathological findings of COVID-19 and non-COVID-19 vaccine-associated lymphadenopathy (NC19-VAL). A search for studies that reported pathological findings in vaccine-associated lymphadenopathy on PubMed and Google Scholar was performed on 11 December 2021. C19-VAL studies were pooled for analysis. These studies were split into clinical lymphadenopathy (CL) and subclinical lymphadenopathy detected on imaging (SLDI) for subgroup analysis. A total of 25 studies were related to COVID-19 vaccines, and 21 studies were included in the pooled analysis. The pooled analysis included 37 patients with a mean age of 47.8 ± 19.1 years old, and 62.2% were females. The mean duration from last vaccination to development of CL/SLDI was 14.5 ± 11.0 days. Most were diagnosed as reactive or negative for malignancy (28/37, 75.5%), followed by Kikuchi-Fujimoto disease (KFD) (3/37, 8.1%), florid lymphoid hyperplasia (2/37, 5.4%), and granulomatous inflammation (2/37, 5.4%). Metastases were reported in two patients with a history of malignancy (2/37, 5.4%). Cases with florid lymphoid hyperplasia and KFD were younger than those with reactive changes. A total of 14 studies were related to non-COVID-19 vaccines. Caseating granulomatous inflammation was reported in BCG vaccine-associated lymphadenopathy, while other vaccines were associated with reactive lymphoid hyperplasia, florid post-vaccinal reactions, and KFD. Although most C19-VAL cases were reported as reactive or negative for malignancy, other diagnoses included florid lymphoid hyperplasia, KFD, and granulomatous inflammation. Metastases were reported in lymphadenopathy of patients with a history of malignancy, who had been incidentally vaccinated. In conclusion, C19-VAL can yield different histopathological diagnoses when sampled, most of which require clinical and radiological correlation for optimal patient management.

267 Impact of COVID-19 healthcare disruption on delays in melanoma treatment in rural and urban Iowa

Previous studies have shown delays in skin cancer diagnosis and treatment due to disrupted care as a result of the COVID-19 pandemic. Diagnoses of melanoma in rural areas are associated with higher all-cause mortality when compared to metropolitan areas. Patients with melanoma treated after three months of diagnosis experience higher mortality than patients treated after one month. This study aimed to determine how COVID-19 shutdowns affected time to treatment of melanoma and patient outcomes between patients who lived in rural vs. urban areas. Patients with a pathologic diagnosis of melanoma at a large academic tertiary referral center were identified from 1/1/2019 to 12/31/2020 (n=408). Data from pathologic reports and demographic information regarding rurality (address and zip code) were collected from medical records. Documented telephone encounters were utilized to determine delays due to COVID-19. Average Breslow depth increased from 1.16 mm to 1.50 mm and proportion of clinical lymphadenopathy increased from 1.12% to 6.76% from 2019 to 2020. Conversely, average time to treatment from diagnosis decreased from 2019 to 2020 (29.55 vs. 23.76 days). These findings suggest that the COVID-19 pandemic resulted in a higher proportion of later stage tumors at presentation, but with no significant treatment delay once melanoma diagnosis was established. These results characterize the impacts of pandemic shutdowns on medical care and can aid health systems in designing optimal strategies to better serve patients from rural backgrounds.

CHOLESTATIC JAUNDICE AS A CLINICAL PRESENTATION OF HODGKIN’S LYMPHOMA IN A 20-YEAR-OLD SAUDI MALE PATIENT, A CASE REPORT

Background: Hodgkin lymphoma (HL) represents approximately 10% of lymphomas and is curable in most, but not all, patients. It has a bimodal incidence, although it most commonly presents in young adults. Presentation with mediastinal, cervical, and supraclavicular involvement is particularly common for the nodular sclerosing subtype. Patients may also present with B symptoms, although that is more commonly seen in elderly patients with more advanced disease. Pruritus may also be a presenting symptom. The diagnosis is established with a lymph node biopsy specimen showing Reed-Sternberg cells, malignant cells that originate from germinal center B cells and are seen in an inammatory inltrate. Case Report: We report a case of a 20 years old Saudi male presented to our emergency department with jaundice without clinical lymphadenopathy, accompanied with laboratory investigations that is showing intrahepatic cholestasis. The patient was admitted initially to evaluate the causes of jaundice that he has mainly by investigating hepatic and post-hepatic diseases. Months later, he has developed palpable lymphadenopathy. Surgical excisional biopsy result concluded that the patient is having Hodgkin's lymphoma. Conclusion:Although it is thought to be an uncommon cause of intrahepatic cholestatic, lymphomas should be considered in evaluating a patient who came with similar presentation.

Clinicopathological Characteristics Related to Etiologies of Erythema Nodosum: A 10-Year Retrospective Study.

BackgroundErythema nodosum (EN) is the most common panniculitis associated with a wide variety of conditions. Updated studies regarding the clinicopathological manifestations related to etiologies of EN and its prognosis are limited.ObjectiveWe aimed to explore the clinicopathological features in relation to the etiologies of EN and determine characteristics of disease recurrence and its predictive factors.MethodsA total of 169 patients with biopsy-proven EN or septal panniculitis from January 2008 to September 2018 were retrospectively reviewed. Patients were classified as either idiopathic or secondary EN. Patients’ general information, clinical manifestations, investigations, and recurrence of EN were recorded. The details on histopathological findings were reviewed by a blinded dermatopathologist.ResultsThe mean age at diagnosis of EN was 40.6 ± 17.3 years. The majority of patients (85.2%) were female. Idiopathic EN was found in 62.7% of patients. Tuberculosis (23.8%) and drugs (23.8%) were the leading causes of secondary EN. In univariate logistic regression analysis, lesions on upper extremities (p = 0.018), fever (p = 0.003), clinical lymphadenopathy (p < 0.001) favored secondary EN. Histopathologically, the presence of focal peripheral lobular panniculitis with eosinophils was linked to idiopathic EN (p = 0.03). However, multivariable logistic regression analysis failed to demonstrate factors associated with secondary EN. Recurrence was found in 46.6% of patients with no identifiable predictive factors.ConclusionAlthough no clinical risk factors were associated with the etiology of EN, the histopathological presence of eosinophils in focal peripheral lobular panniculitis suggested idiopathic EN.

The COVID-19 Vaccines Can Lead to False Positive Mammograms and Breast MRI. How Can we Decrease the Impact Caused by Post-Vaccination Lymphadenopathy in Breast Cancer and Oncology Patients?

There has been an increase in reporting clinical or radiological axillary lymphadenopathy after the coronavirus disease (COVID-19) vaccination. Cancer care is complex and multidisciplinary, which requires care events to be orchestrated promptly; radiology often serves a key role in diagnosis, post-diagnosis and is sometimes the patient’s first step in cancer care initiation, especially in breast cancer. Radiologists are also a key role in other Multidisciplinary Teams (MDT) dealing with different departments. Therefore, identifying unnecessary management within the health system can generally enhance the patient’s experience, reduce the pressure from providing extra health services, and reduce health costs. Based on personal observation and previous literature, the author concludes that patients having breast cancer or recent breast cancer diagnosis in the pre- or peri-treatment setting could benefit from receiving a vaccination, if possible, in the anterolateral thigh or contralateral arm regardless if this vaccine is for influenza, HPV, etc. Whether this is applicable for the COVID-19 vaccine remains unanswered. This approach will potentially reduce the patient anxiety from having a recurrence or failure of treatment and decrease the strain of the health care system both functionally and economically. In addition, this approach can potentially reduce or eliminate cancellations, delays, and rescheduling of relevant imaging modalities. Also, the author suggests adding a history of vaccinations to all the imaging request forms; countries with digital health services can reap the benefit of generating extensive epidemiological data of post-vaccination lymphadenopathy. Thus, creating new base-evidence guidelines for managing reactive post-vaccination lymphadenopathy, and potentially avoiding duplicating unnecessary imaging and patient over-treatment.

Carcinoma Ex-Pleomorphic Adenoma Diagnosis During Global Health Engagement Operations.

In global health engagement settings, performance of oncologic surgery is evaluated by understanding the host nation healthcare capacity to include inpatient care support and the available postoperative adjunctive therapy to include chemotherapy and radiation therapy. We present a case during Pacific Partnership 2018 of a patientwith a malignant facial mass diagnosed postoperatively. A literature review was conducted, searching specifically for cases related to pleomorphic adenoma (PA), carcinoma ex-PA, cases of misdiagnosis, and global health engagement operations. The patient presented without constitutional symptoms, clinical lymphadenopathy, or cranial nerve VII weakness with a preoperative host nation diagnosis of a benign salivary neoplasm (PA). Postoperatively, a gross total resection of the mass was diagnosed as high-grade adenocarcinoma-a carcinoma ex-PA of the parotid gland. Oncologic staging was noted to be advanced at T3N0, and the patient was referred back to the host nation surgeons for radiation oncology consultation and clinical surveillance to follow. Diagnosis of carcinoma ex-PA-a rare form of salivary gland malignancy-is not always straightforward because of its high degree of cellular heterogeneity, leading to inconsistencies in preoperative sampling results. This case addresses the preoperative diagnostic challenges associated with this type of malignancy, different types of possible treatment modalities aimed at reducing postoperative morbidity, and the preoperative and postoperative challenges that are critical to address during health engagement operations.

Should we be imaging lymph nodes at initial diagnosis of early-stage mycosis fungoides? Results from the PROspective Cutaneous Lymphoma International Prognostic Index (PROCLIPI) international study.

Early-stage mycosis fungoides (MF) includes involvement of dermatopathic lymph nodes (LNs) or early lymphomatous LNs. There is a lack of unanimity among current guidelines regarding the indications for initial staging imaging in early-stage presentation of MF in the absence of enlarged palpable LNs. To investigate how often imaging is performed in patients with early-stage presentation of MF, to assess the yield of LN imaging, and to determine what disease characteristics promoted imaging. A review of clinicopathologically confirmed newly diagnosed patients with cutaneous patch/plaque (T1/T2) MF from PROspective Cutaneous Lymphoma International Prognostic Index (PROCLIPI) data. PROCLIPI enrolled 375 patients with stage T1/T2 MF: 304 with classical MF and 71 with folliculotropic MF. Imaging was performed in 169 patients (45%): 83 with computed tomography, 18 with positron emission tomography-computed tomography and 68 with ultrasound. Only nine of these (5%) had palpable enlarged (≥ 15 mm) LNs, with an over-representation of plaques, irrespectively of the 10% body surface area cutoff that distinguishes T1 from T2. Folliculotropic MF was not more frequently imaged than classical MF. Radiologically enlarged LNs (≥ 15 mm) were detected in 30 patients (18%); only seven had clinical lymphadenopathy. On multivariate analysis, plaque presentation was the sole parameter significantly associated with radiologically enlarged LNs. Imaging of only clinically enlarged LNs upstaged 4% of patients (seven of 169) to at least IIA, whereas nonselective imaging upstaged another 14% (24 of 169). LN biopsy, performed in eight of 30 patients, identified N3 (extensive lymphomatous involvement) in two and N1 (dermatopathic changes) in six. Physical examination was a poor determinant of LN enlargement or involvement. Presence of plaques was associated with a significant increase in identification of enlarged or involved LNs in patients with early-stage presentation of MF, which may be important when deciding who to image. Imaging increases the detection rate of stage IIA MF, and identifies rare cases of extensive lymphomatous nodes, upstaging them to advanced-stage IVA2.

Lymphovascular invasion of papillary thyroid carcinoma revisited in the era of active surveillance

IntroductionLymphovascular invasion (LVI) is associated with disease recurrence and compromised survival in patients with thyroid cancer. Nonetheless, LVI is not identifiable on preoperative ultrasound or cytologic assessment. We aimed to explore the clinicopathological features associated with LVI. Patients and methodsWe conducted a retrospective review of our prospectively maintained database from 2009 to 2018. Multivariate analyses were performed to determine the associations between clinicopathological parameters and LVI. Generalized additive models were used to examine the nonlinear relationship between continuous variables and LVI. ResultsA total of 795 patients were included in the analysis, and 174 (22%) had LVI. Patients’ age (odds ratio [OR] = 0.982), tumor size (OR = 1.466), clinical lymphadenopathy (OR = 6.975), and advanced extrathyroidal extension (OR = 2.938) were independently associated with LVI. In the subset analysis of 198 patients with available genetic information, tumor size (OR = 1.599), clinical lymph node metastasis (OR = 3.657), and TERT promoter mutation (OR = 4.726) were predictive of LVI. Among 573 patients who had no clinical lymphadenopathy or advanced extrathyroidal extension, tumor size was the only predictor of LVI. Tumor size >1.5 cm had an increased risk of LVI based on the generalized additive model plot and receiver operating characteristic curve analysis. ConclusionTumor size is positively associated with the risk of LVI in papillary thyroid cancer. To avoid delayed treatment in patients with LVI, a tumor size of 1.5 cm may be considered as the safe upper limit for active surveillance.

Diagnostic evaluation of PET CT, USG neck &amp; FNAC in clinically N0 neck

Introduction : Extent of neck dissection is determined by the neck nodal positivity and indirectly has a bearing on neck dissection related morbidity. The current study prospectively compares the accuracy of these imaging techniques and FNAC to final histopathology. 31 patients of Oral cavity squamous cell carcinoma with no palpable lymphadenopathy were prospectively included in the study. Methodology : Thirty-one patients of oral cavity SCC who did not have any clinical lymphadenopathy treated at our centre from January 2018 to July 2018 were recruited for the study. All these patients underwent a whole body PET with contrast enhanced CT followed by a high-resolution ultrasound of the neck. Patients then underwent a US guided FNAC of the most suspicious lymph node. Results: 14 of the 31 patients had pathologically positive neck node. PET CT had 100 % negative predictive value. USG Neck diagnosed 22 patients to have suspicious lymph node with a negative predicitve value of 66.7% and positive predictive value of 50%. The combined yield of PET CT and USG Neck could produce a PPV of 100% and NPV of 68%. Conclusion : None of the test individually could predict the neck nodal positivity with absolute accuracy in our study. The best accuracy was when a combination of these tests were done.

Recurrence after sentinel lymph node biopsy in cutaneous melanoma: a single-center experience in Slovak patients.

The standard approach in the management of cutaneous malignant melanoma is considered to be a complete excision of the primary lesion with an appropriate margin of the normal tissue according to Breslow thickness. Usually sentinel lymph node biopsy (SLNB) can help to determine the nodal status, and thus improve the accuracy of staging of the disease. However, the role of SLNB in melanoma treatment remains controversial. NCCN guidelines strongly support routine performance of therapeutic lymphadenectomy in all melanoma patients with clinically positive nodes without radiographic evidence of distant metastases. Patients with positive SLNB should have had completion lymph node dissection (CLND) for regional disease control. Between 2012 and 2016, 168 consecutive patients underwent surgery for primary cutaneous malignant melanoma at St. Elisabeth Cancer Institute in Bratislava. The indication for SLNB and the procedure was made according to international guidelines. In this retrospective study, a cohort of 78 patients was analyzed (35 women and 43 men). Inclusion criteria comprised patients with cutaneous melanoma with no evidence of distant metastases or clinical lymphadenopathy. SLNB comprised a dual labelling method (Tc-99m Nanocolloid / blue dye) in a one-day protocol. Median follow-up was 657 days. The primary composite outcome was the time to the first disease-related event (death, reintervention, worsening of symptoms). Primary outcome measures were overall (disease-specific) and disease-free survival. The overall identification rate of SLN in melanoma patients by dual labelling method was 98.5%. All patients with positive SLNB on frozen section underwent complete regional lymphadenectomy. Using multivariable analysis Breslow thickness of the lesion (p=0.00004, HR 4.03 on logarithmic scale) was identified as the strongest independent predictor of the disease-free survival (DFS) and male gender was significant predictor of DFS. An increase in tumor thickness was associated with significantly higher risk of an event. Neither SLN positivity nor initial S-100 level proved to be significant predictors of the event at the 0.05 level of probability. Multidisciplinary approach represents the gold standard of care for melanoma patients and surgery remains the best option for most localized cases. Although the usefulness of SLNB procedure has been questioned, it provides an excellent staging method, moreover, it can identify high-risk patients. The routine use of completion lymphadenectomy after a positive SLNB is still controversial. It is not clear whether CLND following a positive SLN biopsy improves survival but it could provide regional disease control.

How many lymph nodes are enough?-defining the extent of lymph node dissection in stage I-III gastric cancer using the National Cancer Database.

Surgical resection with lymph node dissection is the primary therapeutic modality for gastric cancer. National Cancer Database (NCDB) was used to determine the extent of lymph nodes (LNs) dissection for gastric cancer. The NCDB was queried from 2004-2013 for patients with margin-negative, invasive resected gastric cancer. The optimal number of LNs dissected was determined using a univariate χ2 cut-point analysis. Multiple sensitivity analyses were utilized to decrease bias. A total of 17,851 patients were included. For all patients, the optimal number of LNs needed to be examined was 20+ nodes. When correcting for stage migration (<7 LNs removed), the optimal cut-off value was 20+ LNs. When stratifying by pathologic nodal stage, the cut-off point was 10+ LNs for pN1 and pN2. The 5-year survival was 30.6%±1.6% for 0-9 removed LNs compared to 48.2%±1.2% for 10+ removed LNs (P<0.001) in pN1 disease and 18.3%±1.7% for 0-9 removed LNs compared to 32.6%±1.2% for 10+ removed LNs (P<0.001) in pN2 disease. For pN3 disease, the optimal cut-off point was 20+ LNs; the 5-year survival was 17.2%±1.3% for 0-19 removed LNs compared to 28.5%±1.7% for 20+ removed LNs (P<0.001). Moreover, the outcome was inferior among patients who had >10% positive dissected LNs (P<0.05). The extent of dissected lymph nodes of 20 or greater lymph nodes was associated with superior survival. Extended LN dissection is to be considered especially in patients with clinical lymphadenopathy.

The role of radical surgery in the treatment of lymph node positive prostate cancer

There is no clear consensus on how to manage a subset of patients with prostate cancer (PCa) who present with involved lymph nodes (LN+). Although outcomes for these patients are uniformly worse than those for patients with localized PCa, they are better than outcomes for patients with bone metastases, with more than 60% of patients alive at 10 years after the initial diagnosis. Although radical prostatectomies in patients with clinical lymphadenopathy were abandoned in the era before widespread adoption of PSA screening, radical prostatectomy with extended pelvic lymphadenectomy can help achieve durable cancer control in the contemporary practise. The use of multimodal treatment, including surgery, adjuvant radiotherapy, and ADT, is particularly relevant for younger patients who are at high risk for local and distant relapse over the course of their lives and who may need all treatments to achieve optimal outcomes. Although there is a lack of data from prospective randomized trials directly comparing radiotherapy and radical prostatectomy, retrospective studies and registries suggest that surgery may offer benefits in terms of biochemical recurrence-free survival, metastasis-free survival, prostate-cancer-specific mortality, and overall survival.

Tonsillar Lymphoma in Children According to Age Group: A Systematic Review.

Lymphoma is a common malignant tumor of the head and neck occurring during childhood. Early diagnosis is very important in terms of prognosis in patients with tonsillar lymphoma.Our objective was to evaluate the clinical manifestations of pediatric tonsillar lymphoma according to different age groups. A systematic review of available English, Spanish, or Portuguese literature from January 1996 to June 2012 was performedin the BIREME, Cochrane, IBECS, Lilacs, PubMed/Medline, SCIELO, and Scopus databases, using "tonsillar lymphoma" and "children" as keywords. Inclusion criteria were pediatric case reports, patients aged up to 18 years, and information on clinical features at the time of diagnosis. Out of 87 identified publications, 13 articles were selected describing 53 patients. Tonsillar asymmetry was the most common sign. Snoring is a common sign in patients aged under 5 years; clinical lymphadenopathy is frequent among patients aged between 6 and 10 years; and dysphagia is a common sign in patients between 11 and 18 years of age. Burkitt's lymphoma is the most common form among all ages studied, followed by B-cell lymphoma. Clinical manifestations differ according to age group. However, tonsillar asymmetry is the most frequent sign regardless of age group.

Lymph node retrieval rates in melanoma: a quality assessment parameter.

Regional lymph node dissection (rlnd) for melanoma with nodal metastasis is a specialized procedure that is associated with improved disease-specific survival in selected patients. Furthermore, there is evidence that a higher lymph node retrieval rate (lnrr) is associated with improved local control. Currently, no consensus has been reached on the definition of an adequate lnrr. A minimum lnrr has been proposed as a quality assessment parameter that has to be validated. We conducted a retrospective cohort analysis at the Princess Margaret Cancer Centre (University Health Network, Toronto, ON). The lnrrs for all patients who underwent rlnd for malignant cutaneous melanoma during 2000-2010 were recorded. Indications for rlnd were a positive sentinel lymph node biopsy or clinical lymphadenopathy (palpable or radiologically detected). Of the 207 identified rlnds, 146 (70.5%) were subsequent to a positive sentinel lymph node biopsy, and 61 (29.5%) were performed for clinical lymphadenopathy. The median lnrr was 24 nodes (range: 9-47 nodes; 10th percentile: 14 nodes) for axillary rlnd, 12 nodes (range: 5-30 nodes; 10th percentile: 8 nodes) for inguinal rlnd, and 16 nodes (range: 10-21 nodes; 10th percentile: 11 nodes) for ilioinguinal rlnd. The results were similar when comparing patients with positive sentinel lymph nodes and those with clinical lymphadenopathy, and the same surgical techniques were used in both groups. The lnrrs at our institution are similar to rates reported at other tertiary-care melanoma centres. A minimum acceptable lnrr can be considered a quality assessment parameter in the surgical management of melanoma with nodal metastasis.

The Role of Central Neck Lymph Node Dissection in the Management of Papillary Thyroid Cancer.

Papillary thyroid cancer (PTC) is the most common thyroid malignancy, and cervical nodal metastases are frequent at presentation. The most common site for nodal metastases from PTC is the central compartment of the ipsilateral neck in the paratracheal and pretracheal regions. The decision to resect these lymph nodes at the time of thyroidectomy often depends on if nodes with suspected malignancy can be identified preoperatively. If nodal spread to the central neck nodes is known, then the consensus is to remove all nodes in this area. However, there remains significant controversy regarding the utility of removing central neck lymph nodes for prophylactic reasons. Herein, we review the potential utility of central neck lymph node dissection as well as the risks of performing this procedure. As well, we review the potential of molecular testing to stratify patients who would most benefit from this procedure. We advocate a selective approach in which patients undergo clinical neck examination coupled with ultrasound to detect any concerning lymph nodes that warrant additional evaluation with either fine needle aspiration or excisional biopsy in the operating room. In lieu of clinical lymphadenopathy, we suggest the use of patient and disease characteristics as identified by multiple groups, such as the American Thyroid Association and European Society of Endocrine Surgeons, which include extremes of ages, large primary tumor size, and male gender, when deciding to perform central neck lymph node dissection. Patients should be educated on the potential long-terms risks versus the lack of known long-term benefits.