Determination Of Lymph Node Status Research Articles

Accuracy and Clinical Impact of Persistent Disease Diagnosed on Diffusion-Weighted Imaging and Accuracy of Pelvic Nodal Assessment on Magnetic Resonance Imaging for Squamous Cell Carcinoma of the Anus in the 6-Month Interval Post Chemoradiotherapy

To evaluate the diagnostic performance of diffusion-weighted imaging (DWI) in the 6-month interval post chemoradiation therapy (CRT) in determining persistent disease and whether persistent diffusion restriction on DWI at 6 months is associated with overall survival; and secondarily, to investigate the accuracy of pelvic lymph node assessment on T2-weighted imaging and DWI in the 6-month interval post CRT, in patients with squamous cell carcinoma of the anus. This retrospective study included patients with squamous cell carcinoma of the anus who underwent CRT followed by restaging rectal MRI from January 2010 to April 2020, with ≥1 year of follow-up after CRT. DW images were qualitatively evaluated by 2 junior and 2 senior abdominal radiologists to determine anal persistent disease. The reference standard for anal persistent disease was digital rectal examination/endoscopy and histopathology. Diagnostic performance was estimated using sensitivity, specificity, negative predictive value, and positive predictive value. Survival outcomes were evaluated via Kaplan-Meier analysis, and associations between survival outcomes and DWI status were tested for significance using the log-rank test. Additionally, DW and T2-weighted images were evaluated to determine lymph node status. Among 84 patients (mean age, 63 ± 10.2 years; 64/84 [76%] female), 14 of 84 (17%) had confirmed persistent disease. Interreader agreement on DWI between all 4 radiologists was moderate (Light's κ = 0.553). Overall, DWI had a sensitivity of 71.4%, specificity of 72.1%, positive predictive value of 34.5%, and negative predictive value of 92.5%. Patients with a negative DWI showed better survival than patients with a positive DWI (3-year overall survival of 92% vs 79% and 5-year overall survival of 87% vs 74%), although the difference did not reach statistical significance (P = .063). All patients with suspicious lymph nodes (14/14, 100%) showed negative pathology or decreased size during follow-up. At 6 months post CRT, DWI showed value in excluding anal persistent disease. Persistent diffusion restriction on DWI was not significantly associated with overall survival. Pelvic nodal assessment on DWI and T2-weighted imaging was limited in predicting persistent nodal metastases.

Preoperative CT-based deep learning radiomics model to predict lymph node metastasis and patient prognosis in bladder cancer: a two-center study

ObjectiveTo establish a model for predicting lymph node metastasis in bladder cancer (BCa) patients.MethodsWe retroactively enrolled 239 patients who underwent three-phase CT and resection for BCa in two centers (training set, n = 185; external test set, n = 54). We reviewed the clinical characteristics and CT features to identify significant predictors to construct a clinical model. We extracted the hand-crafted radiomics features and deep learning features of the lesions. We used the Minimum Redundancy Maximum Relevance algorithm and the least absolute shrinkage and selection operator logistic regression algorithm to screen features. We used nine classifiers to establish the radiomics machine learning signatures. To compensate for the uneven distribution of the data, we used the synthetic minority over-sampling technique to retrain each machine-learning classifier. We constructed the combined model using the top-performing radiomics signature and clinical model, and finally presented as a nomogram. We evaluated the combined model’s performance using the area under the receiver operating characteristic, accuracy, calibration curves, and decision curve analysis. We used the Kaplan–Meier survival curve to analyze the prognosis of BCa patients.ResultsThe combined model incorporating radiomics signature and clinical model achieved an area under the receiver operating characteristic of 0.834 (95% CI: 0.659–1.000) for the external test set. The calibration curves and decision curve analysis demonstrated exceptional calibration and promising clinical use. The combined model showed good risk stratification performance for progression-free survival.ConclusionThe proposed CT-based combined model is effective and reliable for predicting lymph node status of BCa patients preoperatively.Critical relevance statementBladder cancer is a type of urogenital cancer that has a high morbidity and mortality rate. Lymph node metastasis is an independent risk factor for death in bladder cancer patients. This study aimed to investigate the performance of a deep learning radiomics model for preoperatively predicting lymph node metastasis in bladder cancer patients.Key points• Conventional imaging is not sufficiently accurate to determine lymph node status.• Deep learning radiomics model accurately predicted bladder cancer lymph node metastasis.• The proposed method showed satisfactory patient risk stratification for progression-free survival.Graphical

Use of Carbon Nanoparticles to Improve the Efficiency of Harvesting Lymph Nodes in Rectal Cancer.

The accurate determination of lymph node status in patients with rectal cancer requires harvesting a certain number of lymph nodes. This study investigated whether using carbon nanoparticles (CNs) could improve the efficiency of harvesting lymph nodes in rectal cancer patients. Data from patients with rectal cancer treated with radical resection were collected from Nanfang Hospital between January 2014 and June 2021. Patients in the CN group received a CN suspension 1 day before surgery, which was endoscopically injected around the tumor. A 1:1 case-matched study was performed using the propensity score. The efficiency of harvesting lymph nodes was investigated by comparing the number of total nodes, total time, and percentage of nodes <5mm in size between the CN and non-CN groups. A total of 768 patients were included, with 246 patients who underwent CN injection and 522 patients who did not. After matching, 246 pairs of patients were analyzed. After matching, the number of total nodes of each sample was significantly higher in the CN group than in the non-CN group ( P <0.001). The total time for node detection ( P <0.001) was significantly shorter in the CN group. The percentage of nodes <5mm in size was increased significantly in the CN group ( P <0.001). Among patients with clinical staging I/II, the difference in positive LNs was significant (21.79% vs. 11.95%, P =0.029). The application of CNs improved the efficiency of harvesting lymph nodes during rectal cancer surgery.

Value of non-coding RNAs to assess lymph node status in cervical cancer.

Cervical cancer (CC) is the fourth cancer in women and is the leading cause of cancer death in 42 countries. Lymph node metastasis is a determinant prognostic factor, as underlined in the latest FIGO classification. However, assessment of lymph node status remains difficult, despite the progress of imaging such as PET-CT and MRI. In the specific setting of CC, all data underlined the need for new biomarkers easily available to assess lymph node status. Previous studies have underlined the potential value of ncRNA expression in gynecological cancers. In this review, we aimed to evaluate the contribution of ncRNAs in tissue and biofluid samples to determine lymph node status in CC with potential impact on both surgical and adjuvant therapies. In tissue samples, our analysis found that there are arguments to support the role of ncRNAs in physiopathology, differential diagnosis from normal tissue, preinvasive and invasive tumors. In biofluids, despite small studies especially concerning miRNAs expression, promising data opens up new avenue to establish a non-invasive signature for lymph node status as well as a tool to predict response to neo- and adjuvant therapies, thus improving management algorithm of patients with CC.

Quantification of linear and nonlinear elasticity by compression optical coherence elastography for determining lymph node status in breast cancer

We report the first application of compression optical coherence elastography (C-OCE) to evaluate both linear and nonlinear elastic properties of lymph nodes (LNs) for assessing their status, which is an important factor for detecting metastasis and staging breast cancer. The reported study involved 27 excised sentinel and axillary LNs from 24 patients with breast cancer, including normal LNs (n = 6), reactive LNs with follicular hyperplasia (n = 7) and sinus histiocytosis (n = 8), and metastatic LNs (n = 6). C-OCE data were compared with co-registered gold-standard histopathology and demonstrated a significantly higher contrast in differentiation of LNs as compared to structural optical coherence tomography imaging. Normal LNs are characterized by low stiffness values in the areas of LN cortex (<200 kPa). C-OCE revealed that abnormal reactive LNs with follicular hyperplasia exhibit moderately increased stiffness (200–300 kPa) in the cortex areas and more pronounced stiffness increase (400–600 kPa) in the areas of sinus histiocytosis. LNs with total metastasis exhibit fairly uniformly distributed highest stiffness values (>600 kPa). Since in terms of the tangent Young’s modulus there remained an appreciable overlap among these types of LNs, we also evaluated their elastic nonlinearity parameters. Complementary usage of both linear and nonlinear elastic parameters enabled very clear differentiation of all four main states of LNs. Thus, C-OCE imaging demonstrates high potential for future intraoperative usage to rapidly determine the LN status during breast-conserving surgery and to assess the extent of the cancer cells propagation in regional lymphatic collectors for preserving benign LNs. This is important for reducing the associated risks and complications (such as lymphedema) from excessive surgical removal of lymphoid structures.

A nomogram for preoperative prediction of lymph node metastasis in patients with intrahepatic cholangiocarcinoma based on inflammation-related markers

Objectives: To construct a nomogram for prediction of intrahepatic cholangiocarcinoma (ICC) lymph node metastasis based on inflammation-related markers,and to conduct its clinical verification. Methods: Clinical and pathological data of 858 ICC patients who underwent radical resection were retrospectively collected at 10 domestic tertiary hospitals in China from January 2010 to December 2018. Among the 508 patients who underwent lymph node dissection,207 cases had complete variable clinical data for constructing the nomogram,including 84 males,123 females,109 patients≥60 years old,98 patients<60 years old and 69 patients were pathologically diagnosed with positive lymph nodes after surgery. Receiver operating characteristic curve was drawn to calculate the accuracy of preoperative imaging examinations to determine lymph node status,and the difference in overall survival time was compared by Log-rank test. Partial regression squares and statistically significant preoperative variables were screened by backward stepwise regression analysis. R software was applied to construct a nomogram,clinical decision curve and clinical influence curve,and Bootstrap method was used for internal verification. Moreover,retrospectively collecting clinical information of 107 ICC patients with intraoperative lymph node dissection admitted to 9 tertiary hospitals in China from January 2019 to June 2021 was for external verification to verify the accuracy of the nomogram. 80 patients with complete clinical data but without lymph node dissection were divided into lymph node metastasis high-risk group and low-risk group according to the score of the nomogram among the 858 patients. Log-rank test was used to compare the overall survival of patients with or without lymph node metastasis diagnosed by pathology. Results: The area under the curve of preoperative imaging examinations for lymph node status assessment of 440 patients was 0.615,with a false negative rate of 62.8% (113/180) and a false positive rate of 14.2% (37/260). The median survival time of 207 patients used to construct a nomogram with positive or negative postoperative pathological lymph node metastases was 18.5 months and 27.1 months,respectively (P<0.05). Five variables related to lymph node metastasis were screened out by backward stepwise regression analysis,which were combined calculi,neutrophil/lymphocyte ratio,albumin,liver capsule invasion and systemic immune inflammation index,according to which a nomogram was constructed with concordance index(C-index) of 0.737 (95%CI: 0.667 to 0.806). The C-index of external verification was 0.674 (95%CI:0.569 to 0.779). The calibration prediction curve was in good agreement with the reference curve. The results of the clinical decision curve showed that when the risk threshold of high lymph node metastasis in the nomogram was set to about 0.32,the maximum net benefit could be obtained by 0.11,and the cost/benefit ratio was 1∶2. The results of clinical influence curve showed that when the risk threshold of high lymph node metastasis in the nomogram was set to about 0.6,the probability of correctly predicting lymph node metastasis could reach more than 90%. There was no significant difference in overall survival time between patients with high/low risk of lymph node metastasis assessed by the nomogram and those with pathologically confirmed lymph node metastasis or without lymph node metastasis (Log-rank test:P=0.082 and 0.510,respectively). Conclusion: The prediction accuracy of preoperative nomogram for ICC lymph node metastasis based on inflammation-related markers is satisfactory,which can be used as a supplementary method for preoperative diagnosis of lymph node metastasis and is helpful for clinicians to make personalized decision of lymph node dissection for patients with ICC.

Less is more in endometrial cancer (SLN, conservative treatment, radical hysterectomy, molecular classification).

The management of endometrial cancer has known many evolutions within the last decades. In this review, we aim to summarize recent evolutions (mainly toward less aggressive management) that have occurred in the management of endometrial cancer. Enhanced by molecular classification, the determination of lymph node status, in young women, in case of cervical invasion, the treatment is evolving toward a less aggressive strategy. The predictive value and the safety of sentinel lymph node biopsy explain why most societies propose to abandon systematic pelvic and para aortic lymphadenectomy. For young women, the safety of fertility preservation is now well established and efficient protocols have been validated. In stage II endometrial cancer (stromal cervical invasion), radical hysterectomy appears excessive. The Cancer Genome Atlas classification increases prognostic evaluation in association with the traditional pathological classification and permits to tailor adjuvant treatment more accurately.

A prognostic nomogram for stage II/III rectal cancer patients treated with neoadjuvant chemoradiotherapy followed by surgical resection

BackgroundThe purpose of this study was to develop a large population-based nomogram incorporating the log odds of positive nodes (LODDS) for predicting the overall survival (OS) of stage II/III rectal cancer patients treated with neoadjuvant chemoradiotherapy (NCRT) followed by surgical resection.MethodsThe Surveillance, Epidemiology, and End Results database was used to collect information on patients diagnosed with stage II/III rectal cancer between 2010 and 2015 and treated with NCRT followed by surgical resection. The Cox regression analyses were performed to determine the independent prognostic factors. In this study, LODDS was employed instead of American Joint Committee on Cancer (AJCC) 7th N stage to determine lymph node status. Then a nomogram integrating independent prognostic factors was developed to predict the 24-, 36-, and 60-month overall survival. The receiver operating characteristic (ROC) curves and calibration curves were used to validate the nomogram. Furthermore, patients were stratified into three risk groups (high-, middle-, and low-risk) based on the total points obtained from the nomogram. And Kaplan–Meier curves were plotted to compare the OS of the three groups.ResultsA total of 3829 patients were included in the study. Race, sex, age, marital status, T stage, tumor grade, tumor size, LODDS, CEA level, and postoperative chemotherapy were identified as independent prognostic factors, based on which the prognostic nomogram was developed. The area under curve values of the nomogram for the 24-, 36-, and 60-month OS in the training cohort were 0.736, 0.720, and 0.688, respectively; and 0.691, 0.696, and 0.694 in the validation cohort, respectively. In both the validation and training cohorts, the calibration curves showed a high degree of consistency between actual and nomogram-predicted survival rates. The Kaplan–Meier curves showed that the three risk groups had significant differences in overall survival (P < 0.001).ConclusionA large population-based nomogram incorporating LODDS was developed to assist in evaluating the prognosis of stage II/III rectal cancer patients treated with NCRT followed by surgical resection. The nomogram showed a satisfactorily discriminative and stable ability to predict the OS for those patients.

100: IMPACT OF INCREASING LYMPH NODE YIELD ON THE NUMBER OF POSITIVE LYMPH NODES, MORBIDITY AND SURVIVAL IN ESOPHAGEAL CANCER SURGERY

Abstract Background and aim Accurate determination of lymph node status after esophagectomy requires complete lymphadenectomy. Extended surgery might also lead to more postoperative morbidity. This study analyzed lymph node yield over time and investigated the influence of lymph node yield on the number of positive lymph nodes, postoperative morbidity and disease-free survival. Methods Patients who underwent transthoracic esophagectomy for esophageal adenocarcinoma between 2010 and 2018, were included. Lymph node yield was both analyzed as continuous variable and as categorical variable (&amp;lt;15, 15–29 (reference category) and ≥ 30 nodes). The effect of lymph node yield on the number of positive lymph nodes, morbidity and disease-free survival was assessed in multivariable regression analyses. Results A total of 469 patients were included with a median follow-up of 20 months. The majority of the included patients received neoadjuvant chemo(radio)therapy (93.1%). The median lymph node yield increased from 25.0 lymph nodes (IQR 20–34) in 2010 to 36.0 lymph nodes (IQR 30–45) in 2018. Higher lymph node yield was significantly associated with more positive lymph nodes both as continuous variable (IRR 1.020, 95%CI 1.006–1.034), and as categorical variable with a threshold of ≥30 nodes (IRR 1.549, 95%CI 1.069–2.244). Lymph node yield was not associated with morbidity. Lymph node yield was not associated with disease-free survival when analyzed as a continuous variable (HR 0.996, 95%CI 0.984–1.008). There was also no difference in disease-free survival between patients with a lymph node yield of &amp;lt;15 and 15–29 (reference) (HR 1.362, 95%CI 0.793–2.338), and between patients with a lymph node yield of 15–29 (reference) and ≥ 30 (HR 0.849, 95%CI 0.650–1.109). Conclusion A higher lymph node yield after esophagectomy was associated with a higher number of positive lymph nodes; a higher number of resected lymph nodes therefore improves staging. A higher lymph node yield did not result in increased morbidity and no association between lymph node yield and disease-free survival could be demonstrated in patients undergoing esophagectomy after neoadjuvant chemo(radio)therapy.

Accuracy of breast MRI in evaluating nodal status after neoadjuvant therapy in invasive lobular carcinoma

Neoadjuvant therapy in breast cancer can downstage axillary lymph nodes and reduce extent of axillary surgery. As such, accurate determination of nodal status after neoadjuvant therapy and before surgery impacts surgical management. There are scarce data on the diagnostic accuracy of breast magnetic resonance imaging (MRI) for nodal evaluation after neoadjuvant therapy in patients with invasive lobular carcinoma (ILC), a diffusely growing tumor type. We retrospectively analyzed patients with stage 1–3 ILC who underwent pre-operative breast MRI after either neoadjuvant chemotherapy or endocrine therapy at our institution between 2006 and 2019. Two breast radiologists reviewed MRIs and evaluated axillary nodes for suspicious features. All patients underwent either sentinel node biopsy or axillary dissection. We evaluated sensitivity, specificity, negative and positive predictive values, and overall accuracy of the post-treatment breast MRI in predicting pathologic nodal status. Of 79 patients, 58.2% received neoadjuvant chemotherapy and 41.8% neoadjuvant endocrine therapy. The sensitivity and negative predictive value of MRI were significantly higher in the neoadjuvant endocrine therapy cohort than in the neoadjuvant chemotherapy cohort (66.7 vs. 37.9%, p = 0.012 and 70.6 vs. 40%, p = 0.007, respectively), while overall accuracy was similar. Upstaging from clinically node negative to pathologically node positive occurred in 28.0 and 41.7%, respectively. In clinically node positive patients, those with an abnormal post-treatment MRI had a significantly higher proportion of patients with ≥4 positive nodes on pathology compared to those with a normal MRI (61.1 versus 16.7%, p = 0.034). Overall, accuracy of breast MRI for predicting nodal status after neoadjuvant therapy in ILC was low in both chemotherapy and endocrine therapy cohorts. However, post-treatment breast MRI may help identify patients with a high burden of nodal disease (≥4 positive nodes), which could impact pre-operative systemic therapy decisions. Further studies are needed to assess other imaging modalities to evaluate for nodal disease following neoadjuvant therapy and to improve clinical staging in patients with ILC.

Sentinel lymph node biopsy for high-thickness cutaneous squamous cell carcinoma

Squamous cell carcinomas are among the most common skin tumors and show a risk of metastasis depending on various factors such as tumor thickness, localization, histological subtype and immune status of the patient. Sentinel lymph node biopsy (SLNB) SLNB represents a possibility for assessing the locoregional lymph node status. In this study, the role of the SLNB in lymph node status and survival was analyzed. Retrospectively, 720 patients with high-risk squamous cell carcinoma (tumor thickness > 5 mm) were examined. 150 patients agreed to SLNB, 570 patients did not undergo histologic confirmation of lymph node status and were included directly in follow-up. In 101 patients, a sentinel lymph node was successfully marked and extirpated, followed by regular follow-up examinations.A total of 11.11% of the patients showed lymph node metastasis in the course of their treatment, with no difference in the proportion of patients in the SLNB group (11.9%) and the observation group (11.4%) (p = 0.873). The proportion of distant metastasis also did not differ between the groups (p = 0.898). In 3.96% of the patients in the SLNB group, a metastasis was found in the sentinel lymph node. Tumor-specific death was observed in 7.14% of the patients in the SLNB group and 4.74% in the observation group (p = 0.269). Although SLNB is a principally suitable method for determining lymph node status, the available data do not provide any benefit regarding further metastasis or tumor-specific survival.

Pilot Study of [18F] Fluorodeoxyglucose Positron Emission Tomography (FDG-PET)/Magnetic Resonance Imaging (MRI) for Staging of Muscle-invasive Bladder Cancer (MIBC).

Computed tomography (CT) has limited diagnostic accuracy for staging of muscle-invasive bladder cancer (MIBC). [18F] Fluorodeoxyglucose positron emission tomography (FDG-PET)/magnetic resonance imaging (MRI) is a novel imaging modality incorporating functional imaging with improved soft tissue characterization. This pilot study evaluated the use of preoperative FDG-PET/MRI for staging of MIBC. Twenty-one patients with MIBC with planned radical cystectomy were enrolled. Two teams of radiologists reviewed FDG-PET/MRI scans to determine: (1) presence of primary bladder tumor; and (2) lymph node involvement and distant metastases. FDG-PET/MRI was compared with cystectomy pathology and computed tomography (CT). Eighteen patients were included in the final analysis, most (72.2%) of whom received neoadjuvant chemotherapy. Final pathology revealed 10 (56%) patients with muscle invasion and only 3 (17%) patients with lymph node involvement. Clustered analysis of FDG-PET/MRI radiology team reads revealed a sensitivity of 0.80 and a specificity of 0.56 for detection of the primary tumor with a sensitivity of 0 and a specificity of 1.00 for detection of lymph node involvement when compared with cystectomy pathology. CT imaging demonstrated similar rates in evaluation of the primary tumor (sensitivity, 0.91; specificity, 0.43) and lymph node involvement (sensitivity, 0; specificity, 0.93) when compared with pathology. This pilot single-institution experience of FDG-PET/MRI for preoperative staging of MIBC performed similar to CT for the detection of the primary tumor; however, the determination of lymph node status was limited by few patients with true pathologic lymph node involvement. Further studies are needed to evaluate the potential role for FDG-PET/MRI in the staging of MIBC.

Regional Lymphadenectomy In Hepatoma Resection: Insight Into Prognosis

Presenter: John Bergquist MD | Stanford University Background: Recent developments in chemotherapeutics for hepatocellular carcinoma (HCC) suggest that new trials of adjuvant therapy are on the horizon. Selection criteria for these trials are as yet undetermined, but prior experience with intrahepatic cholangiocarcinoma suggests that surgical determination of lymph node status may be relevant. To date, the importance of regional lymphadenectomy for prognostication after resection of HCC is poorly understood. We sought to ameliorate this knowledge gap through a nationwide population-based analysis. Methods: Patients with HCC who underwent liver resection (LR) were identified from the Surveillance Epidemiology and End Results (SEER-18) database (2003-2015). Patients undergoing transplant were excluded. A cohort-based study design was used to make clinicopathologic comparisons between patients grouped based on completion of regional lymphadenectomy, defined as removal of any lymph nodes. Propensity-score matching based on age, tumor size, t-stage, and fibrosis score was utilized to reduce bias. Unadjusted and adjusted analysis of overall (OS) and disease-specific survival (DSS) were performed. Results: 5395 patients were included, of which 835 (15.4%) had regional lymphadenectomy completed. While distribution of race, gender, and fibrosis score were similar between cohorts, patients who got regional lymphadenectomy had larger tumors (7.0 vs 4.8 cm), and higher t-stage (30.9 vs. 17.6% T3+ - all p<0.001). Among patients who underwent lymphadenectomy, the overall node positivity rate was 12.0%. Patients who underwent negative lymphadenectomy had equivalent median OS as patients who did not undergo lymphadenectomy (50 months in both cohorts) while DSS was similar (28 months vs. 29 months). Patients found to have node positive disease had substantially decreased OS (20 months) and DSS (16 months, both log-rank p<0.01). The matching algorithm was performed with two controls per case and produced balance among matched covariates (all p>0.1). In the matched cohort, patients undergoing lymphadenectomy had equivalent unadjusted OS (46 vs. 43 months, log-rank p=0.869) and DSS (27 vs 29 months, log-rank p=0.306) to those who did not undergo lymphadenectomy. The prognostic impact of node positive disease persisted in the matched cohort (OS 24 months, DSS 19 months, both log-rank p<0.01). Adjusted overall mortality hazard was independently elevated in patients found to have N1 disease (1.71 unmatched, 1.56 matched, both p<0.01). Disease-specific mortality hazard was independently elevated at 1.40 (p<0.01 prior to matching), but not independently elevated at 1.25 (p=0.09 after matching). Conclusion: Regional lymphadenectomy is performed in only approximately 15% of patients undergoing surgery with curative intent for HCC. Regional lymphadenectomy provides useful prognostic information which can guide patient selection for adjuvant chemotherapy, as well as better facilitate multidisciplinary management of HCC. The prognostic value of regional lymphadenectomy is persistent when adjusted for T-stage. As the era of adjuvant therapy for HCC begins, surgeons should increasingly consider performing regional lymphadenectomy to facilitate optimal multidisciplinary management.

Clinicopathological Factors Influencing Lymph Node Yield in Colorectal Cancer: A Retrospective Study.

Many colorectal resections do not meet the minimum of 12 lymph nodes (LNs) recommended by the American Joint Committee on Cancer for accurate staging of colorectal cancer. The aim of this study was to investigate factors affecting the number of the adequate nodal yield in colorectal specimens subject to routine pathological assessment. We have retrospectively analysed the data of 2319 curatively resected colorectal cancer patients in San Raffaele Scientific Institute, Milan, between 1993 and 2017 (1259 colon cancer patients and 675 rectal cancer patients plus 385 rectal cancer patients who underwent neoadjuvant therapy). The factors influencing lymph node retrieval were subjected to uni- and multivariate analyses. Moreover, a survival analysis was carried out to verify the prognostic implications of nodal counts. The mean number of evaluated nodes was 24.08 ± 11.4, 20.34 ± 11.8, and 15.33 ± 9.64 in surgically treated right-sided colon cancer, left-sided colon cancer, and rectal tumors, respectively. More than 12 lymph nodes were reported in surgical specimens in 1094 (86.9%) cases in the colon cohort and in 425 (63%) cases in the rectal cohort, and patients who underwent neoadjuvant chemoradiation were analysed separately. On univariate analysis of the colon cancer group, higher LNs counts were associated with female sex, right colon cancer, emergency surgery, pT3-T4 diseases, higher tumor size, and resected specimen length. On multivariate analysis right colon tumors, larger mean size of tumor, length of specimen, pT3-T4 disease, and female sex were found to significantly affect lymph node retrieval. Colon cancer patients with 12 or more lymph nodes removed had a significantly better long-term survival than those with 11 or fewer nodes (P = 0.002, log-rank test). Rectal cancer patients with 12 or more lymph nodes removed approached but did not reach a statistically different survival (P = 0.055, log-rank test). Multiple tumor and patients' factors are associated with lymph node yield, but only the removal of at least 12 lymph nodes will reliably determine lymph node status.

Apparent Diffusion Coefficient Histogram Analysis for Assessing Tumor Staging and Detection of Lymph Node Metastasis in Epithelial Ovarian Cancer: Correlation with p53 and Ki-67 Expression.

To investigate the potential of apparent diffusion coefficient (ADC) histogram parameters in epithelial ovarian cancer (EOC) for distinguishing different tumor stages and determining lymph node status and correlations between ADC values and p53 and Ki-67 expression. Forty-nine EOC patients underwent preoperative magnetic resonance imaging. Staging and lymph node status were determined postoperatively. ADC values were measured using histogram analysis and compared between groups. Relationships between ADCs and Ki-67 and p53 expression were explored. DC parameters differed significantly between stage I vs II, I vs III, and I vs IV. The parameters were significantly lower in the lymph node-positive group than in the lymph node-negative group, were significantly negatively correlated with Ki-67 labeling index, and were all significantly lower in the mutation-type p53 group than in the wild-type p53 group. ADC histogram analysis can help discriminate stage I from advanced-stage EOC and predict lymph node metastasis. ADC parameters were correlated with Ki-67 labeling index; the parameters may help indicate p53 expression.

Assessing lymph node status in patients with kidney cancer.

Accurate detection of lymph node involvement on pre-operative imaging in patients diagnosed with renal cell carcinoma (RCC) is critical for determination of disease stage, one of the most significant prognostic factors in RCC. The presence of lymph node involvement in RCC doubles a patient’s risk of distant metastasis and significantly reduces their 5-year survival. Currently, lymph node involvement in patients with RCC is evaluated with numerous modalities, with rapid advancements occurring across these modalities. The purpose of this study was to evaluate the advantages and disadvantages of each modality and utilize sensitivities and specificities to determine the highest performing modalities for accurate lymph node involvement in renal cancer. A comprehensive computer-based literature search of full-length original research English language studies of human subjects with biopsy-proven RCC was performed to evaluate publications on the diagnostic performance of color Doppler sonography (CDS), magnetic resonance imaging (MRI), lymphotrophic nanoparticle enhanced MRI (LNMRI), multidetector-row computed tomography (MDCT), F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET), and PET/CT for evaluation of lymph node status in kidney cancers in articles that were published prior to May 2018. Limited studies were available for evaluating CDS performance for determination of lymph node involvement in renal cancer. While CT is the most common modality for nodal staging, due to its availability and relatively low expense, it did not demonstrate the highest performance of the modalities examined for determination of lymph node status in patients with RCC. Of the modalities examined, MRI demonstrated the highest sensitivity (92–95.7%) for detection of lymph node involvement in RCC. Studies of lymph node involvement in RCC using both MRI and CT indicated that using the current diameter criteria (greater than 1 cm) for determination of positive lymph nodes should be re-evaluated as micro-metastases are frequently overlooked. Studies evaluating lymph node involvement with FDG-PET had the highest specificity (100%), indicating FDG-PET is the preferred modality for confirming lymph node involvement and extent of involvement. However, due to the low sensitivity of FDG-PET, clinicians should be skeptical of negative reports of lymph node involvement in RCC patients. Further studies examining determination of lymph node involvement in renal cancer across modalities are greatly needed, current literature suggests utilizing a combination of MRI and FDG-PET may offer the highest accuracy.

Vaginal brachytherapy for endometrial cancer.

There is limited information about survival effect of vaginal brachytherapy (VBT) and its comparison to external beam pelvic radiotherapy (EBRT) and no radiotherapy (no-RT) of endometrial cancer patients. We performed a multicenter retrospective registry study of 1550 patients with endometrial cancer treated by no-RT (n = 702), VBT (n = 430) and EBRT ± VBT (n = 418). The outcome measure was overall survival. RT did not improve the overall survival of patients with a low risk of recurrence. In univariate analysis, the survival effect of VBT was significant in patients with intermediate and high risk of recurrence (HR 0.42, CI 0.29-0.60, p < 0.0001). EBRT ± VBT demonstrated no survival effect in these groups. Multivariate analysis showed that VBT (HR 0.50, CI 0.36-0.71) significantly reduced the mortality risk in patients with an intermediate and high risk compared with no-RT after adjustment for age, tumor grading, tumor stage, lymphadenectomy, adjuvant therapy and comorbidities. Matching for age, histological type, tumor stage, tumor grade, and performance status between patients treated with no-RT and VBT was performed. The matching analysis again demonstrated the favorable survival effect of VBT compared to no-RT on overall survival with an absolute risk reduction of 17.7%. Notably, in a further 106 matched pairs, EBRT ± VBT did not demonstrate any survival effect over VBT among patients at intermediate and high risk of recurrence. VBT should be performed in patients at intermediate and high risk of recurrence of endometrial cancer, after operative determination of lymph node status.

Preoperative Prediction of Lymph Nodal Metastases in Endometrial Carcinoma: Is it Possible?: A Literature Review.

Lymph node status is one of the most important prognostic factors in endometrial cancer and crucial for deciding adjuvant therapy. The aim of the study was to assess the different models used to predict lymphatic nodal disease. A literature search was conducted to detect the relevant studies. Relevant papers comparing the preoperative modality with the final histopathological results including randomized clinical trials, case-control studies, and any publications with a minimum of 50 patients in the report. Molecular-based predictors are still far from a practical application. Preoperative radiological scans (positron emission tomography, computed tomography, magnetic resonance imaging, and ultrasound) have shown the best predictor of lymphatic dissemination. However, there is currently no ideal model available, which can be used within standard clinical care. Surgical staging still remains the criterion standard in the determination of lymph node status in endometrial cancer.

Laparoscopic function-preserving gastrectomy based on sentinel node concept for early gastric cancer patients.

26 Background: Recent meta-analyses have shown acceptable SN detection rates and accuracy of determination of lymph node status. SN mapping may play a key role to obtain individual metastatic information and allows modification of the surgical procedures such as function-preserving gastrectomy for early gastric cancer. Methods: A dual-tracer method that employs radioactive colloids and blue dyes is currently considered the most reliable method for the stable detection of SNs in patients with early gastric cancer. The new technologies such as indocyanine green infrared or fluorescence imaging are also useful for accurate SN mapping in gastric cancer. Results: SN mapping has been performed for 489 patients with clinically T1N0M0 gastric cancer in our institute since 1999. Sensitivity to predict the lymph node metastasis was 90%, and overall accuracy of nodal status based on SN concept was 99 % (484 of 489). Sentinel lymphatic basin dissection is strongly recommended to cover the false-negative results of SN mapping in clinical practices. Based on these results, laparoscopic minimized gastrectomy such as partial resection, proximal gastrectomy, segmental gastrectomy and pylorus-preserving gastrectomy with individualized selective and modified lymphadenectomy for early gastric cancer with negative SN has been performed in our institution. The recent appearance of a new technique, referred to as non-exposed endoscopic wall-inversion surgery (NEWS) is a technique of full thickness resection using endoscopy and laparoscopic surgery without transluminal access mainly designed to treat gastric cancer with partial resection. The combination of NEWS with SN biopsy is expected to become a promising, ideal minimally invasive, function-preserving surgery for cN0 early gastric cancer. We initiated a new multicenter prospective trial to evaluate function-preserving gastrectomy with SN mapping in terms of long-term survival and patients’ QOL. Conclusions: Our results suggested that SN concept for cN0 early gastric cancer could be validated, and function-preserving surgery based on the SN concept which might retain the patients’ quality of life should be established as the next surgical challenge.

Function-preserving gastrectomy based on the sentinel node concept in early gastric cancer.

Recent meta-analyses and a prospective multicenter trial of sentinel node (SN) mapping in early gastric cancer have demonstrated acceptable SN detection rates and accuracy of determination of lymph node status. SN mapping may play a key role in obtaining individual metastatic information. It also allows modification of surgical procedures, including function-preserving gastrectomy in patients with early gastric cancer. A dual-tracer method that uses radioactive colloids and blue dye is currently considered the most reliable method for the stable detection of SNs in patients with early gastric cancer. New technologies, such as indocyanine green infrared or fluorescence imaging, are also useful for accurate SN mapping in gastric cancer. Theoretically, laparoscopic function-preserving gastrectomy, including partial resection, proximal gastrectomy, segmental gastrectomy, and pylorus-preserving gastrectomy, is feasible in early gastric cancer when the SN(s) is/are nonmetastatic. Our study group conducted a multicenter prospective trial in Japan to evaluate function-preserving gastrectomy with SN mapping for long-term survival and patient quality of life. Non-exposed endoscopic wall-inversion surgery (NEWS) is a new technique for treating gastric cancer with partial resection involving full-thickness resection with endoscopy and laparoscopic surgery without transluminal access. The combination of NEWS and SN biopsy is expected to be a promising, minimally invasive, function-preserving surgery that is ideal for cases of cN0 early gastric cancer.