Evaluation Of Metastatic Lymph Nodes Research Articles

Radiological evaluation of metastatic lymph nodes in carcinoma cervix with emphasis on their infiltrative pattern

Background & objectives:Imaging has been added to the International Federation of Gynecology and Obstetrics (FIGO) 2018 staging system of cervical carcinoma. This study was performed to assess the impact of imaging in staging and to ascertain the prevalence and pattern of nodal metastasis on contrast-enhanced computed tomography (CECT) in patients with cervical carcinoma who were treated based on FIGO 2009 staging system.Methods:This retrospective study was conducted to evaluate all patients with biopsy-proven cervical carcinoma who underwent CECT of abdomen at a tertiary cancer centre in north India from April 2017 to April 2019 and for whom either baseline or follow up scans were available. In patients with enlarged or necrotic lymph nodes, the location, size and pattern of infiltration of adjacent organs were recorded.Results:A total of 602 patients of cervical carcinoma had undergone CT during the study period, of whom 138 (22.9%) underwent CT at baseline and 464 (77.1%) patients during follow up. The FIGO (2009) stage distribution at the time of presentation was stage IB: 109 (18.1%); stage IIA: 14 (2.3%), stage IIB: 118 (19.6%), stage IIIA: 12 (2%), stage IIIB: 277 (46%), stage IVA: 20 (3.3%) and stage IVB: 52 (8.6%). Ninety of the 138 (65.22%) patients underwent a stage shift according to the FIGO 2018 because of the presence of enlarged lymph nodes at baseline scan. Sixteen (2.7%) patients had infiltrative nodal masses most commonly involving the blood vessels (n=14) followed by ureter (n=8), bones (n=5), muscle and bowel (n=3, each). The majority (14/16) of these patients presented with vague abdominal pain, discomfort and vomiting, while two had bone pain.Interpretation & conclusions:CECT at baseline helps in accurately assessing the stage in cervical carcinoma. It helps in the identification of lymph node metastasis in cervical carcinoma, which is crucial for guiding accurate management.

Clinical Outcome of Fine Needle Aspiration Cytology and Washout Thyroglobulin in Suspicious Lymph Nodes in Differentiated Thyroid Carcinoma: Discordant Results in Real-World Practice

Background and Objectives: Fine needle aspiration cytology (FNAC) combined with washout thyroglobulin (Tg) measurement is the gold standard for the evaluation of metastatic lymph nodes (LNs) in thyroid cancer. However, few studies have assessed the clinical outcomes of discordant results between FNAC and washout Tg based on surgery status and follow-up imaging in real-world practice. Materials and Methods: A total of 707 LNs in 512 patients who underwent FNAC and washout Tg measurements from 2015 to 2017 were analyzed. The final LN outcomes were confirmed through postoperative histology, or through metastatic FNAC findings combined with high washout Tg level, follow-up imaging studies, or repeat FNA, if LNs were not dissected. Results: The cut-off values of washout Tg for indicating LN metastasis in preoperative and postoperative LNs were 9.6 ng/mL and 2.1 ng/mL. The diagnostic accuracy was improved by applying washout Tg according to surgery status and the results of discordant rate was reduced, Discordant between results of FNAC with washout Tg and final outcome were 9.2% (27/295) of preoperative LNs and 8.7% (36/412) of postoperative LNs. Due to inconclusive results, unnecessary neck dissection can occur in 13.9% (36/259 dissected cases). Conclusion: To improve diagnostic accuracy, cut-off values of washout Tg should be applied depending on surgery status. New biomarkers in washout fluid is necessary to resolve discordant findings.

Evaluation of Metastatic Lymph Nodes in Oral Squamous Cell Carcinoma: A Comparative Study of Clinical, FNAC, Ultra Sonography and Computed Tomography with Post Operative Histopathology.

All the head and neck tumours, more than 90% are squamous cell carcinomas (SCC). The presence of metastatic cervical lymph nodes histologically positive for SCC provides one of the simplest and most important prognostic factor in patients with head and neck cancer. In this study, all patients were examined clinically for, location, number, size, shape, consistency and fixation of cervical neck nodes to the underlying structure, and the same was carried out by FNAC, USG and CT. Findings of these modalities and histopathological results were compared for the overall metastases of lymph nodes in the neck. The accuracy of clinical examination was 87.77% and sensitivity only 41.66%. FNAC has the greatest specificity, 98.71% and least sensitivity, 33.33%. The accuracy of FNAC was 90%. The positive predictive value and negative predictive value of FNAC were 80.0% and 90.58% respectively. USG revealed 50% of sensitivity. Specificity of USG was 93.58% and accuracy 87.77%. CT scan have the highest sensitivity among all other tests, 66.66%.The negative predictive value for CT scan was also the highest, 94.59%. Specificity and accuracy of CT scan was 89.74% and 86.66% respectively. This study concludes that USG with FNAC is the most accurate in evaluating metastatic lymph nodes in oral squamous cell carcinoma patients along with other investigations like CT scan for staging of the oral squamous cell carcinoma.

Evaluation of metastatic lymph nodes in cN0 thoracic esophageal cancer patients with inconsistent pathological lymph node diagnosis

BackgroundPreoperative clinical diagnosis of lymph node (LN) metastasis and subsequent pathological diagnosis are often not in agreement. Detection of false-negative LNs is essential in selecting an optimal treatment strategy, and most importantly, the presence of false-negative LN is itself a significant prognostic indicator. Therefore, at present, there is an urgent need to establish more accurate and individualized evaluation methods for LN metastasis.MethodsOf 213 cN0 patients who underwent curative esophagectomy without preoperative neoadjuvant treatment, 60 (28%) had LN metastasis diagnosed pathologically. There were 129 false-negative LNs, of which 85 were detectable by preoperative computed tomography (CT). We retrospectively investigated the distribution, frequency, and characteristics of pathologically positive nodes in patients with clinically N0 esophageal cancer.ResultsThe paracardial region was the most frequent region of false-negative LNs, accounting for 26% (22 LNs) of the total incidence. False-negative LNs distributed widely from the neck to the abdomen in patients with a primary tumor in the middle thoracic esophagus. In patients with a primary tumor in the lower thoracic esophagus, four false-negative LNs were detected in the superior mediastinum. When the short-axis diameter, shape, and attenuation patterns of the LNs were used as criteria for metastasis diagnosis, they were insufficient for an accurate diagnosis. However, false-negative LNs in the most frequently occurring sites are characterized by smaller short-axis, suggesting that accurate diagnosis cannot be made unless the diagnostic criteria for the short-axis are reduced in addition to shape and attenuation.ConclusionsAlthough restrictive to the most frequent regions of false-negative LNs occur, reducing size criterion and consideration of their shape and attenuation may contribute to improved diagnosis.

Cervical Lymph Node Evaluation in Oral Squamous Cell Carcinoma Patients Using Ultrasound-Guided Fine-Needle Aspiration Cytology - A Descriptive Diagnostic Evaluation Study in a Tertiary Care Center.

Background:Oral cancer is the most frequent type of cancer of the head and neck area, with squamous cell carcinoma (SCC) being the most common single entity. Worldwide, oral cancer accounts for 2%–4% of all cancer cases, the prevalence being highest in India. Lymph node metastases occur in about 40% of patients with oral cancer. Clinically, their manifestations are hidden in rates of 15% to 34%. More accurate imaging techniques can reduce the risk of undiagnosed metastasis. Ultrasonography has gained wide acceptance as a diagnostic aid in the evaluation of reactive and metastatic lymph nodes. The present study is an attempt to assess the earliest evaluation of the cervical lymph nodes by ultrasound-guided fine-needle aspiration cytology (FNAC).Methodology:A descriptive diagnostic evaluation study was carried out to find out the sensitivity and specificity of ultrasound-guided FNAC in detecting metastasis to cervical lymph nodes from oral SCC in the Department of Oral Medicine and Radiology, Government Dental College, Thiruvananthapuram, in collaboration with the Department of Imageology, Regional Cancer Centre, Thiruvananthapuram during the time period from July 2015 to September 2016.Results:A total of 112 patients with histologically proven oral SCC having palpable lymph nodes were evaluated clinically and ultrasonographically. In this study, sensitivity and specificity of >90% were obtained for ultrasonographic criteria such as the long axis to short axis ratio <2, the absence of hilum, heterogeneous architecture, and altered vascularity in the evaluation of metastatic lymph nodes. The diagnostic yield in the detection of metastatic lymph nodes was much higher in the ultrasonographic examination.Conclusion:Ultrasound-guided FNAC offers an opportunity to enhance patient prognosis through early detection and a specific diagnosis (92.5%) when compared to clinical examination (78.6%) in the current study.

Artificial intelligence system of faster region-based convolutional neural network surpassing senior radiologists in evaluation of metastatic lymph nodes of rectal cancer.

Background:An artificial intelligence system of Faster Region-based Convolutional Neural Network (Faster R-CNN) is newly developed for the diagnosis of metastatic lymph node (LN) in rectal cancer patients. The primary objective of this study was to comprehensively verify its accuracy in clinical use.Methods:Four hundred fourteen patients with rectal cancer discharged between January 2013 and March 2015 were collected from 6 clinical centers, and the magnetic resonance imaging data for pelvic metastatic LNs of each patient was identified by Faster R-CNN. Faster R-CNN based diagnoses were compared with radiologist based diagnoses and pathologist based diagnoses for methodological verification, using correlation analyses and consistency check. For clinical verification, the patients were retrospectively followed up by telephone for 36 months, with post-operative recurrence of rectal cancer as a clinical outcome; recurrence-free survivals of the patients were compared among different diagnostic groups, by methods of Kaplan-Meier and Cox hazards regression model.Results:Significant correlations were observed between any 2 factors among the numbers of metastatic LNs separately diagnosed by radiologists, Faster R-CNN and pathologists, as evidenced by rradiologist-Faster R-CNN of 0.912, rPathologist-radiologist of 0.134, and rPathologist-Faster R-CNN of 0.448 respectively. The value of kappa coefficient in N staging between Faster R-CNN and pathologists was 0.573, and this value between radiologists and pathologists was 0.473. The 3 groups of Faster R-CNN, radiologists and pathologists showed no significant differences in the recurrence-free survival time for stage N0 and N1 patients, but significant differences were found for stage N2 patients.Conclusion:Faster R-CNN surpasses radiologists in the evaluation of pelvic metastatic LNs of rectal cancer, but is not on par with pathologists.Trial Registration:www.chictr.org.cn (No. ChiCTR-DDD-17013842)

Accuracy of F-18 FDG PET/CT with optimal cut-offs of maximum standardized uptake value according to size for diagnosis of regional lymph node metastasis in patients with rectal cancer

BackgroundThe low sensitivity of F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for the evaluation of metastatic lymph nodes (LNs) is mainly due to the partial volume effect in patients with rectal cancer. This retrospective study evaluated the diagnostic accuracy of F-18 FDG PET/CT with optimal cut-off values of the maximum standardized uptake value (SUVmax), according to LN size, for the evaluation of regional LN in rectal cancer patients.MethodsThis study included 176 patients with rectal cancer who underwent F-18 FDG PET/CT for initial staging. Patients were classified based on the long-axis diameter of the regional LN on CT images as small (≤ 7 mm; n = 118) and large (> 7 mm; n = 58) LN groups. The optimal cut-off value of SUVmax was determined for each group, using receiver operating characteristic curve analysis. Areas under the curve (AUC) were compared by C-statistics using two methods: the cut-off value of SUVmax optimized according to LN size, and a fixed SUVmax cut-off value of 2.5.ResultsThe optimal cut-off values of SUVmax for the small and large LN groups were 1.1, and 2.1, respectively. The sensitivity, specificity, and accuracy of F-18 FDG PET/CT using the optimal cut-off values were 90.6, 70.9, and 76.3% in the small LN group, and 68.6, 78.3, and 72.4% in the large LN group. The sensitivity, specificity, and accuracy of F-18 FDG PET/CT using the fixed cut-off value were 18.8, 100, and 78.0% in the small LN group, and 51.4, 87.0, and 65.5% in the large LN group. The AUC was significantly higher using the optimal cut-off values than the fixed cut-off value (0.808 vs. 0.594, p = 0.005) in the small LN group, but not in the large LN group (0.734 vs. 0.692, p = 0.429).ConclusionsApplication of the lower cut-off value of SUVmax improves the diagnostic performance of F-18 FDG PET/CT for the evaluation of small regional LNs in patients with rectal cancer.

Detection of Lymph Node Metastases in Human Colorectal Cancer by Using 5-Aminolevulinic Acid-Induced Protoporphyrin IX Fluorescence with Spectral Unmixing

Accurate evaluation of metastatic lymph nodes (LNs) is indispensable for adequate treatment of colorectal cancer (CRC) patients. Here, we demonstrate detection of metastases of human CRC in removed fresh LNs using 5-aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) fluorescence. A spectral unmixing method was employed to reduce the overlap of collagen autofluorescence on PpIX fluorescence. A total of 17 surgery patients with advanced CRC were included in this study. After 5-ALA at a dose of 15 mg/kg of body weight was applied orally 2 h prior to surgery, 87 LNs were subjected to spectral fluorescence imaging and histopathological diagnosis, and statistical analysis was performed. No apparent side effect was observed to be associated with 5-ALA administration. The spectral unmixing fluorescence intensity of PpIX in metastatic LNs was 10.2-fold greater than that in nonmetastaic LNs. The receiver-operating-characteristic (ROC) analysis showed that the area under the curve (AUC) was calculated as 0.95. Our results show the potential of 5-ALA-induced PpIX fluorescence processed by spectral unmixing for detecting metastases in excised fresh LNs from patients with CRC, suggesting that this rapid and feasible method is applicable to gross evaluation of resected LN samples in pathology laboratories.

Diagnostic histological features of metastatic lymph nodes in adenosquamous carcinoma

Laryngeal adenosquamous carcinoma (ASC) is a rare malignancy, and the problems in true diagnosis of this entity are well known. In this paper, we describe a case of ASC and discuss its distinct histopathology in metastatic lymph nodes. A heavy smoker man presented with a progressive neck mass. Based on incisional biopsy, diagnosis of squamous cell carcinoma (SCC) was made and total laryngectomy with bilateral radical neck dissection was performed. Sections of primary tumor showed a well-differentiated SCC. However, lymph node metastases had a distinct feature of glandular structures. Further investigation with Mayer's mucicarmine stain confirmed the presence of rare scattered glands in primary tumor and the final diagnosis was changed to ASC. Adenosquamous carcinoma is a distinct entity and must be distinguished from the common SCC of larynx. As a result, when a lesion with diagnosis of squamous cell carcinoma shows evidence of glandular differentiation in a subsequent biopsy or in nodal metastases, more investigation is necessary. Moreover, the glandular structures in primary tumor, as in this case, may be rare and inconspicuous. Therefore, we suggest the precise evaluation of metastatic lymph nodes for any laryngeal tumor with diagnosis of SCC. This helps to make appropriate therapeutic decisions with respect to the aggressive behavior of ASC and its high propensity for lymph node metastasis.

Which is important in the evaluation of metastatic lymph nodes in head and neck cancer: palpation, ultrasonography, or computed tomography?

Objective Evaluate palpation, ultrasonography (USG), and computed tomography (CT) with respect to their value for comparative determination of metastatic lymph nodes in head and neck cancer. Study design A prospective study was conducted in a tertiary referral hospital. During September 1996 and April 1999, clinical investigation, USG, and CT were performed preoperatively on 48 patients who would undergo neck dissection for primary head and neck malignancy. The presence of metastatic lymph nodes in pathologic specimens were compared with the findings of palpation, CT, and USG. Results Twenty-two of the patients had positive lymph nodes on pathologic investigation. The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy for palpation are 64%, 85%, 74%, 78%, and 75% respectively. Respective values for USG and CT for sensitivity, specificity, negative predictive value, positive predictive value, and accuracy are 72%, 96%, 80%, 94%, and 85% and 81%, 96%, 85%, 90%, and 87%. Conclusion All of the pretreatment evaluation methods, palpation, CT, and USG yield results that are significantly different from the histopathologic results, suggesting that no pretreatment study can accurately assess the requirement to histopathologically stage the neck. USG findings are more correlated with the pathologic findings than palpation, but CT gives the most effective and reliable results when it is combined with USG in neck staging. Preoperative USG and CT scanning of the neck by an experienced radiologist is essential and useful for diagnosis, staging, and therapy choices. Significance Statistical analysis was done with χ 2 test. The difference between histologic findings and palpation is significant ( P = 0.0005). The difference between histologic findings and USG and CT is significant ( P = 0.0001 and P = 0.0001).

Does Famotidine Enhance Tumor Infiltrating Lymphocytes in Breast Cancer?

Thirty patients with breast cancer were prospectively randomized into case and control groups receiving 40 mg famotidine preoperatively for 10-14 days and routine premedication, respectively. Surgical specimens were evaluated objectively for tumor infiltrating lymphocytes in the center and in the periphery of the tumor along with evaluation of metastatic lymph nodes for reactive changes. Ten famotidine-treated cases (67%) showed significant lymphocytic infiltration in the center compared to 4 controls (27%) (p =0.03). Eleven cases (77%) had significant lymphocytic infiltration in the periphery (p =0.03) compared to 5 controls (33%). Considering both sites, lymphocytic response was significant in 9 (60%) cases as opposed to only 3 (20%) controls (p =0.03). This response did not correlate with the stage, grade of tumor or menopausal status of patients in either group. Seventy-eight percent (78%) of the cases showed significant reactive changes in the metastatic lymph nodes as compared to 22% in controls (p <0.01). This study suggests that famotidine enhances tumor infiltrating lymphocytes in breast cancer and might have potential as an immunomodulator. A larger confirmatory study is suggested.