Excised Lymph Nodes Research Articles

Thyroglobulin Measurement in the Fine-Needle Aspiration Washout for Diagnosing Cervical Lymph Node Metastasis in the Patients with Differentiated Papillary Thyroid Cancer

Purpose: We wanted to evaluate the utility of thyroglobulin measurement in the washout of the needle (FNATg) used for fine needle biopsy for detecting lymph node metastasis in patients with differentiated papillary thyroid carcinoma (DPTC). Materials and Methods: We performed ultrasonography-guided fine-needle aspiration cytology (FNAC) and FNA-Tg for 50 ultrasonographically suspicious lymph nodes in 45 DPTC patients. Eighteen patients underwent thyroidectomy before FNA and the remaining 27 patients underwent fine-needle aspiration prior to surgery. The final diagnoses were determined based on the results of histological examination of the excised specimens (n=21) or on the follow-up examination that was done least 12 months after surgery. Results: Lymph node metastases were confirmed in 19 patients. FNAC detected 14 metastatic lymph nodes in 14 patients, and FNA-Tg detected 18 metastatic lymph nodes in 18 patients. While none of 3 cystic lymph nodes metastasis was detected via FNAC, they all revealed positive results via FNA-Tg. One patient with a negative result on both methods had one metastatic lymph node among 9 excised lymph nodes, and this one node had not been sampled via FNAC or FNA-Tg. The sensitivities and specificities of FNAC and FNA-Tg were 73.6% (14/19) and 100% (27/27), and 94.7% (18/19) and 96.2% (26/27), respectively. Conclusion: FNA-Tg is a useful technique for the early detection of lymph node metastasis, and especially for detecting cystic lymph node metastasis in patients with DPTC.

Keratoacanthoma-like Cutaneous Metastasis of Lung Cancer: a Learning Point

A 58-year-old woman was admitted to our department with a tumour of the scalp. On admission, a 4 cm diameter, round, hard, red tumour with a central keratin plug was observed. During the 10-month period of development of the lesion no ulceration was seen within the tumour. The lesion clinically resembled keratoacanthoma (Fig. 1). Moreover, enlargement of the right supraclavicular lymph node was diagnosed. The patient has also suffered from psoriasis vulgaris, which had been treated in the past with topical agents, including tar preparations and phototherapy (narrowband UVB 311 nm). Moreover, she smoked more than 40 cigarettes per day for over 20 years. Biopsy of the skin lesion surprisingly revealed a metastatic carcinoma consisting of intermediate cells (Fig. 2A). The tumour cells were positive for epithelial membrane antigen (Fig. 2B), CAM 5.2 pancytokeratin marker (Fig. 2C) and chromogranin A (Fig. 2D). Moreover, metastases were also detected in the excised lymph node. Additionally, histological examination confirmed that the central plug consisted mainly of keratin and epithelial cells. On admission, routine laboratory examination revealed slight leukocytosis (10500/mm3), hyperglycaemia Keratoacanthoma-like Cutaneous Metastasis of Lung Cancer: a Learning Point

Intraoperative Sentinel Node Detection Improves Nodal Staging in Invasive Bladder Cancer

We evaluated intraoperative SN detection in patients with invasive bladder cancer during radical cystectomy in conjunction with extended lymphadenectomy. A total of 75 patients with invasive bladder cancer underwent radical cystectomy with extended lymphadenectomy. SNs were identified by preoperative lymphoscintigraphy, intraoperative dynamic lymphoscintigraphy and blue dye detection. An isotope (70 MBq (99m)Tc-nanocolloid) and Patent Blue(R) blue dye were injected peritumorally via a cystoscope. Excised lymph nodes were examined ex vivo using a handheld gamma probe. Identified SNs were evaluated by extended serial sectioning, hematoxylin and eosin staining, and immunohistochemistry. At lymphadenectomy an average of 40 nodes (range 8 to 67) were removed. Of 75 patients 32 (43%) were lymph node positive, of whom 13 (41%) had all lymph node metastases located only outside of the obturator spaces. An SN was identified in 65 of 75 patients (87%). In 7 patients an SN was recognized when the nodal basins were assessed with the gamma probe after lymphadenectomy and cystectomy. Of the 32 lymph node positive cases 26 (81%) had a positive (metastatic) SN. Thus, the false-negative rate was 6 of 32 cases (19%). Five false-negative cases had macrometastases and/or perivesical metastases. In 9 patients (14%) the SN contained micrometastases (less than 2 mm), in 5 of whom the micrometastasis was the only metastatic deposit. SN detection is feasible in invasive bladder cancer, although the false- negative rate was 19% in this study. Extended serial sectioning and immunohistochemistry revealed micrometastases in SNs in 9 patients and radio guided surgery after the completion of lymphadenectomy identified SNs in an additional 7. We believe that the technique that we used in this study improved nodal staging in these 16 of 65 patients (25%).

Long survival after operation for cancer of the lung

A survey is presented of 293 cases of lung cancer operated on by one surgeon over a period of 35 years. Lobectomy was done in 86 cases with a mortality of 3.5 per cent. Simple pneumonectomy was done in 89 cases with a mortality of 20 per cent, and radical pneumonectomy in 118 cases with a mortality of 15-25 per cent. The survival rate after 5 or more years for lobectomy was 41 per cent (34 patients). After simple pneumonectomy 21 patients (30 per cent) lived 5 years or more, and after radical pneumonectomy 39 patients (39 per cent) lived 5 years or more. The survival of the patients in whom the excised lymph nodes were involved by growth is presented. It is pointed out that at least 1 in 3 patients with cancer of the lung treated by operation was alive 5 years later. The very good long term results are presented including the 10-year and 20-year survival rate. Two patients are still alive after 30 and 34 years respectively. One patient is alive 29 years after a lobectomy and 13 years after a contralateral lobectomy for a new primary cancer. A second new cancer occurred in 9 patients. Continuance of smoking is shown to be harmful. The factors affecting the long term freedom from recurrence are discussed. The cell type of the cancer is shown to be important. Squamous-celled growths have the best results and oat-celled and small-celled the worst, although long term survival can follow operation for both these. The occurrence of a pleural infection after operation may be favourable to long term freedom from recurrence and this way probably so in 2 patients who lived 25 and 27 years respectively and 1 patient who is still alive after 34 years. On the whole the evidence is unconvincing that much benefit may follow radiotherapy combined with operation.

Planar Tc99m – sestamibi scintimammography should be considered cautiously in the axillary evaluation of breast cancer protocols: Results of an international multicenter trial

BackgroundLymph node status is the most important prognostic indicator in breast cancer in recently diagnosed primary lesion. As a part of an interregional protocol using scintimammography with Tc99m compounds, the value of planar Tc99m sestamibi scanning for axillary lymph node evaluation is presented. Since there is a wide range of reported values, a standardized protocol of planar imaging was performed.MethodsOne hundred and forty-nine female patients were included prospectively from different regions. Their mean age was 55.1 ± 11.9 years. Histological report was obtained from 2.987 excised lymph nodes from 150 axillas. An early planar chest image was obtained at 10 min in all patients and a delayed one in 95 patients, all images performed with 740–925 MBq dose of Tc99m sestamibi. Blind lecture of all axillary regions was interpreted by 2 independent observers considering any well defined focal area of increased uptake as an involved axilla. Diagnostic values, 95% confidence intervals [CI] and also likelihood ratios (LR) were calculated.ResultsNode histology demonstrated tumor involvement in 546 out of 2987 lymph nodes. Sestamibi was positive in 30 axillas (25 true-positive) and negative in 120 (only 55 true-negative). The sensitivity corresponded to 27.8% [CI = 18.9–38.2] and specificity to 91.7% [81.6–97.2]. The positive and negative LR were 3.33 and 0.79, respectively. There was no difference between early and delayed images. Sensitivity was higher in patients with palpable lesions.ConclusionThis work confirmed that non tomographic Tc99m sestamibi scintimammography had a very low detection rate for axillary lymph node involvement and it should not be applied for clinical assessment of breast cancer.

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma With Trisomy 12 and Focal Cyclin D1 Expression: A Potential Diagnostic Pitfall

Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and mantle cell lymphoma usually are distinctly different in regard to clinical presentation, morphology, immunophenotype, and molecular/genetic findings. In spite of this, select cases may show overlapping characteristics and represent a diagnostic challenge. Cyclin D1 immunohistochemical staining is usually envisioned as a definitive method for resolving this differential diagnosis, with positivity supporting a diagnosis of mantle cell lymphoma. We report a case involving a 58-year-old man with a diagnosis of CLL/SLL for several years. A lymph node excision was performed after increased adenopathy was noted in the cervical region. The excised lymph node showed typical morphologic findings of CLL/SLL, including the presence of characteristic proliferation centers. Cyclin D1 staining, using 3 different antibodies, was present in scattered prolymphocytes and paraimmunoblasts, mostly within proliferation centers. Fluorescence in situ hybridization and conventional cytogenetics demonstrated trisomy 12 and an absence of t(11;14) in lymph node tissue. Focal cyclin D1 expression by immunohistochemistry in nodal CLL/SLL is quite unusual and is discussed as a potential diagnostic pitfall.

The value of frozen section analysis of the sentinel lymph node in clinically N0 squamous cell carcinoma of the oral cavity and oropharynx

To determine the feasibility and accuracy of fine-sectioned frozen-section analysis of the sentinel lymph node (SLN) in cN0 oral cavity and oropharynx squamous cell carcinoma. Thirty-one patients were included and underwent lymphoscintigraphy a day before surgery and marking of the SLN. Intraoperatively, the SLNs were identified using a gamma probe, excised, and analyzed using fine-sectioned frozen section. The remaining SLN tissue was fixed in formalin for further staining and immunohistochemical analysis. An elective neck dissection was performed in all patients and all excised lymph nodes were examined for metastatic disease. SLNs were identified preoperatively by lymphoscintigraphy as well as by gamma probe intraoperatively in all patients. A total of 82 sentinel lymph nodes were excised and analyzed by fine-sectioned frozen section. Micrometastases were found in 16 out of the 82 SLNs, upstaging 14 out of 31 patients (45%) from cN0 to pN+. Furthermore, a total of 1295 lymph nodes from the neck dissection specimens were analyzed, confirming only one more metastatic disease. Sensitivity and negative predictive value of SLN biopsy were 93% and 94% respectively for frozen section analysis. Our study shows that SLN biopsy in cN0 neck of patients with oral cavity and oropharyngeal carcinoma is both feasible and accurate. Provided that larger studies confirm our results, an elective neck dissection may become unnecessary if fine-sectioned frozen-section analysis of the SLN shows no nodal metastases in patients with cN0 oral cavity and oropharynx carcinoma.

Gastric Cancer: Extent of Lymph Node Dissection and Requirements for a Correct Staging

Lymphatic spread is an important prognostic factor in gastric cancer. The TNM classification requires at least 15 lymph nodes to stage and identify three prognostic groups according to the number of metastatic lymph nodes: N1 (1-6), N2 (7-15), N3 (> 15). The aim of this study was to investigate which type of lymph node dissection allows an accurate staging. From 1996 to 2001, we treated 140 gastric cancer patients, 27 with D1 and 113 with D2 dissection. We evaluated lymph node count, status and ratio between metastatic and total number of excised lymph nodes, keeping 20% as the cutoff value. The mean number of lymph nodes was 18 and 33 respectively for D1 and D2 (P < 0.001), 41% of patients in D1 and 5% in D2 had less than 15 lymph nodes (P < 0.001). 59% in D1 and 73% in D2 (P = 0.145) had lymph node metastases, but this incidence decreased to 36% (P = 0.045) and 16% (P < 0.001) respectively for D1 and D2 when less than 15 lymph nodes were available. Considering the ratio between metastatic and total number of lymph nodes, 45% of D1 versus 3% of D2 (P < 0.001) in the N1 group exceeded 20%. D2 lymph node dissection is better than D1 in providing at least 15 lymph nodes required for a correct staging. We confirm the risk of a downstage when less than 15 lymph nodes are available.

In vivo and ex vivo ultrasound, fine needle aspiration and molecular biology of sentinel nodes (SN) in melanoma patients

7522 Background: Final data of a prospective study covering the largest number of SNs examined so far. The recently introduced SN technique allows for detection of micrometastases thus enabling an early staging and characterizing of patients likely to benefit from adjuvant therapies. Method: Over 2 years 136 sentinel nodes of 127 melanoma patients scheduled for sentinel node biopsy (SLND) were examined by in vivo and ex vivo ultrasound (US), fine needle aspiration cytology (FNAC) and tyrosinase RT-PCR. Confirmation by US and measurement of the excised sentinel node. Blood samples of all pts. were tested for tyrosinase by RT-PCR for minimal residual disease. Results: Patients median age 58 yrs., tumor thickness median 3,14mm. 114/127 pts. had 1 SN, 12 pts. 2 SN, 1 patient 3 SN, 1 patient 4 SN. SN size on median 842mm3 in vivo, 714mm3 in vitro. After visualizing and evaluating by US, the SN is punctured and cells are aspirated. FNAC material is partly shock frozen for RT-PCR, partly used for cytology. The excised lymph node was examined by the same procedures. In vivo ultrasound achieved a sensitivity of 78,8% [95% CI.: 61–91] and specificity of 71,6% [95% CI.: 61–81%]. FNAC alone showed a sensitivity of 58,1% [39,1–75,5%] and specificity of 98,7% [92,7–100%]. The in vivo PCR for tyrosinase revealed a sensitivity of 48,5% [30,8–66,5%] and specificity of 97,7% [91,8–99,7%]. By combining all three in vivo methods an overall sensitivity of 81,8% [64,5–93%] and specificity of 71,6% [61–80,7%] was achieved. RT-PCR from peripheral blood reliably depicted pts prior to metastases. Conclusion: US and FNAC is not able to replace SLND with histology, but delivers important additional information prior to SLND since it can identify metastases in all lymph node basins. Patients with positive FNAC may directly undergo elective lymph node dissection, important time is gained. US-FNAC of SN can be performed in all patients refusing operation, in an inoperable status, with a tumor thickness ≤1mm and in departments without know-how of SLND. The method is reproducible, well tolerated, has extremely low risk of spreading tumor cells, infection or other side effects at low cost. No significant financial relationships to disclose.

Cat Scratch Disease

Cat scratch disease presenting as an enlarged submental lymph node in a 5-year-old boy is reported. There was clear history of contact with a cat, raised immunoglobulin G antibody titre against Bartonella henselae, and a granulomatous reaction in the excised lymph node.

VALIDITY OF SENTINEL LYMPH NODE CONCEPT FOR PATIENTS WITH PROSTATE CANCER

We investigated the feasibility and validity of the sentinel lymph node concept for patients with prostate cancer. A total of 24 patients (mean age 68.1 years) with prostate cancer but without detectable distant metastases were enrolled in this study. Radioactive tracer (technetium labeled phytate) was injected into the prostate 5 to 6 hours before surgery. Preoperative lymphoscintigraphy was viewed, and in vivo and ex vivo gamma probing was performed during the surgery, which included backup extended lymph node dissection. Radioactivity of the excised lymph nodes was measured and validated with an autowell scintillation counter. Radioactive positive (hot) nodes were identified in 17 of the 24 (70.8%) patients by lymphoscintigraphy, in 21 of 24 (87.5%) patients by in vivo probing and in 23 of 24 (95.8%) patients by ex vivo probing. On an individual basis the numbers of hot nodes identified by lymphoscintigraphy and in vivo probing were low (40% and 36%, respectively) compared to the high detection rate for ex vivo probing (91%). Although sentinel lymph nodes can be used for prostate cancer, detailed lymph node mapping and extended dissection backup are currently needed. It is also important to establish novel procedures for accurate and complete removal of all hot nodes.

Anatomic Study of Lateral Pelvic Lymph Nodes: Implications in the Treatment of Rectal Cancer

Lateral pelvic lymphadenectomy remains a controversial issue in rectal cancer surgery. Beyond clinical results, disagreement includes surgical anatomy aspects and definitions, as wells as lack of information about location, groups, and number of lymph nodes, all of which makes comparison of results difficult. We performed a systematic examination of the number and distribution of lateral pelvic lymph nodes using cadaveric dissection. Sixteen formalin-fixed cadavers were dissected (14 males). Dissection fields were divided according to the three surgical groups of pelvic wall lymph nodes: presacral, obturator, and hypogastric. Number and site of excised lymph nodes was recorded, noting neurovascular relationships. A total of 458 lymph nodes were found, with a mean of 28.6 nodes per pelvis (range, 16-46). Lymph node size ranged from 2 to 13 mm. The highest number of lymph nodes was found in the obturator fossa group (mean, 7; range, 2-18). Hypogastric lymph nodes were found lying predominantly above the inferior hypogastric nerve plexus but reaching the deep pelvic veins. The mean number of lymph nodes found in lateral pelvic wall compartments was 28.6 per specimen. The group containing most lymph nodes lies in the obturator fossa. Complete excision of hypogastric lymph nodes demands a deep pelvic dissection of neurovascular structures.

Pathologic Quiz Case: A 17-Year-Old Renal Transplant Patient With Persistent Fever, Pancytopenia, and Axillary Lymphadenopathy

17-year-old adolescent boy with end-stage renal disease due to focal segmental glomerulosclerosis underwent a second kidney transplant because of the chronic rejection and loss of the first allograft that he had received 11 years previously. The patient was on several immunosuppressive drugs including FK506 and prednisone. Laboratory studies perioperatively demonstrated pancytopenia, and on the second postoperative day, the patient began to display temperature spikes that reached as high as 398C. The postoperative graft function was excellent. On physical examination, the patient was found to have left axillary lymphadenopathy, which was later confirmed by computerized tomography scanning. Computerized tomography scanning did not demonstrate any other abnormalities. Results of aggressive workups for infectious disease, including blood and urine cultures, cytomegalovirus analysis, and polymerase chain reactions for parvovirus B-19, herpesviruses 6, 7, and 8, and hepatitis serologic studies, were negative. The patient continued to experience temperature spikes despite the discontinuation of some of the immunosuppressive drugs that initially were thought to be the cause of his persistent fever. A biopsy of the axillary lymph node was performed. The excised lymph node measured 2 cm in its greatest dimension and showed a grossly unremarkable cut surface. A microscopic examination of the hematoxylin-eosin‐stained sections demonstrated confluent nodular areas containing proliferation of the vessels of various sizes and

Kikuchi-Fujimoto Disease in Nepal: A Study of 6 Cases

Kikuchi-Fujimoto disease is a benign disorder, predominantly affecting young women with a predilection for cervical lymphadenopathy. Although the disease has been recognized worldwide, to our knowledge no cases have been reported previously from Nepal. To determine the prevalence of Kikuchi-Fujimoto disease in Nepal and to analyze clinicopathologic features. We reviewed 6 cases of Kikuchi-Fujimoto disease recorded at 3 different hospitals in Nepal during a period from June 1998 to June 2002. Clinical data and histopathology are presented. This study included 5 females and 1 boy, aged 13 to 32 years. These patients presented with prolonged fever and lymphadenopathy. The 5 female patients had cervical lymphadenopathy, and the boy had axillary lymphadenopathy. Complete blood counts revealed raised erythrocyte sedimentation rates in all patients and anemia in 2 patients. The size of excised lymph nodes (in greatest dimension) ranged from 1.5 to 5 cm. Typical histologic features were seen, namely, architectural effacement due to presence of pale nodular lymphohistiocytic foci with karyorrhectic debris, coagulation necrosis, eosinophilic debris, and absence of granulocytic infiltration. In a follow-up of the cases, disease recurrence was not found. Our study emphasizes that Kikuchi-Fujimoto disease should be considered as one of the differential diagnoses in patients with prolonged fever and cervical lymphadenopathy and that it should be differentiated from tuberculous lymphadenitis in regions where tuberculosis is prevalent.

Near-infrared fluorescence imaging of lymph nodes using a new enzyme sensing activatable macromolecular optical probe.

The aim of this study was to validate the use of near infrared fluorescence imaging (NIRF) using enzyme-sensitive optical probes for lymph node detection. An optical contrast probe that is activated by cystein proteases, such as cathepsin B, was used to visualize lymph nodes by NIRF reflectance imaging. In order to quantitate the uptake of the optical probe in lymphatic tissue, the biodistribution was assessed using the Indium-111 labeled optical probe. Sixteen Balb-c mice were injected either intravenously (i.v.) or subcutaneously (s.c.) with the NIRF-probe (2 micromol cyanine (Cy)/animal; i.v., n=10; s.c., n=6) and imaged 24 h after injection. Signal intensities and target-to-background ratios of various lymph nodes were measured by manual regions of interest (ROIs). Additional signal intensity measurements were performed of excised lymph nodes (n=21) from i.v. injected mice (24 h after injection) and compared with excised lymph nodes (n=8) of non-injected mice. The probe employed in this study was lymphotropic with approximately 3-4% accumulation in lymph nodes (3.4+/-0.8% ID/g). Measurements of the excised lymph nodes (after i.v. injection) confirmed a significant increase in lymph node fluorescence signal from baseline 26+/-7.6 arbitary units (AU) to 146+/-10.9 AU (p<0.0001). A significant increase in lymph node fluorescence signal was also seen in vivo throughout the body after i.v. injection (96+/-7.8 AU) and/or regionally after s.c. injection (141+/-11.5 AU) in comparison with baseline autofluorescence (26+/-7.6 AU). Target-to-background ratio was significantly higher after s.c. injection (6.6%+/-0.81) compared with i.v. injection (4.8+/-0.67%). Detection and visualization of lymph nodes is feasible by NIRF imaging using a cystein-protease sensitive optical probe.

Lymph node grading for staging of mycosis fungoides may benefit from examination of multiple excised lymph nodes

Background: Lymph node (LN) histopathologic class has been shown to be a significant determinant of survival in patients with mycosis fungoides. Often, histopathologic evaluation of just 1 node is used in staging patients with cutaneous T-cell lymphoma. Objective: We examined whether sampling multiple nodes alters the staging and prognostic group placement of patients with mycosis fungoides as compared with sampling just 1 node. Methods: Multiple LNs were obtained from a single, local region for histopathologic evaluation and grading in 8 patients with mycosis fungoides. Results: Differences in histopathologic grading using multiple nodes were found in 5 of 8 patients. There was a potential upstaging of the assigned disease stage, compared with the stage that might have been assigned had just 1 node been sampled, in 3 patients. The differences in LN grading also potentially led to differences in prognostic group placement in 4 patients. Conclusion: Determining histopathologic grades from multiple LNs may allow a more accurate stage and prognosis to be assigned to patients. (J Am Acad Dermatol 2003;48:702-6.)

Extent of Pelvic Lymphadenectomy and Its Impact On Outcome in Patients Diagnosed With Bladder Cancer: Analysis of Data From the Surveillance, Epidemiology and End Results Program Data Base

The benefit of pelvic lymphadenectomy in patients with bladder cancer remains controversial. We analyzed the impact of lymphadenectomy on disease specific survival in a population based sample of patients with bladder cancer who underwent radical cystectomy. Analysis included data on 1,923 patients who underwent radical cystectomy for bladder cancer between 1988 and 1996 obtained from the Surveillance, Epidemiology and End Results program cancer registry. We analyzed the impact of the number of lymph nodes examined, number of positive lymph nodes and ratio of positive-to-total number of lymph nodes resected on disease specific and overall survival independent of patient age, gender, stage, race, radiation and chemotherapy. Median followup in cystectomy cases was 63.5 months (range 0 to 131). Patients with 0 to 3 lymph nodes examined were at significantly higher risk of death from bladder cancer than those with greater than 3 (HR 1 to 1.2 versus 0.41 to 0.58). Patients with stages I/in situ, III and IV disease benefited from more extensive lymphadenectomy. In stage IV cases, while the total number of positive lymph nodes removed did not correlate with increased survival, the proportion of excised lymph nodes positive for metastatic bladder cancer tended to correlate with the risk of death from the disease. These results indicate significantly increased survival rates after cystectomy in patients with bladder cancer diagnosed with stages III or IV disease who have relatively more lymph nodes examined, suggesting that even some with higher stage disease may benefit from extended pelvic lymphadenectomy at cystectomy.

The effect of changing gamma count threshold on sentinel lymph node accuracy

PURPOSE: Sentinel lymph node (SLN) biopsy has been increasingly accepted in many centers as an alternative to axillary lymph node dissection in the nodal staging of breast cancer. The goal of SLN biopsy is to accurately stage the axilla while minimizing postoperative morbidity. Theoretically, the continuing search for SLNs disrupts additional lymphatics and impacts on operative time. The gamma count threshold is a predefined threshold percentage of the ex vivo count of the “hottest” SLN, which when applied to each individually excised lymph node determines whether a given lymph node is the SLN or a non-SLN. The higher the threshold percentage, the less the number of lymph nodes will meet the criteria of being an SLN. This study examines the hypothesis that changing the gamma count threshold from 10% to 50% will not significantly affect accuracy or the false-negative rate. METHODS: We retrospectively reviewed the charts of patients who underwent SLN biopsy with or without completion axillary lymph node dissection from March 1995 to January 2001 at Walter Reed Army Medical Center. Data were collected on gamma counts for each SLN and histopathology of each SLN. For each SLN ex vivo gamma count, percentage of the ex vivo gamma count of the “hottest” SLN was calculated. RESULTS: The SLN identification success rate was 94% (163 out of 174 patients). On average, 2.07 SLNs were removed per patient and 58% of patients had more than 1 SLN removed (94 out of 163 patients). Only 10% had 4 or more SLNs removed (17 out of 163 patients). Sentinel lymph node metastasis was found in 21% of patients (35 of 163 patients). Of these 35 patients with positive SLNs, 8 patients had a negative “hottest” SLN when a less radioactive SLN was positive for metastasis. Changing the gamma count threshold from 10% to 50% lowers the extrapolated accuracy from 98% to 95% and increases the extrapolated false-negative rate from 8% to 21%. CONCLUSIONS: The accuracy and false-negative rate of SLN biopsy varies based on the lower limit gamma threshold. Maintaining our 10% gamma count threshold results in acceptable accuracy and false-negative rates comparable to reported literature.

Laparoscopic staging of endometrial cancer using laparosonic instruments: comparison with electrosurgery

Objective: To compare perioperative parameters in two groups of women with different laparoscopic operative techniques in surgical staging of endometrial cancer (EC). Study design: Thirty randomly allocated and laparoscopically treated women with EC. Fifteen patients were operated by electrosurgery, 15 patients by laparosonic operative technique. Differences between the two groups were determined by the Wilcoxon rank-sum test. Probability ( P) of less than 0.05 was considered significant. Setting: Department of Gynecology and Obstetrics, Endoscopic Training Center, Baby Friendly Hospital, Kladno, Czech Republic. Results: Laparoscopy was successfully completed in 29 patients. Laparoscopy-assisted surgical staging of EC was performed based on the tumor grade and the depth of myoinvasion. In both groups, in total 18 and 5 women underwent pelvic lymphadenectomy (PLN) and infra-aortic lymph node sampling (IALS), respectively. Three patients had metastases in pelvic lymph nodes. In the electrosurgical hemostasis and laparosonic group the mean total time required to finish the whole operative procedure were 132.1 and 138.3 min, respectively, with no statistically significant difference ( P=0.96). There were no significant differences between the groups in any intraoperative or postoperative follow-up variables, except for the number of excised lymph nodes where the difference between electrosurgery and laparosonic group (12.7 versus 18) was statistically significant ( P=0.05). In one patient with intraoperative venous bleeding the laparosonic hemostasis was ineffective (successful procedure rate 93.3%). One patient from the electrosurgery group was converted to laparotomy due to injury to the epigastric vessels. This complication had no connection with the surgical techniques studied. Conclusion: It is concluded that both operative technique variants in laparoscopy-assisted surgical staging appear to be feasible and effective for patients with EC.

LYMPHATIC MAPPING AND DETECTION OF SENTINEL NODES IN PATIENTS WITH BLADDER CANCER

We examined the possibility for detecting sentinel nodes in patients with bladder cancer and whether the histopathological status of identified sentinel nodes reflected that of the lymphatic field. A total of 13 patients with bladder cancer who met the criteria qualifying them for radical cystectomy had intravesical injections of radioactive tracer and blue dye marker around the tumor followed by lymphoscintigraphy to visualize lymphatic drainage and detect sentinel nodes. Sentinel nodes were identified preoperatively by the blue color and increased radioactivity and were compared histopathologically with other routinely excised lymph nodes. Sentinel nodes were detected in 85% (11 of 13) of patients. There were 4 patients who had sentinel nodes containing tumor cells, and each metastasis was only seen in the detected sentinel node. There were no false-negative sentinel nodes. Of the metastatic sentinel nodes 3 were located outside the normally excised lymph nodes of the obturator fossa. Sentinel nodes can be detected in patients with bladder cancer. The histopathological status of the identified sentinel nodes was diagnostic for all other excised lymph nodes. Sentinel nodes often seem to be located outside the obturator lymphatic field, which is normally examined during preoperative staging of bladder cancer.