Groin Node Research Articles

Outcomes of Prophylactic Inguinal Lymph Node Dissection in Malignancies of Lower Limb.

To evaluate the role of early prophylactic inguinal node dissection in patients with squamous cell cancer and melanoma of lower limb. From 2008 to 2018, a Tertiary Care Hospital connected to a teaching institute served as the site of this retrospective observational study. Patient records were gathered with the purpose of gathering clinical, investigative, surgical, pathological and follow-up information. We included 33 patients in this analysis out of the 47 patients we treated ourselves between 2008 and 2018; among these 33 patients, 21 (63.63%) had palpable inguinal nodes at the time of primary presentation. All 21 patients' FNAC tests were positive for metastases, in 16 patients (76.19%). 5 patients on FNAC (23.80%) exhibited not metastases. The remaining 12 patients did not have enlarged lymph nodes at the time of their initial presentation. Patients who did not have palpable lymph node were given the option of having a modified inguinal block dissection. 8 patients with metastatic disease have nodes that are positive in histology. In addition, out of 5 patients with negative nodes 4 (80%) showed evidence of metastasis. The conclusion of this retrospective observational study is that although palpable lymph nodes in groin are unquestionably a sign that inguinal nodes should be dissected, prophylactic lymph node dissection should be still done even if nodes are not palpable or provide a negative FNAC result. Given that delayed lymphadenectomy has a significant effect on survival, delaying inguinal lymphadenectomy in non-palpable nodes could cause you to lose the battle against cancer in your lower limb. The related surgical morbidity is the only downside to prophylactic lymph node dissection. This can, however, be effectively decreased with a modified inguinal lymphadenectomy operation.

Conservative Management of Vulvar Cancer-Where Should We Draw the Line?

Vulvar cancer is a rare disease, and cure rates were low until the mid-20th century. The introduction of an en bloc radical vulvectomy and bilateral groin and pelvic lymph node dissection saw them rise from 15-20% to 60-70%. However, this very radical surgery was associated with high physical and psychological morbidity. Wounds were usually left open to granulate, and the average post-operative hospital stay was about 90 days. Many attempts have been made to decrease morbidity without compromising survival. Modifications that have proven to be successful are as follows: (i) the elimination of routine pelvic node dissection, (ii) the use of separate incisions for groin dissection, (iii) the use of unilateral groin dissection for lateral, unifocal lesions, (iv) and radical local excision with 1 cm surgical margins for unifocal lesions. Sentinel node biopsy with ultrasonic groin surveillance for patients with node-negative disease has been the most recent modification and is advocated for patients whose primary cancer is <4 cm in diameter. Controversy currently exists around the need for 1 cm surgical margins around all primary lesions and on the appropriate ultrasonic surveillance for patients with negative sentinel nodes.

Enhanced Prognostic Factors for Disease-Free Survival in Penile Squamous Cell Carcinoma: Insights From Songklanagarind Hospital

ObjectiveThis study aimed to investigate disease-free survival (DFS) outcomes and associated prognostic factors among surgically treated penile cancer patients at Songklanagarind Hospital, Thailand, over a 20-year period. MethodsA retrospective analysis was conducted on 208 primary penile cancer patients treated between January 2001 and December 2022. Disease-free survival was assessed using Kaplan-Meier survival curves, and Cox proportional hazard models were employed for multivariate analysis. ResultsAll of patients (100%) were squamous cell carcinoma of penis, with 38.9% having T1 tumors, 70.7% well-differentiated tumors, and 32.6% diagnosed at stage III. The recurrence rate was 16.8%, with a mean time to recurrence of 25.9 months. Disease-free survival rates at 1, 3, and 5 years were 82.1%, 72%, and 70.2%, respectively. Median overall survival was 18.2 months, with rates at 1, 3, and 5 years at 68.7%, 44.7%, and 36.4%, respectively. Significant associations were found between disease-free survival and higher T stage, clinical chronic inflammation, delayed onset of symptoms, primary lesion location, groin node metastasis, lymphovascular invasion, and pelvic lymph node metastases. However, multivariate analysis revealed that higher primary tumor stage (T) was the only independent prognostic factor for disease-free survival. ConclusionThis study provides valuable insights into disease-free survival outcomes in penile cancer treatment at a single institution over an extended period. Higher pathologic T stage emerged as the sole independent prognostic factor for disease-free survival. Further validation through large-scale prospective studies is warranted.

Detection of metastatic lymph node and sentinel lymph node mapping ​using mannose receptor targeting in in vivo mouse footpad tumor models and rabbit uterine cancer models.

This study aimed to evaluate the effectiveness of neo-mannosyl human serum albumin-indocyanine green (MSA-ICG) for detecting metastatic lymph node (LN) and mapping sentinel lymph node (SLN) using mouse footpad uterine tumor models. Additionally, the authors assessed the feasibility of MSA-ICG in SLN mapping in rabbit uterine cancer models. The authors compared the LN targeting ability of MSA-ICG with ICG. Six mouse footpad tumor models and two normal mice were each assigned to MSA-ICG and ICG, respectively. After the assigned tracers were injected, fluorescence images were taken, and the authors compared the signal-to-background ratio (SBR) of the tracers. A SLN biopsy was performed to confirm LN metastasis status and CD206 expression level. Finally, an intraoperative SLN biopsy was performed in rabbit uterine cancer models using MSA-ICG. The authors detected 14 groin LNs out of 16 in the MSA-ICG and ICG groups. The SBR of the MSA-ICG group was significantly higher than that of the ICG group. The metastatic LN subgroup of MSA-ICG showed a significantly higher SBR than that of ICG. CD206 was expressed at a high level in metastatic LN, and the signal intensity difference increased as the CD206 expression level increased. SLN mapping was successfully performed in two of the three rabbit uterine cancer models. MSA-ICG was able to distinguish metastatic LN for an extended period due to its specific tumor-associated macrophage-targeting property. Therefore, it may be a more distinguishable tracer for identifying metastatic LNs and SLNs during uterine cancer surgery. Further research is needed to confirm these results.

Lymphatic-based Lymphosome: A Novel Hypothesis with Clinical Implication for Supermicrosurgical Lymphaticovenous Anastomosis.

Understanding the anatomical territories drained by lymphatic vessels (LVs) is essential for a better comprehension of lymphatic anatomy and functionality, and for performing lymphatic procedures such as lymphaticovenous anastomosis (LVA). However, current concepts regarding the lymphatic territory are insufficient to explain some of the clinical observations. As shown in the figures, within one incision for the LVA, one to two lymphatic vessels (LV) remained unenhanced on indocyanine green (ICG) lymphography, whereas the rest of the LVs were enhanced. To answer this question, one must examine the concept of the lymphosome, first described by Suami, defined as a particular region drained by LVs into the same subgroup of regional lymph nodes (LNs) (eg, superficial groin LNs). Suami's lymphosome concept represents "LN-based lymphosomes." In addition, Shinaoka identified four distinct lymphatic groups (anteromedial, anterolateral, posteromedial, and posterolateral) in the lower limbs after ICG injection. This represents the concept "group-based lymphosomes." Nevertheless, neither the LN- nor group-based lymphosome concepts offer an appropriate explanation for the clinical findings described above. In addition to the aforementioned lymphosome concepts, the author proposes a novel hypothesis called "lymphatic-based lymphosome," which considers each LV as a single lymphosome. Therefore, the normal-type LV remained unenhanced when ICG was not injected into the draining territory. To enhance post-LVA outcomes, an even distribution of anastomoses to different group-based lymphosomes is important, as is avoiding performing all anastomoses onto a single LV or within the same group-based lymphosome.

The role of radiotherapy in the management of squamous cell cancer of the penis.

To review the evidence for radiotherapy in the management of primary penile cancer, either as brachytherapy or external beam radiation, and the role of external beam radiotherapy in node positive penile cancer. English language literature was reviewed for the past 3 decades. As penile cancer is uncommon in developed nations, high quality evidence to guide management is limited. Single institution reports often span decades during which time staging systems and treatments have evolved, reducing their relevance to current practice. Successful clinical trials require collaboration not only among disciplines but also among multiple institutions and nations. Radiotherapy is a definitive organ-preserving option for T1-T2 penile cancers. Interstitial brachytherapy is associated with penile preservation in 85% of men at 5years, maintained in 70% by 10years. Results of external radiotherapy are not quite as promising but nonetheless 60% of men will have an intact penis at 5years. Inguino-pelvic external radiotherapy has been reported to increase overall survival when delivered as adjuvant treatment for men with pN3 groin but pN0 pelvic nodes, and improve disease specific survival for those with involved pelvic nodes. InPACT (ECOG-ACRIN_8134) is investigating the role of inguino-pelvic chemo-radiotherapy for men with pN3 inguinal nodes but imaging negative pelvic nodes. Radiotherapy has a well-defined role to play in treatment of squamous cell cancers of other sites, such as vulva, anal canal, uterine cervix and head and neck malignancies. Emerging data support the incorporation of radiotherapy into treatment paradigms for penile cancer.

Primary squamous cell carcinoma of the scrotum: Outcomes from a specialist center

BackgroundSquamous cell carcinoma (SCC) of the scrotum is a rare and aggressive cancer. There are no established guidelines on the management of scrotal SCC. ObjectiveTo analyze the clinical management and outcomes of scrotal SCC. Patients and methodsA retrospective analysis of patients diagnosed with primary scrotal SCC over a 10-year period was performed. The type of surgery, tumor stage and histological subtypes, recurrence rate and metastases, cancer-specific mortality (CSM), and other-cause mortality (OCM) were analyzed. ResultsBetween 2012 and 2022, a total of 10 men were identified with primary scrotal SCC. The median (interquartile, IQR) age was 65.5 (55–77) years. Wide local excision was performed in 9 patients and 1 patient underwent a total scrotectomy. The pathological T-stage was: pT1, n = 3; pT2, n = 1; pT3, n = 5 (50%); pT4, n = 1. Four patients had pathologically positive inguinal lymph nodes and 2 had distant metastatic disease at presentation. At a median (IQR) follow-up of 10.5 (4–31) months 5 patients died, of which 3 died from scrotal SCC. ConclusionScrotal SCC is extremely rare in the UK with only 10 primary cases identified in our center over the past 10 years. Surgical resection of the tumor and appropriate inguinal node staging are required due to a high proportion of cases which metastasize to the inguinal lymph nodes. Patient SummaryScrotal cancer is rare. 10 cases were diagnosed over 10 years at a single center. Around half had disease spread to the groin nodes or distant organs at presentation. Surgical resection was required in all patients. At the time of analysis, half of the patients are alive. Due to the rarity and aggressiveness of the cancer, management should be carried out within a specialist center.

Assembling High-Quality Lymph Node Clinical Target Volumes for Cervical Cancer Radiotherapy Using a Deep Learning-Based Approach.

The study aimed to explore an approach for accurately assembling high-quality lymph node clinical target volumes (CTV) on CT images in cervical cancer radiotherapy with the encoder-decoder 3D network. 216 cases of CT images treated at our center between 2017 and 2020 were included as a sample, which were divided into two cohorts, including 152 cases and 64 controls, respectively. Para-aortic lymph node, common iliac, external iliac, internal iliac, obturator, presacral, and groin nodal regions were delineated as sub-CTV manually in the cohort including 152 cases. Then, the 152 cases were randomly divided into training (96 cases), validation (36 cases), and test (20 cases) groups for the training process. Each structure was individually trained and optimized through a deep learning model. An additional 64 cases with 6 different clinical conditions were taken as examples to verify the feasibility of CTV generation based on our model. Dice similarity coefficient (DSC) and Hausdorff distance (HD) metrics were both used for quantitative evaluation. Comparing auto-segmentation results to ground truth, the mean DSC value/HD was 0.838/7.7mm, 0.853/4.7mm, 0.855/4.7mm, 0.844/4.7mm, 0.784/5.2mm, 0.826/4.8mm and 0.874/4.8mm for CTV_PAN, CTV_common iliac, CTV_internal iliac, CTV_external iliac, CTV_obturator, CTV_presacral, and CTV_groin, respectively. The similarity comparison results of six different clinical situations were 0.877/4.4mm, 0.879/4.6mm, 0.881/4.2mm, 0.882/4.3mm, 0.872/6.0mm, and 0.875/4.9mm for DSC value/HD, respectively. We have developed a deep learning-based approach to segmenting lymph node sub-regions automatically and assembling high-quality CTVs according to clinical needs in cervical cancer radiotherapy. This work can increase the efficiency of the process of cervical cancer detection and treatment.

Lymphovascular invasion and p16 expression are independent prognostic factors in stage I vulvar squamous cell carcinoma

The objective of this study was to identify clinicopathologic parameters associated with disease outcome in FIGO stage I vulvar squamous cell carcinoma (vSqCC). The cohort consisted of 126 patients diagnosed with vSqCC in the period 2006–2016 who underwent primary vulvar surgery and evaluation of groin lymph node status. Tumors were reviewed by an experienced gynecologic pathologist. p16 and p53 protein expression by immunohistochemistry and HPV status were analyzed in 116 tumors. Clinicopathologic parameters, protein expression and HPV status were analyzed for association with progression-free and overall survival (PFS, OS). p16 expression and aberrant p53 were found in 49 (42%) and 61 (53%) tumors, respectively. Sixty-six tumors were HPV-associated (57%). Relapse was diagnosed in 35/126 (28%) of patients, and 23 (18%) died of disease. Tumor diameter > 4 cm (p = 0.013), lymphovascular space invasion (LVSI; p < 0.001), the presence of lichen sclerosus (p = 0.019), p16 expression (p = 0.007), p53 expression (p = 0.012), HPV status (p = 0.021), lymph node metastasis (p < 0.001) and post-operative radiotherapy (p < 0.001) were significantly related to OS in univariate analysis. Tumor diameter > 4 cm (p = 0.038), LVSI (p = 0.003), the presence of lichen sclerosus (p = 0.004), p16 expression (p = 0.004), HPV status (p = 0.039), lymph node metastasis (p < 0.001) and post-operative treatment (p < 0.001), were significantly related to PFS in univariate analysis. Age, BMI and surgical resection involvement were not significantly associated with OS or PFS. In multivariate Cox analysis, LVSI and p16 expression were independent prognosticators of OS (p < 0.001 and p = 0.02, respectively) and PFS (p = 0.018, p = 0.037). In conclusion, LVSI and p16 expression are independent prognostic factors in stage I vSqCC.

Real world data of recurrent and survival rates of penile cancer patients in Songklanagarind hospital: Tumor stage as a predictor for disease-free survival.

This study investigated disease-free survival and oncological outcomes in penile cancer patients treated surgically at a high-volume center and identified the prognostic factors for disease-free survival. A retrospective analysis was conducted on primary penile cancer patients diagnosed and treated at Songklanagarind Hospital, Thailand, between January 2001 and December 2021. Disease-free survival (DFS) was assessed using Kaplan-Meier survival curves, and Cox proportional hazard models were used for multivariate analysis. The study included 188 patients with primary penile cancer. The majority (98.4%) were uncircumcised. Tumor staging revealed 40.6% with T1 tumors, 72.9% with well-differentiated tumors, and 23.5% diagnosed at stage IIIA. The recurrence rate was 19.1%, with a mean time to recurrence of 25.9 months. Disease-free survival rates at 1, 3, and 5 years were 81.1%, 70.9%, and 70.9%, respectively. Median overall survival was 16.43 months, with survival rates at 1, 3, and 5 years at 67.7%, 42.7%, and 35.4%, respectively. Cox proportional hazard models showed significant associations between disease-free survival and a higher T stage, a high level of CRP (>15 mg/L), delayed onset of symptoms, primary lesion location, groin node metastasis, lymphovascular invasion, and pelvic lymph node metastases. However, multivariate analysis revealed that a higher primary tumor stage (T) was the only independent prognostic factor for disease-free survival. This study presents one of the largest cohorts investigating disease-free survival outcomes in penile cancer treatment at a single institution over a prolonged period. A higher pathologic T stage is a significant prognostic factor for disease-free survival. Further large-scale prospective studies are needed for validation.

Selective Removal of Only Clinically Suspicious Positive Lymph Nodes Instead of a Complete Inguino-Femoral Lymph Node Dissection in Squamous Cell Carcinoma of the Vulva.

The oncological safety of only removing bulky, positive groin lymph nodes followed by radiotherapy without performing a complete inguino-femoral node dissection (IFL) in squamous cell cancer of the vulva is based on two small studies. The aim of this study was to confirm the oncological safety of this treatment policy. The survival of consecutive patients with clinically suspicious and pathologically positive groin nodes treated with the selective removal of these nodes followed by radiotherapy was compared with the survival in historical controls matched for the variables extranodal spread and diameter of the metastasis > 15 mm and treated with a complete IFL. There was no difference in disease-specific survival between patients treated with debulking (n = 40) versus complete IFL (n = 37) (43.1% vs. 44.8%, p = 0.336, respectively). Overall, survival and groin recurrence-free survival did not differ between the groups either. This retrospective study in a cohort of women with vulvar cancer corroborates previous smaller studies that have shown that the selective removal of suspicious inguinal nodes yields similar oncological outcomes compared with patients matched for important prognostic variables and treated with a complete IFL when both are followed by radiotherapy.

Long-term outcomes of vulvar or vaginal cancer patients undergoing laparoendoscopic single-site inguinal lymphadenectomy.

Laparoendoscopic single-site inguinal lymphadenectomy (LESS-IL), a minimally invasive technique, has been reported in patients with vulvar or vaginal cancer regarding its safety and feasibility. However, the long-term outcomes, especially oncologic outcomes, are still lacking. We aimed to evaluate the long-term outcomes of LESS-IL to confirm its safety further. Data were prospectively collected from patients with vulvar or vaginal cancer who underwent LESS-IL at our institution between July 2018 and June 2021. The patients were followed up for at least 12 months. All procedures were performed according to treatment standards. Short- and long-term complications and oncologic outcomes were analysed. A total of 16 patients undergoing 28 LESS-IL procedures were identified, amongst whom 4 underwent unilateral LESS-IL. The median numbers of excised groin lymph nodes were 9.0 (6.5-11.8) and 10.5 (8.3-12.0) in each left and right groin, respectively. Short-term complications occurred in 4 (25%) patients, including 18.7% lymphocele and 6.3% wound infection. Long-term complications regarding lower-limb lymphoedema appeared in 6 (37.5%) patients. Most short- and long-term complications were Clavien-Dindo 1 or 2, accounting for 90% of all post-operative issues. After a median follow-up of 27 (21.3-35.8) months, only 1 (6.3%) patient had isolated inguinal recurrence at 13 months postoperatively. No local or distant recurrence occurred. Our results suggest that LESS-IL is associated with little incidence of complications and promising oncologic outcomes, further demonstrating the safety and feasibility of the LESS-IL technique in patients requiring IL.

Multimodality treatment of a primary vulvar melanoma in a low resource setting: A case report

Primary vulvar melanoma is a rare but highly aggressive malignant neoplasm accounting for 1–2 % of all malignant melanoma and 5–10 % of all vulvar cancers in females. Here we report a case of 32 years old female diagnosed with primary vulvar melanoma during the evaluation of a two cm growth in the inner labia minora on the right side. She underwent wide local excision with excision of the distal one cm of the urethra and bilateral groin node dissection. The final histopathology was vulvar malignant melanoma with 1 out of 15 groin nodes involved but all resected margins were free of tumor. The final surgical stage was T4bN1aM0 (8th AJCC TNM) and IIIC (FIGO). She received adjuvant radiotherapy followed by 17 cycles of Pembrolizumab. To date, she is both clinically and radiologically disease free with a progression-free survival of 9 months.

Indications for Adjuvant (Chemo) Radiotherapy in Vulvar Cancer with Groin Lymph Node Metastases

Guidelines recommend adjuvant treatment when positive lymph nodes are found after surgical treatment for squamous cell cancer of the vulva except for cases with a single occult intranodal metastasis. Recent studies questioned these recommendations and showed benefit of adjuvant radiotherapy for all patients with positive nodes irrespective of number of nodes. However, these studies did not take into account important nodal characteristics, such as clinical node status, extranodal spread or size of the metastasis. When these variables are taken into account, adjuvant radiotherapy does not seem to result in a better survival for patients with a single occult intranodal metastasis. Whether the addition of chemotherapy to the radiotherapy for patients with more than one positive node or extracapsular spread results in a better survival remains uncertain. Only a few studies have been published on this subject and come to the conclusion that adding chemotherapy results in a better survival. The conclusion is that adjuvant radiotherapy improves survival of patients with positive groin nodes, with the exception of patients with a single intranodal metastasis. The beneficial effect of chemo radiotherapy for subgroups of patients with positive nodes seems likely, although more data are needed before a definite conclusion can be made

Sensated Conjoined DIEP Flaps and Vascularized Lymph Node Transfer: Ferrari Flap

Introduction: Alloplastic reconstruction is still the most common choice, but it has been shown that using the patient’s own tissue creates a more natural breast that needs less surgery in the long term and makes the patient satisfied. Patients with lymphedema, and insufficient abdominal tissue following mastectomy require two pedicle flaps to optimize the volume of the deficient abdominal tissue. Materials and Methods: Only 5 patients who had unilateral breast reconstruction with a neurotized conjoined DIEP flap and simultaneous lymph node transfer (Ferrari flap) were included in the study. Two patients underwent nipple sparing mastectomy, two simple mastectomy and one skin sparing mastectomy. Nerve conduit was utilized in 4 of the 5 patients, The remaining flap was neurotized by direct coaptation of the 3rd anterior ICN and the cutaneous branch of the T11 ICN of the DIEP flap. Flap included concurrent groin lymph node transfer. Results: Five patients underwent Ferrari flap breast reconstruction. The mean BMI was 23.0 (21.0 to 24.9). Average operative time was 6 hours and 8 minutes. Mean hospital length of stay was 3.5 days. All the patients in our study had clinically diagnosed lymphedema secondary to previous oncologic surgery, and after surgery, 4 patients had resolution of the lymphedema. Only one patient continued to have stage 1 to 2 lymphedema and is being treated with compression sleeves and physical therapy. There were no complications with the flaps. Conclusion: Autologous unilateral breast reconstruction with neurotized conjoined DIEP flap and lymph node transfer (Ferrari flap) can be performed safely and reliably with high success rates in the hands of experienced surgeons and affords patients the best option for achieving an aesthetic, natural breast reconstruction as well as addressing their lymphedema and sensation in a single operation. This combined surgical technique provides great outcomes and significantly improves the patient’s quality of life.

Lymph Node Metastasis and Patterns of Recurrence in Vulvar Carcinoma: 10 Years' Single Center Experience.

Vulvar carcinoma is a relatively rare malignancy and there is a paucity of data, especially from India and other developing countries regarding the prognostic factors impacting recurrence and survival. A retrospective observational study was conducted in the Department of Gynecologic Oncology at a tertiary care, regional cancer institute, including all patients with carcinoma vulva who underwent surgery between 2009 and 2018. Demographic profile, surgical-pathological information, details of neo-adjuvant chemotherapy, adjuvant radiation and chemotherapy, and peri-operative complications were analyzed. Long-term follow-up data was gathered, with an evaluation of various prognostic factors impacting recurrence and overall survival outcome. Forty-five cases with mean age of 56.2years (range 29-82) were treated during the study period. Surgery was the initial treatment modality in 41 (91.1%) cases. Neo-adjuvant chemotherapy prior to surgery was given to four cases. After complete surgico-pathological staging, most patients had stage I disease (26 cases, 57.8%) and 22.2% had stage II disease. Owing to microscopic lymph node involvement, seven cases (15.6%) belonged to FIGO stage III disease. Two cases had stage IVA disease with fixed groin nodes. Adjuvant chemotherapy in the form of 5-fluoro uracil and cisplatin was administered to four out of the nine patients with nodal involvement. The remaining five were advised adjuvant groin radiation. At a median follow-up of 34months (range 2-114months), 12 cases (26.7%) experienced a recurrence and one case with stage IVA disease progressed during adjuvant chemotherapy. The 5-year overall survival was 76.6% and the 5-year disease-free survival was 69.6%. There were a total number of 10 deaths, of which seven were due to disease recurrence or progression and the remaining 30% of deaths were due to medical co-morbid conditions. Overall survival was negatively impacted by increasing age (age > 60years), number of positive nodes, presence of perinodal spread, and stage of the disease. Recurrence-free survival was significantly reduced in those with the presence of peri-nodal spread and lympho-vascular space invasion. The incidence of lymph node metastasis was found to be higher in patients with age > 60years, increasing tumor size, presence of lympho-vascular space invasion and the number of lymph nodes removed. In carcinoma vulva, treatment should be individualized with multidisciplinary cooperation. In our series, we found that the stage of disease, nodal positivity, and nodal positivity with extra-capsular spread were significant prognostic factors impacting survival on analysis. Lymph nodal positivity was associated with increasing tumour size, presence of lympho-vascular invasion, and patient age.

Comparison of groin lymph node anatomy in patients with upper-extremity lymphedema and healthy subjects using contrast-enhanced computed tomography

Purpose: Lymphedema is a chronic disease that affects patients’ quality of life. Vascularized groin lymph node transfer is a reliable treatment that requires detailed anatomic knowledge of the superficial inguinal lymph nodes (SILNs). This study compared the anatomy of SILNs between patients with upper-extremity lymphedema and individuals without lymphedema using pelvic computed tomography (CT).Methods: The CT scans of 17 patients (the patient group) with upper-extremity lymphedema and 34 individuals without lymphedema (the normal group) were studied. The reference point was marked 3 cm perpendicularly below one-third of the line from the pubic tubercle to the anterior superior iliac spine. The number, distance, and concentration of SILNs were measured relative to the reference point.Results: The SILNs in the normal group had a mean count of 6.47±1.19, a mean distance from the reference point of 21.10±9.66 mm, and a mean concentration of 84%. The patient group had a mean lymph node count of 7.68±1.63, a mean distance of 22.48±9.51 mm, and a mean concentration of 77%. The normal and patient groups had significantly different mean lymph node counts (p=0.01). The mean distance from the reference point (p=0.07) and the mean lymph node concentration (p=0.20) did not differ significantly between groups. Conclusion: Pelvic CT is a reliable method to evaluate the anatomy of SILNs in detail. A statistically significant difference was found in the number of lymph nodes between the lymphedema patient group and the normal group, but not in their distribution.

THE UNFORTUNATE PERFECT STORM - SEPTIC SHOCK DUE TO CHRONIC IMMUNOSUPPRESIVE MEDICAL THERAPY AND MEDICATION-INDUCED LYMPHOMA

Abstract INTRODUCTION Pharmacological treatment of Crohn's Disease (CD) involves immunomodulators such as adalimumab, a tumor necrosis factor (TNF) inhibitor and azathioprine, a purine analogue. These medications have risks associated with severe illness from infectious etiologies as well as lymphoma development. This is due to the immunosuppressive effect of the medications as well as a chronic inflammatory state(1). Anaplastic large-cell lymphoma (ALCL) is a subtype of non-Hodgkin's lymphoma (NHL). We present a rare case of sepsis and ALCL in a patient on immunomodulator therapy. CASE DESCRIPTION A 31-year-old G1P0 female at 19 weeks gestation with history of Crohn’s disease presents with abdominal pain. Her medications are adalimumab and azathioprine which were started one year ago due to poorly controlled CD resulting in anal fistulas. She was recently treated for right thigh folliculitis. This progressed to abdominal pain and right inguinal lymphadenopathy. She met SIRS criteria on presentation and was admitted to the intensive care unit for respiratory failure requiring intubation. Despite broad-spectrum antibiotics for pneumonia, she remained febrile with an increasing leukocytosis. Blood, lower respiratory, and fungal cultures, acid-fast staining, viral cultures and smears, and urine tests were negative for a source of infection. Commuted tomography (CT) of the abdomen and pelvis was significant for extensive retroperitoneal lymphadenopathy but found no infectious source. An excisional biopsy of the right groin lymph node was a preliminary read as Hodgkin's lymphoma (HL), but the initial immunohistochemical stain was consistent with NHL. Her immunomodulator therapy was stopped due to sepsis and her risk of lymphoma. She subsequently developed septic shock, acute renal failure requiring continuous renal replacement therapy, atrial fibrillation with rapid ventricular response, and suffered a spontaneous vaginal delivery of a 20-week stillborn baby. A final diagnosis of ALCL was confirmed by pathology. The molecular studies were significant for positivity for CD45, CD30, EMA, CD2, CD4, CD25, ALK1, granzyme B, perforin, and TIA1. She was started on brentuximab, cyclophosphamide, and prednisone. DISCUSSION ALCL is a rare subtype of NHL that accounts for roughly one percent of all NHL (3). The development of lymphomas occurs when the TNF alpha subunit binds to the cell surface. This inhibits both the apoptosis pathway and cytokine-mediated inhibition of CD30+ lymphoma cells resulting in cell proliferation (4). There is limited documentation of adalimumab or azathioprine associated ALCL and this association should be studied further. The patient suffered from severe consequences of her immunosuppression from her chronic immunomodulator therapy and immunosuppression from her malignancy resulting in septic shock with multiorgan failure. Right inguinal lymph node biopsy showing atypical large lymphoid infiltrate, background small lymphocytes, plasma cells, and histiocytes. The large atypical cells are characterized by large irregular nuclei with occasional bilobed nuclei and horseshoe-shaped nuclei, multiple small nucleoli, and abundant amphophilic cytoplasm.

Carcinoma vulva: Ten years experience in a teaching institution of North India.

Vulvar carcinoma is primarily a disease of post-menopausal women. Surgery is a primary treatment strategy. Chemotherapy and radiotherapy are a part of multimodal therapy. Presently, there is a shift towards neoadjuvant chemotherapy or radiotherapy so as to decrease the surgical morbidities. To study the surgical outcome and prognostic factors in Ca vulva patients. A retrospective analysis of 19 vulvar cancer patients, surgically treated at a teaching institution of Punjab (2009-2019). Mean age of the patients was 60.95 years. Ulcerative swelling (89.5%) over labia majora (73.7%) was the main presenting symptom. Radical vulvectomy-bilateral IFLN dissection was performed in 74% patients, hemivulvectomy-unilateral IFLN dissection in 21% patients and wide local excision in one patient. Squamous cell carcinoma was detected in all, and one had verrucous carcinoma. Thirty-seven per cent patients had FIGO stage III disease, 31.5% - stage II and 31.5% - stage I. On HPE, 78.57% (11/14) patients had positive nodes and two had ECS. Only 5/9 (55.5%) cases could receive PORT. Seven patients defaulted follow-up. Two developed nodal metastasis, and seven women developed recurrence. One patient with regional recurrence faced demise during RT course. In 10/19 regular follow-up patients, four are alive and disease free, five patients are on palliative chemoradiation, and one is undergoing adjuvant radiotherapy for regional recurrence. Estimated 5-year overall survival is 83.33%. Tumour stage, nodal positivity and nodal ECS were poor prognostic factors. Radical surgery-extensive groin node dissection causes significant morbidity; hence, studies evaluating the role of neoadjuvant treatment are needed so as to modify current treatment practices. HPV vaccination as a preventive measure and a thorough and extensive evaluation of patients with suspicious signs in vulvar disease is needed.

Defining the role of bilateral groin dissection for squamous cell carcinoma of the penis in South Africa

The current recommendation for the management of penile cancer is that all patients with palpable groin nodes should undergo a routine lymph node dissection (LND). This study reviews our yield from LND in patients with palpable lymph nodes (LNs) and penile cancer. All patients with a penile cancer, who presented to the urology departments of St Aidan's and Grey's hospitals in KwaZulu-Natal province (KZN) were reviewed. Clinical data records and histological reports of all the patients who underwent a penectomy and inguinal lymph node dissection (ILND) were analysed. A total of 93 cases of penile cancer were managed between 2014 and 2019. Of this total overall cohort, 38 patients had palpable groin nodes and underwent a bilateral ILND. The majority (84%) of these patients were human immunodeficiency virus (HIV) positive and none were circumcised. Tumour grade was mostly grade II (84%), and tumour size was an average of 6.2 cm with a range from 1.5 to 12 cm. The overall incidence of metastatic inguinal lymph nodes (ILNs) in the group undergoing dissection was 23.7%. In the remainder there was only reactive lymphadenopathy. ILND performed in patients with penile cancer and bilateral palpable ILN in our setting has a low yield. This might be a reflection on our high rate of HIV. Local validation of international cancer guidelines is essential prior to adopting them in the South African context.