Lymph Node Groups Research Articles

SURGICAL TREATMENT OF RECTAL CANCER WITH PRESERVATION OF THE LEFT COLIC ARTERY AND ICG NAVIGATION

Goal. To analyze the peculiarities of surgical diagnosis of lymphogenic metastasis in patients with colorectal cancer. Generalization of data from Ukrainian and foreign literature, results of randomized studies and meta-analyses. The study is based on the results of observation of 88 patients with colorectal cancer (CRC) of the prospective study group. To analyze the features of surgical diagnostics of lymphogenic metastasis in patients with colorectal cancer. Materials and methods. The results of surgical treatment of 88 patients with rectal cancer were analyzed and systematized. These patients underwent examination and treatment in 2023-2024 at the "Prykarpattian Clinical Oncology Center of the Ivano-Frankivsk Regional Council." The study included patients with stage II-III colorectal cancer (T2-3N0-2M0) without complicated courses. All patients received treatment based on NCCN recommendations. Surgical treatment was performed in standard volume with the removal of all regional lymph node groups and preservation of the left colic artery using real-time lymph node mapping with indocyanine green. All patients were divided into two study groups: Group I included 45 patients who underwent anterior or low anterior resection of the rectum with preservation of the left colic artery. This group was subdivided into two subgroups: Ia – 13 patients who underwent intraoperative indocyanine green injection for real-time lymph node visualization. Ib – 32 patients who did not receive this drug but underwent the same volume of surgery. Group II consisted of 43 patients who underwent anterior or low anterior resection of the rectum with high ligation of the inferior mesenteric artery. This group served as the control group. Results. The main mechanisms of lymphogenic metastasis in colorectal cancer patients in Ivano-Frankivsk were characterized. Literature data on the features of surgical diagnostics of colorectal cancer metastasis were summarized. A review of literature shows the social significance of these studies, as this pathology often leads to patient disability, requiring surgical interventions and further palliative treatment due to the widespread metastasis associated with this disease. The priority task for researchers remains the search for the most effective treatment methods for this pathology, based on randomized studies of colorectal cancer treatment and international protocols. According to the literature, surgical treatment of colorectal cancer remains insufficiently effective at the current stage of oncology. Modern methods offer low 5-year survival rates, emphasizing the need to study factors for individualized treatment. The overall 5-year survival rate for colorectal cancer patients from 2018-2022 was (45.8±2.3)%. The effectiveness of using real-time ICG navigation for lymph node mapping and preservation of the left colic artery in stage II-III (T2-4N1-2M0) rectal cancer patients has been proven. This technique allows for optimal lymphadenectomy, reducing the frequency of surgical complications by 14.7% (p<0.05). Conclusion. Ensuring radical resection of rectal cancer while maximizing blood supply preservation to the anastomosis is the main goal of colorectal surgeons. Over the past two decades, surgical techniques have significantly improved due to advancements in surgical equipment. It is anticipated that surgical technologies will further evolve towards enhancement and individualization in the future. Our procedure serves as an example of modern and personalized rectal cancer surgery.

Predictive value of methylene blue combined with indocyanine green in sentinel lymph node metastasis in breast cancer: a prospective pilot cohort study.

The status of sentinel lymph nodes is crucial for prognosis and treatment decisions in breast cancer patients. This study aimed to evaluate the predictive value of combined methylene blue and indocyanine green for sentinel lymph node metastasis in breast cancer. This prospective cohort study enrolled 90 clinically node-negative breast cancer patients. Methylene blue and indocyanine green were injected locally before surgery. Sentinel lymph nodes were grouped based on fluorescence intensity and methylene blue staining. A binary logistic regression model was established using 285 lymph node groups to predict metastatic risk. A total of 475 lymph nodes were identified, with 33 being metastatic. The metastatic risk reached 70% for partially blue-stained and weakly fluorescent lymph nodes between 1-2 cm. The model revealed associations between lymph node size, dye staining patterns, and metastatic risks (P<0.05). The AUC of the ROC curve was 0.855. The staining pattern of combined methylene blue and indocyanine green could predict risks of sentinel lymph node metastasis and facilitate rapid intraoperative identification of high-risk lymph nodes.

Cartridge-Based Nucleic Acid Amplification Test Compared to Fine Needle Aspiration Cytology in Suspected Cases of Tubercular Lymphadenitis (the Indian Experience)

INTRODUCTION: Diagnosis of tubercular lymphadenitis is daunting as there are varied clinical presentations and no single confirmatory gold standard test. Cartridge-based nucleic acid amplification test (CBNAAT) of the lymph node is a rapid molecular diagnostic test for simultaneously detecting tuberculosis (TB) and rifampicin resistance. AIM: To evaluate the performance of the CBNAAT test for detecting M. tuberculosis in lymph node specimens compared to fine needle aspiration cytology (FNAC). MATERIALS AND METHODS: The study was conducted in a rural tertiary care hospital in central India. A total of 180 patients clinically suspected of tubercular lymphadenitis were included. The male-to-female ratio was 1:1.3. The average age was 33.3 years. The age group 21–40 years had the highest number of cases. The most common complaints among the patients were fever (29.4%), followed by loss of appetite (9.5%), weight loss (9.5%), and cough (6.6%). However, most patients presented to the hospital with only lymphadenopathy (44.4%). The most common site involved was the anterior cervical lymph node (78.8%), followed by the axillary group (10.5%), submandibular (2.8%), inguinal (2.8%), supraclavicular (2.2%), submental (1.7%) and infraclavicular (1.1%) group of lymph nodes. The patients were subjected to both FNAC and CBNAAT testing. Results were reported as positive or negative for M. tuberculosis as CBNAAT gives a semiquantitative estimate of the concentration of bacilli. Rifampicin resistance results were reported as detected or not detected. RESULTS: Cytological examination of the lymph node aspirates revealed that most were tubercular lymphadenitis cases. Cytomorphological analysis of the cases of tubercular lymphadenitis revealed Type 6 (tubercular abscess) as the predominant pattern. CBNAAT testing detected 26 cases of M. tuberculosis and three cases of rifampicin resistance. The study reported a specificity of 92.92% and low sensitivity of 26.86% of combined FNAC and CBNAAT is much higher compared to only CBNAAT. CONCLUSION: CBNAAT, along with FNAC, is a valuable addition in first-line investigations of tubercular lymphadenitis to make a timely diagnosis.

Characteristics of lymph node metastasis and short-term outcome of esophageal squamous-cell carcinoma undergoing minimally invasive esophagectomy: a prospective cross-sectional study (with video)

Introduction: Surgery for esophageal squamous-cell carcinoma (ESCC) presents many potential challenges owing to malignant lymph node metastasis, complex procedures and severe postoperative complications. The appropriate lymphadenectomy for ESCC remains controversial. This study aims to evaluate the characteristics of lymph node metastasis and postoperative complications in patients with ESCC undergoing minimally invasive esophagectomy and extended two-field lymph node dissection. Patients and methods: This prospective, single-center, cross-sectional study was conducted from October 2022 to May 2024. All patients with ESCC who underwent minimally invasive esophagectomy and extended two-field lymph node dissection were selected for this study. Postoperative lymph nodes were divided into upper thoracic, middle thoracic, lower thoracic and abdominal lymph node groups. Results: Seventy-four patients with ESCC, including 49 patients who underwent upfront surgery and 25 patients who received preoperative chemoradiotherapy, were selected. The rate of lymph node metastasis in all patients was 39.2%, with 13.6% of patients having upper thoracic metastasis. The factors affecting the rate of lymph node metastasis included preoperative chemoradiotherapy, tumor stage, poor differentiation, lymphovascular/perineural invasion, and tumor size greater than 2 cm, all of which were significantly different (P&lt;0.05). Common postoperative complications included pneumonia (25.7%), recurrent laryngeal nerve (RLN) palsy (10.8%) and anastomotic leak (4.1%). There were no cases required conversion to open surgery, nor any deaths within 90 days postoperatively. Conclusion: Lymph node metastasis in esophageal squamous-cell carcinoma has a high incidence, occurs in the early stages, and is widely distributed in all regions of the mediastinum and abdomen. Minimally invasive esophagectomy and extended two-field lymph node dissection are feasible and safe, with low complication rates.

The Upper Extremity Lymphatic System Is Not Symmetrical in Individuals: An Anatomic Study Utilizing ICG Lymphography and SPECT/CT Lymphoscintigraphy.

We evaluated whether superficial lymphatic anatomy and functional lymph node drainage are symmetric between the right and left upper extremities of healthy female volunteers, and if handedness is associated with symmetry of superficial lymphatic anatomy. Symmetry of lymphatic anatomy has been assumed historically. This assumption of individual anatomic symmetry is being utilized clinically and in research without validation. 36 normal female volunteers underwent bilateral indocyanine green (ICG) lymphography and lymphoscintigraphy of the upper extremities. Eight collecting vessel pathways of each upper extremity were mapped on ICG lymphography. 13 lymph node groups were visualized on lymphoscintigraphy. Symmetry of lymphatic anatomy and functional drainage were established by comparing the right and left extremities of each participant. Hand dominance was assessed by hand grip strength on a hand dynamometer. Among the 36 participants, 10 (28%) showed symmetry of all eight upper extremity lymphatic pathways with ICG. However, only 1 (3%) participant demonstrated complete symmetry amongst the 13 lymph node groups. Total symmetry of lymphatic channels was observed on ICG in seven (39%) participants with hand dominance and three (17%) participants without hand dominance (X2 = 2.215, P = 0.137). Lymphatic anatomy and functional drainage of the upper extremities are not consistently symmetric. Functional nodal drainage as demonstrated by lymphoscintigraphy shows less symmetry than anatomic studies of lymphatic channels using ICG. Symmetric lymphatic anatomy does not appear to correlate with hand dominance. These findings challenge the prevailing assumption of left-right lymphatic symmetry.

Research progress on the distribution patterns and surgical dissection of central lymph nodes in left-sided colon cancer

Lymphatic metastasis is one of the main pathways of colorectal cancer spread and also a crucial factor in patient long-term prognosis. Lymph node dissection in the possible tumor drainage area, particularly the central group of lymph nodes at the root of the tumor-associated supplying artery, is a key and challenging aspect of surgical techniques. Currently, the patterns of lymphatic drainage and the distribution of central lymph nodes in left-sided colon cancer are not well illustrated, and there is no consensus on the necessity and extent of central lymph node dissection. This has led to significant variability in the extent of lymph node dissection among different surgeons in clinical practice, a lack of quality control standards for surgical procedures, and impacts on postoperative treatment strategy and long-term outcomes. Moreover, current research on lymphatic drainage and metastasis is primarily based on traditional anatomy, whereas individualized, precise approaches to lymph node dissection have not been realized. The application of preoperative and intraoperative lymph node imaging techniques based on functional anatomy in colorectal cancer patients is still under exploration.

Transesophageal endoscopic ultrasound-guided aspiration of mediastinal lymph node. Clinical case

In oncologic practice, metastatic lesions in the mediastinal lymph nodes are primarily associated with lung cancer because of its high morbidity. However, lesions in mediastinal lymph nodes are quite common in the context of various other benign and malignant processes. Therefore, due to the anatomy of this zone, difficulties of visualization of specific lymph node groups, complicated differential diagnosis of benign and malignant processes, the problem of sampling biological materials from the affected area remains important and unsolved. Transesophageal endoscopic ultrasound-guided aspiration is a highly effective and safe method of diagnosis and staging of oncologic diseases associated with metastatic lesions in the mediastinal lymph nodes.

Spectrum of Kikuchi-Fujimoto Disease: A 10-Year Study in a Tertiary Care Centre in South India.

Background Kikuchi-Fujimoto disease (KFD) is a benign lesion of the lymph nodes predominantly seen in younger women and is a condition associated with a good prognosis due to its indolent nature. Since KFD is chiefly a diagnosis of exclusion, it is liable to a higher degree of misdiagnosis. Aim In our study, we attempt to document and analyse the demographic, clinical, and pathological spectrum of cases diagnosed as KFD in a South Indian tertiary care centre over a period of 10 years. Methodology This study was conducted in a retrospective observational manner. Descriptive statistics, including simple frequency and percentage, were used to analyse and summarise the collected data. Results Among the 44 cases obtained, 36 patients were female and eight were males, with an age range of eight to 70 years. The mean age of the affected population was 26 years. Fever was a presenting complaint in 63.6% of cases, and 100% of the cases had lymphadenopathy, chiefly affecting the posterior cervical group of nodes (32/44 cases). Multiple lymph node groups were involved in 22 cases. Most of the nodes were larger than 1 cm in their greatest dimension. On analysis of peripheral smears, 43.2% of patients showed leukopenia. Anti-nuclear antibody (ANA) analysis showed a positive status among two patients, simultaneously establishing the diagnosis of systemic lupus erythematosus (SLE). A history of treated tuberculosis was present in four patients, and one patient had a history of non-compliance with TB treatment. Two patients had recently been diagnosed with TB and were on treatment. The involved nodes were subjected to fine-needle aspiration studies in 13 patients; 12/13 cases showed reactive lymphadenitis, while one case had atypical lymphoid cells. The involved nodes of all the patients were excised and sent for histopathological analysis. The diagnosis of KFD was confirmed on the biopsy. Conclusion In this study, we note the clinical presentations of all the patients diagnosed with KFD and elaborate on the investigations that were employed to verify the diagnosis via exclusion that enabled differentiation of KFD from its close mimickers, which have specific treatment. Keeping this entity in mind is essential in order to prevent overdiagnosis, as most often this condition resolves spontaneously, and in occasional cases, symptomatic treatment is sufficient for its management.

Application of tissue pneumoperitoneum technique around lymph nodes in thoracoscopic lung cancer resection.

Thoracoscopic surgery is a primary treatment for lung cancer, with lobectomy and mediastinal lymph node dissection being the predominant surgical approaches for invasive lung cancer. While many thoracic surgeons can proficiently perform lobectomy, thorough and standardized lymph node dissection remains challenging. This study aimed to explore a safer and more efficient surgical method for mediastinal lymph node dissection in lung cancer. A prospective randomized controlled study was conducted, involving 100 patients with right lung cancer who were admitted to our hospital from January 2021 to April 2024 and met the inclusion criteria. These patients were randomly divided into an observation group (tissue pneumoperitoneum technique around lymph nodes group) and a control group (conventional surgery group). Thoracoscopic lobectomy and mediastinal lymph node dissection were performed. Intraoperative and postoperative related indicators were observed to validate the effectiveness and safety of the tissue pneumoperitoneum technique around lymph nodes. The observation group showed a significantly shorter lymph node dissection surgery time compared to the control group, with a statistically significant difference (p < 0.05). The number of lymph nodes dissected in the observation group was significantly higher than that in the control group, with a statistically significant difference (p < 0.05). Although the observation group had slightly more mediastinal lymph node stations dissected than the control group, the difference was not statistically significant (p > 0.05). The total drainage volume within three days postoperatively was comparable between the two groups, with no statistically significant difference (p > 0.05). The observation group had shorter chest tube indwelling time and postoperative hospital stay than the control group, with statistically significant differences (p < 0.05). The incidence of surgical complications was similar between the two groups, and there were no perioperative deaths. The tissue pneumoperitoneum technique around lymph nodes is a more efficient method for mediastinal lymph node dissection in lung cancer, demonstrating safety and feasibility, and is worthy of promotion.

Analysis of the expression of cytokines and chemokines, platelet-leukocyte aggregates, sCD40L and sCD62P in cutaneous melanoma.

Cutaneous melanoma (CM) is a malignancy with a variable incidence worldwide and a poor advanced-stage prognosis. Melanoma growth is closely associated with the immune system. A cross-sectional study was performed on CM patients admitted at the Hospital de Cancer de Pernambuco (HCP) between 2015 and 2018. Fifty-one CM patients were included, and 30 healthy individuals. The study aimed to evaluate the association of platelet activation mechanisms and inflammatory response in patients with cutaneous melanoma. Elevated serum IL10 and low serum TNF levels in CM patients compared to controls (p < 0.05). High IL6 levels in patients with negative lymph nodes LN (-) compared to positive lymph nodes group (LN +, p = 0.0005). Low RANTES levels in patients compared to controls (p < 0.05). Elevated levels of platelet-lymphocyte (PLA), platelet-monocytes (PMA), and platelet-neutrophils (PNA) aggregates were observed in patients compared to controls (p < 0.05). CM patients with stage II had lower PMA levels than stages I and III (p < 0.05). High PMA levels were observed in patients with LN (+) compared to the LN (-) group (p < 0.0001). Patients with SSM had high levels of sCD40L and sCD62P compared to controls (p < 0.05)). High sCD40L levels in stage II compared to the stage III group, and sCD62P in stages I and II compared to the stage III group (p < 0.05). High sCD62P levels in patients with LN (-) compared to the group LN (+) (p < 0.05). It was observed the immunosuppressive profile in CM may favor tumor progression. High levels of platelet-leukocyte aggregates, sCD40L, and sCD62P may be associated with the worst prognosis.

The value of net influx constant based on FDG PET/CT dynamic imaging in the differential diagnosis of metastatic from non-metastatic lymph nodes in lung cancer.

This study aims to evaluate the value of the dynamic and static quantitative metabolic parameters derived from 18F-fluorodeoxyglucose (FDG)-positron emission tomography/CT (PET/CT) in the differential diagnosis of metastatic from non-metastatic lymph nodes (LNs) in lung cancer and to validate them based on the results of a previous study. One hundred and twenty-one patients with lung nodules or masses detected on chest CT scan underwent 18F-FDG PET/CT dynamic + static imaging with informed consent. A retrospective collection of 126 LNs in 37 patients with lung cancer was pathologically confirmed. Static image analysis parameters include LN-SUVmax and LN-SUVmax/primary tumor SUVmax (LN-SUVmax/PT-SUVmax). Dynamic metabolic parameters including the net influx rate (Ki) and the surrogate of perfusion (K1) and of each LN were obtained by applying the irreversible two-tissue compartment model using in-house Matlab software. Ki/K1 was then calculated as a separate marker. Based on the pathological findings, we divided into a metastatic group and a non-metastatic group. The χ2 test was used to evaluate the agreement of the individual and combined diagnosis of each metabolic parameter with the gold standard. The receiver-operating characteristic (ROC) analysis was performed for each parameter to determine the diagnostic efficacy in differentiating non-metastatic from metastatic LNs with high FDG-avid. P < 0.05 was considered statistically significant. Among the 126 FDG-avid LNs confirmed by pathology, 70 LNs were metastatic, and 56 LNs were non-metastatic. For ROC analysis, in separate assays, the dynamic metabolic parameter Ki [sensitivity (SEN) of 84.30%, specificity (SPE) of 94.60%, accuracy of 88.89%, and AUC of 0.895] had a better diagnostic value than the static metabolic parameter SUVmax (SEN of 82.90%, SPE of 62.50%, accuracy of 74.60%, and AUC of 0.727) in differentiating between metastatic from non-metastatic LNs groups, respectively. In the combined diagnosis group, the combined SUVmax + Ki diagnosis had a better diagnostic value in the differential diagnosis of metastatic from non-metastatic LNs, with SEN, SPE, accuracy, and AUC of 84.3%, 94.6%, 88.89%, and 0.907, respectively. When the cutoff value of Ki was 0.022ml/g/min, it had a high diagnostic value in the differential diagnosis between metastasis and non-metastasis in FDG-avid LNs of lung cancer, especially in improving the specificity. The combination of SUVmax and Ki is expected to be a reliable metabolic parameter for N-staging of lung cancer.

New Insight for Axillary De-Escalation in Breast Cancer Surgery: "SoFT Study" Retrospective Analysis.

Background: The SOUND study demonstrated that an axillary de-escalation may be sufficient in locoregional and distant disease control in selected early breast cancer (EBC) patients. To establish any preoperative variables that may drive sentinel lymph node biopsy (SLNB) omission, a study named sentinel omission risk factor (SOFT) 1.23 was planned. Methods: A single-center retrospective study from a prospectively maintained database was designed, aiming at underlying preoperative prognostic factors involved in sentinel lymph node (SLN) metastasis (lymph node involvement (LN+) vs. negative lymph node (LN-) group). Secondary outcomes included surgical room occupancy analysis for SLNB in patients fulfilling the SOUND study inclusion criteria. The institutional ethical committee Area Territoriale Lazio 2 approved the study (n° 122/23). Results: Between 1 January 2022 and 30 June 2023, 160 patients were included in the study and 26 (%) were included in the LN+ group. Multifocality, higher cT stage, and larger tumor diameter were reported in the LN+ group (p = 0.020, p = 0.014, and 0.016, respectively). Tumor biology, including estrogen and progesterone receptors, and molecular subtypes showed association with the LN+ group (p < 0.001; p = 0.001; and p = 0.001, respectively). A total of 117 (73.6%) patients were eligible for the SOUND study and the potential operating room time saved was 2696.81 min. Conclusions: De-escalating strategies may rationalize healthcare activities. Multifactorial risk stratification may further refine the selection of patients who could benefit from SLNB omission.

Laparoscopic complete mesocolic excision in colon cancer: a prospective cohort study

Introduction: Compared to conventional colon cancer surgery, laparoscopic complete mesocolic excision (CME) increases the likelihood of lymph node dissection. However, this surgery is not yet considered a safe strategy. The authors study this topic to evaluate the safety and feasibility of this surgery. Methods: A prospective cohort study was performed on patients undergoing laparoscopic CME surgery at the Hue University of Medicine and Pharmacy Hospital and Hue Central Hospital. Results: Demographic data, surgical features, and postoperative complications. Evaluate different clinicopathological factors determining the number and distribution of lymph nodes; and the rate of lymph node metastasis by tumor location and lymph node groups. Three-year overall survival and disease-free survival follow-up after surgery. Conclusion: The results of laparoscopic CME colectomy surgery are safe, with a reliable maximum number of harvested nodes.

Diagnostic efficiency and safety evaluation of different groups of lymph nodes in 193 cases of conventional transbronchial needle aspiration (C-TBNA).

Diagnostic efficiency and safety evaluation of different groups of lymph nodes in 193 cases of conventional transbronchial needle aspiration (C-TBNA).

Investigation of mediastinal lymph node dissection in clinical stage IA pure-solid non-small cell lung cancer patients

ObjectiveTo explore the independent predictors of pathological mediastinal lymph node (pN2) metastasis in clinical stage IA (cIA) pure-solid non-small cell lung cancer (NSCLC) patients, and to find an appropriate method of mediastinal lymph node dissection.MethodsThis study retrospectively evaluated 533 cIA pure-solid NSCLC patients who underwent radical resection of lung cancer (lobectomy combined with systematic lymph node dissection) from January 2014 to December 2016. The relationship between clinicopathological characteristics and pN2 metastasis was analyzed, and the independent predictors of pN2 metastasis were determined by univariate and multivariate logistic regression analysis. We defined the new factor Y as composed of preoperative cT, CEA, and NSE.ResultsThere were 72 cases (13.5%) of pN2 metastasis in cIA pure-solid NSCLC patients. Preoperative clinical tumor diameter (cT), serum CEA level, serum NSE level, and pathological status of station 10 lymph nodes were independent predictors of pN2 metastasis. Patients with cT ≤ 21.5 mm, CEA ≤ 3.85 ng/mL, NSE ≤ 13.40 ng/mL and negative station 10 lymph node group showed lower rates of pN2 metastasis. The new factor Y was an independent predictor of pN2 metastasis. Only 3 (2.1%) of 143 patients in the Y low-risk group showed pN2 metastasis.ConclusionFor patients with low risk of pN2 metastasis, it might be feasible to take lobe-specific lymph node sampling or systematic lymph node sampling. As for those with high risk of pN2 metastasis, systematic lymph node dissection would be recommended.

Heterogeneity in PD-L1 expression between primary and metastatic lymph nodes: a predictor of EGFR-TKI therapy response in non-small cell lung cancer

BackgroundThere is inconclusive evidence to suggest that the expression of programmed cell death ligand 1 (PD-L1) is a putative predictor of response to EGFR-TKI therapy in advanced EGFR-mutant non-small cell lung cancer (NSCLC). We evaluated the heterogeneity in PD-L1 expression in the primary lung site and metastatic lymph nodes to analyze the association between PD-L1 expression and response for patients treated with EGFR-TKI.MethodsThis study reviewed 184 advanced NSCLC patients with EGFR mutations who received first-generation EGFR-TKI as first-line treatment from 2020 to 2021 at Shanghai Chest Hospital. The patients were divided into the primary lung site group (n = 100) and the metastatic lymph nodes group (n = 84) according to the biopsy site. The patients in each group were divided into TPS < 1%, TPS 1–49%, and TPS ≥ 50% groups according to PD-L1 expression.ResultsThe median PFS was 7 (95% CI: 5.7–8.3) months, and the median OS was 26 (95% CI: 23.5–28.5) months for all patients. No correlation existed between PFS or OS and PD-L1 expression. The median PFS in the primary lung site group was 11 months (95% CI: 9.6–12.4) in the TPS < 1% group, 8 months (95% CI: 6.6–9.4) in TPS 1–49% group, and 4 months (95% CI: 3.2–4.8) in TPS ≥ 50% group, with statistically significant differences (p = 0.000). The median OS of the TPS < 1% group and TPS ≥ 50% group showed a statistically significant difference (p = 0.008) in the primary lung site group. In contrast, PD-L1 expression in the lymph nodes of EGFR-mutant patients was unrelated to PFS or OS after EGFR-TKI therapy.ConclusionPD-L1 expression from the primary lung site might predict clinical benefit from EGFR-TKI, whereas PD-L1 from metastatic lymph nodes did not.Trial registration: This retrospective study was approved by the Ethics Committee of Shanghai Chest Hospital (ID: IS23060) and performed following the Helsinki Declaration of 1964 (revised 2008).

Perimarginal lymph node metastasis in gingivo-buccal complex carcinoma: Is it time to push the limits of neck dissection?.

6069 Background: Perimarginal nodes (PMN) are a group of perifacial lymph nodes that lie in close relationship with marginal mandibular nerve (MMN). They lie in the lymphatic drainage pathway of gingivo-buccal cancers (GBC), above the lower border of mandible which forms the superior limit of conventional neck dissection and thus remain unaddressed. With reported incidence of metastasis as high as 20.5%, we aimed to explore incidence of PMN metastasis in GBC, its correlation with histopathological tumor and nodal characteristics. Methods: A prospective study was conducted on 112 consecutive treatment naïve patients of GB squamous cell carcinoma. Patients with unresectable nodal disease, distant metastasis and prior radiotherapy or surgery to neck were excluded. PMN dissection was performed in the quadrangle bounded superiorly by the mandibular alveolar ridge, inferiorly by lower border of mandible, anteriorly by mental foramen and posteriorly by anterior border of masseter. On histopathological analysis, serial step sectioning and cytokeratin immunohistochemistry were performed. Prospective clinical characteristics analyzed were subsite, clinical tumor, nodal stage, location of primary and clinical skin involvement. PMN positivity was correlated with demographic, clinical, nodal status. Histopathological characteristics analyzed included tumor grade, pathological tumor, nodal stage, tumor size, skin and/or bone involvement, depth of invasion, Brandwein Gensler histological risk score and lympho-vascular emboli. MMN functional outcome was graded according to House-Brackman (HB) grading recorded at 3 and 6 months post-operatively. Results: Baseline characteristics are summarized in the table. The PMN were identified histologically in 75.89% (85/112) patients. Metastasis in these nodes were identified in 15.2% (17/112) patients. Our study revealed an occult PMN metastasis of 16.67% (13/78). None of the pre-operative clinical factors was found to be significant in predicting incidence of metastasis. Higher nodal burden (p=0.01) and pathological skin involvement (p=0.03) had statistically significant odds of having PMN metastasis on multivariable analysis. At 6 months follow-up, none of the patients had any MMN functional deformity at rest. Conclusions: There is a high incidence of occult PMN metastasis from gingivo-buccal complex cancer. High nodal stage and pathological skin involvement are independent adverse prognostic factors for PMN metastasis. The limits of conventional neck dissection should be expanded to include clearance of PMN in all cases of gingivo-buccal cancers. [Table: see text]

Robotic Right Hepatectomy with En Bloc Caudatectomy for Bismuth IIIa Hilar Cholangiocarcinoma: A Video Demonstration of Left-Liver-First Anterior Radical Modular Orthotopic Right Hemihepatectomy.

Minimally invasive resection for perihilar cholangiocarcinoma is a complicated and technically demanding surgical procedure. Radical surgical resection is regarded as the best treatment for hepatic hilar cholangiocarcinoma.1,2 Right hepatectomy with caudate lobe resection is necessary as the treatment for bismuth IIIa hilar cholangiocarcinoma.3 The left-liver-first anterior radical modular orthotopic right hemihepatectomy (LARMORH), which can simplify surgical steps and decrease procedural difficulty, may be a better choice for Bismuth IIIa hilar cholangiocarcinoma.4 However, there are no reports of this approach using robotic technique for this operation. We will provide a detailed introduction to this method through this video. A 45-year-old female patient was diagnosed with a hilar cholangiocarcinoma. Following a 7-day percutaneous biliary drainage of the left intrahepatic bile duct and obtaining informed consent, we performed a robotic radical resection of the HCCA using the LARMORH approach. The patient was positioned supine with the entire bed elevated 20° and tilted 15° to the left. Trocars were placed in position (Fig. 1). After entering the abdominal cavity, it was explored for tumor metastasis. The surgery adopted a left approach, initially exploring the left hepatic artery and vein to further assess resectability. After confirming resectability, the right hepatic artery and gastroduodenal artery (GDA) were dissected. The common bile duct was dissected and transected at its distal end, ensuring R0 surgical margins. Lymph nodes were cleared from the foot side to the head side, confirming the metastasis to the lymph node group 13a, so we further cleared the group 16 and 9 lymph nodes.5 Subsequently, we approached the resection of the right half and the entire caudate lobe with the reverse thinking of left hepatic resection mode, preserving only the left branch of the portal vein and left hepatic artery, and dissecting the liver tissue along the resection plane of the left liver. After transection of the left hepatic duct, the activity space of the left liver was larger and the caudate lobe could be better exposed. The Spiegel lobe was lifted to the right in a "turn the page" fashion for in situ resection of the entire caudate lobe and the right half of the liver. Finally, a bilioenteric anastomosis was performed using the Roux-en-Y method. Robotic right hepatectomy with caudate lobectomy was successfully performed in 450 min, with an estimated blood loss of 200ml. The histological grading was determined as T1aN1M0 (stage IIIB) on the basis of postoperative pathological biopsy results. The patient achieved a satisfactory postoperative recovery and was discharged on the 14th postoperative day without any major complications. Following the operation, the patient received capecitabine chemotherapy according to the Chinese Society of Clinical Oncology (CSCO) criteria. Since September 2022, our team has completed three radical resections for Bismuth IIIa HCCA using this technique. All patients achieved a satisfactory postoperative recovery without any further complications. Robotic left-liver-first anterior radical modular orthotopic right hemihepatectomy for Bismuth IIIa HCCA is both safe and feasible. This method may provide a new surgical approach for patients with type IIIA HCCA or liver diseases requiring right hemihepatectomy combined with total caudate lobectomy.

Abstract PO5-24-03: Breast cancer intrinsic subtypes predict outcomes in primary and metastatic samples

Abstract Background: The prognostic and predictive value of the PAM50 intrinsic subtypes, namely Luminal A, Luminal B, Her2, and Basal-like subtypes, is well-studied in primary as well as metastatic breast cancer settings. Prosigna has emerged as a rapid PAM50 subtype predictor based on the NanoString nCounter assay. However, assay reproducibility across various RNASeq or qRT-PCR platforms can be challenging, especially when applying the predictor on metastatic breast cancer tumors. Here, we used SpinAdapt to create an intrinsic subtype predictor that works on RNA sequencing data, and validates on multiple tumor-sites. We evaluate real-world outcomes for our intrinsic subtype predictions across various immunohistochemical (IHC) labels and metastatic sites. Methods: We trained the subtype predictor on a cohort of 2,497 breast cancer patients using the PAM50 genes, profiled using Nanostring RNA nCounter assay (GSE148426). Approximately 5,423 de-identified records of breast cancer patients sequenced using whole-exome capture RNA-seq were included in our reference dataset. The reference dataset contained samples collected from various sites including breast (n=2440), liver (n=936), lymph node (n=577), lung (n=540), and bone (n=304). For subtype classification, we first batch-corrected the external dataset to Tempus RNA-seq reference dataset using SpinAdapt, then trained a Support-Vector Classifier (SVC) on the corrected data. A 10-fold CV experiment was performed on the corrected dataset to analytically validate the intrinsic subtype predictions. We retrospectively analyzed 7,021 de-identified breast cancer patients with known hormone receptor (HR) or HER2 status and a matched RNASeq sample. The concordance between HR/HER2 status and PAM50 prediction was analyzed, and these patients were excluded from training. Real-world overall survival (rwOS) was evaluated from the time of first diagnosis. The outcomes across intrinsic subtypes were further assessed according to tumor collection site and HR/HER2 IHC status. Results: The 10-fold CV experiment on the Tempus-adapted GSE148426 dataset achieved F-1 scores of 0.97, 0.86, 0.94, and 0.87 on Basal, HER2-like, Luminal A, and Luminal B PAM50 subtypes, respectively. On the Tempus evaluation dataset, 85.3% of HR+/HER2- patients (n=4,366), 65.4% of HR-/HER2+ patients (n=240), and 75.4% of HR-/HER2- patients (n=1,930) were classified as Luminal, HER2-like, and Basal, respectively. Evaluating outcomes on Tempus patients for each PAM50 group, the rwOS for the basal group was significantly shorter than patients not predicted to be basal (n=5,845, p&amp;lt; 2e-90). The rwOS for the predicted PAM50 basal patients remained significantly shorter than non-basal patients even when stratified by site of metastasis: breast (n=2,405; p&amp;lt; 1e-27), lymph node (n=577, p&amp;lt; 1e-7), liver (n=936; p&amp;lt; 1e-25), lung (n=540, p&amp;lt; 1e-13), and bone (n=304, p&amp;lt; 1e-3). Interestingly, within both HR+/HER2- (n=3,653) and HR-/HER2- (n=1,664) IHC cohorts with available outcomes data, the predicted PAM50 basal subtype could further stratify each of these populations with basal-subtype showing significantly worse prognosis than the non-basal subtype (p&amp;lt; 1e-27 and p&amp;lt; 1e-7, respectively). Conclusions: We retrospectively analyzed Tempus multimodal RWD to validate an in-house breast intrinsic subtype predictor that is agnostic to the site of metastasis. The prognostic value of the basal subtype was significant for breast cancer patients across various sites of metastasis including lymph node, liver, lung, and bones and IHC groups. For patients in each of the HR+/HER2- and triple negative IHC groups, the intrinsic molecular subtypes provided an additional level of prognostic detail with statistical significance. These data emphasize the importance of combining molecular subtypes with IHC-based diagnostics to fully characterize clinically relevant subpopulations and risk. Citation Format: Talal Ahmed, Mark Carty, Kaveri Nadhamuni, Raphael Pelossof. Breast cancer intrinsic subtypes predict outcomes in primary and metastatic samples [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-24-03.

Superior Parathyroid Masquerading as Retropharyngeal Lymph Node.

Ectopic parathyroid glands have been reported with an incidence of 2-22%. Undescended parathyroid glands, defined as glands situated above the carotid bifurcation or > 1cm cranial to the superior pole of the thyroid gland, comprise 2-7% of all ectopic parathyroid glands. We report a case of incidentally discovered parathyroid gland located in the retropharyngeal space at the level of the oropharynx. The patient in this report was a 60-year-old female with squamous cell carcinoma of the tonsil T2N0M0 with MRI showing a hyperintense ovoid structure, medial to the carotids at the level of the oropharynx, corresponding to the location of the lateral group of retropharyngeal lymph nodes. Patient underwent transoral ultrasonic radical tonsillectomy along with a retropharyngeal lymph node dissection by the transcervical route. Postoperative histopathology revealed the retropharyngeal node sampled to be a normal parathyroid gland. "High" undescended parathyroid gland as reported here along with 4 other cases of infratemporal fossa parathyroid glands reported previously, can be the cause for recurrent missed adenomas. Being extracervical in location, these are likely to be missed if the skull base has not been included in the preoperative Tc-99 sestamibi scan and also during bilateral neck exploration.