Increase In Size Of Nodes Research Articles

Early detection of lung cancer through programmatic management of pulmonary nodules in the Mississippi Delta.

126 Background: Lung cancer (LC) causes the most cancer deaths in the US, but early detection improves outcomes. Uptake of Low-Dose CT screening (LDCT) has been low, contributing to race-based disparities. Programmatic management of incidentally detected pulmonary nodules (PN) provides a complementary avenue for early detection which could address disparities. In our PN cohort, Detecting Early LC in the Mississippi Delta (DELUGE), we provide broad access to early detection across a region fraught with geographic, socioeconomic, and race-based disparities. However, many detected PN will not result in LC. After successful implementation at the program level, we seek to evaluate individual-level factors important for early-detection. We evaluated how individuals with small PN identified in DELUGE differ between those who were and were not diagnosed with LC. Methods: DELUGE is a prospective cohort study where we systematically manage incidentally detected PN with trained navigators and evidence-based risk stratification. We constructed DELUGE in a community-based healthcare system across the mid-south with some of the highest per-capita LC incidence and mortality rates in the US. We evaluated all PN ≤30mm in DELUGE from 2015-2022. We compared clinical and demographic characteristics between individuals who were or were not diagnosed with LC within 24 months. Primary analysis used logistic regression, reporting odds ratios (OR) with 95% confidence intervals. Results: From 2015-2022, 17,945 individuals with PN ≤30 mm (71% of the total cohort of 25,339) were identified and enrolled in DELUGE. They had median age of 65 years, were 56% female, and 27% Black / 69% White. 853 (4.8%) patients were diagnosed with LC within two years. PN size significantly predicted LC diagnosis. For every 1 mm increase in nodule size the odds of LC increased by 15% (OR: 1.15 [1.14-1.16]); PN in an upper lobe (OR: 2.0 [1.7-2.2]) and those with cavitation also increased the odds of LC (OR: 2.9[1.9-4.2]). Sex, rural/urban residence, and number of PN were not associated with LC. The most predictive individual level characteristics were age, prior cancer history (OR: 1.3 [1.1-1.5], family cancer history (OR: 1.7 [1.5-2.0], COPD (OR: 3.3 [2.9-3.8]), and smoking history (OR: 6.6 [5.3-8.4]). In the multiple variable model, the most significant associations with LC diagnosis included PN size, age, insurance, family cancer history, COPD, and smoking history (all p<0.0001). This model could provide estimated sensitivity 0.81 and specificity 0.81 for predicting LC (AUC= 0.88). Conclusions: Factors measurable at baseline have predictive ability, and predictive modeling may be useful in management of small PN. More focused follow-up could improve programmatic efficiency, targeting the alleviation of geographic, socioeconomic, and race-based health disparities in this high poverty region of the US.

Natural progression of deep pelvic endometriosis in women who opt for expectant management.

The natural history of endometriosis is poorly understood, and despite numerous studies, the rate of the disease progression and optimal treatment planning in women who are asymptomatic or experience mild symptoms not requiring treatment are unknown. The aim of this study was to assess the behavior of deep endometriosis in women who are managed expectantly without any medical or surgical intervention. A retrospective cohort study of women diagnosed with deep endometriosis on transvaginal ultrasound scan at the Department of Gynecology, University College London Hospitals and The Gynecology Ultrasound Centre, London, UK, from April 2007 to April 2022. All women attended for at least two ultrasound scans which were carried out by a single expert ultrasound examiner and at least 6 months apart. The number and position of endometriotic nodules were recorded, and the mean diameter of each nodule was calculated from measurements taken in three orthogonal planes. During the study period, 1922 women were found to have moderate or severe deep endometriosis on pelvic ultrasound examination. A total of 135 premenopausal women who were managed expectantly fitted the inclusion criteria. The median number of endometriotic nodules per woman at the initial visit was 2 (range: 0-7), and the median follow-up time was 666 days (181-2984). In the follow-up period, 50/135 women (37%, 95% CI: 29-46) developed additional nodules or experienced an increase in nodule size, and 17/135 women (13%, 95% CI: 8-19) had a regression in the number or size of the nodules. In the remaining 68/135 women (50%, 95% CI: 42-59) the disease remained static during the follow-up. The median change in mean diameter of nodules during the study period per woman was +0.13 mm (-11.67 - +5.83), with an annual growth rate of +0.09 mm/year (-6.65 - +6.45). In our study we found evidence of deep endometriosis progression in just over a third of women. In view of this, asymptomatic or mildly symptomatic women diagnosed with deep endometriosis could be reassured that their disease is unlikely to worsen with time.

AIUM Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound of the Thyroid and Extracranial Head and Neck.

AIUM Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound of the Thyroid and Extracranial Head and Neck.

Production of the plant hormone gibberellin by rhizobia increases host legume nodule size.

Plant-associated microbes have evolved the ability to independently produce gibberellin (GA) phytohormones as a mechanism to influence their host. Indeed, GA was first discovered as a metabolite from the fungal rice pathogen Gibberella fujikuroi, which uses it as a virulence factor. Though some bacterial plant pathogens similarly use GA to promote infection, symbiotic nitrogen-fixing bacteria (rhizobia), which inhabit the root nodules of legumes, also can produce GA, suggesting a role in symbiosis. The bacterial GA biosynthetic operon has been identified, but in rhizobia this typically no longer encodes the final metabolic gene (cyp115), so that these symbionts can only produce the penultimate intermediate GA9. Here, we demonstrate that soybean (Glycine max) expresses functional GA 3-oxidases (GA3ox) within its nodules, which have the capability to convert GA9 produced by the enclosed rhizobial symbiont Bradyrhizobium diazoefficiens to bioactive GA4. This rhizobia-derived GA is demonstrated to cause an increase in nodule size and decrease in the number of nodules. The increase in individual nodule size correlates to greater numbers of bacterial progeny within a nodule, thereby providing a selective advantage to rhizobia that produce GA during the rhizobia-legume symbiosis. The expression of GA3ox in nodules and resultant nodulation effects of the GA product suggests that soybean has co-opted control of bioactive GA production, and thus nodule size, for its own benefit. Thus, our results suggest rhizobial GA biosynthesis has coevolved with host plant metabolism for cooperative production of a phytohormone that influences nodulation in a mutually beneficial manner.

Ultrasound manifestations of acute viral hepatitis a in children

26 children with HAV (12 boys and 14 girls) - mean age 13.2 ± 3.3 years and 21 children (8 boys and 13 girls) - mean age 14.3 ± 2.6 years were examined. In all cases, clinical laboratory examination, determined the level of ALT, AST, alkaline phosphatase. Ultrasound was performed on ultrasound systems Aplio 500 and MyLab Twice. Clinical manifestations of HAV consisted of anorexia (70%), nausea and vomiting (66%), fever (80%), jaundice (85%), dark urine (85%), upper abdominal pain (20%). The following echographic changes were determined: hepatomegaly and reduction of decreased echogenicity by 88.5%,reduced gallbladder 92%, thickening of the gallbladder wall 85%, double contour of the gallbladder wall 46%, increase in lymph node size: in the hepatoduodenal ligament 46% and mesenteric 73%, splenomegaly in 100% Ultrasound examination of the abdominal should be performed in all patients with clinical suspicion of acute viral hepatitis A and jaundice. Abdominal ultrasound examination is an important additional tool for monitoring the dynamics of HAV.

Pediatric lymphadenopathy: Which patients need evaluation by an oncologist?

e13605 Background: While lymphadenopathy may be the first sign of cancer in children, it can also be a manifestation of non-malignant illness. Lymphadenopathy is a common reason for referral to a pediatric oncologist, which can result in significant anxiety for parents. Understanding which patients require an oncology referral for lymphadenopathy is key in order to streamline healthcare utilization for this common clinical entity. Methods: In this single institution study, we retrospectively reviewed the medical records of patients referred to pediatric oncology for lymphadenopathy between 2012 and 2020. A logistic regression model was fitted to examine the association between the maximum size of the lymph nodes and cancer diagnosis. We also obtained estimates of odds ratio and area under the ROC curve. Sensitivity and specificity were estimated using exact Clopper-Pearson method for proportion. SAS v9.4 was used to perform statistical analyses. Institutional IRB approved the study. Results: A total of 91 patients aged 1 to 19 years (median 14 years) were included. There was a statistically significant association between lymph node size and a diagnosis of malignancy. For every centimeter increase in maximal dimension of lymph node(s), there was an estimated 2.2-times increase in the odds of cancer (CI 95% 1.5-3.3; p = 0.0002). The estimated area under the curve for this model was 0.8 (95% CI 0.7-0.9) indicating that lymph node size correlated very well with cancer risk. We evaluated the model to find a threshold for lymph node size that provided a high sensitivity for screening purposes. A cut-off of 2 centimeters resulted in an estimated sensitivity of 0.95 (95%CI 0.7-0.99) and specificity of 0.6 (95%CI 0.5-0.7). Conclusions: This study provides preliminary evidence that the estimated odds of a cancer diagnosis doubles for each centimeter increase in lymph node size. This single institution retrospective study suggests that in patients with lymphadenopathy, the maximum lymph node size may be a predictor of malignancy. Our results demonstrate that the sensitivity for cancer increases at a lymph node size of two centimeters or larger. Navigating when to monitor a patient with lymphadenopathy in the primary care setting versus referring to the oncologist can be a challenge for primary care physicians. Our results are consistent with the practice that using a two centimeter cutoff is a good starting point for referrals; however, these results will need to be verified with a larger sample size before they are adopted into clinical guidelines. Further study is underway to evaluate lymphadenopathy referrals to both surgery and oncology in order to reduce potential bias that may be associated with oncology referrals, which may have a predilection for malignancy. This study underlines the importance of a physical examination by the primary care physician as the crucial step in determining if a patient requires an oncology referral.

Assessment of Factors Affecting the Treatment Efficacy of Radioactive Iodine (I-131) Therapy in Patients with Hyperthyroidism

Objective: Hyperthyroidism is an increase in hormone production in the thyroid gland and the exposure of tissues to the hormones of the thyroid glands in the circulation. The most common causes encountered are Graves’ Disease, Toxic Multinodular Goiter and Toxic Adenoma. The purpose of radioactive iodine treatment is to make patients become euthyroid or hypothyroid. Despite adequate treatment, hyperthyroidism persists or reccurs in some patients. The aim of our study is to investigate the factors affecting the efficacy of radioactive iodine treatment in hyperthyroidism. Methods: In this retrospective study, relevant clinical and laboratory data were recorded in database of Kayseri Training and Research Hospital, Endocrinology and Metabolism Diseases Outpatient Unit between 2013-2016. Results: A total of 79 cases including 17 (21%) male, and 62 (79%) female patients were enrolled in the study. There were 33 (42%) Graves’ disease 9 (11%) Toxic Multinodular Goitre and 37 (47%) Toxic Adenoma patients when grouped according to diagnoses. Mean age was 56.5 ± 16,80. Development of hypothyroidism or euthyroidism were accepted as efficient treatment, hyperthyroidism or recurrence were considered as treatment failure. In 71 (89%) patients, treatment efficiently resulted in hypothyroidism or euthyroidism, whereas in 8 (11%) patients, the treatment failed due to recurrence or persistent disease. Treatment was 100 % effective in Toxic Multinodular Goitre and Toxic Adenoma groups, while it was effective in 75.7 of patients with Graves’ Disease. Patients who did not use antithyroid drugs recovered faster than patients who did. Conclusion: Radioactive iodine therapy is an efficient treatment in patients with hyperthyroidism. It was determined that 1 mm increase in nodule size decreased the treatment efficacy by 1.07 times (p<0,05). However, there are many factors that affect the efficacy of this treatment. To elucidate these factors and improve clinical practice, prospective long-term studies providing more reliable data with larger samples needed.

Evaluation of the skin-sensitizing potential of gold nanoparticles and the impact of established dermal sensitivity on the pulmonary immune response to various forms of gold

Gold nanoparticles (AuNP) are largely biocompatible; however, many studies have demonstrated their potential to modulate various immune cell functions. The potential allergenicity of AuNP remains unclear despite the recognition of gold as a common contact allergen. In these studies, AuNP (29 nm) dermal sensitization potential was assessed via Local Lymph Node Assay (LLNA). Soluble gold (III) chloride (AuCl3) caused lymph node (LN) expansion (SI 10.9), whereas bulk particles (Au, 942 nm) and AuNP did not. Next, the pulmonary immune effects of AuNP (10, 30, 90 µg) were assessed 1, 4, and 8 days post-aspiration. All markers of lung injury and inflammation remained unaltered, but a dose-responsive increase in LN size was observed. Finally, mice were dermally-sensitized to AuCl3 then aspirated once, twice, or three times with Au or AuNP in doses normalized for mass or surface area (SA) to assess the impact of existing contact sensitivity to gold on lung immune responses. Sensitized animals exhibited enhanced responsivity to the metal, wherein subsequent immune alterations were largely conserved with respect to dose SA. The greatest increase in bronchoalveolar lavage (BAL) lymphocyte number was observed in the high dose group – simultaneous to preferential expansion of BAL/LN CD8+ T-cells. Comparatively, the lower SA-based doses of Au/AuNP caused more modest elevations in BAL lymphocyte influx (predominantly CD4+ phenotype), exposure-dependent increases in serum IgE, and selective expansion/activation of LN CD4+ T-cells and B-cells. Overall, these findings suggest that AuNP are unlikely to cause sensitization; however, established contact sensitivity to gold may increase immune responsivity following pulmonary AuNP exposure.

Benign thyroid nodules in pediatric patients: determining best practices for repeat ultrasound evaluations.

Background The American Thyroid Association (ATA) recommendations for the follow-up of thyroid nodules with benign fine needle aspiration (FNA) cytology in children are largely based on adult data, despite well-characterized differences between thyroid nodules in adults and children. We aimed to determine the optimal time interval for repeat evaluation of an FNA-benign thyroid nodule in a pediatric patient. Methods This is a retrospective chart review of patients <19 years of age from 2003 to 2013 with a benign thyroid nodule by FNA cytology. Results We identified 43 patients with benign thyroid nodule cytology on FNA. The average age at diagnosis was 15.6 years, with female predominance (91%). Initial ultrasound (US) findings showed an average nodule size of 2.5 cm, 10% with calcifications, 37% hyperemia, 29% hypoechogenicity and 7% lymphadenopathy. Follow-up US was done in 42%. The first follow-up US occurred on average at 15 months after the initial US. Four patients had nodules with significant growth over time. One patient with papillary thyroid carcinoma (PTC) on final pathology initially had a decreasing nodule size, and then a subsequent increase in the nodule size after 4.5 years. Thyroid nodules were surgically removed in 33% with the final pathology showing a benign cytology in four patients, follicular adenoma in eight patients and PTC in two patients. Conclusions The majority of patients with benign thyroid nodules had no significant increase in nodule size in the first year of follow-up, including one patient who was subsequently found to have PTC. We recommend follow-up US at 1 year after initial presentation in low-risk pediatric patients with benign thyroid nodule cytology.

A novel EUS-guided liquid fiducial marker for image-guided radiotherapy in esophageal cancer: The safety and efficacy in vitro and vivo evaluations.

e15573 Background: The true tumor extent of esophageal cancer is hard to visualize on current modalities during radiotherapy. In this study, we evaluated the safety and feasibility of the mixture of N-Butyl Cyanoacrylate and lipiodol to find the most optimal application as the fiducial marker to marking the true tumor extent in esophageal radiotherapy. Methods: Four types of injection matches (1:1-0.1ml, 1:1-0.15ml, 1:3-0.1ml, 1:30.15ml) were injected via syringes in subcutaneous tissue in rats model. Gross histopathological changes, weight, skin score, nodule volume, neutrophil counts and macrophage counts were observed to analyses the effect of different mixing ratios and injection volumes to find the best match. Evaluations following ISO standard criteria are further delivered to test the biocompatibility of the best applicable setting of this fiducial maker. Results: At 7th week, 42 markers (42/48, 87.5%) were still visualized on CT images. No serious adverse events or obvious artifacts were noted through the study. The overall review about the histopathological reaction of the NBCA/Lipiodol was considered to be a combination of acute inflammation, chronic inflammation, granulation tissue, foreign-body reaction and fibrous capsule formation in development. The quantitative analysis showed that when the density of NBCA was low (1:3), lower injection volume (0.1ml) brought the lower weights (p &lt; 0.001). When the injection volume is high (0.15ml), the high NBCA (1:1) caused the lower weight (p &lt; 0.001). At the most time points, the lower injection volume had the lower weights. High injection volume created a 0.079 cm3 increase in nodule size than low volume and high NBCA density also increased the nodule size. As for the inflammatory cells counts, the 3rd week was a key time point, before which the neutrophils decreased sharply and the macrophages keep almost steady, but after that the neutrophils stayed a low level and the macrophages started a rapid growth. On the comparisons of different index (Table), it is showed that the 1:3-0.15ml had an excellent performance as the fiducial marker and final biocompatibility test proved its safety. Conclusions: Overall, our results show that the mixture of NBCA/Lip as the fiducial marker is safe and feasible and the setting of 1:3-0.15ml was most optimal.[Table: see text]

Echogenicity of Palmar Dupuytren’s Nodules Is Not a Predictor of Disease Progression in Terms of Increase in Nodule Size

Ultrasound might enable us to measure Dupuytren's disease activity and predict disease progression. The aim of this study was to analyze whether echogenicity of Dupuytren's nodules can be used to predict progression in terms of increase in nodule size. Ultrasonographic assessment of a Dupuytren's nodule was performed in 91 patients participating in an existing longitudinal cohort study. Images were scored for echogenicity by two observers. Echogenicity of 89 nodules was matched to growth 1 year later using linear regression analysis. Sensitivity analysis was performed using data obtained 1 year before ultrasound. The interobserver and intraobserver reliability was calculated using the intraclass correlation coefficient. Hypoechogenicity was not a predictor of growth 1 year later (beta = -0.019, p = 0.748). Sensitivity analysis looking at the year before ultrasonographic measurement showed that hypoechogenic nodules were more likely to have grown in the past year (beta = 0.173, p = 0.011). However, these data were influenced by nodules that developed in the year before ultrasound. The intraobserver reliability of echogenicity of Dupuytren's nodules was excellent (intraclass correlation coefficient, 0.996; 95 percent CI, 0.993 to 0.998) and the interobserver reliability was fairly good but imprecise (intraclass correlation coefficient, 0.688; 95 percent CI, 0.329 to 0.977). Hypoechogenicity is not a predictor of progression in terms of increase in nodule size measured by physical examination 1 year later. When using ultrasound to assess echogenicity of Dupuytren's nodules, the use of a single observer leads to more consistent results. Risk III.

DIPNECH: A UNIQUE PRESENTATION OF A RARE DISEASE

SESSION TITLE: Diffuse Lung Disease 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a very rare disease that consists of a proliferation of scattered single cells, small nodules, or linear proliferations of pulmonary neuroendocrine cells (1). The entity has been described as a precursor to pulmonary carcinoid tumors (2), is thought to be more common in middle-aged women, and can be associated with slowly-progressive cough or shortness of breath with exertion (1,3). CASE PRESENTATION: We present a case of a 42-year-old female with a complicated pulmonary history including a childhood diagnosis of asthma, two spontaneous pneumothoraces, chronic daily cough, dyspnea on exertion, and a seven-year history of incidentally-noted pulmonary nodules. An initial workup for her nodules was negative for fungal or autoimmune etiologies. An interval CT scan was obtained and showed an increase in nodule size which was further evaluated with a PET-CT. While none of the lung nodules were PET-avid, a hypermetabolic thyroid nodule was incidentally noted, which was biopsied and found to be papillary thyroid cancer. Pulmonary function testing was obtained for her dyspnea and showed mild restriction with no evidence of obstruction and normal diffusion capacity. After a non-diagnostic CT-guided biopsy of a right middle lobe lung nodule led to an iatrogenic pneumothorax requiring chest tube placement, she eventually underwent video assisted thoracoscopic surgery and right middle and lower lobe wedge resections. Biopsy showed the presence of a typical carcinoid tumor as well as neuroendocrine hyperplasia consistent with DIPNECH. DISCUSSION: This case represents an atypical presentation of a rare disease. Though pulmonary nodules, shortness of breath, and cough are common findings in DIPNECH, the occurrence of spontaneous pneumothoraces is not. Few case reports have described spontaneous pneumothoraces in patients with large endobronchial carcinoid tumors; however, this patient had no evidence of endobronchial obstruction and thus represents a unique presentation of the disease (4,5). This case also demonstrates the importance of maintaining a broad differential in the approach to patients presenting with dyspnea, cough, and pulmonary nodules. While the DIPNECH is very rare, appropriate diagnosis and close follow-up is important given the association of DIPNECH with subsequent development of carcinoid tumors (6). CONCLUSIONS: The differential for diffuse pulmonary nodules in the setting of chronic cough or dyspnea is incredibly broad. After more common etiologies like metastatic disease, granulomatous disease, autoimmune, and infectious disorders are ruled out, one should consider the diagnosis of DIPNECH, particularly in a middle-aged female with chronic, otherwise-unexplained respiratory symptoms and especially with an associated diagnosis of a carcinoid tumor (2). Reference #1: Travis WD, Brambilla EW, Burke AP, et al. WHO Classification of Tumours of the Lung, Pleura, Thymus, and Heart, IARC Press, Lyon 2015. Reference #2: Gorshtein, A., Gross, D. J., Barak, D., Strenov, Y., Refaeli, Y., Shimon, I. and Grozinsky-Glasberg, S. (2012), Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia and the associated lung neuroendocrine tumors. Cancer, 118: 612–619. https://doi.org/10.1002/cncr.26200. Reference #3: Nassar A. A., Jaroszewski D. E., Helmers R. A., Colby T. V., Patel B. M., Mookadam F. Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia—a systematic overview. American Journal of Respiratory and Critical Care Medicine. 2011;184(1):8–16. https://doi.org/10.1164/rccm.201010-1685pp. DISCLOSURES: No relevant relationships by Carleen Risaliti, source=Web Response No relevant relationships by Kyle Stinehart, source=Web Response

3:45 PM Abstract No. 96 CT-fluoroscopy in subcentimeter lung nodule biopsy: does it make a difference?

Percutaneous lung nodule biopsy plays a critical role in the diagnosis, staging and therapeutic planning of primary and metastatic lung malignancies. However, sampling of subcentimeter lesions remains technically challenging and often leads to increased rate of diagnostic failure. We retrospectively reviewed our subcentimeter lung nodule biopsies using CT-fluoroscopy (CTF) to evaluate diagnostic accuracy, radiation dose and complication rate in the context of anatomical location, imaging features and technical intraprocedural data. We determined the diagnostic accuracy of CTF-guided biopsy of nodules 9-10 mm and 6-8 mm in size, respectively, using core sampling or core sampling plus fine-needle aspiration (FNA). Location of the nodule, nodule imaging characteristics, presence of known malignancy, and associated complications were recorded. Independent risk factors for diagnostic accuracy, radiation dose and complications were determined with multivariate logistic regression analysis. After IRB approval, search on our PACS yielded 791 lung biopsies in the past 5 years, 58 of which were subcentimeter. With exclusion criteria, 46 cases are recruited for diagnostic accuracy analysis and 52 for radiation dose and associated complication. Overall the diagnostic accuracy is 84.8%. However, the cohort (14 cases) with both core and FNA samples has higher accuracy of 92.9%, vs. 81.3% with only core samples (32 cases), in par with reported literature. Logistic regression did not reveal any significant difference in biopsy accuracy or radiation doses against nodule characteristics, location or depth. However, the increased true positive yield with each 1 mm increase in size of nodule has an odds ratio (OR) up to 1.20 (95% CI: 0.73-2.00). The minor and major complication rate was 32.7% and 21.2%, per SIR criteria, respectively. Particularly, there is increased risk of major complication for upper lobe nodules, with OR of 2.9 (95% CI: 0.68-7.86) vs. other lobes. CTF-guided percutaneous subcentimeter lung nodule biopsy in the range of 6-10 mm offers high diagnostic accuracy. However, there is relatively high risk for major complications, particularly for the upper lobar nodules.

The effect of pycnogenol on lymphatic nodes and adhesion during in a peritoneal adhesion model in rats.

To investigate the effects of pycnogenol on peritoneal adhesions and additionally to investigate the immunohistochemical effects of free oxygen radicals and reactive lymph nodes detected in the adhesive tissue that was sampled surrounding the cecum on intra-abdominal adhesions. Twenty-seven Wistar Albino rats were divided into three groups. In group 1 (sham), laparotomy was performed and stitched up. In group 2 (control), after laparotomy was performed, punctate hemorrhage was induced by cecal abrasion in the cecum and each rat was intraperitoneally administered 2 cc of saline. In group 3 (experimental), after laparotomy was performed, punctate hemorrhage was induced by cecal abrasion in the cecum and each rat was intraperitoneally administered a sterile Pycnogenol derivative. The rats in all groups were re-laparotomized on postoperative day 7; samples were obtained from the peritoneal tissue surrounding the cecum, and the rats were sacrificed. In group 3, there was a statistically significant difference in terms of inflammation, lymph node size, and free oxygen radicals; these parameters tended to increase. In terms of fibrosis evaluated using H&E and MT, there was no significant difference between groups 2 and 3. No positive outcomes indicating that pycnogenol reduces intra-abdominal adhesions were obtained. However, it caused severe inflammation in the tissue. Moreover, a significant increase in lymph node size was detected secondary to inflammation. Additionally, in immunohistochemical analyses conducted to detect oxidative stress, pycnogenol increased the production of free oxygen radicals in the tissue.

Viable tumor in salvage neck dissections in head and neck cancer: Relation with initial treatment, change of lymph node size and human papillomavirus

ObjectivesTo identify predictive factors for the presence of viable tumor and outcome in head and neck cancer patients who undergo therapeutic salvage neck dissections. Materials and MethodsRetrospective analysis of 76 salvage neck dissections after radiotherapy alone (n = 22), radiotherapy in combination with carboplatin/5-fluorouracil (n = 42) or with cetuximab (n = 12). ResultsViable tumor was detected in 41% of all neck dissections. Univariate analysis revealed initial treatment with radiotherapy without systemic therapy (OR 6.93, 95%CI: 2.28–21.07, p < .001), increased lymph node size after initial treatment compared to pretreatment CT scan (OR 20.48, 95%CI: 2.46–170.73, p = .005), more extensive neck dissections (OR 8.40, 95%CI: 2.94–23.98, p < .001), and human papillomavirus negative cancer (OR 4.22, 95%CI: 1.10–16.22, p = .036) as predictors of viable tumor. Patients with decreased or stable, but persistently enlarged lymph node size after chemoradiation had a significantly lower chance of viable tumor (OR 0.15, 95%CI: 0.05–0.41, p < .001). Disease-specific 5-year survival was 34% in case of viable tumor, and 78% when no viable tumor was found (p < .001). ConclusionsViable tumor in salvage neck dissections is associated with reduced survival. Radiotherapy alone, human papillomavirus negative cancer and increase in lymph node size, are associated with viable tumor in salvage neck dissections. In case of decreased or stable lymph node size after chemoradiation, watchful waiting could be considered.

Correlation between obesity and fat-infiltrated axillary lymph nodes visualized on mammography.

Using screening mammography, this study investigated the association between obesity and axillary lymph node (LN) size and morphology. We conducted a retrospective review of 188 females who underwent screening mammography at an academic medical centre. Length and width of the LN and hilum were measured in the largest, mammographically visible axillary node. The hilo-cortical ratio (HCR) was calculated as the hilar width divided by the cortical width. Measurements were performed by a board certified breast radiologist and a resident radiology physician. Inter-rater agreement was assessed with Pearson correlation coefficient. We performed multivariable regression analysis for associations of LN measurements with body mass index (BMI), breast density and age. There was a strong association between BMI and LN dimensions, hilum dimensions and HCR (p < 0.001 for all metrics). There was no significant change in cortex width with increasing BMI (p = 0.15). Increases in LN length and width were found with increasing BMI [0.6 mm increase in length per unit BMI, 95% CI (0.4-0.8), p < 0.001 and0.3 mm increase in width per unit BMI, 95% CI(0.2-0.4), p < 0.001, respectively]. Inter-rater reliability for lymph node and hilum measurements was 0.57-0.72. We found a highly significant association between increasing BMI and axillary LN dimensions independent of age and breast density with strong interobserver agreement. The increase in LN size was driven by expansion of the LN hilum secondary to fat infiltration. Advances in knowledge: This preliminary work determined a relationship between fat infiltrated axillary lymph nodes and obesity.

Relationship between proliferative activity of tumor cells and the enlargement pattern of metastatic lymph nodes in oral squamous cell carcinomas

ObjectivesThis study was conducted to investigate the time-course changes in the size of metastatic lymph nodes and determine their relationship with the histological features of oral squamous cell carcinomas (OSCC). MethodsThirteen metastatic lymph nodes from 13 OSCC patients were examined in this study. The cervical lymph nodes were periodically followed up with ultrasonographic examination and diagnosed as metastatic when the minimum axis of the nodes (size) reached ≥8mm in three-dimensional measurements. Enlargement patterns of the metastatic nodes were compared with the histological features and proliferative activity of tumor cells by Ki-67 immunostaining of the primary tumors and nodes. ResultsThe enlargement patterns of the metastatic lymph nodes were classified into two types: rapid enlargement (RE), which involved rapid increase in node size, and slow enlargement (SE), which involved slow increase and fluctuation in size. No significant differences in histological findings between the RE and SE types were observed in the primary tumors or metastatic nodes. On the other hand, Ki-67 scores in primary tumors and metastatic foci were associated with the enlargement pattern of the metastatic nodes, wherein metastatic nodes of the RE type showed significantly higher Ki-67 scores than those of the SE type. ConclusionsThe proliferative activity of primary tumors can be a valuable marker for predicting the speed of enlargement of metastatic lymph nodes. In addition, it may aid in reaching a decision regarding follow-up duration in N0 neck cancer patients.

Cervical Lymph Node Metastases After Thyroidectomy for Papillary Thyroid Carcinoma Usually Remain Stable for Years.

Lymph node (LN) recurrence detected by ultrasound (US) is a very common problem after initial treatment for papillary thyroid carcinoma (PTC). Most patients with PTC have an excellent disease-specific survival even with LN recurrence. Recently, watchful waiting with serial cervical US evaluations would be considered a reasonable approach to management of LN recurrence in selected patients. On the other hand, some patients with LN recurrence have demonstrated clinically significant disease progression during follow-up. The objective of the present study was to document the changes of cervical LN metastases after initial treatment and identify useful information for deciding how best to manage individual patients with LN recurrence. This retrospective review identified 83 consecutive PTC patients with at least one LN on the postoperative US diagnosed with fine needle aspiration biopsy or the thyroglobulin titer in the wash-out of the needle. The change in LN size was determined using serial US studies over time. The subjects were 15 men and 68 women, with a median age at initial surgery of 50.6 years (range, 18-80 years). The median LN size at the start of the observation period was 1.3 cm (range, 0.5-2.4 cm) in the largest diameter. After a median follow-up of 7.2 years, the median growth rate of the nodes showing structural progression was 1.4 mm per year (range, 0-12.0 mm/year). Seventeen of 83 patients (20.5%) demonstrated an increase in LN size of at least 3 mm, only 8.4% (7 of 83) had an increase of at least 5 mm, and 39.7% (33 of 83) resolved. Distant metastases were present in 11 of 83 patients. Ten-year and fifteen-year disease-specific survival rates after diagnosis of LN recurrence were 84.7% and 72.6%, respectively. Older age and recurrent LN growth of more than 3 mm/year were recognized as independent predictors for short survival on both univariate and multivariate analyses (p < 0.05). Most lymph node recurrences may remain stable for a long time and not be immediately life-threatening. However, recurrent LN growth of more than 3 mm per year could be related to mortality.

Intraoperative localization and protection of important structures of the neck in thyroid surgery

Nodular thyroid disease affects thousands of people in Poland. Tumors of the thyroid account for about 1% overall human cancers. Thyroidectomy is the most common surgical operation in endocrine tumors. Operative therapy for benign thyroid nodules is recommended for: progressive increase in nodule size, substernal extension, compressive symptoms of the neck, the development of thyrotoxicosis and patient therapeutic prevalence. In Poland thyroidectomy is the fifth surgical procedure and comprises about 25000 operations yearly. Reduction of surgical injury with simultaneous retention of current safety and radical nature of surgical intervention forces the work into a relatively small operating field. Electric devices enabling the achievement of full and lasting haemostasis during thyroidectomy supplant traditional surgical method (ligature, haemostatic sutures) with no impact on the incidence of perioperative complications, while at the same time allowing to shorten the duration of the procedure. The haemostatic effect is associated with generation of heat, which apart from the intended result may bring about thermal tissue injury. During the surgical procedure it is important to determine the thermal spread around the active tip of electric devices in the operating field during thyroidectomy, and the safe temperature range during the operation to protect important structures of the neck. The mean safe distance of the active tip of an electric device from important anatomic structures is 5mm minimally and depends on the device type, time of operation and its power settings. All the modern techniques of vessel sealing are associated with generation of heat and its spherical spread, which causes thermal injury to the surrounding tissues. Their mode of operation through, among others, structural changes in collagen and elastin, leads to durable connection of sealed vessel walls and tissue structures. These systems enable a safe sealing of vessels of up to 7 mm in diameter. In conclusions: In the cases analyzed by the author concerning the thyroidectomy techniques, it is recommended to replace electric devices with ligatures or clips or human fibrinogen in place near the laryngeal nerves, parathyroid glands and the trachea. The decision of the change of the method of haemostasis maintenance in the vicinity of crucial structures has been left to the surgeon.

The Natural History of the Benign Thyroid Nodule: What Is the Appropriate Follow-Up Strategy?

Long-term monitoring of benign thyroid nodules is not addressed in the present American Thyroid Association guidelines. The objective of this study was to determine the appropriate nature and length of follow-up for patients with a benign thyroid nodule. A retrospective review was performed of all patients referred to single endocrine surgeon for evaluation of thyroid nodules between 2006 and 2012. The review included 263 patients who had benign fine needle aspiration (FNA) cytology and either underwent thyroidectomy or had at least a 1-year follow-up ultrasound. Main outcomes measures were repeat FNA and pathology results. There were 231 women and 32 men. Forty-eight patients underwent immediate thyroidectomy, with pathology showing 2 papillary thyroid cancers (PTC), and 215 patients were followed with annual ultrasounds. During follow-up, 89 (41.3%) nodules underwent repeat FNA after initial biopsy. The repeat FNA cytology showed 91% benign, 7% follicular neoplasm, and 2% PTC. During follow-up, 81 (37.6%) patients underwent thyroidectomy after 3.3±2.8 years. Reasons for surgery included development of symptoms in 58 (71.6%), a non-benign repeat FNA in 8 (9.8%), or patient preference in 15 (18.5%). Surgical pathology identified 70 (86.4%) benign, 7 (8.6%) PTC, 3 (4%) follicular thyroid cancers, and 1 (1.2%) lymphoma. Median time from initial FNA to thyroidectomy in patients who had malignancy was 4.3 years. The maximum initial nodule size and average increase in nodule size did not differ between benign and malignant nodules (p=0.54 and p=0.75, respectively). Significant numbers of benign thyroid nodules enlarge more than 5 mm over 3 years, triggering repeat FNA or thyroidectomy. Larger diameter nodules and more rapidly growing nodules were not predictive of malignancy. The practice of annually obtaining ultrasound for benign thyroid nodules should be discouraged.