Intraoperative Node Assessment Research Articles

EP02.03-021 Uncertain Resection for Localized cN0M0 Non Small Cell-Lung Cancer: The Crucial Prognosis of Suboptimal Lymph Node Assessment

Surgery remains the gold standard in the treatment of early stages of lung cancer.To achieve longer overall survival, complete resection of the tumor and careful lymphadenectomy are essential. The concept of uncertain resection R(un) was defined in 2005 by IASLC to highlight inadequate and limited resections and focused on intraoperative lymph node assessment. Although complete lymphadenectomy is recommended even in cN0M0 patients, the effect of R(un) in these patients has never been studied.

Intraoperative Lymph Node Assessment (Touch Preparation Only) for Metastatic Breast Carcinoma in Neoadjuvant and Non-neoadjuvant Settings.

Touch preparation (TP) alone is discouraged for intraoperative lymph node (LN) assessment in the neoadjuvant setting (NAS) owing to overall low sensitivity in detecting metastatic breast cancer. To compare the sensitivity, specificity, and negative predictive value of intraoperative LN assessment via TP and examine potential causes of discrepancies along with the clinical, radiologic, and pathologic parameters in the NAS and non-neoadjuvant setting (NNAS). A total of 99 LNs from 47 neoadjuvant patients and 108 LNs from 56 non-neoadjuvant patients were identified. Discordant cases were reviewed retrospectively to reveal the discrepancy reasons. Clinical, radiologic, and pathologic data were obtained from chart review and the pathology CoPath database. The sensitivity, specificity, and negative predictive value of TP in NAS and NNAS were 34.2% versus 37.5%, 100% versus 100%, and 70.9% versus 90.2%, respectively. In NAS, discrepancy reasons were interpretation challenge due to lobular histotype, poor TP quality secondary to therapy-induced histomorphologic changes, and undersampling due to small tumor deposits (≤2 mm); the latter was the major reason in NNAS. More cases with macrometastasis were missed in NAS compared to NNAS (14 of 25 versus 1 of 10). The parameters associated with discrepancy were lobular histotype, histologic grade 2, estrogen receptor positivity, HER2 human epidermal growth factor receptor 2 negativity, multifocality, and pathologic tumor size greater than 10 mm in NAS; and lymphovascular space involvement and pathologic tumor size greater than 20 mm in NNAS. In NAS, intraoperative TP alone should be used very cautiously owing to a high false-negative rate of macrometastasis, especially for patients with invasive lobular carcinoma and known axillary LN metastasis before neoadjuvant therapy.

88P Uncertain resection for localized cN0M0 non-small cell lung cancer: The crucial prognosis of suboptimal lymph node assessment

Surgery remains the gold standard in the treatment of early stages of lung cancer.To achieve longer overall survival, complete resection of the tumor and careful lymphadenectomy are essential. The concept of uncertain resection R(un) was defined in 2005 by IASLC to highlight inadequate and limited resections and focused on intraoperative lymph node assessment. Although complete lymphadenectomy is recommended even in cN0M0 patients, the effect of R(un) in these patients has never been studied. We include cN0M0 patients who underwent an anatomical lung resection for NSCLC from 2008 to 2018 at Toulouse University Hospital. We retrospectively reclassified tumours according to IASLC R-status based on pathologist reports. The primary outcome was overall patient survival according to the R classification system. Secondary outcomes were to determine whether uncertain resection was an independent factor in mortality, to highlight heterogenity of R(un) to perform subcategorization predicting survival. Of the 1108 cN0M0 patients, we identified 732 (66.1%) R0 patients, 291 (26.2%) R(un) patients, and 85 (7.7%) R1 patients. There was a significant difference in survival according to R status (p<0.0001). The impact of complete resection was confirmed in the adjusted models, with an adjusted hazard ratio of 1.26 (95% CI: 1.01-1.59) between R0 and R(un) patients and 2.41 (95% CI: 1.76-3.30) between R0 and R1 patients. We found substantial heterogeneity among R(un) patients with significantly different survival according to the R(un) definition criteria. Therefore, we defined 3 new subgroups of R(un) to discriminate between populations of homogeneous survival. R(un)c included all patients with lymph node involvement of the highest mediastinal node. R(un)b included patients with less than 3 mediastinal lymph node sites examined or no station 7 nodes examined. All other R(un) patients who did not meet the above criteria were classified as R(un)a. Our study demonstrated the validity of the IASLC R classification in cN0M0 patients. By demonstrating the heterogeneity of R(un)patients, we proposed the creation of subcategories to highlight the critical problem of suboptimal lymph node assessment.

Intraoperative Lymph Node Assessment (Touch Preparation Only) for Metastatic Breast Carcinoma in Neoadjuvant and Non-neoadjuvant Therapy Settings

Intraoperative Lymph Node Assessment (Touch Preparation Only) for Metastatic Breast Carcinoma in Neoadjuvant and Non-neoadjuvant Therapy Settings

Intraoperative lymph-node assessment during NSCLC surgery: the need for standardisation and quality evaluation.

Intraoperative lymph-node assessment during NSCLC surgery: the need for standardisation and quality evaluation.

Evaluation of Diagnostic Accuracy of Cervical Palpation, Contrast Enhanced Multi-detector Computed Tomography, and Intraoperative Macroscopic Nodal Assessment of Cervical Lymph Node Metastasis of Head and Neck Squamous Cell Carcinoma in Filipinos: A Preli

Objectives. 1) To determine if there is an association between physical examination by cervical palpation, preoperative contrast-enhanced multi-detector computed tomography (MDCT), and intraoperative lymph node assessment, with final histopathology in the evaluation of cervical lymph node metastasis in Filipino patients with squamous cell carcinoma of the head and neck. 2) To determine the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and likelihood ratios of cervical palpation, contrast enhanced MDCT, and intra-operative lymph node assessment compared with final histopathology in the evaluation of cervical lymph node metastasis in Filipino patients with squamous cell carcinoma of the head and neck.&#x0D; Methods. Study Design. Retrospective; Cross-sectional. Setting. Tertiary Government Hospital Charity Section, Department of Otorhinolaryngology, Department of Radiology, Department of Pathology. Participants, Patients or Population. Retrospective chart review of all biopsy proven head and neck squamous cell carcinoma patients admitted at the charity ward of a Otorhinolaryngology Department from 2008-2010 who had documented admission physical examination, a preoperative contrast enhanced multi-detector computed tomography (MDCT) scan of the neck done in the same institution within 20 days or less from date of surgery, and underwent neck dissection with appropriate cervical lymph node level specimen labeling with subsequent post-operative histopathologic evaluation of submitted specimens for neck node metastasis by the Pathology Department of the same institution. After set of exclusion criteria was applied, the analyzed sample included 82 lymph node level samples from 9 patients with head and neck Squamous Cell Carcinoma (SCCA).&#x0D; Results. Pre-operative contrast enhanced MDCT, and intraoperative nodal assessment, were both significantly correlated with the final histopathologic evaluation of neck node metastasis as evaluated with Fisher’s Exact test (p = 0.00). Cervical palpation however was not able to show a significant association (p=0.099).Cervical palpation had a sensitivity of 25.00% (8.3352.59%), specificity of 90.91% (80.61-96.25%), NPV of 83.33 (72.30-90.73%), PPV of 40.00 (13.69-72.63%), accuracy of 78.05%, and a likelihood ratio of 3.33. Preoperative contrast enhanced MDCT had a sensitivity of 43.75% (20.75-69.45%), specificity of 93.94% (84.4498.04%), NPV of 87.32 (76.80-93.69%), , PPV of 63.64 (31.61-87.63%), accuracy of 84.15%, and a likelihood ratio of 12.06. Intraoperative surgical evaluation had a sensitivity of 68.75% (41.48-87.87%), specificity of 93.94% (84.44-98.04%), NPV of 92.54 (82.74-97.22%), PPV of 73.33 (44.83-91.09%), accuracy of 89.02%, and a likelihood ratio of 34.10. Further analysis with McNemar’s Test comparing MDCT and Intraoperative assessment showed no significant difference (p = 0.387).&#x0D; Discussion and Conclusions. In the evaluation of cervical lymph node metastasis for head and neck squamous cell carcinoma in the local setting, the extent of neck dissection, clinical staging and prognosis, as well as adjuvant therapy can be guided by pre-operative contrast enhanced MDCT and intraoperative nodal assessment. Contrast-enhanced MDCT can aid treatment planning in preoperative or non-operative cases; but intraoperative evaluation can be used to guide final extent of surgery. Evaluation solely by physical examination by cervical palpation unfortunately in this study was not able to show a significant association with final histopathology.

The Argument and Consensus of Lymphadenectomy on Lung Cancer Surgery

淋巴结转移是肺癌的重要转移途径，淋巴结清扫术已成为肺癌的标准术式，同时也决定着肺癌的分期、预后及治疗策略。在临床实践中肺癌淋巴结的清扫方式各有不同，从选择性的淋巴结采样到扩大的淋巴结清扫，目前各种清扫方式存在着很大的争议，本文就目前的纵隔淋巴结清扫方式的共识及争议进行综述，为今后开展多中心临床研究提供参考。

Utility of single-photon emission tomography/computed tomography for sentinel lymph node localization in breast cancer patients.

Sentinel lymph node (SLN) mapping is currently a routine technique in breast cancer management and preoperative scintigraphic imaging plays a crucial role in the process of SLN detection. The guidelines recommend performing planar acquisition and optional single-photon emission tomography/computed tomography (SPECT/CT) imaging. The aim of this study was to verify whether routine performing of SPECT/CT in addition to planar imaging increases the sensitivity of SLN detection in patients with early-stage breast cancer. The secondary aims were to compare radionuclide SLN imaging with intraoperative SLN detection and identify clinical and histopathological factors affecting the SLN detection rate. A total of 153 early-stage breast cancer patients underwent lymph node scintigraphy in the years 2007-2013. Breast cancer patients with staging T1-2N0M0 were included. Planar and SPECT/CT lymphoscintigraphy were performed on the day before the surgery. The data on presence or absence of SLN, their number and localization were recorded for both methods and compared with each other as well as with intraoperative blue dye staining and histopathological findings. SPECT/CT identified SLN in 119/153 and planar scintigraphy in 114/153 patients. Identification rates were 77.7 and 74.5%, respectively. Intraoperative lymph node assessment identified SLN in 76/126 cases with an identification rate of 60.3%. Identification rates for second echelon lymph node were 34.6% for hybrid imaging and 21.2% for planar scintigraphy. Statistical analysis did not yield a significant difference in diagnostic accuracy between these methods; however, the Wilcoxon signed-rank test showed that SPECT/CT significantly increases SLN identification rate compared with planar scintigraphy and intraoperative detection. Histopathological examination of excised SLN showed that 22 nodes were metastatic. SPECT/CT visualized all of these, whereas planar imaging and intraoperative lymph node detection procedure visualized 19 and 18, respectively. No clinical and histopathological factors affecting SLN detection rate were identified. Hybrid SPECT/CT lymphatic mapping yields a high SLN detection rate in patients with early-stage breast cancer and provides lymph node localization details. It identifies more SLN than planar imaging and intraoperative SLN detection. However, its limited superiority over the remaining two methods does not support its routine use for SLN localization. We suggest using SPECT/CT for SLN detection in case of equivocal planar imaging results.

Invasive Mediastinal Staging Guideline Concordance

Despite guidelines for preoperative invasive mediastinal staging (IMS) for non-small cell lung cancer (NSCLC), concordance with guidelines and whether the use of these guidelines results in expected frequency of lymph node metastases has not been evaluated. Our objectives were to determine guideline concordance, reasons for nonconcordance, and, in patients who did not receive IMS, to determine the use of operative nodal sampling and final pathologic staging. Patients who had a resection for NSCLC between 2010 and 2012 were identified from the Institutional Cancer Registry. A chart audit was performed to determine adherence to Cancer Care Ontario (CCO) IMS guideline criteria, and pathologic reports were reviewed to determine postresection staging. Of 242 resections performed in the study period 102 (42%) did not receive IMS. 66 patients (65%) didnot require IMS based on CCO guidelines and thus were concordant with guidelines, whereas 36 (36%) were guideline nonconcordant. Of 102 patients who did not have preoperative IMS, only 72 had intraoperative lymph node assessment and only 35 (34%) had sampling of three or more ipsilateral (N2) nodal stations. In the guideline concordant group, 2 of 66 patients (5%) had positive N2 nodes, whereas in the nonconcordant group 3 of 36 patients (11%) were N2 positive. Although overall IMS was used in only 140 patients (58%), concordance with guidelines was high at 85% (206 of 242 patients). However, rates of intraoperative nodal sampling for non-IMS cases (both concordant and nonconcordant) was lower than expected, resulting in potentially understaged patients.

ED04.01 Surgery in Bronchopulmonary Typical and Atypical Carcinoids

ED04.01 Surgery in Bronchopulmonary Typical and Atypical Carcinoids

P001 Predicting positive sentinel nodes and assessing feasibility for intra-operative lymph node assessment

P001 Predicting positive sentinel nodes and assessing feasibility for intra-operative lymph node assessment

Prognostic Significance of the Highest Peripancreatic Lymph Node in Biliary Tract Adenocarcinoma

Patients with biliary tract adenocarcinoma with nodal involvement have a poor prognosis. There is currently no standardized method for intraoperative lymph node assessment. The current study aimed to determine the prognostic significance of the highest peripancreatic lymph node (HPLN) in biliary tract malignancy. This was a retrospective study of patients undergoing potential curative resection of biliary tract adenocarcinoma from January 1995 through December 2010 who prospectively had intraoperative sampling of the HPLN. The median follow-up was 72.8 months. The primary end points were recurrence-free survival (RFS) and disease-specific survival (DSS). The rate of HPLN positivity in 110 patients undergoing exploration for potential curative resection was 30 % and did not vary with histologic subtype (gallbladder vs. cholangiocarcinoma). Eighty-five patients underwent complete gross resection. In this subset, median RFS and DSS were 34.3 months (95 % confidence interval [CI] 23.6-not reached [NR]) and 62.4 months (95 % CI 40.8-NR) for HPLN-negative patients, and 9.6 months (95 % CI 4.76-NR) and 20.5 months (95 % CI 7.4-NR) for HPLN-positive patients (p < 0.01), respectively. Median DSS was 14.6 months (95 % CI 9.6-25.4) for patients with unresectable disease. On multivariate analysis, HPLN status was an independent predictor of RFS (hazard ratio 3.73, 95 % CI 1.86-7.45; p < 0.01) and DSS (hazard ratio 3.98, 95 % CI 1.89-8.38; p < 0.01). HPLN status is prognostic of RFS and DSS in biliary tract adenocarcinoma. Intraoperative nodal staging by HPLN sampling warrants further investigation in a prospective trial.

189 Intra-operative lymph node assessment in lung cancer resection

189 Intra-operative lymph node assessment in lung cancer resection

Raman spectroscopy—A new method for the intra-operative assessment of axillary lymph nodes

Sentinel Lymph Node Biopsy has become the standard surgical procedure for the sampling of axillary lymph nodes in breast cancer. Intra operative node assessment is currently not offered to the majority of patients but would allow definitive axillary surgery to take place immediately. This would confer benefits both to the patient and to the healthcare system. Our experimental study aims to demonstrate that a Raman spectroscopy probe device could overcome many of the disadvantages of current intra-operative analysis techniques. 38 axillary lymph nodes, 25 negative and 13 positive from 20 patients undergoing breast surgery for invasive breast cancer were assessed using a commercially available Raman spectroscopy probe. Spectra were assessed using principal component fed linear discriminant analysis trained by the histopathology results. Leave one node out cross validation achieved a sensitivity of up to 92% and a specificity of up to 100% in differentiating between normal and metastatic lymph nodes.

Quality Measures for Breast Cancer Surgery

To identify and quantify surgical outcomes as possible quality measures of initial breast cancer surgery and to assess variation among surgeons. Descriptive analysis of concurrently collected outcome measures. University hospital with a designated breast cancer center. Patients with a preoperative diagnosis of invasive breast cancer or ductal carcinoma in situ undergoing their initial cancer surgery from April 1, 2003, to March 30, 2008. Eight measures were identified: (1) total mastectomy rate; (2) close (<1 mm) and positive margin rate following initial partial mastectomy; (3) number of operations required in breast conservation; (4) number of nodes obtained from sentinel lymph node biopsy; (5) number of nodes from axillary dissection; (6) proportion of patients with positive sentinel lymph node biopsy undergoing axillary dissection; (7) use of intraoperative lymph node assessment; and (8) time from diagnosis to surgery. Nine hundred ten operations (218 for ductal carcinoma in situ, 692 for invasive breast cancer) were performed by 6 surgeons. Variation existed among surgeons in the combined close and positive margin rate, number of nodes obtained from sentinel lymph node biopsy, and use of intraoperative lymph node assessment. No significant variation was seen for the overall mastectomy rate, mean number of operations, positive margin rate alone, and number of lymph nodes from axillary dissection. Quality indicators for breast cancer surgery can be identified and readily monitored. Outcome variation exists at a high-volume breast center. Further study into the causes and effects of this variation on short- and long-term patient outcomes as well as health care costs is needed.

The node-negative neck: accuracy of clinical intraoperative lymph node assessment for metastatic disease in head and neck cancer.

Often, the type of neck dissection performed in patients with head and neck malignancy is finally determined by intraoperative assessment of clinically suspect lymph nodes by frozen section. This prospective study aimed to assess the accuracy of clinical intraoperative lymph node assessment and therefore to examine validity of the underlying assumption that the surgeon can consistently identify nodes that contain metastatic tumor. We also aimed to assess whether gross morphological characteristics of the lymph nodes examined could be correlated with nodal status and therefore used to predict those nodes containing metastatic disease. A prospective study assessing the accuracy of clinical intraoperative lymph node assessment in the node-negative neck. Forty-six neck dissections from 34 patients with head and neck cancer were prospectively examined intraoperatively by a single surgeon. All obvious nodes were clinically assessed, morphologically described, and subsequently correlated with pathological findings. Sixty palpable nodes were identified in 32 neck dissections. They were clinically categorized as malignant or suspect (22) or benign (38). Pathological examination revealed a false-positive rate of 30% and a false-negative rate of 44%. The sensitivity of intraoperative lymph node assessment was 56%, and the specificity was 70%. Apart from "infiltration," morphological characteristics could not be correlated with nodal status. In the 14 neck dissections with no obviously palpable lymph nodes, 4 (29%) were positive for metastatic disease. In the node-negative neck, intraoperative assessment does not seem to improve the accuracy of staging. The only parameter of benefit and correlating with metastatic disease is clinical evidence of infiltration. The assumption that frozen section is a good determinate for selection of type of neck dissection is questionable. If selective neck dissection is not found to be therapeutic, its use leads to over-reliance on other therapeutic treatment such as postoperative radiotherapy, depriving the patient of a potential useful treatment modality in cases of locoregional recurrence.