Intrapulmonary Nodes Research Articles

Predictive model for intraoperative decision-making in video-assisted thoracoscopic lobectomy: optimizing chest drain placement for high-risk patients.

For years, it has been the common and widely accepted practice in thoracic surgery to place apical and basal drains after a lobectomy to completely drain the pleural cavity. With the development of thoracoscopic technology, it became apparent that the use of a single chest tube provided the same clinical results. However, sometimes tension pneumothorax occurs with the need for additional pleural drainage. The aim of this study was to develop a prognostic model to identify high risk patients intraoperatively and to insert additional pleural drainage to prevent the development of pneumothorax after video-assisted thoracoscopic surgery (VATS) lobectomy. This was a retrospective multicenter study of patients (registry data was analyzed) who underwent VATS lobectomy via a standardized multiport approach between 2014 and 2022. In all cases, a single drain was used postoperatively. We used a machine learning algorithm and data synthesis to expand patient selection according to Riley's method. A total of 418 cases were analyzed in this study. After determining the prognostically significant factors, we performed a binary logistic regression analysis using reverse step-by-step inclusion of variables according to the Akaike information criterion. After validation of the model by bootstrap (400 iterations) and with the original dataset, a nomogram with a specific point distribution for each risk factor was created. The rate of tension pneumothorax was 4.53% (n=66). The most significant variables associated with the need for additional drainage were adhesions, intraoperative lung suturing, fused interlobar fissure, enlarged intrapulmonary lymph nodes, chronic obstructive pulmonary disease (P<0.001). The C-index of the model was 0.957, the mean absolute calibration error was 0.6%, and the slope of the calibration curve was 0.959. A score of 26 points indicated a 95% risk of postoperative tension pneumothorax. The nomogram achieved good predictive performance for tension pneumothorax after minimally invasive lobectomy. High-risk patients could be identified, and additional drainage may be placed intraoperatively to reduce the risk of lung collapse in the postoperative period.

Standardized intrapulmonary lymph node dissection in lung cancer specimens: A national Colombian analysis

ObjectiveIn patients with non–small cell lung cancer, lymph node assessment is essential for appropriate staging. The intrapulmonary lymph nodes (IPLNs) should be considered when assigning the N stage but are infrequently evaluated in Colombian centers, resulting in understaging that may hinder optimal treatment. MethodsWe conducted a prospective study of IPLN dissection in patients with clinical stage I or II non–small cell lung cancer who underwent surgical resection at 9 institutions in Colombia between 2021 and 2023. IPLN dissection was performed by trained surgeons who collected lymph nodes from fresh specimens after resection and before formalin fixation. ResultsOne hundred patients were eligible for the analysis. Their mean age was 67 ± 10.9 years, and 76% were women. Most (74%) had adenocarcinoma, 20% had neuroendocrine tumors, and 6% had squamous cell carcinoma. Successful sampling and histopathologic analysis of at least one IPLN station was obtained in 85% of patients, 9% had upstaging due to positive N2 lymph nodes, and 5% had upstaging due to positive N1 lymph nodes. Among the patients with pN0 or pN1 disease, 3.2% (3 out of 91) were upstaged exclusively due to positive IPLNs. ConclusionsFresh-specimen dissection to collect IPLNs is appropriate and feasible to achieve more accurate pathological staging in Colombian lung cancer patients. In clinical N0 patients, IPLN dissection maximizes selection for adjuvant therapy.

The safety and efficacy of the fissure-first approach in lung segmentectomy for patients with incomplete fissures.

Lung segmentectomy has gained much more attention as an important surgical method for treating early-stage lung cancer. However, incomplete fissures increase the difficulty of lung segmentectomy. The aim of this study was to analyze the safety and efficacy of the fissure-first approach in precision resection of lung segments for patients with incomplete fissures. The clinical data of patients with incomplete fissures who underwent lung segmentectomy were retrospectively analyzed. Date was divided into fissure-first approach in lung segmentectomy group (group A) and fissure-last approach in lung segmentectomy group (group B). The general linear data, operation times, intraoperative adverse events, postoperative recovery dates and complications were compared. A total of 122 patients with complete clinical data were included. Patients in group B had more COPD (p < 0.05), and the lesions in group A were more closely related to the hilum of the lung (p < 0.05). Compared to Group B, Group A achieved better surgical outcomes, such as operation time, postoperative hospital stays, intraoperative bleeding, number of intrapulmonary lymph nodes sampled, counts of resected subsegments (except the upper lobe of the right lung), and rate of conversion to thoracotomy (all p < 0.05). The fissure-first approach is a safe and effective surgical approach in lung segmentectomy for patients with incomplete fissures. This approach can reduce the counts of resected subsegments and improve techniques in lung segmentectomy for patients with lung incomplete fissures.

Unveiling the synergetic benefits of the tunneling technique using stapler tractor in precise resection of lung segments: a retrospective cohort study.

Tunneling technique has shown preliminary promise in lung segmentectomy which requires the use of staplers in specific procedures. However, the obstacle when staples pass is the most obvious factor hindering the implementation and development of this technique. This study investigated whether the obstacle of the technology could be addressed by using an innovative self-designed stapler tractor and analyzed the combined and respective advantages of them. The clinical data of patients with lung nodules located near anatomical sites with potential tunnel creation treated by segmentectomy were analyzed in this retrospective case-control study. The data were divided into four groups according to four distinct surgical strategies: In Group A, the tunneling technique was performed with a stapler tractor; in Group B, the tunneling technique was performed without a stapler tractor; in Group C, didn't perform the tunneling technique but using stapler tractor in a normal approach; and in Group D, neither performed the technique nor used the stapler tractor. The general linear data, operation times, intraoperative adverse events, postoperative recovery and complications were compared. Compared with other groups, Group A exhibited the best surgical outcomes in comprehensive aspects. Separately, the tunnel groups (Group A&B) had better outcomes in the macro implementation of operation, including resection margin, the number of sampled intrapulmonary lymph nodes and resected subsegments, while the staple tractor groups (Group A&C) performed better on details of the procedure, including operation time, conversion to thoracotomy, and intraoperative bleeding (p < 0.05). Both of them were beneficial for shorter hospital stay, and the tunnel group was more advantageous. The tunneling technique is an advanced and beneficial surgical strategy for performing precise resection of lung segments while a stapler tractor can promote and facilitate it as a supplementary instrument. They show more combined benefits in effectively minimizing the occurrence of erroneous injuries and enhancing the operational efficacy.

Two Interventions on Pathologic Nodal Staging in a Population-Based Lung Cancer Resection Cohort

BackgroundDespite its prognostic importance, poor pathologic nodal staging of lung cancer prevails. We evaluated the impact of 2 interventions to improve pathologic nodal staging. MethodsWe implemented a lymph node specimen collection kit to improve intraoperative lymph node collection (surgical intervention) and a novel gross dissection method for intrapulmonary node retrieval (pathology intervention) in nonrandomized stepped-wedge fashion, involving 12 hospitals and 7 pathology groups. We used standard statistical methods to compare surgical quality and survival of patients who had neither intervention (group 1), pathology intervention only (group 2), surgical intervention only (group 3), and both interventions (group 4). ResultsOf 4019 patients from 2009 to 2021, 50%, 5%, 21%, and 24%, respectively, were in groups 1 to 4. Rates of nonexamination of lymph nodes were 11%, 9%, 0%, and 0% and rates of nonexamination of mediastinal lymph nodes were 29%, 35%, 2%, and 2%, respectively, in groups 1 to 4 (P < .0001). Rates of attainment of American College of Surgeons Operative Standard 5.8 were 22%, 29%, 72%, and 85%; and rates of International Association for the Study of Lung Cancer complete resection were 14%, 21%, 53%, and 61% (P < .0001).Compared with group 1, adjusted hazard ratios for death were as follows: group 2, 0.93 (95% CI, 0.76-1.15); group 3, 0.91 (0.78-1.03); and group 4, 0.75 (0.64-0.87). Compared with group 2, group 4 adjusted hazard ratio was 0.72 (0.57-0.91); compared with group 3, it was 0.83 (0.69-0.99). These relationships remained after exclusion of wedge resections. ConclusionsCombining a lymph node collection kit with a novel gross dissection method significantly improved pathologic nodal evaluation and survival.

Primary pulmonary hyalinizing clear cell carcinoma with vocal-cord squamous cell carcinoma: a case report with systematic review

BackgroundPrimary pulmonary hyalinizing clear cell carcinoma (HCCC) is a low-grade salivary gland-type carcinoma. Until now, 23 cases of pulmonary HCCC have been reported.Case presentationHere, we present a patient with primary pulmonary HCCC along with vocal-cord squamous cell carcinoma (SCC) revealed by biopsy examination. The patient underwent radiotherapy for vocal-cord SCC, followed by right upper lobectomy and lymph node dissection 10 months later. Histology revealed polygonal cells with eosinophilic or clear cytoplasm in the myxoid matrix together with hyaline degeneration. The tumor involved the whole layer of the segmental bronchus and regionally involved the alveolar tissue along with one intrapulmonary lymph node. Targeted RNA sequencing revealed Ewing Sarcoma Breakpoint Region 1 (EWSR1)- activating transcription factor 1 (ATF1) fusion. We analyzed the data on pulmonary malignant tumors between 2000 and 2019 in the Surveillance, Epidemiology, and End Results (SEER) database and reviewed all cases of pulmonary HCCC with EWSR1 fusion by searching PubMed. The results showed that head and neck (HN) adenoid cystic carcinoma (ACC) (47.89%) and HNSCC (22.54%) were the most common carcinomas occurring with pulmonary salivary gland-type malignant tumors. Screening of 24 cases of pulmonary HCCC with EWSR1 fusion revealed that five cases demonstrated lymph node metastases and only two had documented tumor recurrences. HCCC is rare and easily misdiagnosed as SCC, but the treatment regimen differs between pulmonary HCCC and SCC.ConclusionsHence, pulmonary tumors with clear cells must be diagnosed with caution. Next-generation sequencing (NGS) may be useful for diagnosis, especially in cases with a history of squamous cell carcinoma (SCC).

The nodule in the emphysematous lung: an appeal for surgery in a lung volume reduction concept.

Emphysema patients, who are candidates for lung volume reduction surgery (LVRS) usually present with an extensive smoking history and thus have an increased risk for lung. The incidence of pulmonary nodules in emphysematous lungs is high. We therefore aimed to analyse the incidence and histological findings of pulmonary nodules in our LVRS program. We conducted a retrospective review of all patients who underwent LVRS between 2016 and 2018. Data concerning preoperative workup, 30 days mortality and histopathological findings analysed. Between 2016 and 2018, LVRS was performed in 66 patients. In 18 (27%) a nodule was found in the preoperative computed tomography (CT) scan. Histological findings revealed in two cases squamous cell lung cancer. In two other cases, histopathological findings revealed an anthracotic intrapulmonary lymph node. In eight cases, a tuberculoma was found with a positive culture in one case. The other six histopathological findings were hamartoma, granuloma or sequelae of pneumonia. Malignancy was found in 11.1% of patients presenting with a nodule in preoperative LVRS workup. The relative risk of lung cancer in emphysema patients is increased and if LVRS criteria are fulfilled surgical resection of a pulmonary nodule is a meaningful way to verify the histology.

Positive Association of Serum Vitamin B6 Levels with Intrapulmonary Lymph Node and/or Localized Pleural Metastases in Non-Small Cell Lung Cancer: A Retrospective Study.

The relationship between vitamin B levels and the development and progression of lung cancer remains inconclusive. We aimed to investigate the relationship between B vitamins and intrapulmonary lymph nodes as well as localized pleural metastases in patients with non-small cell lung cancer (NSCLC). This was a retrospective study including patients who underwent lung surgery for suspected NSCLC at our institution from January 2016 to December 2018. Logistic regression models were used to evaluate the associations between serum B vitamin levels and intrapulmonary lymph node and/or localized pleural metastases. Stratified analysis was performed according to different clinical characteristics and tumor types. A total of 1498 patients were included in the analyses. Serum vitamin B6 levels showed a positive association with intrapulmonary metastasis in a multivariate logistic regression (odds ratio (OR) of 1.016, 95% confidence interval (CI) of 1.002-1.031, p = 0.021). After multivariable adjustment, we found a high risk of intrapulmonary metastasis in patients with high serum vitamin B6 levels (fourth quartile (Q4) vs. Q1, OR of 1.676, 95%CI of 1.092 to 2.574, p = 0.018, p for trend of 0.030). Stratified analyses showed that the positive association between serum vitamin B6 and lymph node metastasis appeared to be stronger in females, current smokers, current drinkers, and those with a family history of cancer, squamous cell carcinoma, a tumor of 1-3 cm in diameter, or a solitary tumor. Even though serum vitamin B6 levels were associated with preoperative NSCLC upstaging, B6 did not qualify as a useful biomarker due to weak association and wide confidence intervals. Thus, it would be appropriate to prospectively investigate the relationship between serum vitamin B6 levels and lung cancer further.

Role of intrapulmonary lymph nodes in patients with NSCLC and visceral pleural invasion. The VPI 1314 multicenter registry study protocol.

In the lung cancer classification (TNM), the involvement of thoracic lymph nodes is relevant from a diagnostic and prognostic point of view. Even if imaging modality could help in selecting patients who should undergo surgery, a systematic lymph node dissection during lung surgery is mandatory to identify the subgroup of patients who can benefit from an adjuvant treatment. Patients undergoing elective lobectomy/bilobectomy/segmentectomy) for non-small cell lung cancer and lymphadenectomy with lymph nodes station 10-11-12-13-14 sampling that meet the inclusion and exclusion criteria will be recorded in a multicenter prospective database. The overall incidence of N1 patients (subclassified in: Hilar Lymph nodes, Lobar Lymph nodes and Sublobar Lymph nodes) will be examined as well as the incidence of visceral pleural invasion. The aim of this multicenter prospective study is to evaluate the incidence of intrapulmonary lymph nodes metastases and the possible relation with visceral pleural invasion. Identifying patients with lymph node station 13 and 14 metastases and/or a link between visceral pleural invasion and presence of micro/macro metastases in intrapulmonary lymph nodes may have an impact on decision-making process. ClinicalTrials.gov ID: NCT05596578.

Abstract 4359: Interventions to improve pathologic nodal staging of curatively resected lung cancer: A population-based implementation study

Abstract Introduction. Despite its importance, pathologic nodal (pN) staging of lung cancer remains poor. We evaluated the quality and survival impact of two interventions to improve pN staging. Methods. Using a non-randomized stepped-wedge design, we implemented use of a lymph node (LN) specimen collection kit to improve intraoperative LN collection (surgical intervention) and a novel gross dissection method for intrapulmonary LN retrieval (pathology intervention) in 12 hospitals in five contiguous Hospital Referral Regions in AR, MS and TN (2009-2021). With appropriate statistical methods we compared surgical quality and survival of patients among: neither (Group 1), pathology only (Group 2), surgical only (Group 3), and both (Group 4) interventions. Results. Of 4,019 patients, 50%, 5%, 21% and 24%, were in Groups 1-4 respectively. Rates of non-examination of LNs and non-examination of mediastinal LNs: 11%, 9%, 0% and 0%; 29%, 35%, 2% and 2% respectively in Groups 1-4 (p&amp;lt;0.0001). Attainment of American College of Surgeons Operative Standard 5.8: 22%, 29%, 72%, 85%; International Association for the Study of Lung Cancer’s stringent definition of ‘complete resection’: 14%, 21%, 53%, 61% (p&amp;lt;0.0001). Compared to Group 1, adjusted hazard ratios, aHR (95% CI), were: Group 2, 0.93 (0.76-1.15); Group 3, 0.91 (0.78-1.03); Group 4, 0.75 (0.64-0.87). Compared to Group 2, Group 4 aHR- 0.72 (0.57-0.91); compared to Group 3, was 0.83 (0.69-0.99). These relationships remained after excluding wedge resections. Discussion. Combining a LN collection kit and novel gross dissection method significantly improved pN evaluation and survival in a population-based cohort. Citation Format: Meredith A. Ray, Carrie Fehnel, Olawale Akinbobola, Andrea Saulsberry, Kourtney Dortch, Anberitha Matthews, Amal Anga, Christopher Giampapa, Elizabeth Sales, Sherry Okun, Edward T. Robbins, Bradley Wolf, Paul Levy, Horace L. Wiggins, Thomas Ng, Vishal Sachdev, Ganpat Valaulikar, Hetal D. Patel, Nicholas R. Faris, Matthew Smeltzer, Raymond U. Osarogiagbon. Interventions to improve pathologic nodal staging of curatively resected lung cancer: A population-based implementation study. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4359.

Segmentectomy for ground-glass-dominant lung cancer with a tumour diameter of 3 cm or less including ground-glass opacity (JCOG1211): a multicentre, single-arm, confirmatory, phase 3 trial

Although segmentectomy is a widely used surgical procedure, lobectomy is the standard procedure for resectable non-small-cell lung cancer (NSCLC). This study aimed to evaluate the efficacy and safety of segmentectomy for NSCLC up to 3 cm in size, including ground-glass opacity (GGO) and predominant GGO. A multicentre, single-arm, confirmatory phase 3 trial was conducted across 42 institutions (hospitals, university hospitals, and cancer centres) in Japan. Segmentectomy with hilar, interlobar, and intrapulmonary lymph node dissection was performed as protocol surgery for patients with a tumour diameter of up to 3 cm, including GGO and dominant GGO. Eligible patients were those aged 20-79 years with an Eastern Cooperative Oncology Group performance score of 0 or 1 and clinical stage IA tumour confirmed by thin-sliced CT. The primary endpoint was 5-year relapse-free survival (RFS). This study is registered with the University Hospital Medical Information Network Clinical Trials (UMIN000011819), and is ongoing. A total of 396 patients were registered from Sept 20, 2013, to Nov 13, 2015, of whom 357 underwent segmentectomy. At a median follow-up of 5·4 years (IQR 5·0-6·0), the 5-year RFS was 98·0% (95% CI 95·9-99·1). This finding exceeded the 87% of the pre-set threshold 5-year RFS and the primary endpoint was met. Grade 3 or 4 early postoperative complications occurred in seven patients (2%), but no grade 5 treatment-related deaths occurred. Segmentectomy should be considered as part of standard treatment for patients with predominantly GGO NSCLC with a tumour size of 3 cm or less in diameter, including GGO even if it exceeds 2 cm. National Cancer Centre Research and Development Fund and Japan Agency for Medical Research and Development.

Radioiodine diagnosis of differentiated thyroid cancer lung metastases in children: a case report

Lung metastases (LM) in differentiated thyroid cancer in children occur in 7-30% of cases, 3-4 times more often than in adults. Early diagnosis of LM improves the results of radioiodine therapy and the rate of complete remissions. We present a clinical case demonstrating the specific features of LM diagnosis in children. Patient G., a 9-year-old boy, was for two years observed for excessive body weight. Ultrasound thyroid gland examination revealed multiple hypoechogenic nodules, cytologically verified papillary cancer. Computed tomography (CT) of the chest revealed subpleural foci up to 3 mm in both lungs, which were more consistent with intrapulmonary lymph nodes, but did not completely rule out metastatic lesions. A thyroidectomy with central and lateral neck dissections was performed in January 2022. Histologic examination revealed multifocal papillary cancer growth in the entire thyroid gland with Tall cell sites and metastases to multiple cervical lymph nodes. According to TNM classification (American Joint Committee on Cancer (AJCC), 8th edition), the tumor grade was considered as pT2N1bM0, stage I. Seven weeks after surgical treatment, the patient underwent whole body scintigraphy with I-123 (24 hours after I-123 injection for 50 MBq) followed by radioiodine therapy on endogenous TSH-stimulation (4 weeks of L-thyroxine withdrawal). Scintigraphy with I-123 (whole-body and SPECT/CT) did not detect iodine-accumulating tissue. However, post-therapy (72 hours after administration of 2 GBq I-131) scintigraphy (whole-body and SPECT/CT) revealed residual thyroid tissue and diffuse accumulation of I-131 in both lungs. The TSH-stimulated thyroglobulin was 118 ng/ml, and thyroglobulin antibodies were 21 IU/ml. Pathological accumulation of I-131 in the lungs in combination with the elevated thyroglobulin level and chest CT findings were regarded as LM, therefore the tumor process was restaged — pT2N1bM1, stage II and radioiodine therapy was planned to continue.Conclusion. In this clinical case, when diagnosing LM, the result of scintigraphy with I-123 was false-negative, and chest CT scan was uncertain, requiring dynamic monitoring. Scintigraphy after administration of I-131 therapeutic activity revealed LM, thereby changing further treatment strategy to continued radioiodine therapy and increasing the possibility of achieving complete disease remission. Factors associated with LM were miltifocal growth, massive neck lymph node involvement and high TSH-stimulated thyroglobulin levels.

Perifissural pulmonary nodules in oncology patients – Always benign?

Pulmonary nodules are a frequent finding on chest CT. Many are Perifissural Pulmonary Nodules (PFN), which are shown to be benign on follow-up in lung cancer screening and routine care subjects and represent intrapulmonary lymph nodes. Since a growing number of patients that undergo CT have an oncology history, it is increasingly important to have knowledge on whether metastases can mimic PFN and whether these lesions should be treated with more suspicion in oncology patients. We present eight oncology patients harbouring PFN to illustrate the current diagnostic uncertainty of this finding and highlight the need for further prospective data collection.

Isolated adrenocorticotropic hormone deficiency associated with sintilimab therapy in a patient with advanced lung adenocarcinoma: a case report and literature review

BackgroundSeveral immune checkpoint inhibitors have been implemented for cancer treatment which have shown some degree of antitumor effcacy, while immune-related adverse events (irAEs) that affect multiple organ functions ensue which obviously should not be neglected. Though less common than other kinds of irAEs, Immune checkpoint inhibitors (ICIs) related Isolated ACTH deficiency (IAD) may cause long-term damage to pituitary-adrenal axis. Several case reports are available about IAD during anti-PD-1 therapy. We report the first case of immune checkpoint inhibitor-induced IAD following 3 month of sintilimab therapy.Case presentationA 66-year-old Chinese man was diagnosed with stage IIIB lung adenocarcinoma with involving ipsilateral intrapulmonary and hilar lymph node metastasis. After 3 months of combination therapy of nedaplatin, pemetrexed and sintilimab, the patient presented with general fatigue, nausea and vomiting. Laboratory investigation at admission revealed hyponatremia and hypokalemia. Further investigation revealed adrenocorticotropic hormone and cortisol levels were far below than normal limits. His other pituitary hormone levels were normal, except for mild elevation of follicle stimulating hormone and estradiol. Cranic magnetic resonance imaging showed a normal pituitary gland. Isolated adrenocorticotropic hormone deficiency was diagnosed, and corticosteroid replacement therapy was administered, leading to a significant improvement of his symptoms while ACTH level maintaining low level.ConclusionsOur patient developed isolated ACTH deficiency during combination cancer treatment with chemotherapy and sintilimab. Although isolated ACTH deficiency due to anti-PD-1 including sintilimab therapy is rare occurrence, it can often cause severe clinical symptoms. Its diagnosis basically relies on clinical symptoms and endocrinological examination. Unlike traditional hypophysitis diagnosed by cranial MRI, pituitary MRI of IAD due to anti-PD-1 often indicates normal pituitary gland implying that over-reliance on imaging findings is not recommended. Even if clinical symptoms have relieved after corticosteroid replacement therapy was commenced, low levels of ACTH or cortisol could maintain for a long period which highlights the need for long term corticosteroid therapy. The purpose of the current report was to provide increased awareness of early detection and therapy of IAD.

Human lymph node degeneration in the thoracic region: A morphometric and immunohistochemical analysis using surgically obtained specimens.

Lymph node degeneration was examined in 539 mediastinal and intrapulmonary nodes removed from 78 patients, aged 49–82 years, without cancer metastasis. Medullary sinus hyalinization observed in 36.2% of the hilar and 38.5% of the interlobar nodes. Early and smaller lesions were eosinophilic and factor VIII-positive, whereas advanced and large lesions contained a bulky mass of collagenous fiber bundles with few slender cells positive for smooth muscle actin (SMA) and factor VIII, as well as anthracotic macrophages. Subcapsular sinus hyalinization, observed in 4.3% of hilar nodes, was detected as a thick fibrous layer (over 0.2 mm) between the surface cortex and the thickened capsule. The fibrous layer contained SMA-positive slender cells, whereas the thickened capsule contained fibers positive for elastin and factor VIII. These hyalinization lesions occupied 3.6% and 0.8% of the sectional areas of hilar and lower paratracheal nodes, respectively. Areas of early and small cortical degeneration, surrounded by fibers positive for SMA and vimentin, did not contain lymphocytes and macrophages, but contained abundant small stromal cells. Silver staining suggested that advanced cortical degeneration was composed of collagen fibrils other than type I. Fatty tissues, seen in 47.8% of hilar nodes, often extended into and replaced medullary sinus tissue. Island-like remnants of medullary sinuses in areas of fatty degeneration contained various stromal cells positive for SMA, elastin, factor VIII and/or CD34. These degenerative morphologies, however, did not correlate with either age or smoking index. The present cortical degeneration usually seemed to follow hyalinization, but both were likely to occur independently.

EP02.03-010 Intrapulmonary and Hilar Lymph Node Dissection Performed by the Surgical Team: Impact on Pathological Stage of NSCLC

Lymph node assessment improves staging and results in better overall survival in surgically treated lung cancer patients. Routinely, the hilar and intrapulmonary lymph nodes are collected by the pathologist in surgical specimens after surgical treatment of lung cancer. Our hypothesis is that the dissection and identification of hilar and intrapulmonary lymph nodes performed by the surgeon results in greater lymph node sampling than the same dissection performed by pathologist.

Lymph node metastases outside tumor-bearing lobes and/or segments in non-small cell lung cancer.

ObjectiveHilar and lung lymph node metastases (N1) are defined as ipsilateral bronchial and intrapulmonary lymph nodes. However, the cleaning standards for ipsilateral bronchial lymph nodes in different lobes and segments within the same lobe in segmentectomy are not clearly defined.Materials and methodsSixty-six patients undergoing pulmonary resection for the treatment of lung cancer were evaluated. Intraoperatively visible non-tumor-bearing lobe (NTBL) and post-operatively non-tumor-bearing segment (NTBS) lymph nodes were removed and analyzed. The associations between the NTBL LNs and clinicopathological characteristics were analyzed.ResultsNon-tumor-bearing lobe LNs metastases were found in 8 (12.1%) of the 66 patients, NTBS LNs metastasis were not found (0/13). The presence of NTBL metastases was significantly associated with age (<60 years vs. ≥60 years, P = 0.037), differentiation (Grade 1 well differentiated vs. Grade 2 moderately differentiated vs. Grade 3 poorly differentiated, P = 0.012), CAT-scan-findings of Mediastinal and hilar lymph nodes metastasis (node-positive vs. node-negative, P = 0.022), pN stage (N0 vs. N1 vs. N2, P = 0.003) and p stage (I vs. II vs. III, P = 0.009). Multivariate logistic analysis showed that tumor differentiation (P = 0.048, HR 6.229; 95% CI 1.016–38.181) and pN (P = 0.024, HR 5.099; 95% CI 1.245–20.878) were statistically significant predictors.ConclusionsLobar lymph node metastasis of NTBL occurs frequently in patients with NSCLC, but lymph node metastases in NTBS LNs are rare. Advanced age, poorly differentiated and N1 and N2 status of CAT-scan-findings were independent risk factors for the involvement of the NTBL lobar lymph nodes. Although lymph node metastases in NTBS are rare, further investigation of the need to dissect is required.

Spiral CT Image Characteristics and Differential Diagnosis Secondary Pulmonary Tuberculosis and Lung Cancer Based on Visual Sensors.

Helical CT plain scan has high spatial and area resolution, which is beneficial to the extraction of CT features of pulmonary nodules, and is of great significance for the diagnosis and differential diagnosis of pulmonary diseases. In order to deeply study the role of visual sensor image algorithm in CT image, this paper adopts clinical simulation method, data fusion method, and image acquisition method to collect images, analyze CT image features, and simplify the algorithm and create a CT model that can better diagnose secondary tuberculosis and lung cancer. We selected 45 patients with lung disease in this group, with an average age of 38 years. At the same time, the consistency analysis results of the diameter and plain CT value data of the five groups of cases measured by two observers are between 0.82 and 0.88, which has a good consistency. We could find that the nodule diameters of the five groups of cases were different (F =16.99, P < 0.01), and the difference was statistically significant (P < 0.06), indicating that our data are not only accurate but also very reliable. ROC was used to analyze the precise value of CT values in the pulmonary tuberculosis group and lung cancer group, intrapulmonary lymph node group, and pulmonary hamartoma group to determine the cutoff value. The results showed that the AUC values of the pulmonary tuberculosis group and the lung cancer group were 0.788, and the middle was the largest, indicating that the values were guaranteed. The basic realization starts with visual sensor technology and designs a clinical model that can more accurately identify CT images and differential diagnosis.

The pattern of lymph node metastasis in peripheral pulmonary nodules patients and risk prediction models.

BackgroundFor peripheral pulmonary nodules, the regularity of lymph node (LN) metastasis has not been studied. This study aimed to evaluate the metastasis pattern of intrapulmonary and relevant mediastinal lymph nodes in early-stage lung cancer, and further selected patients who were of low risk of LN metastasis as potential population to receive sub-lobectomy.MethodsThis study prospectively included consecutive patients with peripheral clinical T1N0M0 disease who underwent complete resection with LN dissection or sampling from August 2014 to July 2015. The patients were followed up to 15, May 2021. Univariable or multivariable Logistic analysis was used to identify the risk factors. Models predicting LN metastasis risk were conducted. The area under the curve for the receiver operating characteristic curves was used to evaluate the diagnostic value. Disease-free survival and overall survival were compared between groups.ResultsFinally, 201 patients were included in this study. For patients with negative tumor-bearing (TB) 13 and 14 station LNs, the positive rate of other lymph node stations was extremely low. Maximum CT value, pleural indentation and CEA level were risk factors for N1 station LNs metastasis. Besides, the factors above and lobulation sign were risk factors for skip metastasis beyond TB 13 and 14 station LNs. We constructed two scoring tables to predict N1 station metastasis and skip metastasis beyond TB 13 and 14 station. The AUC were 0·837 and 0·823, respectively. Based on the first table, 40·9% of patients suffered N1 station LNs metastasis and 27·3% had N2 disease in “high risk group” while the proportion was only 5·7% and 4·5% in “low risk group”. For patients with negative TB13 and TB14 station LNs, based on the latter table, 11·1% of patients had N1 stations LNs metastasis and 16·7% had pN2 disease in “high risk group” while only 2·3% patients in “low risk group” suffered this kind of metastasis.ConclusionFor peripheral pulmonary nodules patients, stations 13 and 14 LNs may be the sentinel nodes. For patients with low risk of N1 metastasis and skip metastasis, sub-lobar resection might be sufficient for those who were of negative TB 13 and 14 station LNs.

A standard for hilar and intrapulmonary lymph node dissection and pathological examination in early non-small cell lung cancer.

BackgroundThere is considerable variation in the staging of lymph nodes (LNs) as part of tumor, node, metastasis (TNM) staging of non-small cell lung cancer (NSCLC). A new dissection and pathological examination standard for hilar and intrapulmonary LNs needs to be established for patients with early-stage T1–3N0M0 NSCLC.MethodsThis study involved 3,002 patients with T1–3N0M0 NSCLC who underwent radical lobectomy or total pneumonectomy in the thoracic departments of 11 Chinese institutions between January 1999 and October 2013. The Cox model was applied for univariate and multivariate analyses in the examination of station 10, 11 LN and station 12, 13, 14 LN. A hilar and intrapulmonary standard (HI standard) was then established based on univariate and multiple-factor analyses conducted using the Cox model.ResultsAmong the 3,002 patients enrolled in the study, 2,609 underwent at least one examination of station 10, 11 LN (A1), while 393 did not undergo examination of station 10, 11 LN (A0). The A0 and A1 groups had 5-year survival rates of 76% and 80%, respectively (P=0.018). Further, 1,764 patients underwent at least one examination of station 12, 13, 14 LN (B1), while 1,238 patients did not (B0). The B0 and B1 groups had 5-year survival rates of 77% and 82%, respectively (P=0.008). In total, 1,269 patients attained the HI standard (C1), and 1,733 did not (C0). The C0 and C1 groups had 5-year survival rates of 77% and 83%, respectively (P<0.001).ConclusionsThe HI standard can improve both the prognosis and survival rates of patients with T1–3N0M0 NSCLC. This will provide important guidance for pulmonary LN dissection and pathological examination in NSCLC cases.