Lateral Node Research Articles

Feasibility of hybrid robotic rectal surgery.

To investigate the feasibility of combined robotic rectal surgery and transanal total mesorectal excision (hybrid robotic surgery). Among 143 robotic rectal surgeries performed from 2017 to 2022, 85 were hybrid robotic surgeries and were analyzed in this study. The cohort comprised 59 males and 26 females with a mean age of 65.8years old and a mean body mass index of 22.6kg/m2. The cStage was I in 20 cases, II in 21, III in 36, IV in 4, and other in 4. The operation types were low anterior resection in 21 cases, intersphincteric resection in 27, abdominoperineal resection in 32, total pelvic exenteration in 2, and other in 3. Twelve patients (14.1%) received neoadjuvant chemotherapy or chemoradiotherapy, and 39 (45.9%) underwent lateral lymph node dissection. The mean operation time for total mesorectal excision was 302.7min, and the median blood loss was 71.5ml. No cases required conversion to laparotomy. The median length of postoperative hospital stay was 15.9days. Complications of Clavien-Dindo grade ≥ 3 occurred in 3 cases (4.2%). Urinary dysfunction occurred in 6 cases (8.3%). Three (4.2%) patients were diagnosed with positive circumferential resection margins. Hybrid robotic surgery is safe and oncologically feasible.

Minimal Invasive Robotic Surgery in Lateral Lymph Node Dissection by Pelvic Floor First Approach.

Minimal Invasive Robotic Surgery in Lateral Lymph Node Dissection by Pelvic Floor First Approach.

Artificial intelligence-assisted precise preoperative prediction of lateral cervical lymph nodes metastasis in papillary thyroid carcinoma via a clinical-CT radiomic combined model.

This study aimed to develop an artificial intelligence-assisted model for the preoperative prediction of lateral cervical lymph node metastasis (LCLNM) in papillary thyroid carcinoma (PTC) using computed tomography (CT) radiomics, providing a new noninvasive and accurate diagnostic tool for PTC patients with LCLNM. This retrospective study included 389 confirmed PTC patients, randomly divided into a training set (n = 272) and an internal validation set (n = 117), with an additional 40 patients from another hospital as an external validation set. Patient demographics were evaluated to establish a clinical model. Radiomic features were extracted from preoperative contrast-enhanced CT images (venous phase) for each patient. Feature selection was performed using analysis of variance and the least absolute shrinkage and selection operator algorithm. We employed support vector machine, random forest (RF), logistic regression, and XGBoost algorithms to build CT radiomic models for predicting LCLNM. A radiomics score (Rad-score) was calculated using a radiomic signature-based formula. A combined clinical-radiomic model was then developed. The performance of the combined model was evaluated using the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA). A total of 1724 radiomic features were extracted from each patient's CT images, with 13 features selected based on nonzero coefficients related to LCLNM. Four clinically relevant factors (age, tumor location, thyroid capsule invasion, and central cervical lymph node metastasis) were significantly associated with LCLNM. Among the algorithms tested, the RF algorithm outperformed the others with five-fold cross-validation on the training set. After integrating the best algorithm with clinical factors, the areas under the ROC curves for the training, internal validation, and external validation sets were 0.910 (95% confidence interval [CI]: 0.729-0.851), 0.876 (95% CI: 0.747-0.911), and 0.821 (95% CI: 0.555-0.802), respectively, with DCA demonstrating the clinical utility of the combined radiomic model. This study successfully established a clinical-CT radiomic combined model for predicting LCLNM, which may significantly enhance surgical decision-making for lateral cervical lymph node dissection in patients with PTC.

Surgical anatomy of lateral lymph node dissection: landmarks and areas of dissection in minimally invasive surgery.

Lateral lymph node dissection (LLND) for rectal cancer is a vital procedure to achieve en bloc removal of metastatic laterallymph nodes with surrounding fat tissues, guided by precise anatomicallandmarks. The anatomy of the lateral compartment, however, isnot straightforwardfor the majority of surgeons. Inadequate knowledge of the vascular and neural anatomy may increase the risk of intraoperative complications such as bleeding, nerve injury andincompletelymph node dissection. Minimallyinvasive surgery provides enhanced visualization of the surgical anatomyin the lateral compartment. Comprehensive knowledge of surgical anatomy is indispensable for successful LLND, and simplifying the anatomy into the planes makes the procedure accessible for surgeons. This article presentsanatomical landmarks essential forstandardizing the step-by-step procedures ofLLNDand review the literature. i.e., for safe implementation of the procedures.

Total neoadjuvant therapy followed by total mesorectal excision and selective lateral lymph node dissection for locoregionally advanced low rectal cancer: A phase III randomized controlled trial (JCOG2207).

TPS312 Background: For locally advanced low rectal cancer (RC), total neoadjuvant therapy (TNT) followed by total mesorectal excision (TME) confers a survival advantage compared with neoadjuvant chemoradiotherapy (nCRT) in the West, even though the local control rate was similar between TNT and nCRT. The Japan Clinical Oncology Group (JCOG) Colorectal Cancer Study Group has been developing therapies for RC based on recurrence risk according to presence/absence of clinical lateral lymph node metastasis (cLLNM). Our previous study in Japan showed that the standard of care (SOC) for RC is TME with lateral lymph node dissection (LLND) plus adjuvant chemotherapy (CTx). However, the prognosis for cStage III low RC remains poor regardless of cLLNM status. Therefore, new treatment strategies are needed for this population. In cLLNM-positive cStage III low RC patients, previous research suggests that adding nCRT to LLND would reduce local recurrence and improve survival. TNT and LLND may further improve outcomes. In cLLNM-negative cStage III low RC, several reports have suggested that nCRT as an alternative addition to LLND has comparable efficacy in terms of local control. Thus, in these populations, if TNT can replace LLND, adverse events due to LLND can be avoided while improving prognosis. We hypothesize that TNT + TME + selective LLND would be the most promising strategy for cLLNM-positive and -negative cStage III low RC. Methods: Eligibility criteria include low rectal adenocarcinoma or adenosquamous carcinoma, cT2-cT4 tumor depth, clinically positive lymph node metastasis, no distant metastasis, no history of pelvic irradiation or rectal surgery, age 18-75 years, and sufficient organ function. Eligible patients are randomized (1:1) with adjustment factors of institution, sex, and cLLNM status. The experimental treatment arm receives TNT, short-course radiotherapy (25 Gy/5 fractions to whole pelvis), and consolidation chemotherapy consisting of 6 courses of CAPOX (oxaliplatin 130 mg/m2 on day 1 and capecitabine 2000 mg/m2/day on days 1-14). After completing TNT, TME + selective LLND are performed for cLLNM-positive cases or TME alone for cLLNM-negative cases. The SOC arm receives TME + LLND followed by adjuvant chemotherapy with 8 cycles of CAPOX (same as above). The primary endpoint is overall survival (OS) in the intention-to-treat population. To detect an increase in 5-year OS from 76% to 84%, corresponding to a target hazard ratio of 0.64, 408 patients (108 events) would achieve 75% power at a one-sided α of 0.05, an expected accrual period of 4 years, and a follow-up period of 5 years. The total sample size was set at 420 patients to account for patients lost to follow-up. Accrual in JCOG2207 began in October 2023. Clinical trial information: s031230415 .

Total neoadjuvant therapy with FOLFOX plus bevacizumab and short-course radiotherapy for Ras mutant, high-risk, locally advanced rectal cancer: The TRAINER trial.

133 Background: Total neoadjuvant therapy (TNT) intensified by the combination of targeted therapy or immunotherapy is warranted to achieve satisfying local and systemic control for high-risk locally advanced rectal cancer (LARC). Our study aimed to explore the efficacy and safety of a FOLFOX-based TNT regimen plus bevacizumab and short-course radiotherapy (SCRT) in Ras-mutant high-risk LARC patients. Methods: In this single-arm, single-center, phase II trial, LARC patients with at least one risk factor (cT3c-4, mesorectal fascia positive, cN2, lateral lymph node involvement, and extramural venous invasion positive) were recruited and only Ras-mutant patients were included. Four cycles of FOLFOX plus bevacizumab were arranged as induction chemotherapy followed by SCRT (25Gy/5Fx) and two cycles of FOLFOX as consolidation chemotherapy. Surgery was performed 8 weeks after completion of radiotherapy. After surgery, high-risk stage III patients (T4 or N2) were recommended to receive an extra 6 cycles of FOLFOX as adjuvant chemotherapy, while low-risk stage III patients were scheduled for regular follow-up. Patients with clinical complete response(cCR) were allowed to choose the “Watch & Wait” (W&W) strategy instead of surgery. The primary endpoint was the complete response (CR) rate, defined as the total rate of cCR plus pathological complete response (pCR). Secondary endpoints included adverse events of TNT, postoperative complications, 2-year disease-free survival, and overall survival. Results: Between April 2, 2021, and March 12, 2024, 47 of 51 enrolled patients were eligible for treatment. All patients completed the prescribed TNT cycles, and six (12.8%) of them had dose reduction. The CR was achieved in 18 (38.3%) patients, including 14 (29.8%) pCR. No grade IV-V toxicity was observed and the incidence of grade III toxicities was 34.0%. Four patients (8.5%) achieved cCR and chose the W&W strategy. The other 43 patients underwent curative surgery and anal preservation was achieved in 39 (90.7%) patients. Seven patients (16.3%) experienced postoperative complications, including four (9.3%) cases of anastomotic leakage. Conclusions: The intensified TNT regimen combined with bevacizumab achieved a satisfying CR rate with acceptable toxicities and complications for Ras-mutant high-risk LARC patients. Long-term survival data of this cohort are needed to validate the efficacy of this regimen further. Clinical trial information: NCT04923620 .

Risk factors for lateral pelvic lymph node metastasis in patients with rectal neuroendocrine tumors: a systematic review and meta-analysis

Risk factors for lateral pelvic lymph node metastasis in patients with rectal neuroendocrine tumors: a systematic review and meta-analysis

Detection of Central Compartment Lymph Node Metastasis of Thyroid Cancer: Usefulness of Intraoperative Thyroglobulin Measurement in Fine Needle Aspiration Washout with and Without Blue Dye Injection

Background/Objectives: The management of lymph node metastases of the central neck compartment (CNC) in differentiated thyroid carcinoma is debated. The intraoperative measurement of thyroglobulin (Tg) has gained attention in accurately detecting metastases, reducing unnecessary CNC dissections. Methods: A total of 37 patients underwent surgery. An intraoperative assay of thyroglobulin from fine needle aspiration (Tg-FNA) was performed on CNC lymph nodes, identified by blue dye injection in 15 patients (23 nodes, group A) and by palpation in 22 patients (35 nodes, group B). The Tg-FNA values were compared with histology to calculate the diagnostic accuracy. Results: In group A, the blue dye diffused widely, complicating lymph node identification: 2 were metastatic and 21 non-metastatic, with median Tg-FNA levels of 6236 ng/mL and 99.20 ng/mL, respectively. In group B, 8 were metastatic and 27 benign, with median Tg-FNA levels of 4063 ng/mL and 121 ng/mL (p < 0.0001), respectively. ROC analysis identified 500 ng/mL as a cutoff, achieving 100% sensitivity and 74% specificity in group B and 90% sensitivity and 70% specificity overall. Finally, among the non-metastatic lymph nodes, group A exhibited some cases of very high Tg-FNA values compared to group B, with lower accuracy for the cutoff, suggesting that colorant injection might lead to increased Tg-FNA levels. Conclusions: Blue dye injection showed low accuracy. Intraoperative Tg-FNA was reliable in detecting CNC metastases, although a higher cutoff is needed in this compartment compared to what has been reported for lateral lymph nodes. Lymphatic drainage and surgical manipulation might explain these findings. The careful interpretation of Tg-FNA in CNC should be adopted.

Metastatic Status and Dissection Effect of Regional/Extraregional Lymph Nodes in Japanese Patients with Squamous Cell Carcinoma of the Anal Canal: A Multicenter Retrospective Cohort Study

Squamous cell carcinoma of the anal canal (SCCA) is a rare condition. Standard treatment includes chemoradiotherapy, with surgical treatment reserved for limited cases. In the future, the decrease in surgical frequency makes it more difficult to pathologically assess the depth of tumor invasion and lymph node status; therefore, those studies based on relatively recent surgical cases may offer valuable insights into diagnosing and treating SCCA. This multicenter, retrospective cohort study evaluated 435 patients with SCCA in Japan, of which 84 underwent surgical lymph node dissection. The correlation of regional/extraregional lymph node metastasis with T-primary tumor category/depth of tumor invasion, and the index of estimated benefit from lymph node dissection (IEBLD) was evaluated histopathologically. Primary tumor progression was associated with metastasis and recurrence of the inguinal node and further inferior mesenteric trunk/root node metastasis, an extraregional lymph node. The IEBLD for the inferior mesenteric trunk/root node was 6.9, which was higher than 4.0 IEBLD of the lateral lymph nodes classified as the regional lymph nodes. The assessment of the primary tumor involvement can predict metastases of the inguinal node and inferior mesenteric trunk/root node and recurrence of the inguinal node. Although the UICC TNM Classification considered the inferior mesenteric trunk/root nodes as extraregional lymph nodes, actively targeting them with the treatment can improve the prognosis.

Who is a candidate at the initial presentation? Prediction of positive lateral lymph node and survival after dissection.

Metastatic lateral pelvic lymph node (LPN) in rectal cancer has a significant clinical impact on the prognosis and treatment strategies. But there are still debates regarding prediction of lateral pelvic lymph node metastasis and its oncological impact. This review explores the evidence for predicting lateral pelvic lymph node metastasis and survival in locally advanced rectal cancer. Until now many studies have reported that magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET/CT) are considered as essential tools for predicting metastatic LPN, with MRI-based size criteria, particularly the short-axis diameter of LPN. But several studies have reported that the addition of tumor location or artificial intelligence (AI) can further enhance diagnostic accuracy. Western practices focus more on neoadjuvant chemoradiation (nCRT), while Eastern countries focus more on lateral pelvic lymph node dissection (LPND). LPND has been shown to reduce lateral local recurrence (LLR) rates compared to total mesorectal excision (TME) alone, particularly in patients with enlarged LPNs, but its impact on overall survival is uncertain. The decision to perform LPND should be individualized according to LPN size and response to nCRT; and through selective LPND based on those criteria, patients could achieve a balance between the benefit of local control and the risk of surgical complications from LPND, such as sexual and urinary dysfunction.

Positive lateral lymph node turned negative after neoadjuvant therapy-surgery or observation?

Since the adoption of neoadjuvant chemoradiation and total mesorectal excision as the standard in rectal cancer care, there has been marked improvement in the local recurrence rates. In this context, restaging magnetic resonance imaging (MRI) plays a key role in the assessment of tumor response, occasionally enabling organ-sparing approaches. However, the role of restaging MRI in evaluating lateral lymph nodes remains limited. Most studies suggest a high risk of lateral local recurrence regardless of a decrease in lymph node size on restaging MRI. Therefore, it is recommended that clinical decisions should rely on the primary MRI scan. Watchful waiting may be appropriate only in cases of a clinical complete response with substantial downsizing of lateral lymph nodes (≤ 4.0mm). Notably, some lateral lymph nodes may enlarge during follow-up despite complete tumor response, in which case, lateral lymph node dissection can be considered while preserving the rectum. Thus, continuous surveillance of lateral lymph nodes is essential during watchful waiting. Restaging MRI may hold greater importance for smaller lymph nodes (5.0-6.9 mm), as those with persistent malignant features on imaging carry a 13% risk of lateral recurrence at 4 years. Understanding these risks is critical when engaging in shared decision-making with the patient.

The oncologic benefits of lateral lymph node dissection after neoadjuvant therapy - local control or survival?

Lateral pelvic lymph node dissection (LPLND) for rectal adenocarcinoma is an established treatment modality for selected patients with abnormal lateral pelvic lymph nodes on magnetic resonance imaging (MRI) imaging. The goal of this treatment is to achieve a true R0 resection, including lymphadenectomy, with the aim of improving patient oncological outcome, potentially at the expense of surgical and functional complications. However, there remain several areas of controversy resulting from a distinct lack of clarity regarding effective patient selection, lymph node size criteria, the role and extent of routine neoadjuvant treatment versus surgery alone in selected cases, the impact on patient survival metrics and whether the existing data are even valid in the era of total neoadjuvant therapy (TNT). Furthermore, the lack of widely disseminated surgical standardisation and expertise in performing this procedure potentially contributes to the lack of utilisation in certain countries and regions. In this narrative review, we summarize the current state of the literature and attempt to answer the question of what oncological benefits there are, if any, from LPLND after neoadjuvant therapy in rectal cancer, and whether these justify the risks and potential need for inter-hospital transfer.

Reversed anatomy in transanal lateral lymph node dissection: landmarks and pitfalls.

Lateral lymph node dissection (LLND) is getting global attention as an asurgical option to reduce local recurrence inlocally advanced rectal cancer. As the transanal total mesorectal excision (TaTME) is gaining popularity worldwide, a novel LLND approach was established adoptinga two-teamapproach that combines the transabdominal and transanal approaches using the TaTME technique. Thisnarrative review describes the advantages, anatomical landmarks, surgical techniques, and pitfalls of transanal LLND (TaLLND). The advantages of TaLLND include a magnified view and enhanced maneuverability of the laparoscopic instruments in the deep pelvis. TaLLND is also beneficial for LLND in patients with a history of pelvic surgery because surgeons can have access to theareas unaffected by previous surgery. To master the TaLLND technique, the procedure should be understood according to the following steps: S4 nerve identification, lateral space entry, lateral dissection, obturator vein, artery, and nerve identification, dissection along the external iliac vein, medial dissection, median and bottom dissection, dissection along the internal iliac artery, and dissection along the obturator nerve. TaLLND can be applied to highly advanced diseasethat requires combined resection of themajor internal iliacvessels, pelvic nerves, or adjacentorgans. In such cases, simultaneous transanal and transabdomiinalLLND utilizing a two team approachhas advantages as theseapproachescan providemutualcomplementary roles. TaLLND is expected to overcome the difficulty of transabdominal LLND and improve the quality of LLND.

Gross recurrent laryngeal nerve invasion by extranodal extension in thyroid carcinoma

BackgroundLymphatic metastasis commonly occurs in patients with papillary thyroid carcinoma and medullary thyroid carcinoma. The clinical and imaging characteristics of recurrent laryngeal nerve (RLN) invasion by extranodal extension (ENE) of metastatic lymph nodes remain understudied. This study aimed to evaluate these characteristics in patients with thyroid carcinoma.MethodsA retrospective cohort study was conducted on 77 patients treated between January 2012 and March 2024 with thyroid carcinoma demonstrating gross RLN invasion during surgery. Fifteen patients with gross RLN invasion by ENE of the metastatic lymph nodes were included. The primary endpoint was the percentage of preserved nerves. The secondary endpoints included vocal cord function and recurrence-free survival.ResultsFourteen patients had papillary thyroid carcinoma (PTC), and one had medullary thyroid carcinoma (MTC). There was no case of distant metastasis in the series. In the PTC group, two patients presented with hoarseness. There were two (14.3%) cases of T1a, six (42.9%) cases of T1b, and nine (64.3%) cases with concomitant lateral lymph node metastasis. The stage of the MTC case was T3bN1a. Among all the cases included, ten (67.7%) and five (33.3%) right and left RLNs, respectively, were invaded by ENE of the central compartment lymph nodes. Ultrasonography showed lymph nodes wrapping beyond half of the circumference of the RLNs and indistinct boundaries between the nodes and RLNs. Seven patients (46.7%) had the tumor shaved off from the epineurium, and three (20.0%) had the integrity of the RLNs preserved with gross residual tumor. Permanent vocal cord paralysis occurred in two (13.3%) cases receiving neurectomy, of which one was of the PTC group, and the other one belonged to the MTC group. At the end of the follow-up period, two patients in the PTC group experienced locoregional recurrence.ConclusionsMost patients with RLN invasion by ENE were asymptomatic. Sonography is feasible for assessing the location of metastatic lymph nodes in relation to the RLN in this preliminary study. Careful central compartment evaluation for patients with lymphatic metastases from thyroid carcinoma is conducive to nerve preservation and radical resection of lesions, especially for patients with MTC.

Clinical characteristics and predictive factors of pathological lateral pelvic lymph node metastasis in patients with rectal cancer.

In recent years, selective lateral lymph node dissection (LLND) has been performed more frequently. The present study aimed to explore the clinical characteristics and predictive factors of pathological lateral pelvic lymph node metastasis (LPLNM), which may be helpful for pre-treatment decisions. The present study included 64 patients with rectal cancer and clinically suspected LPLNM who underwent total mesorectal excision (TME) and LLND between February 2019 and April 2024. According to pathological outcomes, the patients were divided into the negative LPLN (n=40) and positive LPLN (n=24) groups. The primary endpoints were the overall pathological LPLNM positivity rate and different clinical characteristics between the two groups. The secondary endpoint was the identification of predictive factors of pathological LPLNM before surgery. Among the 64 patients, 24 (37.5%) had pathologically confirmed LPLNM, and pathological LPLNM was related to initial lymph node size. When initial LPLN size was <7 mm, the pathological LPLNM rate was 10.5%, whereas when LPLN size was between 7 and 10 mm, the rate was 34.6%, and when LPLN size was >10 mm, the rate was 68.4%. Initial LPLN size (≥7.1 mm, P=0.003) and cN stage (N1-2, P=0.005) were significantly associated with pathological LPLNM. In multivariate analysis of risk factors, initial LPN size (≥7.1 mm; hazard ratio=4.856, 95% confidence interval 1.158-20.359, P=0.031) was the only independent risk factor for pathological LPLNM. When the cut-off initial LPLN size was 7.1 mm, the sensitivity and specificity were 87.5 and 52.5%, respectively, and the area under the curve was 0.748 (P=0.0009). When both LPLN size ≥7.1 mm and cN1-2 were satisfied, the sensitivity was 66.7%, the specificity increased to 77.5%, and the positive and negative predictive values were 64.0 and 79.5%, respectively. In conclusion, initial LPLN size and cN stage were identified as significant clinical characteristics associated with pathological LPLNM. Patients with an initial LPLN size of ≥7.1 mm and with cN1-2 stage cancer could benefit from TME + LLND surgery.

Simultaneous integrated boost to lateral pelvic lymph nodes during chemoradiotherapy in high-risk rectal cancer.

Preoperative chemoradiotherapy combined with total mesorectal excision (TME) is astandard treatment for locally advanced rectal cancer (LARC). However, lateral pelvic lymph nodes (LPLNs) are often inadequately treated with standard regimens. This study examines the treatment and postoperative outcomes in LARC patients receiving asimultaneous integrated boost (SIB) for LPLNs during long-course chemoradiotherapy. This retrospective study included high-risk LARC patients (UICC, "Union Internationale Contre le Cancer", stageIII) treated with preoperative chemoradiotherapy and SIB to LPLNs. Radiotherapy was delivered to the primary tumor and elective volumes with 50.4 Gy in 28fractions, and anSIB with amedian dose of 60.2 Gy was administered to clinically positive LPLNs. TME quality and postoperative complications were assessed using MERCURY and Clavien-Dindo, respectively. Time-to-event data were analyzed according to Kaplan-Meier. Between 2019 and 2023, 27patients with high-risk LARC and LPLN metastases were treated with chemoradiotherapy. After amedian follow-up of 19months, 2‑year overall survival was 80%, disease-free survival 80%, and local control of dose-escalated lymph nodes 100%. Three patients were managed nonoperatively after aclinical complete response on endoscopy and imaging. Of the 22patients who had surgery, only one had complications higher than Clavien-DindogradeI; TME was graded as MERCURYI in 73%. The SIB approach for LPLNs in LARC is feasible, does not increase postoperative morbidity, and achieves excellent local control. This study supports the consideration of dose-escalated radiotherapy for LPLNs to address high local recurrence risks.

High-risk habitat radiomics model based on ultrasound images for predicting lateral neck lymph node metastasis in differentiated thyroid cancer

BackgroundThis study aims to evaluate the predictive usefulness of a habitat radiomics model based on ultrasound images for anticipating lateral neck lymph node metastasis (LLNM) in differentiated thyroid cancer (DTC), and for pinpointing high-risk habitat regions and significant radiomics traits.MethodsA group of 214 patients diagnosed with differentiated thyroid carcinoma (DTC) between August 2021 and August 2023 were included, consisting of 107 patients with confirmed postoperative lateral lymph node metastasis (LLNM) and 107 patients without metastasis or lateral cervical lymph node involvement. An additional cohort of 43 patients was recruited to serve as an independent external testing group for this study. Patients were randomly divided into training and internal testing group at an 8:2 ratio. Region of interest (ROI) was manually outlined, and habitat analysis subregions were defined using the K-means method. The ideal number of subregions (n = 5) was determined using the Calinski-Harabasz score, leading to the creation of a habitat radiomics model with 5 subregions and the identification of the high-risk habitat model. Area under the curve (AUC) values were calculated for all models to assess their validity, and predictive model nomograms were created by integrating clinical features. The internal and external testing dataset is employed to assess the predictive performance and stability of the model.ResultsIn internal testing group, Habitat 3 was identified as the high-risk habitat model in the study, showing the best diagnostic efficacy among all models (AUC(CRM) vs. AUC(Habitat 3) vs. AUC(CRM + Habitat 3) = 0.84(95%CI:0.71–0.97) vs. 0.90(95%CI:0.80-1.00) vs. 0.79(95%CI:0.65–0.93)). Moreover, integrating the Habitat 3 model with clinical features and constructing nomograms enhanced the predictive capability of the combined model (AUC = 0.95(95%CI:0.88-1.00)). In this study, an independent external testing cohort was utilized to assess the model’s accuracy, yielding an AUC of 0.88 (95%CI: 0.78–0.98).ConclusionThe integration of the High-Risk Habitats (Habitat 3) radiomics model with clinical characteristics demonstrated a high predictive accuracy in identifying LLNM. This model has the potential to offer valuable guidance to surgeons in deciding the necessity of LLNM dissection for DTC.Clinical trial numberNot applicable.

Anatomical Studies on the Morphology and Topography of Cavity Lymphnodes in Pigs

The lymphatic system, supported by the lymphatic vessels, is a vascular network in higher vertebrates, having essential roles, such as regulating tissue pressure, monitoring the immune system and absorbing fats from the diet. The lymphatic vessels constitute an unidirectional system that transports fluids and proteins, taking them from the interstitial space and returning them to the bloodstream. Objectives: The objectives pursued in this study are the following: to identify the topography of the main cavity lymph nodes and the morphological and topographic variants that may occur; to identify the main interspecific histological characteristics of vessels and lymph nodes in pigs. Materials and methods: The study was carried out on 20 animals weighing 25-30 kg, aged about 3.5 months, of both sexes. They came from private breeders. Ultrasonographic investigations were also performed on half of them. The macro- and microscopic anatomical studies as well as the ultrasonographic investigations were performed at the Faculty of Veterinary Medicine in Bucharest. For macroscopic and topographic analysis, lymph nodes in both the thoracic and abdominal cavities were examined "in situ". Results. Caudal mediastinal lymph nodes were always fewer in number (between one and three). They were associated with the esophagus, immediately behind the tracheobronchial and ventral lymph nodes of the aorta. The afferents originated from the pericardium, the caudal part of the mediastinum and the corresponding part of the esophagus. The efferents connected to the tracheobronchial lymph nodes or could also approach some thoraco-aortic lymph nodes. The lumbo-aortic lymph nodes were located on the lateral surfaces of the aorta, starting from the diaphragmatic orifice to the origin of the deep iliac circumflex artery. The iliac lymphocenters were represented by large lymph nodes that formed a bundle at the origin of the celiac artery. Colic lymph nodes were located along the path of the right colonic artery. Splenic lymph nodes were placed on the path of the homonymous vessels. Their topography was between the aorta and the hilum of the spleen. In this sector there could be 2-4 lymph nodes, but there were others (2-5) located along the upper quarter of the spleen. The jejunal lymph nodes formed a double chain in the middle of the jejuno-ileum meso, about 30 cm long. The caudal mesenteric lymph nodes were reduced, located dorsally by the descending colon on the path of the caudal mesenteric artery. Conclusions. In the case of mediastinal lymph nodes, the anterior ones are present, but their topography differs significantly from individual to individual. The most important groups of visceral lymph nodes are jejunal and colic. The most important parietal lymphocenter is the ileosacral one. In it, we were able to describe for the first time some individual variants, namely: lateral iliac lymph nodes dominant in volume compared to the medial ones, the absence in some cases (10%) of anorectal lymph nodes in some specimens, in which, however, a compensation was observed by the development of a chain of small units on the path of the median sacral artery.

Total Pelvic Exenteration with Presacral Fascia and Pelvic Musculature Excision for Pelvic Recurrence of Rectal Cancer.

Local relapse has not been eradicated even in the era of total mesorectum excision.1,2 Although various approaches have been attempted, R0 resection remains the only potentially curative treatment.3,4 PATIENT AND METHODS: A 45-year-old woman with a history of laparoscopic abdominoperineal resection was diagnosed with pelvic recurrence 7 months ago. Then, she received chemoradiotherapy. Magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET-CT) showed pelvic recurrences at the surface of the right piriformis and obturator internus, posterior vaginal wall, and presacral fascia. The patient also had bilateral hydronephrosis. No distant metastasis was found. First, the lateral pelvic lymph nodes were removed. Then, the internal iliac arteries and veins were transected. Next, the fibrotic ureters were isolated and cut. Then, presacral fascia at the S4 and S5 levels was excised. Anteriorly, the urethra and vagina were transected. Lastly, the suspected pelvic recurrent lesions were resected en bloc with partial right piriformis, obturator internus, and gluteus maximus through a combined abdominal and perineal approach. Greater omental pedicle flap was transplanted into the pelvic cavity and pelvic floor was reconstructed. The operative time was 600min, and blood loss was 400ml. Postoperative course was uneventful, and the patient was discharged 14days after surgery. Pathology report showed a moderately differentiated rectal adenocarcinoma invading the vagina, presacral fascia, and pelvic musculature. All margins were negative. As demonstrated by this case, image-guided total pelvic exenteration with presacral fascia and sidewall musculature excision provides an opportunity to cure pelvic recurrence of rectal cancer.5.

Effect of Fast-Track Surgery Based on Nutritional Support in the Rehabilitation of Patients Undergoing Radical Thyroidectomy and Lateral Lymphadenectomy: A Retrospective Analysis.

This study aims to investigate the impact of fast-track surgery (FTS), based on nutritional support, on postoperative rehabilitation and nutritional status in patients undergoing radical thyroidectomy and lateral lymphadenectomy. This retrospective study included 112 patients who underwent radical thyroid cancer surgery and lateral neck lymph node dissection at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, between April 2021 and April 2023. Based on various nursing methods, patients were divided into two groups, with 58 patients included in the observation group (FTS care based on nutritional support), and 54 patients in the control group (routine perioperative care). Postoperative clinical indicators, nutritional status, Quality of Life, associated complications, and follow-up outcomes at 3 and 12 months were compared between the two groups. Patients in the observation group showed significantly shorter meal times, hospital stays, and off-bed time compared to the control group (p < 0.05). After three months of intervention, the observation group had higher body weight, muscle mass, and body fat, and lower Nutritional Risk Screening (NRS) scores compared to the control group (p < 0.05). At the 12-month follow-up, the observation group had better nutritional status indicators than the control group (p < 0.05). Furthermore, the observation group exhibited higher Quality of Life scores (p < 0.001) and reduced incidence of delayed complications (p < 0.05). During the three-month follow-up, the observation group demonstrated higher Quality of Life Questionnaire Core 30 (QLQ-C30) score compared to the control group (p < 0.05). Additionally, the overall incidence of complications was significantly lower in the observation group (p < 0.05). FTS nursing based on nutritional support effectively promotes postoperative recovery, improves nutritional status, and enhances Quality of Life in patients following radical thyroidectomy and lateral lymphadenectomy, which is worthy of being widely popularized.