Location Of Metastatic Nodes Research Articles

Факторы прогноза у больных с диссеминированными гастроинтестинальными стромальными опухолями

The main method of treatment of patients with metastatic GIST is targeted therapy using tyrosine kinase inhibitors in contrast to localized forms of the disease. The efficiency and the duration of targeted therapy efficiency are the main prognostic factors in patients with metastatic gastrointestinal stromal tumors (GIST). Targeted therapy was ineffective among patients with the median survival of only 12-19 months, whereas in cases of effective targeted therapy the median survival was incomparably higher - 60-72 months. The main prognostic factors in patients with primary localized gastrointestinal stromal tumors are: the size of the primary tumor, mitotic index, the localization of tumors, mutation status and morphological characteristics of GIST. Taking into consideration that the main method of treatment in patients with disseminated GIST is drug therapy, the predictive values of several mentioned factors have lost the value, but other factors such as mutation status, morphological characteristics, the number and size of tumors and the localization of metastatic nodes have become more important.

Remembrance: Keiichi Suemasu, MD, 1926-2015.

Keiichi Suemasu died on January 29, 2015 at the age of 88 at Saiseikai Central Hospital in Tokyo, where he was the Emeritus Director. He was admitted due to the worsening of pneumonia symptoms that had started 1 month previously. Despite rigorous treatment, he passed away. Dr. Suemasu was born in Yokosuka city in 1926. He graduated and received his MD degree from Keio University School of Medicine, Tokyo in 1951. Before becoming an attending surgeon at the National Cancer Center (NCC) Hospital in 1962, he obtained a residency and was enrolled in fellowship training programs at Keio University Hospital, and worked at Ashikaga Red Cross Hospital as Chief of Surgery. From the beginning of Dr. Suemasu’s career at NCC, he devoted himself to surgical practice and research on lung cancer. He was promoted to Chief of the Endoscopy Department in 1974 and to Chief of Operation Theatre in 1978, and played a principal role in the development and management of surgical practice in the cancer hospital. He was appointed Deputy-Director of the hospital in 1978, Director in 1989, and President in 1992. Until he retired in 1994, he was actively involved in establishing nationwide systems of treatment and research for patients with cancer. In 1997, he became the Director of Saiseikai Central Hospital, Tokyo, which was one of the most active general hospitals in the Tokyo metropolitan area. His talent and leadership in hospital management had extended from the field of cancer to general medicine, and he remained successful until his retirement in 2006. Throughout his professional life, Dr. Suemasu was an active academic surgeon, a great mentor, and a mediator who brought harmony to the groups he worked with. As a pioneer in lung cancer surgery in Japan, he helped establish lymph node mapping and evaluated the prognostic significance of systematic lymph node dissection in lung cancer, developed a new surgical technique (bronchoplasty) for lung cancer, established clinicopathological concept of ‘‘early’’ lung cancer, refined the lung cancer screening program, together with his colleagues Dr. Shichiro Ishikawa and Dr. Tsuguo Naruke [1–3]. Among these, the promulgation of lymph node map had a significant impact on surgeons: the concept of classifying lymph node stations in the hilum and mediastinum according to anatomical landmarks was not only quite novel, it was also practically convenient for describing the exact location of metastatic lymph nodes during surgery for lung cancer. Dr. Suemasu strongly supported the series of studies that were mainly performed by Dr. Naruke. He never intended to principally lead the study in the group, but rather made every possible effort to facilitate the studies of his junior colleagues and achieve harmony in groups with different, yet strong, personalities. These & Hisao Asamura hasamura@keio.jp; thymoma1983@gmail.com

Comprehensive analysis of metastatic N1 lymph nodes in completely resected non-small-cell lung cancer.

The aim of this study was to comprehensively analyse metastatic lymph nodes as prognostic factors after complete resection in N1 non-small-cell lung cancer (NSCLC). We enrolled 195 patients with pathological N1 NSCLC after complete resection. The number of metastatic lymph nodes and metastatic stations, locations of metastatic lymph nodes, total number of dissected LNs, number of dissected N1 and N2 nodes and the ratio of the number of metastatic N1 nodes to the total number of dissected LNs were evaluated. Univariate analysis by the log-rank test and multivariate analysis by a Cox proportional hazards model were performed to identify prognostic factors of metastatic N1 lymph nodes. The median follow-up duration was 44.2 (6-135) months, recurrence occurred in 76 (39%) and 66 (34%) died. The 3- and 5-year disease-free survival rates and overall survival rates were 65 and 58%, and 89 and 72%, respectively. Univariate analysis identified being a never smoker, adenocarcinoma, pathological stage, hilar node metastasis, multistation metastasis, having four or more metastatic LNs and the lymph node ratio as factors predicting recurrence. Multivariate analysis revealed that adenocarcinoma, pathological stage III and multiple stations of metastatic lymph node were independent risk factors of recurrence. Besides adenocarcinoma and pathological stage III, multistation metastasis was the single prognostic factor among various characteristics of metastatic N1 lymph nodes.

Prognostic significance of extranodal extension of regional lymph node metastasis in papillary thyroid cancer.

The presence and location of regional lymph node metastasis affect the prognosis of patients with thyroid cancer. Lymph node classification of the current TNM system may be inadequate because it insufficiently characterizes the nature and severity of lymph node metastasis that may influence prognosis. We retrospectively studied 240 patients with papillary thyroid cancer and node metastases who had undergone total thyroidectomy, lymph node dissection, and postoperative (131) I treatment at the University Cancer Center between 1994 and 2004. We reviewed the status of regional lymph node metastasis, including the location, number, largest size, and extranodal tumor extension and analyzed their effect on the prognosis of the patients. There were 172 women and 68 men, with a median age of 38 years and median tumor size of 1.9 cm. Thirty-five percent had only central compartment (N1a) nodal metastasis and 65% had involvement of both central and lateral compartments (N1b). There were a median of 4 nodes containing metastasis with a median largest diameter of 1.2 cm. Sixty patients (25%) had extranodal extension of cancer. Multivariate analysis showed that patient age (p = .0017; hazard ratio [HR], 2.156), >3 lymph node metastasis (p = .0316; HR, 1.806), and extranodal extension (p < .0001; HR, 4.027) were independent predictors of disease recurrence. Patient age (p = .0034; HR, 22.068), vascular invasion (p = .01; HR, 8.2), and extranodal extension (p = .022; HR, 12.597) were independent predictors of disease-specific survival (DSS). The DSS and recurrence-free survival curve between patients with and without extranodal extension differ significantly (p < .0001). For those older than 45 years, the 10-year recurrence was 11 of 43 patients for those without extranodal extension and 24 of 27 patients for those with extranodal extension (p < .001). Among patients with stage 4a/4b, those with extranodal extension had a significantly worse DSS and disease-free survival (DFS; p < .001) than those without extranodal extension. The prognosis of patients with stage 4a/4b cancer who had no extranodal extension was the same as patients with stage 3 cancer. The status of extranodal extension seems to be a stronger prognostic predictor than the location of metastatic lymph nodes (N1a/1b). Presence of extranodal extension of metastatic nodes is a significant adverse independent prognostic factor for patients with lymph node metastasis from papillary cancer. This may need to be considered in future updates of the TNM system for thyroid cancer.

A New pN Staging System Based on Both the Number and Anatomic Location of Metastatic Lymph Nodes in Gastric Cancer

BackgroundOur aim was to establish a new pN staging system for gastric cancer based on the number and location of metastatic lymph nodes (MLNs) and to compare it with other systems. MethodsWe retrospectively analyzed the prognostic data of 521 gastric cancer patients who underwent curative resection. Survival analyses were used to establish a pN staging system that considers both the number and location of MLNs and to compare discriminatory ability and monotonicity of gradients (linear trend χ2 score), homogeneity ability (likelihood ratio test), and prognostic stratification ability (Akaike information criterion) between Japanese Gastric Cancer Association (JGCA) and Union for International Cancer Control (UICC) systems. ResultsCut-point survival analysis divided pN+ patients into two groups: Nxn1~6 and Nxn≥7. N0, N1, N2, and N3 (the previous classifications) were replaced by N0, N1n1~6, N2n1~6, and N1n≥7 + N2n≥7 + N3n1~6 + N3n≥7, respectively. Compared with two widely used staging systems, the new system had the highest likelihood ratio test [106.06 (new) vs 95.09 (JGCA) vs 94.33 (UICC)] and linear trend χ2 scores [102.30 (new) vs 89.12 (JGCA) vs 86.97(UICC)] and the lowest Akaike information criterion (AIC) score [2,283.88 (new) vs 2,285.31 (JGCA) vs 2,299.88 (UICC)]. ConclusionA new pN staging system based on the number and location of MLNs is an efficient prognostic indicator of the survival of patients with gastric cancer following radical surgery.

APPLICATION OF IMAGING METHODS IN THE DIAGNOSTICS OF MALIGNANT NECK LYMPH NODES

The presence of malignant lymph nodes in the neck is a prognostic factor in planocellular carcinomas of the head and neck which are the most common primary tumors of this region. Determination of neck lymph nodes involvement is necessary for deciding on surgical treatment and planning chemotherapy and radiation therapy. Metastases in the neck lymph nodes reduce patient survival to a half. Localization of metastatic lymph nodes, their number and size are also very important factors which correlate with distant metastases. Besides clinical examination which includes inspection and palpation of the neck, the diagnostics of metastatic neck lymph nodes also uses imaging techniques: ultrasound (US), computerized tomography (CT) and magnetic resonance imaging (MRI). Precision and reliability of these methods depends on the application of adequate radiological criteria in the diagnostics of malignant lymph nodes of the neck. Acta Medica Medianae 2013;52(2):45-50.

Incidence and location of lymph node metastases in patients undergoing radical cystectomy for clinical non–muscle invasive bladder cancer: Results from a prospective lymph node mapping study

ObjectivesThe objective of this study is to investigate the incidence and location of lymph node metastases (LNMs) in patients undergoing radical cystectomy (RC) and lymph node dissection (LND) for clinical non–muscle invasive bladder cancer (NMIBC). Methods and materialsProspectively collected data of 637 patients who underwent RC and ‘superextended’ LND with intent-to-cure for urothelial carcinoma of the bladder between 2002 and 2008 were examined. Inclusion criteria were (a) clinical stage Ta, Tis-only, or T1, (b) muscle presence at diagnostic transurethral resection in clinical T1 patients, (c) no prior diagnosis of≥T2 disease, (d) no neoadjuvant therapy, and (e) lymphatic tissue sample submitted from all 13 predesignated locations. Lymph node mapping was performed in all patients to determine the location of metastatic lymph nodes. Median follow-up time was 4.7 years. Recurrence-free survival and overall survival were reported. ResultsA total of 114 patients were included of whom 9 patients (7.9%) had LNM. Stratified by clinical stage, LNM was present in 6/67 (9.0%) patients with cT1, 3/25 (12.0%) patients with cTis-only, and none of the 22 patients with cTa. Of the 9 node-positive patients (33.3%), 3 had LNM proximal to the aortic bifurcation. No skip metastases were found. After RC, 27 patients (23.7%) were upstaged to muscle invasive disease; of whom 16.7% had cT1, 2.6% had cTa, and 4.4% had cTis-only. Of the remaining 87 patients with pathologic NMIBC, 1 patient (1.1%) had LNM, limited to the true pelvis. Five-year RFS was 82.3%, 81.5%, and 62.0% in patients with pathologic NMIBC, clinical NMIBC, and pathologic muscle invasive bladder cancer, respectively. ConclusionsRoutine LND is important in patients with cT1 and cTis-only bladder cancer, but may have limited value in patients with cTa. LNM beyond the boundaries of a standard LND occurred in up to one-third of node-positive patients. In the absence of skip metastases, however, performing a standard LND would correctly identify all node-positive patients. Whether removal of LNM proximal to the common iliac vessels provides a survival benefit remains to be evaluated in future prospective studies.

Poor Prognosis of Advanced Gastric Cancer with Metastatic Suprapancreatic Lymph Nodes

BackgroundWhether gastrectomy with D2 lymphadenectomy improves survival of patients with advanced gastric cancer (AGC) remains controversial. Few studies have described the pathological features of AGC with metastatic suprapancreatic lymph nodes (LN), which are the target of D2 lymphadenectomy. This study therefore aims to clarify the prognosis and clinical pathological features including the number and location of metastatic LN in AGC with metastatic suprapancreatic LN.Methods406 patients with AGC, who underwent gastrectomy with D2 lymphadenectomy from 1982 to 2007 at Oita University, were reviewed retrospectively with regard to presence or absence of metastatic suprapancreatic LN. The pathological factors associated with AGC with metastatic suprapancreatic LN were examined by univariate and multivariate analysis.ResultsOf 362 patients with AGC, 78 had suprapancreatic LN metastasis (21.5 %), differing significantly in terms of presence of vascular invasion and having a larger number of metastatic perigastric LN in comparison with only metastatic perigastric LN on univariate analysis. According to multivariate analysis, they were associated with presence of vascular invasion and a large number of total metastatic LN (more than two; N2≤). The overall 5-year survival rate of the AGC with perigastric LN metastasis (station 1–7) group was 37.9 % and of the AGC with suprapancreatic LN metastasis group was 12.8 %. There were significant differences in each group (P < 0.05).ConclusionsPatients with AGC with metastatic suprapancreatic LN had a large number of total metastatic LN and poor prognosis, suggesting that it may be a systemic disease.

Mapping patterns of nodal metastases in seminoma: Rethinking radiotherapy fields

Background and purposeTo analyze the location of metastatic lymph nodes in seminoma patients relative to vascular and bony anatomy and conventional radiation fields. Materials and methodsCross-sectional scans of 90 seminoma patients with infradiaphragmatic adenopathy were analyzed. The position of each node respective to vascular anatomy was transferred to a standardized template. Conventional radiation fields were overlaid on the template and locations of metastatic nodes were assessed. ResultsOne hundred and forty-five nodes were radiographically positive. Eighty-four percent, 9%, and 7% of nodes were located in the para-aortic, common iliac, and pelvic regions, respectively. Ninety-nine percent of nodes were within a 2.5cm lateral and 2.1cm anterior expansion of the aorta inferior to T12/L1. No radiographically positive nodes were identified within the renal hilum or superior to L1 in left-sided seminomas. For right-sided seminomas, no radiographically positive nodes were superior to L2. Three percent of all radiographically positive nodes would have been located outside of conventional and modified fields. ConclusionsInfradiaphragmatic nodal metastases from a contemporary cohort of seminoma patients localized to a smaller area than is targeted by conventional radiation fields. Modified treatment fields based on vascular, rather than bony, anatomy are smaller and may allow for a significant decrease in normal tissue irradiation and toxicity.

Prognostic significance of lymph node station 7 for patients with gastric cancers underwent radical surgery

To investigate the validity of gastric cancers with nodes metastasis at Level II stations limited to No. 7 being classified as level-based n1 stage disease and the impact of this revision on lymph node staging. Clinicopathologic features and prognosis of 1,606 node positive gastric cancers were retrospectively reviewed. Four patient groups were classified according to the status of node involvement: Group A, 734 patients with node metastasis at Level I stations; Group B, 317 patients with nodes metastasis at Level II stations limited to No. 7; Group C, 501 patients with nodes metastasis at Level II stations besides No. 7; and Group D, 54 patients with nodes metastasis at Level III stations. Although the extent of node metastasis for patients in Group B was more severe than that for patients in Group A, clinicopathologic features (especially pT stage) were not significantly different. Although overall survival for patients in Group B was significantly worse than that for patients in Group A, no significant differences in prognosis could be observed when stratified by pN or rN category. A revised level-based n category was established by considering cancers in Group B as level-based n1 stage disease. Multivariate analysis confirmed rN category and the revised level-based n category independently predicted patients' survival. A novel N category was established by combining rN category and the revised level-based n category. Further analysis revealed the novel N category had better homogeneity, discriminatory ability, and monotonicity of gradients than the other node categories, indicating the novel N system might be the most valuable node staging system for prognostic assessment. It might be more suitable for cancers in Group B being classified as level-based n1 stage disease. And we recommend the anatomical location of metastatic lymph nodes also being considered in the categorization of lymph node metastasis.

Prognostic Implications of Lymph Node Metastases in Carcinoma of the Body and Tail of the Pancreas

The current classification of pancreatic cancer is based only on anatomic location of metastatic lymph nodes (LNs). On the other hand, the number of metastatic LNs has been used in staging of colorectal, esophageal, and gastric cancers. The aim of this study was to assess the prognostic impact of the number or ratio of the metastatic LNs in pancreatic body and tail carcinoma. Eighty-five patients with pancreatic body and tail adenocarcinoma who underwent pancreatectomy were included. Location, number, ratio of metastatic LNs, and the survival of patients were analyzed. Forty patients with LN metastasis had poor prognosis (P = 0.007). The prognoses of patients with 5 or more metastatic LNs were poorer than those with less than 5 metastatic LNs (P = 0.046), and patients with a metastatic LN ratio of 0.2 or more had the worst prognosis. Multivariate analysis revealed that 5 or more metastatic LNs and metastatic LN ratio of 0.2 or more were independent prognostic factors for survival (P = 0.0015 and P = 0.014, respectively). These results indicate that the number and the ratio of metastatic LNs can be used to predict poor patient survival and as a staging strategy.

Proposal of new nodal classifications for non-small-cell lung cancer based on the number and ratio of metastatic lymph nodes

The study aimed to evaluate the effectiveness of two new nodal classifications based on the number of metastatic lymph nodes (LNs) or ratio of metastatic to examined LNs (LNR) in making a prognosis, compared with the current nodal classification based on the location of metastatic LNs. We analyzed 651 non-small-cell lung cancer patients who had undergone complete resection with the removal of more than five LNs between 1986 and 2003, excluding preoperative treatment cases, and a Tis, T4, N3, and M1 status, along with limited resection and operative death cases. The cutoff numbers for each category in the two new nodal classifications (number of metastatic LNs (nN0-2): 0, 1-2, and >3, and LNR (rN0-2): 0, 1-12, and >12%) were defined so that the numbers corresponded with paired categories within the current nodal classification. The 5-year survival rate was 75.4% for patients with the N0 categories in all three classifications. The 5-year survival rates for patients with N1 and N2 categories were 52.2% and 42.6% according to the current nodal classification, 54.3% and 39.8% according to the number of metastatic LNs, and 58.8% and 35.0% according to the LNR, respectively. Although all three nodal classifications were independent prognostic factors along with the age and pathological T status, when the three nodal classifications were entered into multivariate analysis individually, the hazard ratio of rN2 was the highest, at 3.15, followed by that of nN2 at 2.96. The LNR followed by the number of metastatic LNs may be more effective prognostic indicators than the current nodal classification based on the location of metastatic LNs. For the future revision, the number of metastatic LNs and LNR should be evaluated as indicators for the nodal classification of lung cancer.

A novel insight of sentinel lymph node concept based on 1-3 positive nodes in patients with pT1-2 gastric cancer

BackgroundSentinel node (SN) biopsy has been practiced in gastric cancer in recent years, and many studies focused on the distribution of solitary lymph node metastasis (SLM) to assess the pattern of SN. In fact, there is usually more than one SN existing in gastric cancer. The distribution of SNs needs to be further re-evaluated.MethodsA total of 289 patients in pT1-2 stage with 1-3 positive nodes confined to same compartment were included in this study with informed consents. The primary lesion was solitary (≤ 5.0 cm in diameter) and D2 or D3 lymph node dissection had been performed. The location of metastatic lymph nodes was analyzed retrospectively.ResultsMost positive nodes occurred in N1 compartment, with frequency of 79.6% to 85.7% based on site of tumor. In the lower third of stomach, no. 6 was the most common metastatic site and no. 3 was the second; the order was reversed for SLM. With increasing depth of tumor invasion, a progressively augmented nodal involvement was shown. Nearly a half appeared transverse metastasis when the tumor located at the lesser or greater curvature. Among skip metastasis, no. 7, 8a, 9 and 11p were the most common metastatic sites and the prognosis was as similar as that of patients with N1 involved only.ConclusionsThe 1-3 positive nodes in the same compartment should be possible SNs, and most of which are restricted in N1 in pT1-2 gastric cancer. Transversal and 2 stations lymph node metastasis are common.

Diagnostyka różnicowa i leczenie guzów szyi w materiale Oddziału Otolaryngologii Międzyleskiego Szpitala Specjalistycznego w Warszawie

In otolaryngology practice we quite often encounter neck masses in all age group patients. The differential diagnosis is extensive and represents a variety of pathologic conditions of various origins, especially in relation to patient age. The authors present a retrospective analysis of patients with a neck mass treated in Otolaryngology Department of Miedzyleski Specialistic Hospital in Warsaw over the period of two years. Patients were divided into groups according to their age. Within each group the incidence of congenital, inflammatory and neoplastic disease was assessed. The most numerous was the group of adults older than 40 years of age with the highest incidence of malignant neoplasms. The location of metastatic lymph nodes in relation to primary site was described. Finally, methods of management for each tumour type were presented. Then we discuss a work-up of a neck mass with regard to literature data.

Lymph node involvement in ampullary cancer: The importance of the number, ratio, and location of metastatic nodes

Lymph node involvement significantly affects survival of cancer patients. The aim of this study was to evaluate the importance of the number, ratio, and location of metastatic lymph nodes in ampullary cancers. Medical records of 111 patients who underwent curative pancreaticoduodenectomy for ampullary carcinomas were reviewed. Metastatic lymph nodes were found in 52 (47%) patients and the median number of involved nodes was 3 (95% confidence interval (CI) 3-4; range 1-17). In the univariate analysis, gender, type of pancreaticoduodenectomy, depth of tumor invasion, perineural invasion, presence of metastatic nodes, their number, and ratio of metastatic nodes significantly correlated with patient survival. However, the location of metastatic nodes did not influence survival among patients with nodal involvement. Only four or more metastatic nodes (relative risk 7.35, 95% CI 3.34-16.17) and tumor invasion of peripancreatic soft tissues (relative risk 5.00, 95% CI 1.20-20.92) were the independent prognostic factors in the multivariate analysis. The number of metastatic nodes significantly affected patient survival. Although the location and ratio of metastatic nodes were not independent prognostic factors, these variables should be further evaluated with large-scale population data sets.

The most appropriate category of metastatic lymph nodes to evaluate overall survival of gastric cancer following curative resection

The purpose of this study was to provide a nodal grouping category based on metastatic lymph nodes to evaluate overall survival in gastric cancer patients following curative resection (R0). We reviewed data of 308 gastric cancer patients following curative resection to evaluate significantly survival differences in different categories of the number of metastatic lymph nodes. In 308 evaluable patients, 5-year survival rate (YSR) was 52.9% (median follow-up, 84 months; range, 6-144 months). A total of 6309 lymph nodes were harvested and examined from all 308 patients, and the average number of lymph nodes harvested for per patient was 20.5 (range, 15-49). The average number of metastatic lymph nodes was 5.4 (range, 0-37) per patient. The initial metastatic node cutoffs were designed as 0, 1-4, 5-8, 9-11, 12-16, and >or=17. According to this new category of the number of metastatic lymph nodes, the 5-YSR of various patient groups were 85.7%, 62.8%, 34.3%, 0%, 0%, and 3.4%, respectively. However, we found that there were not significant prognostic differences between patients with 9 metastatic lymph nodes and patients with more than 9 metastatic lymph nodes (P > 0.05). So we redesigned the later cutoffs of number of metastatic lymph nodes. They were as follows: 0, 1-4, 5-8, and >or=9 of metastatic lymph nodes. We demonstrated this new category of the number of metastatic lymph nodes was more appropriate to evaluate overall survival of gastric cancer patients following curative resection than anyone of the current metastatic lymph nodal stagings (such as N stag in UICC, location of metastatic lymph nodes in JCGC, or ratio of metastatic lymph nodes) by using the case-control matched fashion. Our new category of the number of metastatic lymph nodes was an important prognostic factor of gastric cancer patients following curative resection. There were significant overall survival differences in gastric cancer patient groups with various numbers of metastatic lymph nodes following curative resection.

Distribution of solitary lymph nodes in primary gastric cancer: A retrospective study and clinical implications

To investigate the distribution pathway of metastatic lymph nodes in gastric carcinoma as a foundation for rational lymphadenectomy. We investigated 173 cases with solitary or single station metastatic lymph nodes (LN) from among 2476 gastric carcinoma patients. The location of metastatic LN, histological type and growth patterns were analyzed retrospectively. Of 88 solitary node metastases cases, 65 were limited to perigastric nodes (N(1)), while 23 showed skipping metastasis. Among 8 tumors in the upper third stomach, 3 involved right paracardial LN (station number: No.1), and one in the greater curvature was found in No.1. In the 28 middle third stomach tumors, 10 were found in LN of the lesser curvature (No.3) and 6 in LN of the left gastric artery (No.7); 5 of the 20 cases on the lesser curvature spread to No.7, while 2 of the 8 on the greater curvature metastasized to LN of the spleen hilum (No.10). Of 52 lower third stomach tumors, 13 involved in No.3 and 19 were detected in inferior pyloric LN (No.6); 9 of the 29 cases along the lesser curvature were involved in No.6. Transversal and skipping metastases of sentinel lymph nodes (SLN) are notable, and rational lymphadenectomy should, therefore, be performed.

Definition and delineation of the clinical target volume for rectal cancer

Optimization of radiation techniques to maximize local tumor control and to minimize small bowel toxicity in locally advanced rectal cancer requires proper definition and delineation guidelines for the clinical target volume (CTV). The purpose of this investigation was to analyze reported data on the predominant locations and frequency of local recurrences and lymph node involvement in rectal cancer, to propose a definition of the CTV for rectal cancer and guidelines for its delineation. Seven reports were analyzed to assess the incidence and predominant location of local recurrences in rectal cancer. The distribution of lymphatic spread was analyzed in another 10 reports to record the relative frequency and location of metastatic lymph nodes in rectal cancer, according to the stage and level of the primary tumor. The mesorectal, posterior, and inferior pelvic subsites are most at risk for local recurrences, whereas lymphatic tumor spread occurs mainly in three directions: upward into the inferior mesenteric nodes; lateral into the internal iliac lymph nodes; and, in a few cases, downward into the external iliac and inguinal lymph nodes. The risk for recurrence or lymph node involvement is related to the stage and the level of the primary lesion. Based on a review of articles reporting on the incidence and predominant location of local recurrences and the distribution of lymphatic spread in rectal cancer, we defined guidelines for CTV delineation including the pelvic subsites and lymph node groups at risk for microscopic involvement. We propose to include the primary tumor, the mesorectal subsite, and the posterior pelvic subsite in the CTV in all patients. Moreover, the lateral lymph nodes are at high risk for microscopic involvement and should also be added in the CTV.

Comparison between Site N-Category and Number N-Category for Nodal Staging in Carcinoma of the Gastroesophageal Junction: Our Experience and Literature Review

Gastroesophageal junction (GEJ) neoplasms have become more common over the past decade. Like mediastinal and abdominal lymph nodes and other gastric tumors, GEJ tumors spread to the retroperitoneal nodes. The TNM staging system does not consider this pattern and does not clinically distinguish GEJ tumors from gastric and esophageal cancers. The aim of the study is to compare the old and new TNM staging systems to assess whether the new TNM classifies lymph node involvement in these tumors as a prognostic factor. From January 1983 to December 1995, 438 patients underwent curative gastric resections for cancer at the Department of Surgery "P. Valdoni" of the University of Rome "La Sapienza". Sixty-two had GEJ type II and III tumors according to the Siewert classification system. The old pN1 and new pN1 survival rates (P < 0.05) were statistically different; the old pN2 and new pN2 survival rates (P = 0.483) were not. The multivariate analysis of significant statistical prognostic factors showed that the pTNM staging in type II and type III GEJ tumors is the most important prognostic factor (P < 0.001), followed by the old pN and new pN (P < 0.001) and the pT (P < 0.005). Gender, age, Lauren type, and tumor location according to Siewert (II vs III) were not independently significant prognostic factors. This study concludes that the numbers and locations of metastatic lymph nodes are important prognostic factors that should be included in the next TNM edition.

Lymph node metastasis in ovarian cancer: Difference between serous and non-serous primary tumors

Objective. To investigate the lymph node sites most susceptible to involvement relative to primary tumor histology in ovarian cancer. Methods. The locations of metastatic lymph nodes were investigated in 208 patients with primary ovarian cancer who underwent systemic lymphadenectomy covering both the pelvic and para-aortic regions. Results. Lymph node metastasis was present in 12.8% (20/156) of patients with stage I (pT1M0), 48.6% (18/37) with stage II (pT2M0), and 60% (9/15) with stage III (pT3M0) disease, thus in 22.6% (47/208) of all study patients. Isolated para-aortic nodal involvement was present in 23.3% (14/60) of patients with serous tumor and 4.1% (6/148) of those with non-serous tumor ( P = 0.00002). In an analysis of 35 positive nodes from 25 patients with up to 3 positive nodes, 86.4% (19/22) of metastatic lymph nodes from patients with serous tumor were found in the para-aortic region, with 14 positive nodes located above the inferior mesenteric artery (IMA) and 5 below it, whereas metastasis to para-aortic lymph nodes accounted for 53.8% (7/13) of metastatic lymph nodes from patients with non-serous tumor ( P = 0.0334). Conclusions. The locations of metastatic lymph nodes in ovarian cancer depend upon the histologic type of the primary cancer. In cases of serous tumor, the para-aortic region, particularly above the IMA, is the prime site for the earliest lymph node metastasis. However, the likelihood of pelvic node involvement is almost equal to that of para-aortic node involvement in cases of non-serous tumor.