Node Assessment Research Articles

Role of Ultrasound in Diagnosis of Fibrocystic Breast Disease

Background: Fibrocystic breast disease is the most typical benign breast disease, which is seen in women worldwide with features of pain and feeling of nodules. Its diagnosis is based on clinical symptoms, ultrasound, mammography, and in doubt cases, biopsy is indicated. For assessment of the breast, we clinically examined the breast, axilla, and both supra and infraclavicular regions for lymph node assessment, followed by ultrasound examination. Detection of lesions in any breast quadrant assessed by BIRADs, Breast Imaging Reporting, and Data System grouped in five brackets. Scanning by sonography using B-mode and Doppler study was improved for detecting and characterizing benign and malignant lesions. Objective: To assess a breast lesion by ultrasound with features suggestive of a benign or malignant nature. Method: This study included 210 women aged 20 - 45 who visited a clinic from October 2020 to April 2022 and were examined by ultrasound machine Samsung HS50 (KOREA) with an LA3-14AD probe. B-mode images obtained detection of the lesion, and we also used Doppler ultrasound for assessment of the vascularity of the lesion. The BI-RADS system was used for the categorization of all findings. Result: In 210 women, complaints of lumps were involved in our study. Imaging by B-mode ultrasound using the Doppler study assesses the vascularity of the lesion and provides more characterization of benign and malignant lesions. By B–mode imaging, 99 patients had regular ultrasound study, and 79 patients had simple cysts that appeared well defined, had familiar outlines, and had an anechoic rounded or oval shape with posterior enhancement. Twenty-eight patients with fibroadenoma visualized as round or oval-shaped hypoechoic lesions horizontally oriented to the planes of the breast with lateral shadowing. 2 patients had complex cysts that appear as well-defined, irregular outlines, rounded shape, a thick wall with internal echoes with posterior enhancement. 2 patients have a malignant lesion that appears ill-defined rough outline vertically oriented with breast planes and show posterior shadowing. Conclusion: Ultrasound was established as the most suitable imaging modality for the categorization of breast lesions and exclusion of malignancy, which is helpful for evading unnecessary biopsies.

Early Breast Cancer Risk Assessment: Integrating Histopathology with Artificial Intelligence.

Effective risk assessment in early breast cancer is essential for informed clinical decision-making, yet consensus on defining risk categories remains challenging. This paper explores evolving approaches in risk stratification, encompassing histopathological, immunohistochemical, and molecular biomarkers alongside cutting-edge artificial intelligence (AI) techniques. Leveraging machine learning, deep learning, and convolutional neural networks, AI is reshaping predictive algorithms for recurrence risk, thereby revolutionizing diagnostic accuracy and treatment planning. Beyond detection, AI applications extend to histological subtyping, grading, lymph node assessment, and molecular feature identification, fostering personalized therapy decisions. With rising cancer rates, it is crucial to implement AI to accelerate breakthroughs in clinical practice, benefiting both patients and healthcare providers. However, it is important to recognize that while AI offers powerful automation and analysis tools, it lacks the nuanced understanding, clinical context, and ethical considerations inherent to human pathologists in patient care. Hence, the successful integration of AI into clinical practice demands collaborative efforts between medical experts and computational pathologists to optimize patient outcomes.

Systematic Review-Role of MRI in Cervical Cancer Staging.

A systematic review of the diagnostic accuracy of MRI in the staging of cervical cancer was conducted based on the literature from the last 5 years. A literature search was performed in the Cochrane Library, EMBASE, MEDLINE and PubMed databases using the MeSH terms "cervical cancer", "MRI" and "neoplasm staging". A total of 110 studies were identified, of which 8 fit the inclusion criteria. MRI showed adequate accuracy (74-95%) and high sensitivity (92-100%) in assessing stromal invasion. The data for MRI in terms of assessing vaginal and pelvic side wall involvement were wide ranging and inconclusive. In assessing lymph node metastasis, MRI showed an adequate accuracy (73-90%), specificity (75-91%) and NPV (71-96%) but poor sensitivity (52-75%) and PPV (52-75%). MRI showed high accuracy (95%), sensitivity (78-96%), specificity (87-94%), and NPV (98-100%) but poor PPV (27-42%) in detecting bladder involvement. There was a paucity of data on the use of MRI in assessing rectal involvement in cervical cancer. Overall, the literature was heterogenous in the definitions and language used, which reduced the comparability between articles. More research is required into the diagnostic accuracy of MRI in the staging of cervical cancer and there must be increased consistency in the definitions and language used in the literature.

A preliminary investigation of precise visualization, localization, and resection of pelvic lymph nodes in bladder cancer by using indocyanine green fluorescence-guided approach through intracutaneous dye injection into the lower limbs and perineum.

This study aimed to investigate the feasibility and effectiveness of using indocyanine green (ICG) injected intracutaneously through the lower limbs and perineum for visualized tracking, localization, and qualitative assessment of pelvic lymph nodes (LNs) in bladder cancer to achieve their accurate resection. First, ICG was injected into the LN metastasis model mice lower limbs, and real-time and dynamic in vivo and ex vivo imaging was conducted by using a near-infrared fluorescence imaging system. Additionally, 26 patients with bladder cancer were enrolled and divided into intracutaneous group and transurethral group. A near-infrared fluorescence imaging device with internal and external imaging probes was used to perform real-time tracking, localization, and resection of the pelvic LNs. The mice normal LNs and the metastatic LNs exhibited fluorescence. The metastatic LNs showed a significantly higher signal-to-background ratio than the normal LNs (3.9 ± 0.2 vs. 2.0 ± 0.1, p < 0.05). In the intracutaneous group, the accuracy rate of fluorescent-labeled LNs was 97.6%, with an average of 11.3 ± 2.4 LNs resected per patient. Six positive LNs were detected in three patients (18.8%). In the transurethral group, the accuracy rate of fluorescent-labeled LNs was 84.4%, with an average of 8.6 ± 2.3 LNs resected per patient. Two positive LNs were detected in one patient (12.5%). Following the intracutaneous injection of ICG into the lower limbs and perineum, the dye accumulates in pelvic LNs through lymphatic reflux. By using near-infrared fluorescence laparoscopic fusion imaging, physicians can perform real-time tracking, localization, and precise resection of pelvic LNs.

Current Preoperative Management of Vulvar Squamous Cell Carcinoma: An Overview.

Vulvar carcinoma is a rare cancer affecting the genital tract, constituting 4% of gynecological tumors. Vulvar squamous cell carcinoma (VSCC) is the most common type. Diagnosis relies on biopsy during vulvoscopy, plus imaging such as ultrasonography (USG), magnetic resonance imaging (MRI) and positron emission tomography (PET). This review aims to lay out a thorough overview as to the current preoperative management of VSCC, both in case of vulvar and lymph node involvement. The data research was conducted using the following databases: MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane Library from 2010 to 2024. The selection criteria included only original articles. Seventeen studies were assessed for eligibility. A concordance rate of 62.3% for vHSIL and 65.2% for carcinoma at vulvoscopy, with a sensitivity of 98%, specificity of 40%, PPV (Positive Predictive Value) of 37% and NPV (Negative Predictive Value) of 98% in identifying malignant lesions was found. Regarding the reliability of PET for staging and assessing lymph node involvement, a mean SUV (Standardized Uptake Value) for malignant vulvar lesions of 8.4 (range 2.5-14.7) was reported. In the case of MRI, useful for the evaluation of loco-regional infiltration and lymph node involvement, the ratio of the short-to-long-axis diameter and the reader's diagnostic confidence for the presence of lymph node metastasis yielded accuracy of 84.8% and 86.9%, sensitivity of 86.7% and 87.5%, specificity of 81.3% and 86.2%, PPV of 89.7% and 87.5% and NPV of 76.5% and 86.2%, respectively. A long lymph node axis >10 mm and a short diameter >5.8 mm were found to be predictors of malignancy. At USG, instead, the two main characteristics of potentially malignant lymph nodes are cortical thickness and short axis length; the combination of these ultrasound parameters yielded the highest accuracy in distinguishing between negative and positive lymph nodes. Despite the heterogeneity of the included studies and the lack of randomized clinical trials, this review provides a broad overview of the three imaging tools used for the presurgical management of VSCC. Nowadays, although MRI and PET represent the gold standard, ultrasound evaluation is taking on a growing role, as long as it is carried out by expert sonographer. The management of this rare disease should be always performed by a multidisciplinary team in order to precisely stage the tumor and determine the most suitable treatment approach.

The performance of the node reporting and data system 1.0 (Node-RADS) and DWI–MRI in staging patients with cervical carcinoma according to the new FIGO classification (2018)

PurposeTo evaluate the diagnostic accuracy of the Node-RADS score and the utility of apparent diffusion coefficient (ADC) values in predicting metastatic lymph nodes (LNs) involvement in cervical cancer (CC) patients using magnetic resonance imaging (MRI). The applicability of the Node RADS score across three readers with different years of experience in pelvic imaging was also assessed.Material and methodsAmong 140 patients, 68 underwent staging MRI, neoadjuvant chemotherapy and radical surgery, forming the study cohort. Node-RADS scores of the main pelvic stations were retrospectively determined to assess LN metastatic likelihood and compared with the histological findings. Mean ADC, relative ADC (rADC), and correct ADC (cADC) values of LNs classified as Node-RADS ≥ 3 were measured and compared with histological reports, considered as gold standard.ResultsSensitivity, specificity, positive and negative predictive values (PPVs and NPVs), and accuracy were calculated for different Node-RADS thresholds. Node RADS ≥ 3 showed a sensitivity of 92.8% and specificity of 72.5%. Node RADS ≥ 4 yielded a sensitivity of 71.4% and specificity of 100%, while Node RADS 5 yielded 42.9% and 100%, respectively. The diagnostic performance of mean ADC, cADC and rADC values from 78 LNs with Node-RADS score ≥ 3 was assessed, with ADC demonstrating the highest area under the curve (AUC 0.820), compared to cADC and rADC values.ConclusionThe Node-RADS score provides a standardized LNs assessment, enhancing diagnostic accuracy in CC patients. Its ease of use and high inter-observer concordance support its clinical utility. ADC measurement of LNs shows promise as an additional tool for optimizing patient diagnostic evaluation.

Abstract PO3-03-03: Prospective non-randomized study to compare accuracy of clinical examination under anesthesia, axillary ultrasound and histo-pathological evaluation for axillary nodal staging in women with clinically N0 early breast cancer

Abstract Introduction: Accurate assessment of axillary lymph nodes is crucial in the management of early breast cancer (EBC), especially in clinically node negative (cN0) axilla to avoid extensive axillary surgery. Clinical examination alone underestimates nodal disease in nearly 30% women with cN0 axilla. The current study compares, in cN0 axilla, the benefit of axillary ultrasonography (USG) and clinical axillary examination under anesthesia (EUA) to predict involvement of axillary lymph nodes. The gold standard in these patients however remains pathological evaluation after sentinel node biopsy/low axillary sampling (SNB/LAS) and a complete axillary lymph node dissection (ALND) if node positive. Methodology: Prospectively, 500 women with cN0 EBC were enrolled from Aug 2015 to April 2023 in a study approved by Institutional Ethics Committee. After informed consenting, a preoperative axillary USG was carried out in addition to standard breast imaging to determine number of axillary node(s) and its architecture. The USG assessment was labeled as suspicious or not and the result was blinded to the surgeons. A USG-guided FNAC was not performed as it would then be difficult to blind the surgeon and pathologist preoperatively. During surgery, an initial axillary EUA was performed before starting and any suspicious node was documented. This was followed by axillary staging by standard dual tracer SNB/LAS. A complete axillary dissection was done (level 1-3) if any node was positive on frozen section evaluation or final histopathology. Axillary node histopathology was the gold standard for comparison of effectiveness of clinical exam, USG, EUA, and SNB/LAS for prediction of axilla. Standard diagnostic tests such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were used. Results: Thirty-six patients were excluded in the final analysis (disease progression, chemotherapy first, or had a surgery elsewhere). Of the eligible 464 cN0 patients, 129 were detected to have axillary metastases (27.8%) in final histopathology. The 2 interventions namely USG axilla, EUA were compared to final axillary nodal histopathology. Axillary USG reported suspicious/indeterminate node(s) in 129 (27.8%) patients. USG had a low sensitivity of 46.5% and a low PPV of 46.5% to identify a positive node. However, the specificity and NPV both were 79.4%. Axillary USG was 70.2% accurate in predicting axillary nodal involvement. EUA also had sensitivity of 60% and low PPV of 14.8%. However, the specificity of EUA was 73.4%, NPV of 95.9%; higher than that of USG. EUA was 72.4% accurate. SNB/LAS had the sensitivity of 93.3%, specificity 79.2%, NPV 82.9%, PPV 91.6% and accuracy rate 89.2% in predicting a positive axilla. Conclusions: While the fallacy of clinical exam remains at 27.8%, both USG alone (without FNAC) and EUA failed in predicting a positive axillary node. EUA fared better at predicting a negative axilla. USG guided FNAC would perhaps improve the sensitivity of USG, however additional investigations are difficult in resource constraint and high-volume center, especially, when surgical interventions like SNB or LAS remain standard of care. Table 1 Citation Format: Vani Parmar, Zeal Sanghvi, Shalaka Joshi, Nita Nair, Palak Popat, Seema Kembhavi, Souwmyashree KN, Soujanya Mynalli, Purvi Thakkar, Garvit Chitkara, Sangeeta Desai, Tanuja Shet, Rajendra Badwe. Prospective non-randomized study to compare accuracy of clinical examination under anesthesia, axillary ultrasound and histo-pathological evaluation for axillary nodal staging in women with clinically N0 early breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-03-03.

Abstract PS05-03: MagSense® HER2, a Molecularly Targeted Magnetic Resonance Imaging Agent for the Detection of Axillary Nodal Metastasis in Subjects with Human Epidermal Growth Factor Receptor 2 Positive (HER2+) Breast Cancer

Abstract Background Precise nodal staging is critical in guiding systemic and regional treatments including surgery in the management of breast cancer. Regional nodal assessment includes axillary imaging (mostly by ultrasound) and lymph node sampling. Since imaging findings suggestive of nodal metastasis are based on size and morphologic changes and not specific to tumor type, pathologic confirmation through either biopsy or removal of sentinel lymph node (SLN) remains the gold standard. Imagion is developing the MagSense® HER2 Imaging Agent (MSH2IA), an anti-human epidermal growth factor receptor 2 (HER2) conjugated with iron oxide nanoparticles, for the detection of nodal metastasis in HER2+ breast cancer patients. MSH2IA is currently being investigated in a first-in-human phase 1 study (ACTRN12621000126819) in HER2+ breast cancer patients who are diagnosed to have suspicious nodes by conventional imaging. Methods The key objectives of the phase 1 study are safety and tolerability of MSH2IA and confirmation that MSH2IA drains to the axillary lymph nodes. The study also explores MSH2IA’s ability to detect metastatic nodes when used with magnetic resonance imaging (MRI), with tumor status assessed by standard tissue histopathology. All eligible subjects receive a 22.5 mg (iron equivalent) subareolar or peritumoral injection of MSH2IA. MRI of the axilla are obtained before and 24 to 72 hours after MSH2IA injection. Core biopsy or dissection of a node suspicious by ultrasound is obtained for histopathology assessments. After completing the first cohort of 6 subjects, the protocol was amended to include the insertion of an MRI compatible clip in a node suspicious by ultrasound to localize the suspicious node for core biopsy and postdose MRI scan. Review of MRI scans and histopathology are performed in respective central laboratories. Results Thirteen participants with HER2+ breast cancer have completed the study. MSH2IA appears safe and well tolerated. The imaging agent, as administered, is detectable by MRI and pathology, confirming that MSH2IA drains to the lymph nodes via the chosen route of administration. In postdose MRI scans, study central radiologists reported distinct and differentiable MRI appearance in morphologically normal and suspicious nodes. The presence of a distinct postdose MR image appearance was confirmed by a group of independent radiologists in a separate blinded review. While normal nodes appeared with homogeneous hypointensity, morphologically suspicious nodes showed partial irregular darkening and/or speckled heterogeneous hypointensity. In evaluable subjects, histopathology of the core biopsies obtained from the clipped nodes confirmed the presence of HER2+ nodal metastasis, providing preliminary evidence for node-level concordance between MRI vs pathology observations. Safety, imaging, and pathology results from all available subjects will be presented. This phase 1 study in Australia will be closing enrollment by July 31, 2023. A phase 2 study in the United States and elsewhere is being planned with the objectives of optimizing dose, schedule, and imaging parameters for best diagnostic performance for clinical utility. Conclusion Available data from the ongoing phase 1 study show that MSH2IA appears safe and drains to the axillary lymph nodes. MSH2IA displays a distinct and differentiable MRI appearance in nodes morphologically highly suspicious for tumor, which is confirmed to be HER2+ metastasis by histopathology by node level concordance. This data provides preliminary proof of principle for the mechanism of molecularly targeted MR imaging and suggests that MSH2IA has the potential to provide tumor-specific MR imaging not currently available in conventional axillary imaging. Citation Format: Jane Fox, Shanta Velaiutham, Natalie Yang, Eddie lau, Kowsi Murugappan, Beena Kumar, Alex Laslowski, Koushik Govindarajan, Steven Reich, Stephen Thomas, Nitika Neha, Marie Zhang, Isaac Bright. MagSense® HER2, a Molecularly Targeted Magnetic Resonance Imaging Agent for the Detection of Axillary Nodal Metastasis in Subjects with Human Epidermal Growth Factor Receptor 2 Positive (HER2+) Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PS05-03.

AI-driven Characterization of Solid Pulmonary Nodules on CT Imaging for Enhanced Malignancy Prediction in Small-sized Lung Adenocarcinoma

ObjectivesDistinguishing solid nodules from nodules with ground-glass lesions in lung cancer is a critical diagnostic challenge, especially for tumors ≤2 cm. Human assessment of these nodules is associated with high inter-observer variability, which is why an objective and reliable diagnostic tool is necessary. This study focuses on artificial intelligence (AI) to automatically analyze such tumors and to develop prospective AI systems that can independently differentiate highly malignant nodules. Materials and methodsOur retrospective study analyzed 246 patients who were diagnosed with negative clinical lymph node metastases (cN0) using positron emission tomography-computed tomography (PET/CT) imaging and underwent surgical resection for lung adenocarcinoma. AI detected tumor sizes ≤2 cm in these patients. By utilizing AI to classify these nodules as solid (AI_solid) or non-solid (non-AI_solid) based on confidence scores, we aim to correlate AI determinations with pathological findings, thereby advancing the precision of preoperative assessments. ResultsSolid nodules identified by AI with a confidence score ≥0.87 showed significantly higher solid component volumes and proportions in patients with AI_solid than in those with non-AI_solid, with no differences in overall diameter or total volume of the tumors. Among patients with AI_solid, 16% demonstrated lymph node metastasis, and a significant 94% harbored invasive adenocarcinoma. Additionally, 44% were upstaging postoperatively. These AI_solid nodules represented high-grade malignancies. ConclusionIn small-sized lung cancer diagnosed as cN0, AI automatically identifies tumors as solid nodules ≤2 cm and evaluates their malignancy preoperatively. The AI classification can inform lymph node assessment necessity in sublobar resections, reflecting metastatic potential.

Organ preservation in locally advanced colorectal cancer with microsatellite instability-high after immunotherapy

Neoadjuvant immunotherapy has achieved exciting efficacy with high clinical complete response (cCR) and pathologic complete response (pCR) rates and durable long-term effects. PD-1 checkpoint blockade-based immunotherapy has been highly successful in microsatellite instability high (MSI-H)/mismatch repair deficiency (dMMR) colorectal cancer and has been recommended as the first-line treatment for metastatic colorectal cancer by domestic and international guidelines. Several studies have shown that immunotherapy can be a potentially curable treatment for MSI-H rectal cancer and has even shown promise in organ preservation in colon cancer. In this study, we first clarified the feasibility of the watch-and-wait strategy after PD-1 checkpoint blockade treatment by indirect and direct evidence. Then from the assessment tools (including digital rectal examination, endoscopy, radiology, and lymph node assessment), the viable assessment methods of cCR for immunotherapy and related difficulties are proposed. Finally, the medication choices of immunotherapy, the treatment regimen, and the follow-up strategy are further discussed. We hope that neoadjuvant immunotherapy could be appropriately applied in MSI-H/dMMR colorectal cancer so that more patients can achieve organ preservation.

The diameter of cutaneous melanoma serves as a prognostic indicator for survival among acral-melanoma predominant East Asian patients.

Tumor staging plays a pivotal role in melanoma management, where the depth of tumor invasion has been traditionally used as the cornerstone of staging. Paradoxically, the tumor diameter has not been integrated into the staging system. The aim of this study is to elucidate the clinical implications and prognostic value of tumor diameter in cutaneous melanoma, with a particular emphasis on the acral-melanoma predominant East Asian population, thus potentially enriching the clinical evaluation and treatment strategies for cutaneous melanoma. From January 1st, 2006 to December 31st, 2022, a total of 352 patients were diagnosed with melanoma in our center. Among them, there were 135 patients diagnosed as cutaneous melanoma who received complete surgical wide excision and regional lymph nodes assessment. The diameter of the tumor, the depth of tumor invasion, lymph node status and patient survival were all collected and analyzed. The diameter of cutaneous melanoma had a weak positive correlation with tumor thickness (r=0.26), however, it still had a significant predictive value for patients' overall survival (p=0.005) and disease free survival (p=0.023). As for lymph node metastasis prediction, the Breslow thickness had a better predictive value than tumor diameter (p=0.002 vs. p=0.565). In this study, though with only weak positive correlation to tumor thickness, the tumor diameter of melanoma showed a statistically significant correlation with the patients' overall survival and disease free survival. However, the larger tumor diameter cannot be used as an indicator of high risk of lymph node metastasis.

Nodal staging in high and high-intermediate risk endometrial cancer surgery: Which role in the molecular classification era?

ObjectivesNodal staging contributes to risk group definition and the indication to adjuvant treatment in endometrial cancer (EC) patients. However, the role of nodal assessment evolved and requires redefinition.Primary outcome of the study was to assess the impact of surgical nodal staging in defining high-risk (HR) EC. Secondary outcome was to evaluate the contribution of nodal assessment to the decision for adjuvant treatment in both high-risk and high-intermediate risk (HIR) patients submitted to surgery. MethodsClinical stage I-II EC patients with postoperative diagnosis of HR and HIR disease were included. The contribution of nodal staging in prognostic groups allocation was assessed by reviewing HR patients to identify those without any other feature of such class (non-endometrioid histology, p53abn immunohistochemistry, post-operative T3-T4 disease) and HIR cases to assess how nodal staging affected adjuvant treatment indication. Descriptive statistics were conducted to describe the two populations. ResultsFifty-seven patients were included, 46 with HR and 11 with HIR disease. Chemotherapy and external-beam radiotherapy (EBRT) were proposed in 40 HR patients. Considering histology, immunohistochemical profile and FIGO stage, high risk classification was exclusively relied on nodal involvement in 2/46 cases (4.3 %). Omitting retroperitoneal staging, one of them would have been classified in the intermediate risk group and the other as HIR: without nodal staging, chemotherapy and EBRT would have been omitted in 1/40 (2.5 %) case.Among HIR patients, chemotherapy was proposed in 7/11 cases and EBRT in all cases. Adjuvant chemotherapy was indicated in 5/6 (83.3 %) and omitted in 1/6 (16.7 %) pN0 patient (stage Ib G2, substantial LVSI). In HIRpN0 patients, omitting nodal staging could have changed adjuvant treatment indication in 1/6 (16.7 %) case. In HIRpNx patients, adjuvant chemotherapy was omitted in one patient (stage II, grade 2 and LVSI negative): nodal staging unavailability might have changed indication to chemotherapy in 1/5 (20 %) case, without changing indication to EBRT.Unavailable nodal staging could globally be related to omission of chemotherapy in 2/57 (3.5 %) patients and of EBRT in 1/57 (1.8 %) patient. ConclusionsIn this series, nodal staging had limited impact on definition of HR class and on the choice of adjuvant treatment in HR and HIR EC patients.

Use of 18F-fluoro-2-deoxy-d-glucose (18F-FDG) PET/CT for lymph node assessment before radical cystectomy in bladder cancer patients.

To assess the diagnostic performance of 18F-fluoro-2-deoxy-d-glucose (18F-FDG) positron emission tomograpy (PET)/computed tomography (CT) in nodal staging before radical cystectomy (RC) and pelvic lymph node dissection (PLND) for bladder cancer (BCa). This analysis was based on a cohort of 199 BCa patients undergoing RC and bilateral PLND between 2015 and 2022. Neoadjuvant chemotherapy (NAC) or immunotherapy (NAI) was administered after oncological evaluation. All patients received preoperative 18F-FDG PET/CT to assess extravesical disease. Point estimates for true negative, false negative, false positive, true positive, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of conventional imaging and PET/CT were calculated. Subgroup analysis in patients receiving neoadjuvant treatment was performed. At preoperative evaluation, 30 patients (15.1%) had 48 suspicious nodal spots on 18F-FDG PET/CT. At RC and bilateral PLND, a total of 4871 lymph nodes (LNs) were removed with 237 node metastases corresponding to 126 different regions. Pathological node metastases were found in 17/30 (57%) vs 39/169 patients (23%) with suspicious vs negative preoperative 18F-FDG PET/CT, respectively (sensitivity = 0.30, specificity = 0.91, PPV = 0.57, NPV = 0.77, accuracy = 0.74). On per-region analysis including 1367 nodal regions, LN involvement was found in 19/48 (39%) vs 105/1319 (8%) suspicious vs negative regions at PET/CT, respectively (sensitivity = 0.15, specificity = 0.98, PPV = 0.40, NPV = 0.92, ACC = 0.90). Similar results were observed for patients receiving NAC (n = 44, 32.1%) and NAI (n = 93, 67.9% [per-patient: sensitivity = 0.36, specificity = 0.91, PPV = 0.59, NPV = 0.80, accuracy = 0.77; per-region: sensitivity = 0.12, specificity = 0.98, PPV = 0.32, NPV = 0.93, ACC = 0.91]). Study limitations include its retrospective design and limited patient numbers. In eight out of 10 patients with negative preoperative 18F-FDG PET/CT, pN0 disease was confirmed at final pathology. No differences were found based on NAC vs NAI treatment. These findings suggest that 18F-FDG PET/CT could play a role in the preoperative evaluation of nodal metastases in BCa patients, although its cost-effectiveness is uncertain.

Phallus preservation and reconstruction: 5-year outcomes of national penile cancer centralisation in the Republic of Ireland

IntroductionPenile cancer is a rare urological malignancy with an age-standardised incidence of 0.8 per 100,000 person-years [1]. Given this low incidence it has been suggested that centralised care may improve patient outcomes in relation to phallus sparing surgery and nodal assessment [2]. We aim to assess the outcomes after 5-years of national centralisation of penile cancer care. MethodsA retrospective analysis of prospectively collected data was performed. All patients undergoing penile cancer surgery from January 2018 to December 2022 following centralisation of care were included. The primary outcome was proportion of phallus sparing procedures performed. Secondary outcomes were patient characteristics, histologic outcomes and procedures performed. Results124 patients underwent surgery in the study period. Mean age was 64.49 (±13.87). Overall, 82.3% of patients underwent phallus sparing surgery. This remained stable over the 5-year period from 2018 to 2022 ​at 92%, 85%, 76%, 79% and 78% respectively (p ​= ​0.534). 62.7% had reconstruction performed, including split-thickness skin graft neoglans formation, (57.8% [n ​= ​37]), preputial flap (32.8% [n ​= ​21]), glans resurfacing (4.7% [n ​= ​3]), shaft advancement flap (1.6% [n ​= ​1]), penile shaft skin graft (1.6% [n ​= ​1]), and partial penectomy with urethral centralisation (1.6% [n ​= ​1]). Phallus preservation was not affected by positive nodal status (OR 0.75 [95% CI 0.249–2.266], p ​= ​0.564) or T-stage ≥1b (OR 0.51 [95% CI 0.153–1.711], p ​= ​0.276). There has been a significant reduction in Nx nodal status from 64% in 2017 to 15% in 2021 (p ​= ​0.009). ConclusionCentralisation of treatment for rare malignancies such as penile cancer may improve oncologic outcomes and rates of phallus preservation. This study has shown centralisation to has a high rate of phallus preservation. Further long-term analysis of outcomes in Ireland is required.

Pathology of Surgically Resected Lung Cancers Following Neoadjuvant Therapy.

In around 30% of patients, non-small cell lung cancer is diagnosed at an advanced but resectable stage. Adding systemic therapy has shown clear benefit over surgery alone in locally advanced disease, and currently, chemo-immunotherapy in the adjuvant or neoadjuvant setting is the new standard for patients without targetable mutations. One major advantage of the neoadjuvant approach is the possibility of an immediate evaluation of the treatment effect, highlighting the role of pathology as an important contributor at the forefront of clinical decision-making and research. This review provides a summary and an update on current guidelines for histological evaluation of treatment effect after neoadjuvant therapy, also known as regression grading, and discusses newer data focusing on areas of evolving questions and controversies, such as the gross examination of the tumor and tumor bed, weighted versus unweighted evaluation approaches, discussion of histologic tumor type-specific cut-offs for major pathologic response, assessment of lymph nodes and regression grading after immunotherapy and targeted therapy. As no data or recommendations exist on regression grading of multiple tumor nodules, a practical approach is recommended. Lastly, we will touch on additional tissue biomarkers and summarize recent advances in the ardently discussed field of using circulating tumor DNA for the evaluation of treatment response.

Lymph node dissection in lung cancer surgery.

Lung cancer, a leading cause of cancer-related death, often requires surgical resection for early-stage cases, with recent data supporting less invasive resections for tumors smaller than 2 cm. Central to resection is lymph node assessment, an area of controversy worldwide, compounded by advances in minimally invasive techniques. The review aims to assess current standards for lymph node assessment, recent data from the surgical era, and the immunobiological basis of how lymph node metastases impact patient outcomes. The British Thoracic Society guidelines recommend systematic nodal dissection during lung cancer resection, without specifying node removal or sampling. Historical data on mediastinal lymph node dissection (MLND) survival benefits are inconclusive, although proponents argue for lower recurrence rates. Recent trials such as ACOSOG Z0030 found no survival difference between MLND and nodal sampling, reinforcing the need for robust staging. While lobe-specific dissection strategies have been proposed, they currently lack consensus. JCOG1413 aims to compare the clinical benefits of lobe-specific and systematic dissection. TNM-9 staging revisions emphasize the prognostic significance of single-station N2 involvement. Robotic surgery shows promise, with trials such as RAVAL, which reported comparable outcomes to video-assisted thoracic surgery (VATS) and improved lymph node sampling. Immunobiological insights suggest preserving key immunological sites during lymphadenectomy, especially for patients receiving adjuvant immunotherapy. In conclusion, the standard lymph node resection strategy remains unsettled. The debate between systematic and selective dissection continues, with implications for staging accuracy and patient outcomes. As minimally invasive techniques evolve, robotic surgery emerges as an effective and low-risk approach to delivering optimal lymph node assessment.

Phase II Trial of Cisplatin, Gemcitabine, and Intensity-Modulated Radiation Therapy for Locally Advanced Vulvar Squamous Cell Carcinoma: NRG Oncology/GOG Study 279.

To assess efficacy and toxicity of cisplatin (C) and gemcitabine (G) with intensity-modulated radiation therapy (IMRT) in patients with locally advanced vulvar cancer not amenable to surgery. Patients enrolled in a single-arm phase II study. Pretreatment inguinal-femoral nodal assessment was performed. Sixty-four Gy IMRT was prescribed to the vulva, with 50-64 Gy delivered to the groins/low pelvis. Radiation therapy (RT) plans were quality-reviewed pretreatment. C 40 mg/m2 and G 50 mg/m2 were administered once per week throughout IMRT. Complete pathologic response (CPR) was the primary end point. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method, and adverse events were assessed with Common Terminology Criteria for Adverse Events v 4.0. Fifty-seven patients enrolled, of which 52 were evaluable. The median age was 58 years (range, 25-58), and 94% were White. Forty (77%) had stage II or III disease, and all had squamous histology. A median of six chemotherapy cycles (range, 1-8) were received. Eighty-five percent of RT plans were quality-reviewed with 100% compliance to protocol. Seven patients came off trial because of toxicity or patient withdrawal. Of 52 patients available for pathologic assessment, 38 (73% [90% CI, 61 to 83]) achieved CPR. No pelvic exenterations were performed. With a median follow-up of 51 months, the 12-month PFS was 74% (90% CI, 62.2 to 82.7) and the 24-month OS was 70% (90% CI, 57 to 79). The most common grade 3 or 4 adverse events were hematologic toxicity and radiation dermatitis. There was one grade 5 event unlikely related to treatment. Weekly C and G concurrent with IMRT sufficiently improved CPR in women with locally advanced vulvar squamous cell carcinoma not amenable to surgical resection.

Radioguided surgery for lymph node metastases in prostate cancer.

This review highlights recent advancements in radioguided surgery (RGS) for prostate cancer. Our objective is to provide expert insights into the state of research, as reflected in the selected articles, and to offer perspectives on the clinical implications and future directions that emerge from this rapidly evolving domain. Key findings include the potential of PSMA-RGS surgery to improve the detection of lymph node invasion in primary prostate cancer, to guide successful removal of metastatic lesions in oligorecurrent patients with acceptable complications, and the feasibility of robot-assisted PSMA-RGS using a miniaturized gamma probe. Additionally, the development of novel PSMA ligands and the integration of fluorescence imaging offer promising improvements in imaging and surgical guidance. PSMA-RGS is an emerging approach that shows promise for improving lymph node assessment and treatment outcomes in prostate cancer. However, its effect on cancer-specific as well as overall survival are still being investigated, and PSMA-targeted surgery remains an area of active research.

The predictive value of serum NLR, SII, and OPNI for lymph node metastasis in breast cancer patients with internal mammary lymph nodes after thoracoscopic surgery.

In this research, we delved into the predictive potential of three key markers - the neutrophil-to-lymphocyte ratio (NLR), systemic immune inflammation index (SII), and Onodera's prognostic nutritional index (OPNI), in assessing lymph node metastases in breast cancer patients who had internal mammary lymph node involvement following thoracoscopic surgery. Our study revealed notable pathological distinctions between the groups with and without metastases, while age, tumor size, and histological grade exhibited no significant differences. The analysis unveiled statistically significant variances in NLR, SII, and OPNI when comparing these two groups. Multivariate analysis pinpointed NLR (OR = 1.503), SII (OR = 1.987), and OPNI (OR = 0.612) as robust predictors of lymph node metastases. Remarkably, combining these markers (AUC: 0.897) substantially enhanced the precision of predicting lymph node metastases compared to individual measurements (NLR: 0.749, SII: 0.717, and OPNI: 0.787). In conclusion, this study underscores the pivotal role of NLR, SII, and OPNI in predicting lymph node metastasis among breast cancer patients with internal mammary lymph node involvement post-thoracoscopic surgery, affirming our utility as reliable independent predictors of this critical clinical outcome.

Multimodal ultrasound imaging: a method to improve the accuracy of sentinel lymph node diagnosis in breast cancer.

This study assessed the utility of multimodal ultrasound in enhancing the accuracy of breast cancer sentinel lymph node (SLN) assessment and compared it with single-modality ultrasound. Preoperative examinations, including two-dimensional ultrasound (2D US), intradermal contrast-enhanced ultrasound (CEUS), intravenous CEUS, shear-wave elastography (SWE), and surface localization, were conducted on 86 SLNs from breast cancer patients. The diagnostic performance of single and multimodal approaches for detecting metastatic SLNs was compared to postoperative pathological results. Among the 86 SLNs, 29 were pathologically diagnosed as metastatic, and 57 as non-metastatic. Single-modality ultrasounds had AUC values of 0.826 (intradermal CEUS), 0.705 (intravenous CEUS), 0.678 (2D US), and 0.677 (SWE), respectively. Intradermal CEUS significantly outperformed the other methods (p<0.05), while the remaining three methods had no statistically significant differences (p>0.05). Multimodal ultrasound, combining intradermal CEUS, intravenous CEUS, 2D US, and SWE, achieved an AUC of 0.893, with 86.21% sensitivity and 84.21% specificity. The DeLong test confirmed that multimodal ultrasound was significantly better than the four single-modal ultrasound methods (p<0.05). Decision curve analysis and clinical impact curves demonstrated the superior performance of multimodal ultrasound in identifying high-risk SLN patients. Multimodal ultrasound improves breast cancer SLN identification and diagnostic accuracy.