Node Necrosis Research Articles

Homotypic cell-in-cell structure as a novel prognostic predictor in non-small cell lung cancer and frequently localized at the invasive front

Homotypic cell-in-cell structures (hoCICs) are associated with tumor proliferation, invasion, and metastasis and is considered a promising prognostic marker in various cancers. However, the role of hoCICs in non-small cell lung cancer (NSCLC) remains unclear. Tumor tissue sections were obtained from 411 NSCLC patients. We analyzed the relationship between clinicopathological variables and the number of hoCICs. LASSO and multivariate Cox regression analysis were employed to identify prognostic factors for NSCLC. The impact of hoCICs on overall survival (OS) and disease-free survival (DFS) was assessed using the Kaplan–Meier curves and log-rank test. Prognostic models for OS and DFS were developed and validated using the C-index, time-dependent area under the curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI), calibration curves and decision curve analysis (DCA). Among the cohort, 56% of patients had hoCICs while 44% did not. Notably, hoCICs were primarily found at the tumor invasion front. Male gender, smoking, squamous cell carcinoma, low differentiation, tumor size ≥ 3 cm, advanced TNM stage, lymph node metastasis, pleural invasion, vascular invasion, necrosis, P53 mutation, and high expression of Ki-67 were identified as relative risk factors for hoCICs. Furthermore, hoCICs was found to be a significant prognostic factor for both OS and DFS, with higher frequencies of hoCICs correlating with poorer outcomes. We constructed nomograms for predicting 1-, 3-, and 5-year OS and DFS based on hoCICs, and the calibration curves showed good agreement between the predicted and actual outcomes. The results of the C-index, time-dependent AUC, NRI, IDI, and DCA analyses demonstrated that incorporating hoCICs into the prognostic model significantly enhanced its predictive power and clinical applicability. HoCICs indicated independent perdictive value for OS and DFS in patients with NSCLC. Furthermore, the frequent localization of hoCICs at the tumor invasion front suggested a strong association between hoCICs and tumor invasion as well as metastasis.

Study of Diagnostic Yield of Nucleic Acid Amplification Test among Tuberculous Cervical Lymphadenitis in Immunocompetent Patients.

The most common form of extrapulmonary tuberculosis (TB) is tuberculous lymphadenitis, which constitutes about 30-40% of all extrapulmonary TB cases. A new diagnostic method like the nucleic acid amplification test (NAAT) is a very sensitive and rapid test for diagnosing tuberculous cervical lymphadenopathy. It also detects rifampicin sensitivity among positive patients. (1) To evaluate the diagnostic yield of TrueNAT for detecting Mycobacterium tuberculosis bacteria in the fine-needle aspirated samples of cervical lymph nodes compared with Ziehl-Neelsen (ZN) staining; (2) to evaluate the diagnostic yield of TrueNAT for diagnosis of tuberculosis through comparison with the cytology report of fine-needle aspiration (FNA) sample of cervical lymph node and with necrotic cervical lymph node on ultrasonography (USG) neck. A total of 50 patients enrolled in this prospective study from January to December 2022. Demographic profile and clinical history were noted. Fine-needle aspirate samples were sent for TrueNAT assay, cytological examination, and ZN staining. USG neck was done for necrotic findings in the cervical lymph nodes. The TrueNAT positivity rate was 70%. TrueNAT sensitivity and specificity were assessed according to the cytology report, acid-fast bacilli (AFB) positivity on ZN stain, and the finding of necrosis in the cervical lymph node on the USG neck. The sensitivity and specificity of the TrueNAT assay were 80.49 and 77.78%, respectively, in accordance with necrosis on FNA cytology; 17.14 and 93.33%, respectively, in accordance with AFB positivity on ZN stain; and 74.29 and 33.33%, respectively, in accordance with lymph node necrosis on USG neck. The TrueNAT assay should be used as an adjunctive test in addition to the conventional cytological examination of the FNA sample of lymph nodes for the rapid diagnosis of tuberculosis. It also detects rifampicin resistance simultaneously.

Can Ultrasound Evaluation of Lymph Node Size and Necrosis Rate Predict Chemotherapy Response in Cervical Tuberculous Lymphadenitis?

To explore the relationship between the initial size and the necrotic rate of lymph nodes evaluated by ultrasound in patients with cervical tuberculous lymphadenitis (CTL) and therapeutic response. Overall, 55 patients were included in this study. Conventional ultrasound and contrast-enhanced ultrasound examination were performed before anti-tuberculosis chemotherapy. Based on the different therapeutic outcomes, they were divided into responder groups (n = 39) and non-responder groups (n = 16). The relationship between the initial size (maximum area, length diameter, short diameter), rate of necrosis, and therapeutic response were compared and analyzed between two groups. There was a significant difference in maximum area, short diameter and rate of necrosis of lymph nodes between the responder groups and the non-responder groups (P < 0.05). The receiver-operating-characteristic (ROC) curve analysis was used to differentiate the two groups, it showed that the area under the curve was 0.746 for maximum area and 0.721 for short diameter, respectively. The cut-off value for the lymph node maximum area and short diameter based on ROC curve analysis was determined as 3.94cm2 (sensitivity 76.9%, specificity 68.7%) and 1.15cm (sensitivity 59.0%, specificity 93.7%), respectively. A negative correlation was observed between maximum area, short diameter, and therapeutic response. The initial maximum area and short diameter of lymph nodes were found to have a negative correlation with chemotherapy response in patients with CTL. The treatment outcomes are typically unsatisfactory for lymph nodes exhibiting an initial necrosis rate of 50% or higher. These findings may be helpful for evaluating therapeutic response.

International Multi-Specialty Expert Physician Preoperative Identification of Extranodal Extension n Oropharyngeal Cancer Patients using Computed Tomography: Prospective Blinded Human Inter-Observer Performance Evaluation.

Extranodal extension (pENE) is a critical prognostic factor in oropharyngeal cancer (OPC) that drives therapeutic disposition. Determination of pENE from radiological imaging has been associated with high inter-observer variability. However, the impact of clinician specialty on human observer performance of imaging-detected extranodal extension (iENE) remains poorly understood. To characterize the impact of clinician specialty on the accuracy of pre-operative iENE in human papillomavirus-positive (HPV+) OPC using computed tomography (CT) images. This prospective observational human performance study analyzed pre-therapy CT images from 24 HPV+ OPC patients, with duplication of 6 scans (n=30) of which 21 were pathologically confirmed pENE. Thirty-four expert observers, including 11 radiologists, 12 surgeons, and 11 radiation oncologists, independently assessed these scans for iENE and reported human-detected radiologic criteria and observer confidence. The primary outcomes included accuracy, sensitivity, specificity, area under the receiver operating characteristic curve (AUC), and Brier score for each physician, compared to ground-truth pENE. The significance of radiographic signs for prediction of pENE were determined through logistic regression analysis. Fleiss' kappa measured interobserver agreement, and Hanley-MacNeil AUC discrimination testing. Median accuracy across all specialties was 0.57 (95%CI 0.39 to 0.73), with no specialty showing discriminate performance greater than random estimation (median AUC 0.64, 95%CI 0.44 to 0.83). Significant differences between radiologists and surgeons in Brier scores (0.33 vs. 0.26, p < 0.01), radiation oncologists and surgeons in sensitivity (0.48 vs. 0.69, p > 0.1), and radiation oncologists and radiologists/surgeons in specificity (0.89 vs. 0.56, p > 0.1). Indistinct capsular contour and nodal necrosis were significant predictors of correct pENE status among all specialties. Interobserver agreement was weak for all the radiographic criteria, regardless of specialty (κ<0.6). Multiobserver testing shows physician discrimination of HPV+OPC pENE on pre-operative CT remains non-different than blind guessing, with high interrater variability and low diagnostic accuracy, regardless of clinician specialty. While minor differences in diagnostic performance among specialties are noted, they do not significantly affect the overall poor agreement and discrimination rates observed. The findings underscore the need for further research into automated detection systems or enhanced imaging techniques to improve the accuracy and reliability of iENE assessments in clinical practice.

Distinguishing Kikuchi-Fujimoto disease from lymphoma in patients by clinical and PET/CT features.

To develop a scheme for distinguishing Kikuchi-Fujimoto disease (KFD) from lymphoma in patients presenting enlarged lymph nodes (LNs) predominantly on the upper side of the diaphragm. From November 2015 to August 2023, 32 KFD patients and 38 lymphoma patients were pathologically confirmed and enrolled in this retrospectively study. Clinical and 18F-fluorodeoxyglucose positron emission tomography (PET)/computed tomography (CT) features were collected. When comparing those PET/CT parameters, we set 5 models with different research objects: (1) all affected LNs; (2) the 5 largest affected LNs in terms of maximum diameter; (3) the 5 largest affected LNs in terms of maximum standard uptake values (SUVmax); (4) the largest affected LNs in terms of maximum diameter; (5) the largest affected LNs in terms of SUVmax. Compared to lymphoma patients, KFD patients were younger; and with higher incidence of fever, arthralgia, abnormal serum white blood cell, lactate dehydrogenase (LDH) and splenomegaly; lower incidence of affected LNs perinodal infiltration, necrosis and conglomeration; more affected LNs in Head and Neck nodes (particularly in level II) and Axillary in KFD (P ˂ .05). PET/CT parameters presented as various difference in each model. Finally, 11 clinical and PET/CT features (age ≤ 34, with fever, arthralgia, abnormal white blood cell, abnormal LDH, and without node necrosis and node conglomeration have a score of 2 each; splenomegaly, perinodal infiltration, median maximum diameter ≤ 20.5 and median SUVmax ≤ 7.1 of affected LNs in model 2 have score of 1 each) were selected as scheme items for distinguishing KFD from lymphoma. Individuals who have a total score > 8, meet the criteria for KFD. Sensitivity and specificity were high: 86.8% (95% CI: 71.9%, 95.5%) and 96.9% (95% CI: 83.7%, 99.5%), AUC = 0.975 (95% CI: 90.5%, 99.6%), respectively. It can effectively distinguish KFD from lymphoma by clinical and PET/CT parameters.

Valor clínico da alfafetoproteína na detecção de carcinoma mamário em cadelas

ABSTRACT This study aimed to assess the behavior of Alpha-Fetoprotein (AFP) in healthy female dogs, those with non-metastatic mammary carcinomas, and those with metastatic mammary carcinomas. Additionally, it aimed to evaluate serum levels concerning the clinical-pathological variables of diseased dogs. To achieve this, sera from 35 female dogs were utilized, divided into three groups: G1 (n=10), control group (dogs free of neoplasms); G2 (n=20), dogs with mammary carcinoma without lymph node metastasis; and G3 (n=5), dogs with mammary carcinoma with lymph node metastasis. AFP was measured through ELISA, and the results were assessed using the Tukey test with a significance level of 5% in terms of the marker's presence in the patient's serum, its relationship with the neoplasm's biological behavior, and the clinical-pathological alterations encountered. Additionally, sensitivity and specificity values were obtained to establish the clinical value of AFP as a serological marker. The results revealed that AFP values (p&lt;0.001) were significantly higher in dogs with mammary carcinoma compared to healthy dogs. Furthermore, there was a significant increase in AFP in non-spayed animals (p=0.0307). The marker demonstrated a sensitivity of 92% and specificity of 90% in distinguishing diseased animals from healthy ones. No relationship was found between the variables of tumor size, lymph node metastasis, histological grade, necrosis, ulceration, and inflammation with AFP (p&lt;0.05). The findings indicated that AFP is elevated in female dogs with mammary tumors and could be a promising marker for monitoring dogs with mammary neoplasms. Future studies that include patient follow-up will be necessary.

Immunohistochemical Expression of Immune Checkpoints; CTLA-4, LAG3, and TIM-3 in Cancer Cells and Tumor-infiltrating Lymphocytes (TILs) in Colorectal Carcinoma.

Colorectal cancer is considered the third most prevalent cancer in both sexes. Immune checkpoint receptors that regulate T-cell response, stimulation, and development include lymphocyte activating gene 3 (LAG-3), cytotoxic T lymphocyte-associated antigen-4 (CTLA-4), and T-cell immunoglobulin and mucin domain 3 (Tim-3). In addition, they are crucial for the advancement of cancer and tumor immune escape. This work's aim was to assess the immunohistochemistry expression of Tim-3, CTLA-4, and LAG-3 in cancer cells and tumor-infiltrating lymphocytes (TILs) in colorectal cancer (CRC) and the correlation between these markers and clinicopathological variables and survival data. This study involved 206 CRC specimens processed for CTLA-4, LAG3, and TIM-3 immunohistochemistry and correlated with the clinicopathological and survival parameters of the patients. High CTLA-4 epithelial expression was highly related to the old age group, large tumor size, low tumor-stroma ratio (TSR), high grade, advanced stage, the presence of distant metastasis (DM), perineural invasion (PNI), necrosis, lymphovascular invasion (LVI), relapse, mortality, overall survival (OS), and disease-free survival (DFS), while negative CTLA-4 TILs expression was highly linked with the presence of gross perforation, low TSR, high tumor budding (TB) score, high grade, advanced stage, the existence of lymph node (LN) metastasis, DM, necrosis, LVI, PNI, DFS, mortality, and OS. Positive LAG-3 TILs expression was highly correlated with large tumor size, gross perforation, low TSR, high TB score, high grade, advanced phase, the presence of LN, necrosis, LVI, PNI, relapse DFS, mortality, and OS. High Tim-3 epithelial expression was extremely linked with low TSR, advanced phase, the presence of LN, LVI, PNI, relapse, DFS, mortality, and OS, while positive Tim-3 TILs expression was related to gross perforation, low TSR, high TB score, advanced stage, the presence of LN, DM, necrosis, relapse, DFS, mortality, and OS. The patients' poor prognosis may be related to the immunohistochemistry expression of LAG-3, Tim-3, and CTLA-4 in CRC cancer tissue and TILs. Poor patient consequences can result from the CTLA-4, Tim-3, and LAG-3 co-expression, but CTLA-4 TILs' expression of these proteins may inhibit the growth of tumors.

Radiologic extranodal extension for nodal staging in nasopharyngeal carcinoma

PurposeExtranodal extension (ENE) has the potential to add value to the current nodal staging system (N8th) for predicting outcome in nasopharyngeal carcinoma (NPC). This study aimed to incorporate ENE, as well as cervical nodal necrosis (CNN) to the current stage N3 and evaluated their impact on outcome prediction. The findings were validated on an external cohort. Methods & MaterialsPre-treatment MRI of 750 patients from the internal cohort were retrospectively reviewed. Predictive values of six modified nodal staging systems that incorporated four patterns of ENE and two patterns of CNN to the current stage N3 for disease-free survival (DFS) were compared with that of N8th using multivariate cox-regression and concordance statistics in the internal cohort. Performance of stage N3 for predicting disease recurrence was calculated. An external cohort of 179 patients was used to validate the findings. ResultsIncorporation of advanced ENE, which infiltrates into adjacent muscle/skin/salivary glands outperformed the other five modifications for predicting outcomes (p < 0.01) and achieved a significantly higher c-index for 5-year DFS (0.69 vs 0.72) (p < 0.01) when compared with that of N8th staging system. By adding advanced ENE to the current N3 increased the sensitivity for predicting disease recurrence from 22.4 % to 47.1 %. The finding was validated in the external cohort (5-year DFS 0.65 vs. 0.72, p < 0.01; sensitivity of stage N3 increased from 14.0 % to 41.9 % for disease recurrence). ConclusionResults from two centre cohorts confirmed that the radiological advanced ENE should be considered as a criterion for stage N3 disease in NPC.

Observer- and radiomics model-based computed tomography classification of suppurative versus tuberculous lymphadenitis complicated with nodal necrosis of the neck in children.

Computed tomography (CT) can be used for the early detection of lymphadenitis. Radiomics is able to identify a large amount of hidden information from images. However, few CT-based radiomics studies on cervical lymphadenitis in children have been published. This study aimed to investigate the role of visual CT analysis and CT radiomics in differentiating cervical suppurative node necrosis from tuberculous node necrosis in pediatric patients. A total of 101 patients with cervical suppurative lymphadenitis (n=52) or cervical tuberculous lymphadenitis (n=49) were included. Clinical data and CT images were retrieved for analysis. For visual observation, 11 major CT features were identified for univariate and multivariate analyses. For radiomics analysis, image segmentation, feature value extraction, and dimension reduction, feature selection and the construction of radiomics-based models were performed through the RadCloud platform. For the visual observation, significant differences were found between the two groups, including the short diameter of the largest necrotic lymph node (P=0.03), sharp border of the node (P=0.02), fusion of nodes (P=0.02), regular silhouette of the necrotic area (P=0.001), multilocular necrotic area (P=0.02), node calcification (P=0.004), and enhancement degree of the nodal nonnecrotic area (P=0.01). No feature was found to be an independent predictor for suppurative or tuberculous lymphadenitis (P>0.05 for all features). Concerning the radiomics analysis, after feature value extraction and dimension reduction, nine related features were selected. The support vector machine classifier achieved high diagnostic performance in distinguishing suppurative from tuberculous lymphadenitis. The area under the curve, accuracy, sensitivity, and specificity of the support vector machine model test set were 0.89 (95% confidence interval: 0.72-1.00), 0.88, 0.78, and 0.90, respectively. Compared to observer-based CT image analyses, radiomics model-based CT image analyses exhibit better performance in the differential diagnosis of cervical suppurative and tuberculous lymphadenitis complicated with nodal necrosis in children.

Integrating pretreatment MRI-detected nodal features and Epstein-Barr virus DNA to identify optimal candidates for intensity-modulated radiotherapy alone in patients with stage II nasopharyngeal carcinoma

ObjectivesTo develop and validate a prognostic nomogram based on MRI-detected features of retropharyngeal and cervical lymph nodes and Epstein–Barr virus (EBV) DNA in patients with stage II nasopharyngeal carcinoma (NPC) to distinguish low-risk patients for whom intensity-modulated radiotherapy (IMRT) alone is sufficient. MethodsThis retrospective study enrolled 894 patients with stage II NPC (596 and 298 in the training and validation cohorts, respectively) with pretreatment MRI between August 2010 and May 2019. All patients received IMRT with or without additional chemotherapy. We identified independent risk factors using univariate and multivariate Cox regression analyses. Survival was compared using Kaplan–Meier curves with the log-rank test. ResultsIndependent factors derived from the multivariate analysis include cervical nodal necrosis (CNN), the extracapsular spread (ECS) of cervical and retropharyngeal lymph nodes, and gamma-glutamyl transferase (γ-GGT). Nomograms A, B, and C were established based on the clinical [tumor-node-metastasis (TNM) stage + Epstein–Barr virus (EBV) DNA], the clinical-radiological [all independent predictors] and the combined models [the clinical-radiological model + EBV DNA], respectively. Nomogram C (C-index 0.769 [0.718–0.820]) demonstrated better risk discrimination than nomogram B (0.762 [0.715–0.809]), nomogram A (0.619 [0.564–0.674]), and the TNM stage (0.560 [0.509–0.611]). In the low-risk group divided by nomogram C, no significant survival differences were observed between patients treated with radiotherapy (RT) alone and other regimens including additional chemotherapy. ConclusionsThe nomogram combining MRI-detected retropharyngeal and cervical lymph node features with pretreatment EBV-DNA improved the prognostic risk stratification for stage II NPC.

Applications of new radiological scores: the Node-rads in colon cancer staging.

The study focuses on the evaluation of the new Node Reporting and Data System 1.0 (Node-rads) scoring accuracy in the assessment of metastatic lymph nodes (LN) in patients with colon carcinoma. From April 2021 to May 2022, retrospective chart reviews were performed on 67 preoperative CT (Computed Tomography) of patients undergoing excisional surgery for colon cancer at the Polyclinic of Bari, Italy. Primary endpoints were to assess lymph node size and configuration to express the likelihood of a metastatic site adopting the Node-rads score system, whose categories of risk are defined from 1 (very low) to 5 (very high). The nodal postsurgical histological evaluation was the gold standard. The relationship between Node-rads score, LN size, configuration criteria (texture, border and shape) and the presence of histological metastases was statistically evaluated. All surgical specimens examined had correlation with Node-rads score. They were significantly more likely to present nodes micrometastasis those patients with (a) spherical LN shape (82.8%), (b) with lymph node necrosis (100%), (c) irregular borders (87%) and (d) the LN short axis more than 10mm (61.9%). Our experience highlights how the Node-rads system proposes an intuitive and effective definition of criteria to standardize the lymph node radiological reports in colon cancer disease. Further studies are needed to streamline the classification of the nodal and peripheral LN in all the oncological imaging.

Advanced Age Impacts Survival After Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinoma is rare but has a poor prognosis. Prognostic factors have been extensively studied in order to provide the best possible management for patients. We have aimed to investigate commonly available factors predictive of recurrence and survival in this patient population at high risk of death and recurrence, with an emphasis on the effects of age (using a cutoff of 70 years) on survival outcomes. From 1387 patients with clinically nonmetastatic upper tract urothelial carcinoma treated with radical nephroureterectomy at 21 academic hospital centers between 2005 and 2021, 776 patients were eligible and included in the study. Univariable and multivariable Cox regression models were built to evaluate the independent prognosticators for intravesical and extravesical recurrence, overall survival, and cancer-specific survival according to age groups. A P value of <.05 was considered statistically significant. We did not find an association between groups aged <70 and >70 years old and preoperatively clinical or histopathological characteristics. Kaplan-Meier analysis was found no statistical significance between the 2 age groups in terms of intravesical or extravesical recurrence (P = .09 and P = .57). Overall survival (P = .0001) and cancer-specific survival (P = .0001) have been found to be statistically significantly associated with age as independent predictors (confounding factors: gender, tumor size, tumor side, clinical T stage, localization, preoperative hydronephrosis, tumor localization, type of surgery, multifocality of the tumor, pathological grade, lymphovascular invasion, concomitant CIS, lymph node status, necrosis, or history of previous bladder cancer). This research confirms that patients aged 70 and above who undergo radical nephroureterectomy may have worse outcomes compared to younger patients, older patients needing an improved care and management of UTUC to improve their outcomes in the setting of an increase in this aged population group.

Imaging Characteristics Predictive of Cervical Extranodal Tumor Extension in Patients With Head and Neck Squamous Cell Carcinoma.

The aims of the study were to determine the predictive imaging findings of extranodal extension (ENE) in metastatic cervical lymph nodes of head and neck squamous cell carcinoma and to investigate the interobserver agreement among radiologists with different experience levels. Patients with cervical lymph node dissection and who had metastatic lymph nodes and preoperative imaging were included. Three radiologists evaluated nodal necrosis, irregular contour, gross invasion, and perinodal fat stranding. They also noted their overall impression regarding the presence of the ENE. Sensitivity, specificity, odds ratios based on logistic regression, and interobserver agreement of ENE status were calculated. Of 106 lymph nodes (that met inclusion criteria), 31 had radiologically determined ENE. On pathologic examination, 22 of 31 nodes were positive for ENE. The increasing number of metastatic lymph nodes was associated with the presence of the ENE ( P = 0.010). Irregular contour had the highest sensitivity (78.6%) and gross invasion had the highest specificity (96%) for the determination of the ENE. The radiologists' impression regarding the presence of the pathlogical ENE had 39.3% sensitivity and 82% specificity. Metastatic lymph nodes with a perinodal fat stranding and with the longest diameter of greater than 2 cm were found to be strong predictors of the ENE. The gross invasion demonstrated the highest κ value (0.731) among the evaluated imaging criteria. In the assessment of ENE, the gross invasion had the highest specificity among imaging features and showed the highest interobserver agreement. Perinodal fat stranding and the longest diameter of greater than 2 cm in a metastatic lymph node were the best predictors of the ENE.

Prognostic nomograms for nasopharyngeal carcinoma with nodal features and potential indication for N staging system: Validation and comparison of seven N stage schemes

PurposeTo identify the prognostic value of the nodal features, propose a nomogram-based N stage system and evaluate the performance of seven N stage schemes of nasopharyngeal carcinoma (NPC) patients. MethodsData from 1638 non-distant metastatic NPC patients were used to develop nomograms predicting 3-year and 5-year overall survival (OS) and distant metastasis-free survival (DMFS). Based on nomogram and multivariate analyses, a new N-stage scheme was proposed. The performance of the nomogram-based N staging system was assessed against five newly proposed N staging systems and the current 8th N staging system using a quantitative model to compare hazard consistency, discrimination, outcome prediction, and sample size balance. The Kaplan-Meier method with log-rank tests was used to compare survival differences. ResultsNomograms to predict OS and DMFS were constructed using extranodal extension infiltrating the surrounding structures (ENEmax), maximal axial diameter (MAD), large retropharyngeal lymph nodes (RLN, minimal axial diameter > 1.5 cm), multiple central nodal necrosis (CNN), and total lymph node (LN) number and level. Multivariate analysis showed the independent prognostic value of ENEmax and MAD > 3 cm for all selected survival endpoints (p < 0.05). Large RLN and lower neck involvement were independently associated with OS (p < 0.05). We proposed using a large RLN and MAD > 3 cm as N2 factors, and ENEmax and lower neck involvement as N3 factors. Among the seven N-stage schemes, our nomogram-based N scheme and ENEmax to N3 scheme (ENE3) ranked in the top two in the overall comparison with the elevated outcome predicting value (highest c-index). However, between the N0, N1, N1, and N2 subgroups, the ENE3 scheme showed no difference in OS or DMFS (p > 0.05). ConclusionThe predictive model highlighted the independent prognostic value of ENEmax, cervical lymph node, MAD, and large RLN, which can be used as criteria for future N staging.

Necrosis in lymph nodes and their differential diagnoses: application of reticulin staining.

This study aimed to enhance the histopathological diagnosis of necrotic lymph node specimens. A chart review was conducted, revealing that the most common causes of lymph node necrosis were Kikuchi disease (33%), granulomatous inflammation (25%), metastasis (17%), and lymphomas (12%). Histological analysis of necrotic tissue in 333 specimens demonstrated significant differences between the four diseases. The necrotic tissue of Kikuchi disease was amorphous, and hypercellular, and exhibited karyorrhexis and congestion. Granulomatous inflammation presented amorphous necrotic tissue with a nodular-like pattern. Metastasis exhibited heterogeneous morphology that varied between cancer types. Lymphomas displayed extensive necrosis with ghost cells, congestion, and bubbles. Reticulin staining patterns also differed between diseases. Kikuchi disease and lymphomas exhibited preserved reticular fiber networks in the necrotic tissue, resembling the viable tissue. Granulomatous inflammation and metastasis showed disrupted reticular fiber networks in the necrotic tissue. Based on these findings, histological features and reticulin staining patterns can aid in diagnosing Kikuchi disease, granulomatous inflammation, metastasis, and lymphomas in necrotic lymph node specimens.

Dual-energy computed tomography for improved visualization of internal jugular chain neck lymph node metastasis and nodal necrosis in head and neck squamous cell carcinoma.

To evaluate and compare the utility of 40-keV virtual monochromatic imaging (VMI) reconstructed from dual-energy computed tomography (DECT) in the assessment of neck lymph node metastasis with 70-keV VMI, which is reportedly equivalent to conventional 120-kVp single-energy computed tomography. Patients with head and neck squamous cell carcinoma who had neck lymph node metastasis in contact with the sternocleidomastoid muscle (SCM) and underwent contrast-enhanced DECT were included. In 40- and 70-keV VMI, contrast differences and contrast noise ratio (CNR) between the solid component of neck lymph node metastasis (SC) and the SCM and between SC and nodal necrosis (NN) were calculated. Two board-certified radiologists independently and qualitatively evaluated the boundary discrimination between SC and SCM and the diagnostic certainty of NN. We evaluated 45 neck lymph node metastases. The contrast difference between SC and SCM and SC and NN were significantly higher at 40-keV VMI than at 70-keV VMI (p < 0.001). The CNR between SC and SCM was significantly higher at 40-keV VMI than at 70-keV VMI (p < 0.001). Scoring of the boundary discrimination between SC and SCM as well as the diagnostic certainty of NN at 40-keV VMI was significantly higher than that at 70-keV VMI (p < 0.001). The inter-rater agreements for these scores were higher at 40-keV VMI than at 70-keV VMI. Additional employing 40-keV VMI in routine clinical practice may be useful in the diagnosis of head and neck lymph node metastases and nodal necrosis.

An aberrant presentation of non-hodgkin’s lymphoma as pus: A curious journey

T-lymphoblastic lymphoma (T-LBL) is most commonly found in younger age group and rare. It is most aggressive form ofnon-Hodgkin’s lymphoma. T-lymphoblastic lymphoma (T-LBL) response rate to chemotherapy is very good although relapse is common with poor survival rates.A 25 years old female presented to emergency department of a tertiary care centre with dyspnoea and chest tube in left Hemothorax in situ. She had earlier history of pulmonary tuberculosis 3 years back and took anti tubercular treatment for 6 months. On general examination we found left supraclavicular lymphadenopathy of size 2 × 1.5cm and grade 2 clubbing.The pleural fluid was sent for analysis. It was reported as exudative pleural effusion with low ADA and negative for malignant cells. Lymph node biopsy was sent for histopathological examination which was reported as T Lymphoblastic lymphoma. NHL is a diverse category of cancers that originate from B or T cells at different stages of maturation. In relation to our case; earlier history of tuberculosis, pus from lymph node could mislead to infective aetiology; as lymph node necrosis is commonly found in Hodgkin’s disease. This fact reiterates the fact that through clinical examination and history leads to proper diagnosis and management of the patient and can save time of the patients.

Prognostic Value of Lymph Node Necrosis at Different N Stages in Patients with Nasopharyngeal Carcinoma.

Background: Lymph node necrosis (LNN), including retropharyngeal nodal necrosis and cervical nodal necrosis, which is related to radiotherapy/ chemotherapy resistance, is a common phenomenon in nasopharyngeal carcinoma (NPC). This study was to assess the prognostic value of LNN at different N stages in NPC patients. Materials and Methods: In total, 1,665 newly diagnosed NPC patients at stage TxN1-3M0 from two centers were enrolled. Univariate and multivariate models were constructed to assess the association between LNN and long-term survival outcomes. The propensity score matching method was performed to balance treatment groups for baseline characteristics. Results: Of the 1,665, 540 patients (540/1665, 32.4%) were diagnosed with LNN, of which 54.1% (292/540) patients were at stage N1, 31.3% (169/540) at stage N2, and 14.6% (79/540) at stage N3. Univariate and multivariate analyses indicated LNN as an independent predictor for progression‑free survival (PFS), overall survival (OS), distant metastasis-free survival (DMFS), and locoregional relapse-free survival (LRRFS) in stage N1-3 patients (all P<0.001). When patients were analyzed according to stage, similar findings were observed for N1 patients (all P<0.001); for N2 patients, LNN independently predicted PFS (P=0.003), OS (P=0.011), and DMFS (P=0.004), and for stage N3, LNN only independently predicted LRRFS (P=0.019). 123 pairs of patients who received induction chemotherapy plus concurrent chemoradiotherapy or only concurrent chemoradiotherapy were matched, adding induction chemotherapy improved 5-year OS, PFS and LRFFS, but the results were not statistically significant. Conclusions: In NPC patients, LNN could independently predict poor prognosis at all N1-3 stages and at each N stage (N1 to N3). The value of adding induction chemotherapy to concurrent chemoradiotherapy in patients with LNN still requires further prospective studies.

Efficacy of adjuvant chemotherapy/maintenance chemotherapy after induction chemotherapy and concurrent chemoradiotherapy in patients with locoregionally advanced nasopharyngeal carcinoma: Experiences of two centers.

In general, there are not many studies exploring the clinical value of adjuvant chemotherapy or maintenance chemotherapy (AC/MC) after induction chemotherapy and concurrent chemoradiotherapy (IC+CCRT+AC/MC). The purpose of this study was to establish a clinical nomogram for the use of AC/MC in patients with locoregionally advanced nasopharyngeal carcinoma (LA-NPC). Two centers (Guangzhou Medical University Cancer Center [N=1226] and Zhongshan People's Hospital [N=150]) recruited 1376 patients with LA-NPC. All the patients underwent IC+CCRT; 560 patients received AC with cisplatin/nedaplatin plus docetaxel/paclitaxel (TP) or cisplatin/nedaplatin plus fluorouracil (PF), and 81 patients received MC with S-1. Multivariate Cox regression was used to confirm optimal predictors of progression-free survival (PFS), and a nomogram was established to identify patients into low-risk and high-risk cohorts. Additionally, bootstrap internal validation was performed to further verify our nomogram. After propensity score matching (PSM), the survival curves were not statistically different between IC+CCRT+AC/MC and IC+CCRT (all p > 0.05). Then, a nomogram was developed based on variables that were screened by univariate and multivariate Cox regression, including N stage, cumulative platinum dose during CCRT, body mass index (BMI), IC cycles, IC regimen and cervical lymph node (CLN) necrosis and infiltration of adjacent tissues. The results of the nomogram showed that the high-risk cohort had greatly worse 5-year DMFS, LRFS, PFS and OS compared to low-risk cohort (all p < 0.05), and subgroup analysis found that the 5-year DMFS, PFS and OS of patients treated with IC+CCRT+AC/MC were better than those treated with IC+CCRT in high-risk cohort (all p < 0.05). Notably, the incidence of adverse effects for IC+CCRT+AC cohort was higher than that for IC+CCRT+MC cohort, especially leukocytopenia and neutropenia. IC+CCRT and IC+CCRT+MC were associated with similar incidences of adverse effects. The addition of AC or MC to IC+CCRT could improve the DMFS of patients with high-risk NPC and prolong their survival. Additionally, our findings suggest a potential role of AC/MC following IC plus CCRT in the treatment of high-risk LA-NPC.

Prognostic value of the cervical lymph node necrosis ratio in nasopharyngeal carcinoma

PurposeWhether cervical lymph node necrosis (CNN) is an independent adverse prognostic factor in nasopharyngeal carcinoma (NPC) has not been determined. In this study, the CNN ratio was graded quantitatively to explore the prognostic value in NPC. Participants and methodsWe retrospectively reviewed a total of 648 pathologically confirmed as NPC. We outlined metastatic lymph nodes and necrotic area of lymph nodes slice by slice on the magneticresonanceimages (MRI) cross section, and calculated the corresponding CNN ratio. ResultsThe median CNN ratio (17.37 %) was taken as the cut-off point, 256 (39.51 %) patients were divided into CNN1 group (<17.37 %, n = 128) and CNN2 group (≥17.37 %, n = 128), 392 (60.49 %) patients without lymph nodes necrosis were CNN0. Among the CNN0, CNN1 and CNN2 groups, five-year overall survival (OS) was 82.4 %, 76.6 % and 71.1 %, locoregional recurrence-free survival (LRRFS) was 91.3 %, 91.1 % and 90.5 %, distant metastasis‐free survival (DMFS) was 83.7 %, 78.5 % and 68.7 %, progression-free survival (PFS) was 78.3 %, 71.7 % and 61.6 % respectively. By multivariate analysis, CNN was an independent prognostic factor for OS (P = 0.003), DMFS (P = 0.019) and PFS (P = 0.007). More than 3 cycles of chemotherapy significantly increased OS (P = 0.024) and DMFS (P = 0.015) in the CNN1 group. ConclusionsThis study indicated that CNN is one of the factors with the negative prognosis of NPC. The CNN ratio might be used as one of the reference factors in the formulation of individualized treatment plan.