Lymph Node Stations Research Articles

Enzymatic Fat Dissolution Improves Detection of Small Lymph Nodes in Colon Cancer Surgery.

Background Accurate lymph node evaluation is essential for staging colon cancer and guiding postoperative treatment decisions. In this study, we compared the efficacy of a simple enzymatic fat dissolution method with the conventional method for lymph node sampling from specimens after colon cancer surgery. Methods We enrolled 58 patients who underwent elective laparoscopic surgery for colon adenocarcinoma between May 2018 and May 2021 at Fukuoka University Hospital in Fukuoka, Japan. The specimens from these patients were treated using fat dissolution and were compared with specimens from 58 patients for which conventional manual palpation was used. Results A significantly greater number of lymph nodes were detected by the fat dissolution method compared with the conventional method (average per patient, 27.5 vs. 22.6, P = 0.02). In particular, the between-group difference was significant for lymph nodes measuring <5 mm (average per patient, 26.1 vs. 20.9; P = 0.01). Multivariate analysis showed that, compared with the conventional method, the fat dissolution method was significantly associated with the identification of lymph node metastasis. The positive rate of lymph nodes ≥10 mm in diameter was markedly higher along the inferior mesenteric artery than the ileocolic artery (100% vs. 52.6%). Conclusions The use of the fat dissolution method led to an increase in the number of small lymph nodes detected. Rates of metastasis according to lymph node size may depend on the lymph node station.

Pathological response and tumor stroma immunogenic features predict long-term survival in non-small cell lung cancer after neoadjuvant chemotherapy.

Major pathological response (MPR) has become a surrogate endpoint for overall survival (OS) in non-small cell lung cancer (NSCLC) after neoadjuvant therapy, however, the prognostic histologic features and optimal N descriptor after neoadjuvant therapy are poorly defined. We retrospectively analyzed data from 368 NSCLC patients who underwent surgery after neoadjuvant chemotherapy (NAC) from January 2010 to December 2020. The percentage of residual viable tumors in the primary tumor, lymph nodes (LN), and inflammation components within the tumor stroma were comprehensively reviewed. The primary endpoint was OS. Of the 368 enrolled patients, 12.0% (44/368) achieved MPR in the primary tumor, which was associated with significantly better OS (HR, 0.36 0.17-0.77, p = 0.008) and DFS (HR = 0.59, 0.36-0.92, p = 0.038). In patients who did not have an MPR, we identified an immune-activated phenotype in primary tumors, characterized by intense tumor-infiltrating lymphocyte or multinucleated giant cell infiltration, that was associated with similar OS and DFS as patients who had MPR. Neoadjuvant pathologic grade (NPG), consisting of MPR and immune-activated phenotype, identified 30.7% (113/368) patients that derived significant OS (HR 0.28, 0.17-0.46, p < 0.001) and DFS (HR 0.44, 0.31-0.61, p < 0.001) benefit from NAC. Moreover, the combination of NPG and the number of positive LN stations (nS) in the multivariate analysis had a higher C-index (0.711 vs. 0.663, p < 0.001) than the ypTNM Stage when examining OS. NPG integrated with nS can provide a simple, practical, and robust approach that may allow for better stratification of patients when evaluating neoadjuvant chemotherapy in clinical practice.

Increased resected lymph node stations improved survival of esophageal squamous cell carcinoma.

Neoadjuvant chemoradiotherapy (nCRT) and surgery have been recommended as the standard treatments for locally advanced esophageal squamous cell carcinoma (ESCC). In addition, nodal metastases decreased in frequency and changed in distribution after neoadjuvant therapy. This study aimed to examine the optimal strategy for lymph node dissection (LND) in patients with ESCC who underwent nCRT. The hazard ratios (HRs) for overall survival (OS) and disease-free survival (DFS) were calculated using the Cox proportional hazard model. To determine the minimal number of LNDs (n-LNS) or least station of LNDs (e-LNS), the Chow test was used. In total, 333 patients were included. The estimated cut-off values for e-LNS and n-LNS were 9 and 15, respectively. A higher number of e-LNS was significantly associated with improved OS (HR: 0.90; 95% CI 0.84-0.97, P = 0.0075) and DFS (HR: 0.012; 95% CI: 0.84-0.98, P = 0.0074). The e-LNS was a significant prognostic factor in multivariate analyses. The local recurrence rate of 23.1% in high e-LNS is much lower than the results of low e-LNS (13.3%). Comparable morbidity was found in both the e-LNS and n-LND subgroups. This cohort study revealed an association between the extent of LND and overall survival, suggesting the therapeutic value of extended lymphadenectomy during esophagectomy. Therefore, more lymph node stations being sampled leads to higher survival rates among patients who receive nCRT, and standard lymphadenectomy of at least 9 stations is strongly recommended.

Frequency and predictive factors of nodal micro-metastasis (NMM) in resectable non-small cell lung cancer.

The frequency of lymph nodal micrometastasis (NMM) in resectable non-small cell lung cancer (NSCLC) is frequently underestimated when relying solely on standard hematoxylin and eosin staining during pathological examination. This is a retrospective cross-sectional diagnostic research. Medical records of resectable pN0 NSCLC patients who underwent curative resection in Maharaj Nakorn Chiang Mai Hospital between January 2006 to December 2017 were retrospectively reviewed. Immunohistochemistry (IHC) staining using cytokeratin AE1/AE3, p53 and BerEP4 markers was employed to detect NMM. Primary objective of this study was to determine frequency of NMM in pN0 resectable NSCLC. This study included 98 patients with pN0 NSCLC, of which 47 were male and 51 were female. NMM was detected in 21 of 98 patients (21.43%). Lymph node station 10 and 7 were the most common site of micrometastasis among patients with N1 and N2 micrometastasis, respectively. Cytokeratin AE1/AE3 was the most sensitive antibody in detecting micrometastasis in lymph nodes, identifying 25 out of 27 positive lymph nodes. Tumor size greater than 4 cm was a statistically significant predictive factor for NMM with risk ratio 6.69 [95% confidence interval (CI): 2.38-18.85, P<0.001]. NMM was identified in 21.43% of pN0 resectable NSCLC patients and tumor size greater than 4 cm is predictive factor for NMM.

Clinical Efficacy of Resected Lymph Nodes Should Depend on Lymph Nodes Stations and the Primary Location of the Tumor.

Clinical Efficacy of Resected Lymph Nodes Should Depend on Lymph Nodes Stations and the Primary Location of the Tumor.

Perioperative outcomes of uniportal versus three-port video-assisted thoracoscopic surgery in lung cancer patients aged ≥ 75 years old: a cohort study

BackgroundIncreasing attention has been raised on the surgical option for lung cancer patients aged ≥75 years, however, few studies have focused on whether uniportal video-assisted thoracoscopic surgery (VATS) is safe and feasible for these patients. This study aimed to evaluate short-term results of uniportal versus three-port VATS for the treatment of lung cancer patients aged ≥75 years.MethodsWe retrospectively evaluated 582 lung cancer patients (≥75 years) who underwent uniportal or three-port VATS from August 2007 to August 2021 based on the Western China Lung Cancer Database. The baseline and perioperative outcomes between uniportal and three-port VATS were compared in the whole cohort (WC) and the patients undergoing lobectomy (lobectomy cohort, LC) respectively. Propensity score matching (PSM) was used to minimize confounding bias between the uniportal and three-port cohorts in WC and LC.ResultsIntraoperative blood loss was significantly less in the uniportal than three-port LC (50 mL vs. 83 mL, P = 0.007) before PSM and relatively less in the uniportal than three-port LC (50 mL vs. 83 mL, P = 0.05) after PSM. Significantly more lymph nodes harvested (13 vs. 9, P = 0.007) were found in the uniportal than three-port LC after PSM. In addition, in WC and LC, there were no significant differences between uniportal and three-port cohorts in terms of operation time, the rate of conversion to thoracotomy during surgery, nodal treatments (dissection or sampling or not), the overall number of lymph node stations dissected, postoperative complications, volume and duration of postoperative thoracic drainage, hospital stay after operation and hospitalization expenses before and after PSM (P > 0.05).ConclusionsThere were no significant differences in short-term outcomes between uniportal and three-port VATS for lung cancer patients (≥75 years), except relatively less intraoperative blood loss (P < 0.05 before PSM and P = 0.05 after PSM) and significantly more lymph nodes harvested (P < 0.05 after PSM) were found in uniportal LC. It is reasonable to indicate that uniportal VATS is a safe, feasible and effective operation procedure for lung cancer patients aged ≥75 years.

Bi-institutional spline curve analysis of lymph node mapping in gallbladder cancer operated over 12 years: impact of location and number of lymph nodal stations

Bi-institutional spline curve analysis of lymph node mapping in gallbladder cancer operated over 12 years: impact of location and number of lymph nodal stations

Metastasis to certain lymph node stations for whipple patients impacts survival

Metastasis to certain lymph node stations for whipple patients impacts survival

Gastric Cancer in the Lesser and Greater Curvature: A Comparative Analysis from a Single Western Center.

To date, the different clinicopathological characteristics of gastric cancer (GC) in the lesser curvature and greater curvature remain unclear. The aim of this study was to investigate the different features of the tumors in the two sites and provide new strategy for a tailored therapy. Between January 2003 and December 2019, 121 patients with GC located in the lesser or greater curvature were surgically treated with curative intent. Data about clinico-pathological features were retrospectively analyzed. In addition, we analyzed the different lymph node patterns according to the lymph node (LN) metastasis between the two groups of patients. No statistically significant differences were found regarding the 5-year overall survival (5y-OS) and 5y disease-free survival (5y-DFS) between patients with GC in the two sites (p=0.94 and p=0.98, respectively). Considering TNM pathological stage, patients with GC in the lesser curvature in stage II and III, showed a worse survival than those with GC in the greater curvature (stage II 5y-OS: 80 vs. 100% and stage III 5y-OS: 18.9 vs. 55.5%). Considering the median value of metastasis LNs, GC in the greater curvature metastasized more often to LN stations no. 8, 10, and 11, whereas GC in the lesser curvature to LN stations no. 8, 9, and 12. GC in the lesser curvature showed a worse prognosis than GC in the greater curvature. Therefore, GC in the lesser curvature could undergo a more aggressive surgery, including an extended lymphadenectomy, and a close follow-up.

A machine learning based radiomics approach for predicting No. 14v station lymph node metastasis in gastric cancer.

To evaluate the potential of radiomics approach for predicting No. 14v station lymph node metastasis (14vM) in gastric cancer (GC). The contrast enhanced CT (CECT) images with corresponding clinical information of 288 GC patients were retrospectively collected. Patients were separated into training set (n = 202) and testing set (n = 86). A total of 1,316 radiomics feature were extracted from portal venous phase images of CECT. Seven machine learning (ML) algorithms including naïve Bayes (NB), k-nearest neighbor (KNN), decision tree (DT), logistic regression (LR), random forest (RF), eXtreme gradient boosting (XGBoost) and support vector machine (SVM) were trained for development of optimal radiomics signature. A combined model was established by combining radiomics with important clinicopathological factors. The diagnostic ability of the signature and model were evaluated. LR algorithm was chosen for signature construction. The radiomics signature exhibited good discrimination accuracy of 14vM with AUCs of 0.83 in the training and 0.77 in the testing set. The risk of 14vM showed significant association with higher radiomics score. A combined model exhibited increased predictive ability and good agreement in the training (AUC = 0.87) and testing (AUC = 0.85) sets. The ML-based radiomics model provided a promising image biomarker for preoperative detection of 14vM and may help the surgeon to decide whether to add 14v dissection to lymphadenectomy.

Prevalence of Lymphedema and Associated Risk Factors Following Multimodal Breast Cancer Treatment

Background: Breast cancer related Lymphedema (BCRL) in the respective arm is a common but serious negative sequel of breast cancer management. Risk factors include dissection of Axillary lymph nodes and irradiation of Regional lymph nodes. Nearly 20% of patients receiving treatment of breast cancer develop this complication and it has a negative impact on quality of life of the patient. Objective: Current study aims to equip the medical professionals with all the details needed for prevention, early detection, intervention and management of this hazardous late treatment related complication. Material and Methods: Total 350 breast cancer patients (with their consent) treated at Government Cancer Hospital, Indore in the Radiotherapy and Oncology Department, in period from January 2019till December 2021, with chest wall radiotherapy following subsequent hormonal therapy, as needed. Patients then analysed for occurrence of lymphedema. Subsequently, efforts were given for finding out the correlation between lymphedema and related treatment modality like adjuvant radiotherapy following definitive surgery with number of excised lymph nodes and number of involved lymph nodes, chemotherapy, hormonal therapy, subjective co-morbid condition (obesity, diabetes mellitus and high blood pressure). Results: Current study demonstrate a significant correlation of adjuvant radiotherapy, including progressive involvement of the lymph node stations, with radical or conservative breast surgery with lymph node dissection represents a statistically significant risk factor, with relative risk, RR=1.49 (95% CI=0.72–3.05), p&lt;0.001. Subsequent increase in number of dissected lymph nodes shown a risk factor with statistical significance as relative risk for more than 25 removed lymph nodes, demonstrated significant risk of lymphedema than for 16-25 removed lymph nodes. Other analysed risk factors, which did not influence lymphedema development like, associated chemotherapy, hormonal therapy or presence of co-morbid illnesses. Conclusions: Arm lymphedema is a late sequel associated with carcinoma breast treatment using radiation or surgery, and quite capricious occurrence that can happen years after axillary clearance surgery. With the use of sentinel node sampling, could reduce the need of frank axillary clearance by showing either involvement of lymph node in axilla, so as to manage only by radiotherapy. That significantly reduces the risk of lymphedema from 16% with axillary clearance to 5% without dissection. Keywords: Lymphedema, Breast cancer, Risk factors, Axillary lymph node

LNAS: a clinically applicable deep-learning system for mediastinal enlarged lymph nodes segmentation and station mapping without regard to the pathogenesis using unenhanced CT images.

The accurate identification and evaluation of lymph nodes by CT images is of great significance for disease diagnosis, treatment, and prognosis. To assess the lymph nodes' segmentation, size, and station by artificial intelligence (AI) for unenhanced chest CT images and evaluate its value in clinical scenarios. This retrospective study proposed an end-to-end Lymph Nodes Analysis System (LNAS) consisting of three models: the Lymph Node Segmentation model (LNS), the Mediastinal Organ Segmentation model (MOS), and the Lymph Node Station Registration model (LNR). We selected a healthy chest CT image as the template image and annotated 14 lymph node station masks according to the IASLC to build the lymph node station mapping template. The exact contours and stations of the lymph nodes were annotated by two junior radiologists and reviewed by a senior radiologist. Patients aged 18 and above, who had undergone unenhanced chest CT and had at least one suspicious enlarged mediastinal lymph node in imaging reports, were included. Exclusions were patients who had thoracic surgeries in the past 2weeks or artifacts on CT images affecting lymph node observation by radiologists. The system was trained on 6725 consecutive chest CTs that from Tianjin Medical University General Hospital, among which 6249 patients had suspicious enlarged mediastinal lymph nodes. A total of 519 consecutive chest CTs from Qilu Hospital of Shandong University (Qingdao) were used for external validation. The gold standard for each CT was determined by two radiologists and reviewed by one senior radiologist. The patient-level sensitivity of the LNAS system reached of 93.94% and 92.89% in internal and external test dataset, respectively. And the lesion-level sensitivity (recall) reached 89.48% and 85.97% in internal and external test dataset. For man-machine comparison, AI significantly apparently shortened the average reading time (p < 0.001) and had better lesion-level and patient-level sensitivities. AI improved the sensitivity lymph node segmentation by radiologists with an advantage in reading time.

Sphericity of lymph nodes using 3D-CT predicts metastasis in lung cancer patients

BackgroundThe presence of mediastinal lymph node metastasis is important because it is related to the treatment and prognosis of lung cancer. Although prevalently used, evaluation of lymph nodes is not always reliable. We introduced sphericity as a criterion for evaluating morphologic differences between metastatic and nonmetastatic nodes.MethodsWe reviewed the cases of 66 patients with N2 disease and of 68 patients with N0-1 disease who underwent lobectomy with mediastinal dissection between January 2012 and December 2021. The sphericity of the dissected station lymph nodes, which represents how close the node is to being a true sphere, was evaluated along with the diameter and volume. Each parameter was obtained and evaluated for ability to predict metastasis.ResultsMetastatic lymph nodes had a larger short-axis diameter (average: 8.2 mm vs. 5.4 mm, p < 0.001) and sphericity (average: 0.72 vs. 0.60, p < 0.001) than those of nonmetastatic lymph nodes. Short-axis diameter ≥ 6 mm and sphericity ≥ 0.60 identified metastasis with 76.2% sensitivity and 70.2% specificity (AUC = 0.78, p < 0.001) and 92.1% sensitivity and 53.9% specificity (AUC = 0.78, p < 0.001), respectively. For lymph nodes with a short-axis diameter ≥ 5 mm, sphericity ≥ 0.60 identified metastasis with 84.1% sensitivity and 89.3% specificity.ConclusionBy using 3D-CT analysis to examine sphericity, we showed that metastatic lymph nodes became spherical. Our method for predicting lymph node metastasis based on sphericity of lymph nodes with a short-axis diameter ≥ 5 mm could do so with higher sensitivity than the conventional method, and with acceptable specificity.

PP94 Robotic-Assisted Thoracoscopic Surgery Versus Video-Assisted Thoracoscopic Surgery And Open Thoracotomy: A Systematic Review And Meta-Analysis

IntroductionRobot-assisted surgery is one of the minimally invasive surgical approaches that has been increasingly utilized across a wide range of surgeries. However, there is limited evidence of robotic-assisted thoracic surgery (RATS) for patients with lung cancer. This study aims to evaluate the safety and effectiveness of RATS in lung cancer patients compared with video-assisted thoracoscopic surgery (VATS) and open thoracotomy.MethodsA comprehensive search for studies that compared RATS versus VATS or open thoracotomy published until 12 April 2022, was conducted. Two review authors independently assessed studies for inclusion and risk of bias, and extracted data. We used results of reported perioperative outcomes, oncological outcomes, and survival outcomes. When more than two studies contributed data, meta-analyses were performed.ResultsFour randomized controlled trials (RCT) were included. Firstly, three RCTs comparing RATS with VATS were identified. Compared with the VATS group, the RATS group had significantly lower blood loss, more harvested lymph nodes and lymph node stations. However, there were no significant differences in operative time, transfusion rates, hospital stay, drainage duration, reoperation, readmission, postoperative pain, and postoperative complications. Survival outcomes were not reported. Secondly, one RCT comparing RATS with open thoracotomy was identified. Compared with open thoracotomy group, the RATS group had significantly lower blood loss, less postoperative pain, and shorter chest drainage duration. On the other hand, there were no significant differences in operative time, hospital stay, postoperative complications, number of harvested lymph nodes and lymph node stations, and survival outcomes (disease-free survival, overall survival).ConclusionsEvidence on the effectiveness and safety of RATS compared with VATS or open thoracotomy for lung cancer is of low certainty, but we suggest that RATS is a feasible and safe alternative to conventional thoracic surgeries for lung cancer patients on the basis of current data. Additionally, more and better studies are required to provide evidence on the benefits and cost-effectiveness of RATS.

Segmentectomy quality remains important in ground-glass-dominant stage I lung cancer.

Segmentectomy for early-stage lung cancer has benefits for survival and parenchymal preservation. However, segmentectomies are technically challenging, thereby resulting in considerable variability in the quality of resection. In this study, we aimed to review the quality of segmentectomies and analyze their clinical impact. This retrospective study reviewed patients diagnosed with stage I lung cancer after segmentectomies between 2013 and 2021. Segmentectomies were classified as anatomical or nonanatomical; anatomical resection included segmental bronchus and vessel (artery and/or vein) divisions; others were classified as nonanatomical. The primary outcome was recurrence-free and overall survival, and the secondary outcome was postoperative spirometry and lung plication, which is seen as a fibrotic line along the stapling site. Of the 132 segmental resections included in this study, 101 (76.5%) were anatomical segmentectomies. The median consolidation-tumor ratio was 0.40, and 83.3% (110/132) had ground-glass opacities (GGOs). Compared to nonanatomical resections, more N1 and total lymph node stations were retrieved after anatomical segmentectomies. Regarding clinical outcomes, recurrence-free survival was better after anatomical segmentectomy (p = 0.049); however, overall survival was not significantly different (p = 0.064). Furthermore, at 3-6 months postoperatively, thicker lung plication at the stapling site was observed in nonanatomical resections (p < 0.001). Subgroup analysis for complex segmentectomies revealed a larger decrease in forced-expiration volume in 1 s after nonanatomical resection. Anatomical segmentectomy resulted in better survival and a lower incidence of thick lung plication, even in GGO-dominant tumors. Therefore, further standardization and quality management of segmentectomy procedures will improve the clinical outcomes.

Key nodal stations for predicting splenic hilar nodal metastasis in upper advanced gastric cancer without invasion of the greater curvature.

Standard surgery for upper advanced gastric cancer without invasion of the greater curvature (UGC-GC) is spleen-preserving D2 total gastrectomy without dissection of the splenic-hilar nodes (#10). However, some patients with nodal metastasis to #10 survive more than 5 years due to nodal dissection of #10. If nodal metastasis to #10 is predictable based on the positivity of other nodes dissected by the current standard surgery without #10 nodal dissection, physicians may be able to consider #10 dissection. This study retrospectively reviewed data from the National Cancer Center Hospital in Japan between 2000 and 2012. We selected cases that met the following criteria: (1) D2 or more total gastrectomy with splenectomy, (2) UGC-GC, and (3) histological type is gastric adenocarcinoma. We performed univariate and multivariate analyses concerning lymph node stations associated with #10 metastasis. A total of 366 patients were examined. A multivariate analysis revealed that #10 metastasis was associated with positivity of the nodes along the short gastric arteries (#4sa) and distal nodes along the splenic artery (#11d) (#4sa: p = 0.003, #11d: p = 0.016). When either key node was positive, the metastatic rate of #10 was 24.4%, and the therapeutic value index was 13.3. #4sa and #11d were key lymph nodes predicting #10 nodal metastasis in UGC-GC. When these key nodes are positive on computed tomography before surgery or according to a rapid pathological examination during surgery, dissection of #10 should be considered even if upper advanced tumors are not invading the greater curvature.

Preoperative mediastinal staging in early-stage lung cancer: Targeted nodal sampling is not inferior to systematic nodal sampling

ObjectiveTo determine whether targeted sampling (TS), which omits biopsy of triple- normal lymph nodes (LNs) on positron emission tomography, computed tomography, and endobronchial ultrasound (EBUS), is noninferior to systematic sampling (SS) of mediastinal LNs during EBUS for staging of patients with early-stage non–small cell lung cancer (NSCLC). MethodsPatients who are clinical nodal (cN)0-N1 with suspected NSCLC eligible for EBUS based on positron emission tomography/computed tomography were enrolled in this prospective, multicenter trial. During EBUS, all patients underwent TS and then crossed over to SS, whereby at least 3 mediastinal LN stations (4R, 4L, 7) were routinely sampled. Gold standard of comparison was pathologic results. Based on the previous feasibility trial, a noninferiority margin of 6% was established for difference in missed nodal metastasis (MNM) incidence between TS and SS. The McNemar test on paired proportions was used to determine MNM incidence for each sampling method. Analysis was per-protocol using a level of significance of P < .05. ResultsBetween November 2020 and April 2022, 91 patients were enrolled at 6 high-volume Canadian tertiary care centers. A total of 256 LNs underwent TS and SS. Incidence of MNM was 0.78% in SS and 2.34% in TS, with an absolute difference of 1.56% (95% confidence interval, −0.003% to 4.1%; P = .13). This falls within the noninferiority margin. A total of 6/256 LNs from 4 patients who were not sampled by TS were found to be malignant when sampled by SS. ConclusionsIn high-volume thoracic endosonography centers, TS is not inferior to SS in nodal staging of early-stage NSCLC. This results in change of clinical management for a minority of patients.

Advantages of contrast-enhanced ultrasound in the localization and diagnostics of sentinel lymph nodes in breast cancer.

Sentinel lymph nodes (SLNs) are the first station of lymph nodes that extend from the breast tumor to the axillary lymphatic drainage. The pathological status of these LNs can predict that of the entire axillary lymph node. Therefore, the accurate identification of SLNs is necessary for sentinel lymph node biopsy (SLNB) to replace axillary lymph node dissection (ALND). The quality of life and prognosis of breast cancer patients are related to proper surgical treatment after the precise identification of SLNs. Some of the SLN tracers that have been identified include radioisotope, nano-carbon, indocyanine green (ICG), and methylene blue (MB). However, these tracers have certain limitations, such as pigmentation, radiation dangers, and the requirement for costly detection equipment. Ultrasound contrast agents (UCAs) have good specificity and sensitivity, and thus can compensate for some shortcomings of the mentioned tracers. This technique is also being applied to SLNB in patients with breast cancer, and can even provide an initial judgment on SLN status. Contrast-enhanced ultrasound (CEUS) has the advantages of high distinguishability, simple operation, no radiation harm, low cost, and accurate localization; therefore, it is expected to replace the traditional biopsy methods. In addition, it can significantly enhance the accuracy of SLN localization and shorten the operation time.

Multicentric Hyaline-Vascular Castleman Disease: The Missing Link?

Introduction: Castleman disease (CD) is a rare lymphoproliferative disorder that encompasses distinct clinicopathological entities. Unicentric form of the disease (UCD) usually involves a single lymph node station, exhibits hyaline vascular (HV) pathological changes with follicular dendritic cell expansion, and may associate with specific and life-threatening complications including paraneoplastic pemphigus (PNP) and follicular dendritic cell sarcoma (FDCS). Plasma cell interfollicular infiltration is absent in the HV subtype as opposed to the Plasma-Cell (PC) or Mixed subtypes. PC subtype has been associated with inflammatory symptoms thought to be secondary to plasma cell infiltration and represents the majority of HHV8-negative “idiopathic” multicentric forms of the disease. Interestingly, patients with PC-UCD behave as PC-MCD, suggesting a stronger role of histology rather than Unicentric vs Multicentric phenotype in disease expression. We here studied the phenotype of HV-MCD, a rare subtype of CD characterized by hyaline-vascular pathological changes involving 2 or more lymph node stations. Methods: Patients were screened through the French national reference center for CD between January 1994 and June 2023. Cases were followed from first symptoms to last follow-up visit. Comparators consisted of patients with HV-UCD and patients with PC/Mixed iMCD (P/M-iMCD). All cases and biopsies were reviewed by three expert clinicians and one expert pathologist. Results: Sixteen patients with a diagnosis of HHV8-negative HV-MCD were identified. All patients had supra- and infradiaphragmatic involvement. Four were excluded because of a subsequent diagnosis of POEMS, systemic lupus erythematosus, tuberculosis, or inborn error of immunity. The 12 remaining patients were considered as having HV-iMCD and compared to 101 patients with P/M-iMCD and 139 patients with HV-UCD. Characteristics and comparison between the 3 groups are depicted in Table 1. When compared to HV-UCD, HV-iMCD displayed frequent systemic involvement with significantly higher ECOG, higher frequency of fever and splenomegaly, and higher levels of C-reactive protein, gammaglobulins, leukocytes and ferritinemia ( Figure 1). Age at diagnosis was not different between HV-UCD and HV-iMCD. No cases of TAFRO syndrome were observed in HV-UCD whereas 4 cases were observed in HV-iMCD. All cases of PNP (n=12) and FDCS (n=3) were observed in the HV-UCD group. We observed a younger age at diagnosis in HV-iMCD compared to P/M-iMCD (median 24 [range 13-70] vs median 50 [range 11-88] years respectively, p = 0.01). We also noted a trend towards lower levels of C reactive protein and gammaglobulins as well a higher albumin level in HV-iMCD vs P/M-iMCD but these differences were not significant ( Figure 1 and Table 1). Treatments were similar between HV-iMCD and P/M-iMCD with prescription of steroids or anti-IL6R as first line therapy in 8/12 (67%) and 61/101 (60%) respectively. As expected, surgery was the first line therapy in 98/139 (72%) of HV-UCD patients. One patient with HV-iMCD and two with HV-UCD died (logrank p = 0.10), whereas 13 died in the P/M-iMCD group (logrank p = 0.8). Conclusions: These data altogether indicate that HV-iMCD appears to be a distinct entity in CD landscape, sharing pathological aspects of HV-UCD and clinical/biological features of P/M iMCD. In line with this view, there seems to be no overlap between HV-UCD and HV-iMCD-related complications. The findings also suggest that nodal PC infiltration is not sufficient to explain the inflammatory pattern of iMCD.

Dissection and resection of the left paratracheal lymph node (station 4L) using a traditional mediastinoscope with a 30-degree, 5 mm lens, connected to the video camera.

Dissection and resection of the left paratracheal lymph node (station 4L) using a traditional mediastinoscope with a 30-degree, 5 mm lens, connected to the video camera.