Management Of Lymph Node Metastases Research Articles

SENTINEL LYMPH NODE BIOPSY IN TREATMENT OF PENILE CANCER

Objective: The management of lymph node metastases is crucial in penile cancer surgery. Sentinel lymph node biopsy (SLNB) is a minimally invasive procedure used to assess the presence of lymph node metastasis. The objective is to evaluate the efficiency of SLNB in the treatment of penile cancer. Methods: This retrospective observational study included 31 patients diagnosed with penile cancer who underwent surgery and SLNB at the National Hospital of Dermatology between January 2018 and May 2021. Results: The average age of patients was 58.4 ± 12.3 years old. The majority of patients had a history of phimosis (87.1%) and a treatment delay of over 1 year (67.7%). All 31 patients with penile cancer had squamous cell carcinoma (SCC) as the histological type, with the majority undergoing partial penectomy (87.1%). Out of 61 inguinal regions examined in 31 patients, lymph node metastasis was detected in one region (3.2%). The average follow-up time was 45.2 ± 12.1 months. One SLNB-negative patient was found to have inguinal lymph node metastasis after 12 months, resulting in a false-negative rate of 50%. The complication rate was 8.2%. Conclusion: SLNB utilizing a radioisotope tracer can significantly reduce the incidence and severity of complications associated with inguinal lymph node dissection in patients with penile cancer. Received 25 June 2023Revised 24 September 2023Accepted 28 November 2023

Review on Lymph Node Metastases, Sentinel Lymph Node Biopsy, and Lymphadenectomy in Sarcoma.

Soft tissue sarcomas (STS) originating from connective tissue rarely affect the lymph nodes. However, involvement of lymph nodes in STS is an important aspect of prognosis and treatment. Currently, there is no consensus on the diagnosis and management of lymph node metastases in STS. The key risk factor for nodal involvement is the histological subtype of sarcoma. Radiological and pathological evaluation seems to be the most effective method of assessing lymph nodes in these neoplasms. Thus, sentinel lymph node biopsy (SLNB), which has been shown to be valuable in the management of melanoma or breast cancer, may also be a beneficial diagnostic option in some high-risk STS subtypes. This review summarizes data on the risk factors and clinical characteristics of lymph node involvement in STS. Possible management and therapeutic options are also discussed.

Management of lymph node metastasis via local chemotherapy can prevent distant metastasis and improve survival in mice

Management of lymph node metastasis (LNM) by conventional modalities such as radiotherapy and systemic chemotherapy exhibit limited LNM selectivity and therefore can cause off-target adverse events. While development of LNM-specific drug delivery systems has tremendous potential to provide a safer treatment modality and improve cancer treatment, precise assessment of therapeutic efficacy and implications has been challenging due to lack of a suitable preclinical model. Here, we established an experimental LNM model in mice by directly seeding cancer cells into a lymph node (LN), which developed spontaneous LNM-borne distant metastasis (DM) in the absence of a primary tumor. In the model, early, but not late, management of LNM before thereof tumor cells systemically disseminated could confer significant survival benefit, which suggests that time to LNM management is critical. Systematic comparative assessment of various local drug delivery systems revealed that a micellar formulation could achieve highly LNM-specific delivery of a chemotherapeutic agent, which was superior to systemic chemotherapy, effective at a very low dose, and safe. This study suggests not only that the experimental LNM model provides a useful preclinical model to study LNM management and its therapeutic implications but also that micelles are a promising drug delivery system for LNM management via local administration.

Recurrence pattern of stereotactic body radiotherapy in oligometastatic prostate cancer: amulti-institutional analysis.

For patients with oligometastatic/oligorecurrent/oligoprogressive lymph node metastases from PCa, metastases-directed therapy is an emerging strategy. The aim of this retrospective study was to evaluate the oncological outcome and pattern of recurrence in patients treated with stereotactic body radiation therapy (SBRT) to lymph node metastases. In this multi-institutional analysis, patients with a maximum of five lymph node metastases from PCa treated with SBRT were included. Primary endpoints of the analysis were local control (LC), out-of-field nodal progression-free survival (NPFS), overall progression-free survival (PFS), and overall survival (OS). 109 patients and 155 lymph node metastases were evaluated. Patients' median age was 70.8 years (range 51-84) and median PSA before SBRT was 1.88 ng/ml (range 0.3-45.5 ng/ml). The dose delivered to the target ranged from 25 to 48 Gy in 4-7fractions; median BED1.5 Gy was 198 Gy (range 108.3-432 Gy). With amedian follow-up of 16months, LC rates at 1 and 3years were 93% and 86%, respectively. In-field progression of disease was observed in 11 (7%) lesions. One- and 3‑year NPFS was 59% and 29%, and median NPFS was 15months. Rates of OS at 1 and 3years were 100% and 95%. The median time to administration of asystemic treatment after SBRT was 7.8months (1.7-54.8). SBRT is an effective and well-tolerated treatment option in the management of lymph node metastases from PCa. Prospective trials are necessary to better select patients who benefit most from this ablative focal treatment and better define the recurrence patterns.

A Multi-Institutional Analysis on the Use of Stereotactic Body Radiotherapy (SBRT) for the Treatment of Lymph Node Oligometastases in Prostate Cancer Patients

for patients with oligometastatic/oligorecurrent/oligoprogressive lymph node metastases from PCa, metastases-directed therapy is an emerging strategy. The aim of this retrospective study was to evaluate the oncological outcome and pattern of recurrence of patients treated with stereotactic body radiation therapy (SBRT) on lymph node metastases. in this multi-institutional analysis, patients with maximum 5 lymph node metastases from PCa treated with SBRT were included. Primary end-points of the analysis were local control (LC), out-of-field nodal progression-free survival (NPFS), overall progression-free survival (PFS) and overall survival (OS). 109 patients and 155 lymph node metastases were evaluated. Patients’ median age was 70.8 years (range, 51-84) and median PSA before SBRT was 1.88 ng/ml (range, 0.3-45.5 ng/ml). The dose delivered to the target ranged from 25 to 48 Gy in 4-7 fractions; median BED1.5Gy was 198 Gy (range 108.3 – 432 Gy). With a median follow-up of 16 months, LC rates at 1- and 3-years were 93% and 86%, respectively. In-field progression of disease was observed in 11 (7%) lesions. One and 3-years NPFS was 59% and 29% and median NPFS was 15 months. Rates of OS at 1- and 3-years were 100% and 95%. The median time to the administration of a systemic treatment after SBRT was 7.8 months (1.7-54.8). SBRT is an effective and well tolerated treatment option in the management of lymph node metastases from PCa. Prospective trials are necessary to better select patients who benefit the most from this ablative focal treatment, and better define the recurrence patterns.

Management of lymph node metastasis for penile cancer in a tertiary referral centre

Management of lymph node metastasis for penile cancer in a tertiary referral centre

The role of neck dissection in squamous cell carcinoma of the head and neck.

Lymph node metastases in the neck are a major prognostic factor in patients with head and neck squamous cell carcinoma (HNSCC). Assessment and treatment of lymph nodes in the neck are of utmost importance. Inappropriate management of lymph node metastases can result in regional failure. Radical neck dissection has been and is still considered the "gold standard" for the surgical management of lymph node metastases of HNSCC. However, the philosophy of treatment of the neck has evolved during the last decades. Surgeons progressively realized that extensive neck dissections were associated with a higher morbidity but not always with a better oncologic outcome than more limited procedures. Today, a comprehensive therapeutic approach of the neck is multidisciplinary, taking into account the patient's quality of life without jeopardizing cure and survival. A better understanding of the patterns of lymph node metastasis promoted the use of selective neck dissection in selected patients. Sentinel lymph node biopsy is a reliable diagnostic procedure for staging the neck in node-negative early oral cavity squamous cell carcinoma. With increasing use of chemoradiation in locally advanced HNSCC, paradigms are evolving. Currently, there are strong arguments supporting the position that neck dissection is no longer justified in patients without clinically residual disease in the neck.

Management of lymph node metastases from an unknown primary site to the head and neck (Review).

Cancer of unknown primary site (CUP) is an intriguing clinical phenomenon found in ~3-9% of all head and neck cancers. It has not yet been determined whether CUP forms a distinct biological entity with specific genetic and phenotypic characteristics, or whether it is the clinical presentation of metastasis in patients with an undetected primary tumor and no visible clinical signs. The treatment of patients with cervical lymph node metastases from CUP remains controversial, due to the lack of randomized clinical trials comparing different treatment options. Consequently, treatment is currently based on non-randomized data and institutional policy. In the present review, the range and limitations of diagnostic procedures are summarized and an optimal diagnostic work-up is recommended. The initial preferred diagnostic procedures include fine-needle aspiration biopsy (FNAB) and imaging. Although neck dissection followed by postoperative radiotherapy is the the most generally accepted approach, other curative options may be used in certain patients, such as neck dissection alone, nodal excision followed by postoperative radiotherapy, or radiotherapy alone. There remains controversy regarding target radiation volumes, ranging from ipsilateral neck irradiation to prophylactic irradiation of all the potential mucosal sites and both sides of the neck. When no primary lesion is identified with imaging and endoscopy in patients without history of smoking and alcohol abuse, molecular profiling of an FNAB sample for human papillomavirus and/or Epstein-Barr virus is required.

Percutaneous Cryoablation for Local Control of Metachronous Inguinal Lymph Node Metastases

Percutaneous Cryoablation for Local Control of Metachronous Inguinal Lymph Node Metastases

Neck dissection with cervical sensory preservation in thyroid cancer.

Thyroid cancer is the most common endocrine malignancy. Recently, controversy has focused on the management of lymph node metastases, which represent approximately 90% of disease recurrences and may require considerable time, effort, and resources to diagnose and treat. Neck dissections play an essential role in the management of head and neck cancer. A modified radical neck dissection (MND) refers to resection of the lymph nodes in levels II through V and often including the central nodes in level VI. When performing modified neck dissection, we recommend to protect more reserved cervical plexus. The purpose is to better protect patient's neck skin feeling.

Radical neck dissection: is it still indicated?

The presence of lymph node metastases in the neck remains a significant prognostic factor affecting patients with head and neck squamous cell carcinoma (HNSCC). Thus, treatment of regional disease remains a critical issue in the management of many patients. The ‘‘classical’’ radical neck dissection (RND), consisting of removal of all the lymphatic and non-lymphatic structures from the mandible to the clavicle, with the exception of the carotid artery, hypoglossal, lingual, vagus and phrenic nerves, and brachial plexus, was developed in the late nineteenth and early twentieth century [1‐4]. The procedure did not achieve widespread use in the medical community until the work of Martin et al. [5] when midcentury advances such as antibiotics, blood transfusion and modern anesthesia permitted safe and efficacious operation in a large series of patients. The classic RND has been and is still considered the ‘‘gold standard’’ for the surgical management of lymph node metastases of cancers of the head and neck.

Contemporary management of lymph node metastases from an unknown primary to the neck: II. A review of therapeutic options

Although uncommon, cancer of an unknown primary (CUP) metastatic to cervical lymph nodes poses a range of dilemmas relating to optimal treatment. The ideal resolution would be a properly designed prospective randomized trial, but it is unlikely that this will ever be conducted in this group of patients. Accordingly, knowledge gained from retrospective studies and experience from treating patients with known head and neck primary tumors form the basis of therapeutic strategies in CUP. This review provides a critical appraisal of various treatment approaches described in the literature. Emerging treatment options for CUP with metastases to cervical lymph nodes are discussed in view of recent innovations in the field of head and neck oncology and suitable therapeutic strategies for particular clinical scenarios are presented. For pN1 or cN1 disease without extracapsular extension (ECE), selective neck dissection or radiotherapy offer high rates of regional control. For more advanced neck disease, intensive combined treatment is required, either a combination of neck dissection and radiotherapy, or initial (chemo)radiotherapy followed by neck dissection if a complete response is not recorded on imaging. Each of these approaches seems to be equally effective. Use of extensive bilateral neck/mucosal irradiation must be weighed against toxicity, availability of close follow-up with elective neck imaging and guided fine-needle aspiration biopsy (FNAB) when appropriate, the human papillomavirus (HPV) status of the tumor, and particularly against the distribution pattern (oropharynx in the majority of cases) and the emergence rate of hidden primary lesions (<10% after comprehensive workup). The addition of systemic agents is expected to yield similar improvement in outcome as has been observed for known head and neck primary tumors.

Contemporary management of lymph node metastases from an unknown primary to the neck: I. A review of diagnostic approaches

In an era of advanced diagnostics, metastasis to cervical lymph nodes from an occult primary tumor is a rare clinical entity and accounts for approximately 3% of head and neck malignancies. Histologically, two thirds of cases are squamous cell carcinomas (SCCs), with other tissue types less common in the neck. With modern imaging and tissue examinations, a primary tumor initially undetected on physical examination is revealed in >50% of patients and the site of the index primary can be predicted with a high level of probability. In the present review, the range and limitations of diagnostic procedures are summarized and the optimal diagnostic workup is proposed. Initial preferred diagnostic procedures are a fine-needle aspiration biopsy (FNAB) and imaging. This allows directed surgical biopsy (such as tonsillectomy), based on the preliminary findings, and prevents misinterpretation of postsurgical images. When no primary lesion is suggested after imaging and panendoscopy, and for patients without a history of smoking and alcohol abuse, molecular profiling of an FNAB sample for human papillomavirus (HPV) and/or Epstein-Barr virus (EBV) is important.

Operative Technique for Modified Radical Neck Dissection in Papillary Thyroid Carcinoma

Papillary thyroid carcinoma is the most common endocrine malignancy. Recently, controversy has focused on the management of lymph node metastases, which represent approximately 90% of disease recurrences and may require considerable time, effort, and resources to diagnose and treat. Current intense postoperative surveillance by endocrinologists nationwide has the sensitivity to detect even minute lymph node metastases using ultrasonography, radioactive iodine scan, and thyroglobulin monitoring. To (1) present a succinct synopsis of the rationale and elements of our current surgical management strategy for papillary thyroid carcinoma and, within this context, (2) provide a detailed stepwise description of a compartment-oriented modified radical neck dissection. This description is combined with intraoperative photographs and a medical artist's illustrations to enhance and emphasize the most important points. With anatomically defined precise dissection, following the steps outlined and illustrated, a thorough lymphadenectomy can be accomplished safely, with reasonable cosmetic results, minimizing disease relapse.

Development in the management of lymph node metastasis in breast cancer

淋巴结转移是乳腺癌重要的转移形式,一直受到临床医生的高度关注.针对淋巴结的外科治疗是改善乳腺癌临床疗效的重要方面.随着人们对疾病本质的深入了解和治疗理念的不断变化,对乳腺癌淋巴转移的意义和治疗观点也在发生明显变化.时至今日,乳腺癌淋巴结转移在评价病情、准确分期、指导综合治疗和判断预后等方面仍具有重要作用.近年来,在乳腺癌淋巴转移的诊断方法、治疗模式和评价体系方面已取得重要进展,但仍存在诸多尚待探索和解决的问题.对乳腺癌淋巴结转移的深入认识和研究将有助于进一步改善临床疗效。

Multimodality therapy in penile cancer: when and which treatments?

Metastatic penile cancer typically comes to attention while the clinical extent of disease is limited to the inguinal or pelvic lymph nodes. Primary surgical management of lymph node metastases achieves tumor control and long-term survival for only a small percentage of these patients. To determine the optimal use of multimodality treatment in locally advanced penile cancer, we conducted a literature review. Relevant English-language literature was identified with the use of Medline; additional cited works not detected on the initial search were also reviewed. There is an emerging strategy of preoperative (neoadjuvant) combination chemotherapy to improve the progression-free survival of penile cancer patients with bulky regional lymph node metastases. Radiotherapy for inguinal metastases and postoperative (adjuvant) radiation for selected patients has also been effective in this setting. In patients with lymph node metastases, the benefit of ilioinguinal lymphadenectomy may be extended by the addition of neoadjuvant chemotherapy. Postoperative radiotherapy can be offered depending on the amount of residual disease after chemotherapy. Chemo-radiotherapy has been successful in squamous cell cancers from other sites (vulva and anal canal) and may be considered for unresectable penile cancer.

Up-to-date management of lymph node metastasis and the role of tailored lymphadenectomy in cervical cancer

Lymph node metastasis (LNM), together with parametrial infiltration and positive surgical margins, is an important prognostic factor in cervical cancer. The incidence of LNM increases with International Federation of Gynecology and Obstetrics (FIGO) stage, with rates being 12%-22% in stage Ib, 10%-27% in stage IIa, and 34%-43% in stage IIb. Radical hysterectomy and pelvic lymphadenectomy are widely used treatments for early-stage (Ib to IIa) cervical cancer, as well as for stage IIb disease, in some European and Asian countries. In several types of cancer, the therapeutic significance of systematic lymphadenectomy has been demonstrated by recent reports showing that a larger number of lymph nodes removed relates to better survival. In cervical cancer, a significant relationship between the number of lymph nodes removed and disease-free survival has been reported in node-positive patients. Preoperative evaluation of nodal status with computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) imaging techniques is not sensitive enough to replace the histological examination of dissected nodes. The sentinel node procedure may be an alternative to systematic lymphadenectomy to reduce treatment-related morbidity, but more work on this is needed. Although the presence of LNM does not change FIGO staging, it will modulate postoperative therapy. Progression-free and overall survivals were significantly improved by the addition of chemotherapy to adjuvant radiotherapy after radical hysterectomy and lymphadenectomy. Adjuvant chemotherapy combined solely with radical hysterectomy and systematic lymphadenectomy may also provide a survival benefit. In conclusion, efforts to establish more tailored surgical strategies, by introducing advanced imaging technologies and molecular diagnostic procedures, are needed for cervical cancer.

口腔癌７３症例の臨床的検討―頚部リンパ節転移の診断と治療を中心に―

Seventy-three patients treated for cancer of the oral cavity between 1997 and 2004 were retrospectively reviewed, especially diagnosis and management of lymph node metastasis. Standard methods of diagnosing and treating cancer of the oral cavity were used. Metastatic lymph node was defined as shown as minor axis/major axis >0.5, and minor axis >6mm (Levels I, II), 7mm (III-V) on ultrasonic echo.Fifty-four cases underwent neck dissection. Seven cases of N0 (40 cases) were positive for metastasis histopathologically. Fourteen cases were determined to be positive for metastasis by preoperative Ultrasonography (US) and they all were found to be positive in histopathological examinations after operations.Thirty-eight cases of T2 were performed neck dissection. Nine cases were determined to be positive for metastasis by preoperative US. Five cases were positive for metastasis on frozen section biopsy (FSB). Three cases showed occult metastasis. There were 17 histologicallly positive nodes in T2 (40.4%).Many reports suggest that the prognosis of cancer of the oral cavity depends on the number of metastatic lymph nodes. However, since it is often difficult to detect the number of positive lymph nodes by US, there is a high possibility that there will be multiple metastatic lymph nodes when one metastatic lymph node is detected on US. It is necessary for us to establish a diagnostic standard for metastatic nodes and to identify metastatic nodes by prophylactic neck dissection.

Papillary thyroid cancer: Surgical management of lymph node metastases

Papillary thyroid cancer (PTC), the most common thyroid malignancy, is associated with cervical lymph node metastases in 30% to 90% of patients. While surgery is the primary treatment modality for PTC, radioactive iodine and thyroid hormone suppression often complement the treatment plan. Although thyroid hormone suppression may decrease the incidence of recurrent disease and radioactive iodine may diagnose and treat metastases, lymph node dissection (LND) is the mainstay treatment for clinically evident cervical lymph node metastases. The surgical treatment options published in the literature include the traditional radical LND, the modified radical LND, the selective LND (compartment-based resection based on documented lymph node metastases), and a 'berry picking' resection (in which only the grossly abnormal lymph nodes are excised). At the University of California, San Francisco, we prefer the modified radical LND with preservation of the cervical sensory nerves for the first lymph node dissection with the 'berry picking' procedure limited to surgical treatment of recurrent nodal metastases in previously resected lymph node basins. Some centers are evaluating the potential role of sentinel lymph node biopsies for PTC. While the extent of lymphadenectomy is debated, most physicians treating patients with PTC agree that clinical evidence of lymphatic metastases should be surgically exercised and there is no role for prophylactic LND.

Unknown head and neck primary: Treatment with neck dissection followed by concurrent chemoradiotherapy

5530 Background:The best management of lymph node metastasis from unknown primary in the head and neck has not been clearly established. Our objective was to review the outcome in a specific cohort of patients treated uniformly with modified neck dissection followed by concurrent chemoradiation. Methods: We conducted a retrospective evaluation of patients (pts) treated between 1995 and 2002 who had resectable nodal squamous cell cancer (SCC) of unknown primary sites and were treated with modified neck dissection followed by concurrent high-dose cisplatin (CIS) and radiotherapy (RT) using a port inclusive of the nasopharynx. Results: Thirty-six pts were identified (median age of 57; male to female ratio 3:1; African American to White ratio 1: 3; stage distribution: N1 (8%), N2a (20%), N2b (36%), N2c (8%), N3 (16%), unknown (11%); at least 60% of pts had locally advanced disease (>N2b). Chemotherapy was given as cisplatin 100mg/m2 x 3 cycles in 86% or CIS=>carboplatin in 14 %. Concurrent RT was given as fol...