Maximum Lymph Node Size Research Articles

Prognostic impact of lymph node characteristics after therapeutic neck dissection for classic N1 papillary thyroid cancer.

The impact of lymph node characteristics on mortality and recurrence remains controversial. This study evaluated the prognostic impact of lymph node characteristics in a large, homogenous cohort of patients with therapeutic neck dissection for clinically N1 classic papillary thyroid cancer (PTC). All consecutive adult patients with therapeutic central and lateral neck dissection for PTC at a French referral centre were prospectively enrolled from January 2000 until June 2021. The primary outcome was the impact of lymph node characteristics in predicting a disease event (persistence or recurrence), using univariable and multivariable logistic regression modelling. A total of 462 patients were included. Lymph node capsular rupture was seen in 260 patients (56.3 per cent). Median maximum lymph node size was 15 (i.q.r. 9-23) mm. The median central, lateral, and total lymph node ratio (LNR) was 0.50 (i.q.r. 0.22-0.75), 0.15 (i.q.r. 0.07-0.29), and 0.26 (i.q.r. 0.14-0.41), respectively. After a median follow-up of 93 (i.q.r. 50-149) months, 182 (39.4 per cent) patients had a disease event. After multivariable analysis, the number of harvested lymph node >35 (OR 2.33 (95 per cent c.i. 1.10-4.95)), presence of lymph node capsular rupture (OR 1.92 (1.17-3.14)), and total LNR >0.20 (OR 2.37 (1.08-5.19)) and >0.40 (OR 4.92 (1.61-15.03)) predicted a disease event. An LNR of 0.20 predicted a disease event with a sensitivity of 80.8 per cent and a specificity of 50.4 per cent. Disease persistence or recurrence after thyroidectomy with therapeutic neck dissection for classic PTC with preoperative nodal disease appears to depend on number of harvested lymph node, presence of lymph node capsular rupture, and total LNR.

Differential Diagnosis of Histiocytic Necrotizing Lymphadenitis and Malignant Lymphoma with Simple Clinical Findings.

It is desirable that noninvasive differential diagnosis takes place without lymph node biopsy for histiocytic necrotizing lymphadenitis (HNL) or malignant lymphoma (ML). In this study, we propose a novel scoring model for the differential diagnosis of these diseases using clinical information and clinical findings. We retrospectively analyzed the data from 15 HNL and 13 ML pediatric patients. First, a univariate analysis identified 14 clinical factors with significant differences. Second, a subsequent analysis using receiver operating characteristic (ROC) curve analysis identified three factors among them with area under the ROC curve values of >0.95: body temperature (°C), maximum lymph node size (cm), and serum β2-microglobulin level (mg/L). Finally, the cut-off values of each of these three factors were determined and examined for the 28 cases. All 15 HNL cases were within 2–3 of the cut-off values among the three factors, no ML case was within two or more cut-off values. Thus, the diagnostic sensitivity and specificity of this novel scoring system were both 100%, indicating that clinical scoring with body temperature, maximum lymph node size, and β2-microglobulin are useful for distinguishing between HNL and ML.

Pediatric lymphadenopathy: Which patients need evaluation by an oncologist?

e13605 Background: While lymphadenopathy may be the first sign of cancer in children, it can also be a manifestation of non-malignant illness. Lymphadenopathy is a common reason for referral to a pediatric oncologist, which can result in significant anxiety for parents. Understanding which patients require an oncology referral for lymphadenopathy is key in order to streamline healthcare utilization for this common clinical entity. Methods: In this single institution study, we retrospectively reviewed the medical records of patients referred to pediatric oncology for lymphadenopathy between 2012 and 2020. A logistic regression model was fitted to examine the association between the maximum size of the lymph nodes and cancer diagnosis. We also obtained estimates of odds ratio and area under the ROC curve. Sensitivity and specificity were estimated using exact Clopper-Pearson method for proportion. SAS v9.4 was used to perform statistical analyses. Institutional IRB approved the study. Results: A total of 91 patients aged 1 to 19 years (median 14 years) were included. There was a statistically significant association between lymph node size and a diagnosis of malignancy. For every centimeter increase in maximal dimension of lymph node(s), there was an estimated 2.2-times increase in the odds of cancer (CI 95% 1.5-3.3; p = 0.0002). The estimated area under the curve for this model was 0.8 (95% CI 0.7-0.9) indicating that lymph node size correlated very well with cancer risk. We evaluated the model to find a threshold for lymph node size that provided a high sensitivity for screening purposes. A cut-off of 2 centimeters resulted in an estimated sensitivity of 0.95 (95%CI 0.7-0.99) and specificity of 0.6 (95%CI 0.5-0.7). Conclusions: This study provides preliminary evidence that the estimated odds of a cancer diagnosis doubles for each centimeter increase in lymph node size. This single institution retrospective study suggests that in patients with lymphadenopathy, the maximum lymph node size may be a predictor of malignancy. Our results demonstrate that the sensitivity for cancer increases at a lymph node size of two centimeters or larger. Navigating when to monitor a patient with lymphadenopathy in the primary care setting versus referring to the oncologist can be a challenge for primary care physicians. Our results are consistent with the practice that using a two centimeter cutoff is a good starting point for referrals; however, these results will need to be verified with a larger sample size before they are adopted into clinical guidelines. Further study is underway to evaluate lymphadenopathy referrals to both surgery and oncology in order to reduce potential bias that may be associated with oncology referrals, which may have a predilection for malignancy. This study underlines the importance of a physical examination by the primary care physician as the crucial step in determining if a patient requires an oncology referral.

Predictors for hilar/intrapulmonary lymph node metastasis in discrete type of clinical N1 non-small cell lung cancer.

Accurate preoperative evaluation of lymph nodes can provide optimal treatment for patients. However, in patients with clinical N1 disease (cN1) non-small cell lung cancer (NSCLC), no suitable predictor has been identified for hilar/intrapulmonary lymph node metastasis (pathological N1 disease; pN1). The purpose of this study was to identify pN1 in cN1 NSCLC patients. We retrospectively reviewed the clinicoradiological features of 109 patients with a discrete type of cN1 NSCLC who had undergone complete resection at our institution from 2004 to 2015. The association between clinicoradiological variables and nodal status was analyzed to identify predictors for pN1. The cohort consisted of 77 males and 32 females, ranging in age from 39 to 84years. The breakdown by pathological N category was 40 (37%) pN0, 41 (38%) pN1, and 28 (25%) pN2 patients. Maximum lymph node diameter was identified as a significant predictor for pN1, with an odds ratio of 1.25 (P=0.010). When limited to 63 patients who underwent positron emission tomography (FDG-PET) at our institution, the maximum standardized uptake value (SUVmax) of the lymph node was an independent predictor, with an odds ratio of 1.91 with logistic regression analysis (P=0.004). The size of lymph node and the SUVmax were significant factors for pN1, with optimal cut-off values of 13mm and 4.28, respectively. Among the patients with cN1, maximum lymph node size and SUVmax of the FDG-PET were significant predictors for pN1.

A study of patients with isolated mediastinal and hilar lymphadenopathy undergoing EBUS-TBNA

BackgroundIsolated mediastinal and/or hilar lymphadenopathy (IMHL) may be caused by benign and malignant disorders or be ‘reactive’. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has a reported low negative predictive value...

An evidential reasoning based model for diagnosis of lymph node metastasis in gastric cancer

BackgroundLymph node metastasis (LNM) in gastric cancer is a very important prognostic factor affecting long-term survival. Currently, several common imaging techniques are used to evaluate the lymph node status. However, they are incapable of achieving both high sensitivity and specificity simultaneously. In order to deal with this complex issue, a new evidential reasoning (ER) based model is proposed to support diagnosis of LNM in gastric cancer.MethodsThere are 175 consecutive patients who went through multidetector computed tomography (MDCT) consecutively before the surgery. Eight indicators, which are serosal invasion, tumor classification, tumor enhancement pattern, tumor thickness, number of lymph nodes, maximum lymph node size, lymph node station and lymph node enhancement are utilized to evaluate the tumor and lymph node through CT images. All of the above indicators reflect the biological behavior of gastric cancer. An ER based model is constructed by taking the above indicators as input index. The output index determines whether LNM occurs for the patients, which is decided by the surgery and histopathology. A technique called k-fold cross-validation is used for training and testing the new model. The diagnostic capability of LNM is evaluated by receiver operating characteristic (ROC) curves. A Radiologist classifies LNM by adopting lymph node size for comparison.Results134 out of 175 cases are cases of LNM, and the remains are not. Eight indicators have statistically significant difference between the positive and negative groups. The sensitivity, specificity and AUC of the ER based model are 88.41%, 77.57% and 0.813, respectively. However, for the radiologist evaluating LNM by maximum lymph node size, the corresponding values are only 63.4%, 75.6% and 0.757. Therefore, the proposed model can obtain better performance than the radiologist. Besides, the proposed model also outperforms other machine learning methods.ConclusionsAccording to the biological behavior information of gastric cancer, the ER based model can diagnose LNM effectively and preoperatively.

Usefulness of Systemic Computed Tomography (CT) Scanning in the Detection of Malignant Lymphadenopathy [RETRACTED

We developed a prediction model to distinguish between malignant and nonmalignant lymphadenopathies. We first analyzed clinical features of 222 patients with lymphadenopathy (161 malignant and 61 nonmalignant) in the derivation group. Through logistic regression analysis we identified 6 covariates that independently predict malignancy: age (X1), abdominal lymphadenopathy (X2), lymphadenopathy of the other sites (X3), number of enlarged lymph node regions (X4), absence of fever (X5), and largest lymph node size (X6). We determined the formula as follows: predictive score=-2.3+x1+2.8x2+1.3x3+1.6x4-2.2x5+1.8x6.A higher score correlated with increased likelihood of malignancy. With the cutoff value of 0.4, the sensitivity and specificity of the model were 91.9% and 77.0%, respectively. The validation study using 117 cases (82 malignant and 35 nonmalignant) yielded 90.2% sensitivity and 68.6% specificity. A maximum lymph node size of less than 2.0 cm on systemic computed tomography (CT) scanning indicated a low probability of malignant lymphadenopathy. In this model, 4 of the 6 covariates were obtained by CT scanning, which strongly indicates the usefulness of initial evaluation with systemic CT scanning in the detection of malignant lymphadenopathy.

Support vector machine model for diagnosis of lymph node metastasis in gastric cancer with multidetector computed tomography: a preliminary study

BackgroundLymph node metastasis (LNM) of gastric cancer is an important prognostic factor regarding long-term survival. But several imaging techniques which are commonly used in stomach cannot satisfactorily assess the gastric cancer lymph node status. They can not achieve both high sensitivity and specificity. As a kind of machine-learning methods, Support Vector Machine has the potential to solve this complex issue.MethodsThe institutional review board approved this retrospective study. 175 consecutive patients with gastric cancer who underwent MDCT before surgery were included. We evaluated the tumor and lymph node indicators on CT images including serosal invasion, tumor classification, tumor maximum diameter, number of lymph nodes, maximum lymph node size and lymph nodes station, which reflected the biological behavior of gastric cancer. Univariate analysis was used to analyze the relationship between the six image indicators with LNM. A SVM model was built with these indicators above as input index. The output index was that lymph node metastasis of the patient was positive or negative. It was confirmed by the surgery and histopathology. A standard machine-learning technique called k-fold cross-validation (5-fold in our study) was used to train and test SVM models. We evaluated the diagnostic capability of the SVM models in lymph node metastasis with the receiver operating characteristic (ROC) curves. And the radiologist classified the lymph node metastasis of patients by using maximum lymph node size on CT images as criterion. We compared the areas under ROC curves (AUC) of the radiologist and SVM models.ResultsIn 175 cases, the cases of lymph node metastasis were 134 and 41 cases were not. The six image indicators all had statistically significant differences between the LNM negative and positive groups. The means of the sensitivity, specificity and AUC of SVM models with 5-fold cross-validation were 88.5%, 78.5% and 0.876, respectively. While the diagnostic power of the radiologist classifying lymph node metastasis by maximum lymph node size were only 63.4%, 75.6% and 0.757. Each SVM model of the 5-fold cross-validation performed significantly better than the radiologist.ConclusionsBased on biological behavior information of gastric cancer on MDCT images, SVM model can help diagnose the lymph node metastasis preoperatively.

Improved Progression-Free Survival (PFS) of Alemtuzumab (Campath®, MabCampath®) Plus Fludarabine (Fludara®) Versus Fludarabine Alone as Second-Line Treatment of Patients with B-Cell Chronic Lymphocytic Leukemia: Preliminary Results From a Phase III Randomized Trial.

Improved Progression-Free Survival (PFS) of Alemtuzumab (Campath®, MabCampath®) Plus Fludarabine (Fludara®) Versus Fludarabine Alone as Second-Line Treatment of Patients with B-Cell Chronic Lymphocytic Leukemia: Preliminary Results From a Phase III Randomized Trial.

Impact of prognostic factors on outcome in a phase III study comparing alemtuzumab to chlorambucil as first-line therapy for B-cell chronic lymphocytic leukemia (BCLL)

7035 Background: CAM307 is a phase III, open-label, randomized controlled trial comparing alemtuzumab (CAM) with chlorambucil (CHLO) for previously untreated B-CLL. Methods: The trial enrolled 297 previously untreated patients requiring therapy according to NCI-WG criteria. Patients were randomized 1:1 to CAM (n=149) vs CHLO (n=148) using standard dosing regimens. Diagnosis, Rai stage, response and disease progression were confirmed by an independent response review panel. In the overall study population, CAM demonstrated significantly higher overall response rates (ORR) than CHLO (83 % vs 55%) and a significant improvement in PFS (p= 0.0001) with manageable toxicities1. Outcomes according to Rai stage and cytogenetics have been previously reported.1,2 A pre-specified subgroup analysis of response rates (RR) and progression-free survival (PFS) by prognostic factors was performed. Results: Additional analyses revealed statistically significant PFS advantage in favor for CAM vs. CHLO for patients with β-2 microglobulin =3 mg/L (p<0.0001) or marrow infiltration =90% (p=0.0001). Conclusions: CAM is significantly superior to CHLO relative to overall and complete RR and PFS in the overall study population of previously untreated patients with CLL, and in patients < 65 years of age, < 70 years of age, maximum lymph node size < 5cm, and, performance status <2. Campath deserves further study in patients with age = 70, patients with massive lymphadenopathy, and in those with poor performance status. 1. Hillmen, P et al, Blood 108(11), abstract 301 2. Robak, T et al, Blood 108(11), abstract 2092 No significant financial relationships to disclose. [Table: see text]

Alemtuzumab (CAMPATH®, MABCAMPATH®) Has Superior Progression Free Survival (PFS) vs Chlorambucil as Front-Line Therapy for Patients with Progressive B-Cell Chronic Lymphocytic Leukemia (BCLL).

CAM307 is a phase III, open-label, multinational, randomized controlled trial comparing alemtuzumab (CAM) with chlorambucil (CHLO) for previously untreated BCLL requiring therapy. Eligible patients with Rai Stages I–IV were randomized 1:1 to either CAM 30 mg IV tiw for up to 12 weeks or CHLO 40 mg/m2 po q 28 days up to 12 cycles. CAM patients received prophylactic trimethoprim/sulfamethoxazole DS and famciclovir treatment during therapy and until CD4+ counts were ≥200 cells/μL. The primary endpoint was PFS; secondary endpoints were response rate, overall survival, and safety. A total of 297 patients were enrolled (CAM n=149 and CHLO n=148); median age: 60 years; performance status 0–1: 96%; maximum lymph node size ≥5 cm: 22%; and Rai Stage I–II: 63%, Rai Stage III–IV: 33%. Diagnosis, Rai Stage, response and disease progression were confirmed by an independent response review panel (IRRP). CAM has a significantly prolonged PFS compared to CHLO (p=0.0001; see KM survival curve).PFS in CAM vs CHLO patients with adverse cytogenetic findings of del 17p (n=21) was 10.7 mo vs 2.2 mo and for trisomy 12 (n=39) was 18.3 mo vs 12.9 mo. Results were similar for patients with del 11q (n=54, 8.5 mo vs 8.6 mo). Common (≥15%) CAM reported adverse events (AEs) (n=147), likely infusion-related, included pyrexia (70%), chills (53%), nausea (18%), hypotension (16%) and urticaria (16%). Common AEs (≥15%) in the CHLO arm (n=147) were nausea (37%) and vomiting (18%). Frequency of asymptomatic CMV viremia on the CAM arm was 52%; CMV infection occurred in only 16%, none grade 4. CAM treatment was interrupted in 56% of CMV viremic patients, and resumed in 92% with ORR 92% (31% CR). Ganciclovir was administered to 41% of CAM patients with CMV viremia. Infections, including CMV, were reported in 76% of CAM and 50% of CHLO patients while on study. Relevant grade 3/4 treatment-emergent events included (CAM vs CHLO): lymphopenia (97% vs 3%), pyrexia (8% vs 0%), CMV events (8% vs 0%) and chills (3% vs 0%). Treatment emergent grade 3/4 thrombocytopenia (16% vs 13%) and anemia (14% vs 19%) were similar, and although grade 3/4 neutropenia was more common with CAM, (45% vs. 26%), AEs of CAM vs CHLO bacteremia/sepsis (3% vs 2%) and febrile neutropenia (5% vs 3%) were comparable. Serious AEs were reported for 44% of CAM (20% for IV Ganciclovir only in CMV viremic patients) and 20% of CHLO patients while on study treatment. CONCLUSIONS: CAM307 demonstrates that therapy-naïve BCLL patients treated with CAM have significantly longer PFS and higher ORR than those treated with CHLO, with manageable toxicities. Although CMV reactivation was reported in the CAM arm, prompt intervention maintained efficacy. The activity seen here supports ongoing investigations of CAM in first line combination therapy, high risk patients and consolidation. Figure Figure

Evaluation of anatomic changes in young children with natural rotavirus infection: is intussusception biologically plausible?

Several studies have shown an association between vaccination with the rotavirus vaccine and the development of intussusception. We evaluated the plausibility of a causal association between natural rotavirus infection and intussusception. We performed ultrasound measurements, in infants with confirmed rotavirus infection and in healthy control subjects, of the ileum wall thickness and mesenteric lymph nodes, at enrollment and 1 month later. Thirteen pairs of patients with rotavirus infection and control subjects were enrolled. The mean distal ileum wall thickness at the first examination was 3.0 mm in patients with rotavirus infection and 2.0 mm in control subjects (P = .037). The maximum lymph node size in patients with rotavirus infection was 11.6 mm at the first examination and 7.4 mm at the second examination (P = .017). Nodal aggregates and free fluid were also observed more commonly among patients with rotavirus infection (54% vs. 9%; P = .033 for both). Rotavirus infection was associated with increased distal ileum wall thickness and lymphadenopathy during the illness period. These changes suggest a plausible mechanism by which rotavirus infection could cause intussusception.

THE ETIOLOGY OF PERIPHERAL LYMPHADENOPATHY IN CHILDREN

This prospective study evaluated 382 pediatric patients with peripheral lymphadenopathy (LA) presenting at the Pediatric Oncology and Hematology Departments of Social Security Children's Hospital and Gazi University Medical Faculty Hospital. The ages of the patients ranged between 2 months and 16 years (median 7 years); 72% of the patients were male. Of the 382 patients, 138 had localized LA (a single anatomic area involved), 171 had limited LA (two or three areas involved), and 73 had generalized LA ( four or more anatomic areas involved). The specific etiology (either benign or malign) was defined in 79% of patients with generalized LA. However, in patients with localized LA and limited LA, specific etiology could be identified only in 43 and 53% of patients, respectively. Based on this study, BCG-LA and pyogenic infections are more frequently manifested by localized LA; LA of unknown origin, Hodgkin's disease, tuberculosis, nasopharyngeal carcinoma, and toxoplasmosis are frequently manifested by localized or limited LA; and cytomegalovirus infection (CMV), infectious mononucleous, rubella, acute leukemia, non-Hodgkin's lymphoma are frequently manifested by limited or generalized LA. Out of 382 patients, 196 patients had a maximum lymph node diameter of less than 2 cm. A benign etiology was shown in 159/196 of these patients. In 37/196 of these patients LA was due to a malignancy, and these cases almost invariably had some apparent additional diagnostic clinical and laboratory findings. Based on this observation a maximum lymph node size of 2 cm was considered an appropriate limit to distinguish malignant disease from benign causes except when there is other evidence of an underlying malignant disease. However, lymphadenopathies located at supraclavicular region (27 patients) either localized or as part of generalized LA had a specific benign or malignant disease in etiology (malignancy in 20, tuberculosis in 3, CMV in 2, sarcoidosis in 1, and lipoma in 1) even though they were less than 2 cm in diameter.

Radiotherapeutic management of bulky cervical lymphadenopathy in squamous cell carcinoma of the head and neck:Is Postradiotherapy Neck Dissection Necessary?

Although traditional recommendations for the management of bulky cervical lymphadenopathy (AJCC categories N2-3) with definitive radiotherapy call for postradiotherapy neck dissection regardless of treatment response, recent data suggests that this policy can be modified on the basis of tumor regression rate. In a series of 130 patients with stage III-IV squamous cell carcinoma of the head and neck managed with a concomitant boost-accelerated hyperfractionated radiotherapy schedule, 81 cases had cervical lymphadenopathy at the time of referral. Patients were analyzed with respect to regional control outcomes for those having complete and incomplete clinical responses during the initial 3-month follow-up interval. The general management policy has been close observation of patients demonstrating complete clinical responses to radiation rather than postradiotherapy neck dissection. Failure patterns were examined in the 58 patients classified as complete responders. Failure occurred in the primary site in 16 (28%) of these patients, while isolated neck failure occurred in only 3 (5%). Neck recurrence rates for patients with maximum lymph node size < or = 3 cm vs. > 3 cm were not statistically different at 3-year follow-up (94% vs. 86%). Among the 23 incomplete clinical responders, 18 had incomplete neck responses. Five of these patients underwent salvage neck dissection; 4 remain clinically free of recurrence. The remaining 13 patients who either refused or were not eligible for salvage surgery ultimately succumbed with persistent loco-regional disease. The policy of observation after complete response to the radiotherapy schedule employed here was associated with a very low incidence of isolated neck failures and was safe and appropriate in patients who can be followed reliably. The prognosis for patients who failed to respond in the neck was poor except for those who underwent salvage surgery.