Node Assessment Research Articles

Ovarian preservation compared to oophorectomy in premenopausal women with early-stage, low-grade endometrial Cancer: A cost-effectiveness analysis

ObjectivesStandard treatment for endometrial cancer is a hysterectomy, bilateral salpingo-oophorectomy, and lymph node assessment. In premenopausal women, removal of the ovaries may not be necessary and could increase the risk of all-cause mortality. We sought to estimate the outcomes, costs, and cost-effectiveness of oophorectomy versus ovarian preservation in premenopausal women with early-stage, low-grade endometrial cancer. MethodsA decision-analytic model was designed using TreeAge software comparing oophorectomy to ovarian preservation in premenopausal women with early-stage, low-grade endometrial cancer. We used a theoretical cohort of 10,600 women to represent our population of interest in the United States in 2021. Outcomes included cancer recurrences, ovarian cancer diagnoses, deaths, rates of vaginal atrophy, costs, and quality-adjusted life years (QALYs). The cost-effectiveness threshold was set at $100,000/QALY. Model inputs were derived from the literature. Sensitivity analyses were conducted to evaluate the robustness of the results. ResultsOophorectomy resulted in more deaths and higher rates of vaginal atrophy, while ovarian preservation resulted in 100 cases of ovarian cancer. Ovarian preservation resulted in lower costs and higher QALYs making it cost effective when compared to oophorectomy. Sensitivity analyses demonstrated the probability of cancer recurrence after ovarian preservation and probability of developing ovarian cancer were the most impactful variables in our model. ConclusionOvarian preservation is cost-effective in premenopausal women with early-stage, low-grade endometrial cancer when compared to oophorectomy. Ovarian preservation may prevent surgical menopause, which may improve quality of life and overall mortality without compromising oncologic outcomes, and should be strongly considered in premenopausal women with early stage disease.

Node Essentiality Assessment and Distributed Collaborative Virtual Network Embedding in Datacenters

Network virtualization (NV) has extensive and significant applications in cloud computing and parallel and distributed systems. Virtual network embedding (VNE) is a key issue in NV, which is an effective means to advance systems' performance. While existing VNE research lacks resource allocation coordination between mappings of different virtual network requests, resulting in insufficient resource utilization and high overhead. In this paper, we propose a novel node essentiality evaluation model for data center networks (DCNs), and design an efficient distributed collaborative virtual network embedding. Firstly, we propose a node essentiality evaluation scheme based on dynamic model, which combines the characteristics of network topology and nodes to make the evaluation results more comprehensive. Secondly, we establish the two-stage node importance evaluation criteria for the deviation mean of the data center dynamic model and the variance based on the deviation mean. Furthermore, we investigate a nodal importance assessment method based on the data center dynamic model for perturbation testing. Finally, we design a distributed coordinated VNE algorithm ( <bold xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">CNI-VNE</b> ) which calculates the importance index of physical nodes through topology awareness. The proposed algorithm can increase the coordination between different request mappings, thereby reducing the mapping cost of physical node resources and minimizing the cost of VNE. We use the real Fat-tree DCN of 128 servers and 80 switches as testbed, and evaluate them from indicators such as average reliability, average bandwidth consumption, average energy consumption, and average mapping time. Massive simulation results in different scenarios show that our algorithm achieves the best performance on most indicators compared with the existing state-of-the-art proposals, mapping acceptance and average revenue increased by 19.4% and 21.3%, respectively, and DCN reduced bandwidth consumption by about 30%.

The absence of lymph nodes removed (pNx status) impacts survival in patients with lung cancer treated surgically

ObjectivesWe aimed to study the clinical significance of the lack of lymph node assessment (pNx status) and its impact on survival in non-small-cell lung cancer patients. MethodsWe retrospectively analysed the Polish Lung Cancer Study Group database. pNx status was defined as 0 lymph nodes removed. We included 17,192 patients. ResultsA total of 1080 patients (6%) had pNx status. pNx patients were more likely to be younger, be female, have a different pT distribution, have squamous cell carcinoma, undergo open thoracotomy, be operated on in non-academic hospitals, and have a lower rate of some comorbidities. pNx was more likely to be cN0 than pN1 and pN2 but less likely than pN0 (p < 0.001). pNx patients were less likely to undergo preoperative invasive mediastinal diagnostics than pN1 and pN2 patients but more likely than pN0 patients (p < 0.001). Overall, the five-year overall survival rates were 64%, 45%, 32% and 50% for pN0, pN1, pN2 and pNx, respectively. In pairwise comparisons, all pN descriptors differed significantly from each other (all p < 0.0001 but pNx vs. pN1 p = 0.016). The placement of the pNx survival curve and survival rate depended on histopathology, surgical approach and pT status. In multivariable analysis, pNx was an independent prognostic risk factor (HR = 1.37, 95%CI: 1.23–1.51, p < 0.01). ConclusionThe resection of lymph nodes in lung cancer remains a crucial step in the surgical treatment of this disease. The survival of pNx patients is similar to that of pN1 patients. pNx survival curve placement depends on the other variables which could be useful in clinical decisions.

A National Survey of Surgeons Evaluating the Accuracy of Mediastinal Lymph Node Identification

The Commission on Cancer implemented Standard 5.8 in 2021, which requires removal of 3 mediastinal nodes and 1 hilar node with lung cancer resection. We conducted a national survey to assess whether surgeons who treat lung cancer in different clinical settings correctly identify mediastinal lymph node stations. Cardiac or thoracic surgeons expressing interest in lung cancer surgery on the Cardiothoracic Surgery Network were asked to complete a 7-question survey assessing their knowledge of lymph node anatomy. General surgeons whose practice includes thoracic surgery were invited through American College of Surgeon's Cancer Research Program. Results were analyzed using Pearson's chi-square test. Multivariable linear regression was used to identify predictors of a higher score on the survey. Of the 280 surgeons that responded, 86.8% were male and 13.2% were female; the median age was 50 years. Of these surgeons, 211 (75.4%) were thoracic, 59 (21.1%) were cardiac, and 10 (3.6%) were general surgeons. Surgeons were most likely to correctly identify lymph node stations 8R and 9R and least likely to correctly identify the midline pretracheal node just superior to the carina (4R). Surgeons whose practice involved a greater percentage of thoracic surgery patients and surgeons who performed a greater number of lobectomies scored higher on the lymph node assessment. Knowledge of mediastinal node anatomy among surgeons who perform thoracic surgery is generally high, but varies by clinical setting. Efforts are under way to better educate lung cancer surgeons on nodal anatomy, and to increase adoption of Standard 5.8.

Is Substantial Lymphovascular Space Invasion Prognostic in Patients With Pathologically Lymph Node-Negative Endometrial Cancer?

Lymphovascular space invasion (LVSI) predicts for higher rates of recurrence and increased mortality in endometrial cancer. Using 3-tier LVSI scoring, a PORTEC-1 and -2 trials analysis demonstrated that substantial LVSI was associated with worse locoregional (LR-DFS) and distant metastasis disease-free survival (DM-DFS), and these patients possibly benefited from external beam radiation therapy (EBRT). Furthermore, LVSI is a predictor for lymph node (LN) involvement, but the significance of substantial LVSI is unknown in patients with a pathologically negative LN assessment. We aimed to evaluate clinical outcomes of these patients in relation to the 3-tier LVSI scoring system. We performed a single-institutional retrospective review of patients with stage I endometrioid-type endometrial cancer who underwent surgical staging with pathologically negative LN evaluation from 2017 to 2019 with 3-tier LVSI scoring (none, focal, or substantial). Clinical outcomes (LR-DFS, DM-DFS, and overall survival) were analyzed using the Kaplan-Meier method. A total of 335 patients with pathologically LN-negative stage I endometrioid-type endometrial carcinoma were identified. Substantial LVSI was present in 17.6% of patients; 39.7% of patients received adjuvant vaginal brachytherapy and 6.9% of patients received EBRT. Adjuvant radiation treatment varied by LVSI status. In patients with focal LVSI, 81.0% received vaginal brachytherapy. Among patients with substantial LVSI, 57.9% received vaginal brachytherapy alone, and 31.6% of patients received EBRT. The 2-year LR-DFS rates were 92.5%, 98.0%, and 91.4% for no LVSI, focal LVSI, and substantial LVSI, respectively. The 2-year DM-DFS rates were 95.5%, 93.3%, and 93.8% for no LVSI, focal LVSI, and substantial LVSI, respectively. In our institutional study, patients with pathologically LN-negative stage I endometrial cancer with substantial LVSI had similar rates of LR-DFS and DM-DFS compared with patients with none or focal LVSI. These findings highlight the need for multi-institutional studies to validate the prognostic value of substantial LVSI in this patient population.

Diagnostic Performance of Endosonography to Detect Mediastinal Lymph Node Metastasis in Patients with Radiological N1 Non-Small Cell Lung Cancer.

Guidelines recommend that non-small cell lung cancer (NSCLC) patients with suspected hilar lymph node (LN) metastases should undergo invasive mediastinal LN staging prior to surgical treatment via endosonography. We evaluated the diagnostic performance of endosonography for detecting occult mediastinal metastases (OMM) and determined the factors associated with OMM in NSCLC patients with radiological N1. Patients with confirmed primary NSCLC with radiological N1 who underwent endosonography for nodal staging assessment from January 2013 to December 2019 were retrospectively analyzed. The prevalence of OMM was found to be 83/279 (29.7%) and only 38.6% (32/83) were diagnosed via endosonography. However, five of them were confirmed as N3 by endosonography. The overall diagnostic sensitivity, negative predictive value, accuracy, and area under the curve of endosonography were 38.6%, 79.4%, 81.7%, and 0.69, respectively. In multivariable analysis, central tumor (adjusted odds ratio [aOR], 2.05; 95% confidence interval [CI], 1.15-3.68; p=0.016), solid tumor (aOR, 10.24; 95% CI, 1.32-79.49; p=0.026), and adenocarcinoma (aOR, 3.01; 95% CI, 1.63-5.55; p<0.001) were related to OMM in radiological N1 NSCLC patients. Although the sensitivity of endosonography for detecting OMM was only 40%, the prevalence of OMM was not low (30%) and some cases even turned out to be N3 diseases. Clinicians should be aware that OMM may be more likely in patients with central, solid, and adenocarcinomatous tumor when performing nodal staging in radiological N1 NSCLC via endosonography.

Sonographic localisation and description of inguinofemoral lymph nodes in patients with vulvar squamous cell carcinoma

AbstractSonographic imaging of the inguinofemoral lymph nodes can be performed in patients with vulvar cancer to discriminate between normal (benign and reactive) and malignant appearing lymph nodes. A systematic sonographic protocol for imaging inguinofemoral lymph nodes is not commonly used, but could aid in homogenising the reporting of lymph node location and status. This paper unpacks the relative anatomy of the inguinofemoral lymph nodes. A protocol outlining the sonographic assessment of inguinofemoral lymph nodes and the criteria to use to guide the reporting of their size, shape, echogenicity and vascular architecture is discussed.

Role of apparent diffusion coefficient in assessment of loco-regional nodal spread in cancer rectum: correlative study with histopathological findings

BackgroundRectal cancer is associated with high morbidity and mortality rates. Preoperative assessment and detection of nodal metastasis are crucial for selecting a proper treatment plan. Diffusion-weighted imaging is considered to be a crucial functional imaging technique that can aid in determining the condition of lymph nodes. This study aimed to assess the diagnostic utility of MRI functional images by use of apparent diffusion coefficient in regional nodal assessment in rectal cancer.ResultsThis study included 54 patients including 29 males (53.7%) and 25 females (46.3%) presented with pathologically proven rectal cancer. Regarding rectal adenocarcinoma, functional MRI imaging using ADC values found to have a better sensitivity (86.24%) in detection of regional nodal metastasis than conventional morphological MRI criteria with 1.05 × 10−3 mm2/s was employed as cutoff value to distinguish metastatic from non-metastatic lymph nodes with statistically significant P value (< 0.001); nevertheless, regarding the accuracy there was no difference (68.52%). As regards mucinous and signet ring cell carcinoma, morphological assessment using conventional MRI sequences were found to have a better accuracy (72.96%) and sensitivity (57.69%) than ADC value, with the latter showed low statistically significant results (P- value < 0.201) in distinguishing metastatic and non-metastatic nodes. This could be explained by extremely high ADC values of nodes for these pathological types owing to their high mucin content.ConclusionsMRI functional imaging using ADC values can be utilized to distinguish metastatic from non-metastatic lymph nodes in rectal adenocarcinoma employing diagnostic accuracy of 86.52%. However, morphological assessment using conventional MRI was found to be better in assessment of regional lymph nodes at mucinous and signet ring rectal carcinoma.

Abstract P5-01-01: Multiscale Deep Learning framework to capture systemic immune features in lymph nodes predictive of triple negative breast cancer outcome

Abstract Systemic immune responses in lymph nodes (LN) convey significant prognostic value for breast cancer patients, which can inform disease progression and optimal treatment management. However, have, so far, not been assessed in large patient cohorts. We have previously shown that morphological alterations in axillary LNs, namely the formation of germinal centres (GCs) in cancer-free LNs, add prognostic value to tumour infiltrating lymphocytes (TILs) in triple-negative breast cancer patients (TNBC) for the development of distant metastasis. Extending manual assessment of LNs beyond the detection of cancer requires the integration of robust deep learning pipelines into the digital pathology workflow. Here, we propose a supervised multiscale deep learning framework named smuLymphNet to capture and quantify GCs and sinuses within LNs from digitised Haematoxylin and Eosin-stained (H&amp;E) whole slide images (WSIs) and show good concordance compared with an inter-pathologist Dice coefficient of manual annotations from four pathologists. The smuLymphNet framework consists of (i) a detection algorithm to determine the boundaries of each LN section on the WSI, using an Otsu-based thresholding method and contouring algorithm; (ii) a supervised multiscale deep learning module for the segmentation of GCs and sinuses; and (iii) quantification of the number, size, and shape of the predicted features. We applied smuLymphNet to a total of 1,800 H&amp;E-stained WSI of &amp;gt;4,000 cancer-free and involved LNs from a retrospectively collected breast cancer cohort collected at Guy’s Hospital (London, UK) from 177 patients (122 N+) enriched for the triple-negative phenotype. A subset of 114 WSI and five breast cancer LN WSIs from each Barts Hospital (London, UK) and Tianjin University Hospital (Tianjin, China) were used to train and evaluate the supervised deep learning module. For training Fully Convolutional Networks (FCNs), WSIs manually annotated for both GCs and sinuses formed a ground-truth set and three FCNs were implemented: (i) a standard U-Net architecture; (ii) a U-Net model with an attention gate mechanism; and (iii) a multiscale-U-Net network (MS U-Net) that encodes, in parallel, a feature representation of the image at multiple resolutions. The MS U-Net achieved the best performance with an average dice score of 0.86 for GCs and 0.74 for sinuses. In comparison, the average dice score amongst four pathologists assessing 24 LN WSI for GCs and sinuses was 0.67 and 0.61, respectively, demonstrating the robustness of the smuLymphNet framework. To establish associations between morphometric immune features and patients’ outcomes, we assessed smuLymphNet captured GCs and sinuses from 686 WSIs from 96 TNBC patients with extensive longitudinal outcome data. We found significant morphological differences in involved and cancer-free LNs between N0 and N+ patients, with the latter displaying larger GCs with more irregular shapes, especially in their involved LNs. Moreover, in alignment with our previously published studies, our multiscale smuLymphNet framework recapitulated and extended the prognostic value of the assessment of GC formation in TNBC N0 patients. We further revealed, for the first time, the prognostic significance of the intranodal lymphatic sinuses when measured in their totality in involved LNs, and the association of alterations in subcapsular sinus areas with superior distant metastasis-free survival in cancer-free and involved LNs in TNBC N+ patients. In summary, smuLymphNet presents a robust multiscale deep learning framework to automatically detect, localise and quantify histopathological immune features in WSI of LNs. By applying smuLymphNet to LNs of TNBC patients from clinical trials, and thereby further evaluating its clinical utility, smuLymphNet could be implemented into the diagnostic digital pathology workflow and, as such, aid in informing on a patient’s disease trajectory. Citation Format: Gregory Verghese, Mengyuan Li, Fangfang Liu, Amit Lohan, Nikhil Cherian, Patrycja Gazinska, Aekta Shah, Aasiyah Oozeer, Cheryl Gillett, Elena Alberts, Thomas Hardiman, Roberto Salgado, Samantha Jones, Louise Jones, Selvam Thavaraj, Sarah E. Pinder, Swapni Rane, Amit Sethi, Anita Grigoriadis. Multiscale Deep Learning framework to capture systemic immune features in lymph nodes predictive of triple negative breast cancer outcome [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-01-01.

Lymph node assessment technique matters in radical cystectomy for bladder cancer.

For patients undergoing radical cystectomy with pelvic lymph node dissection for urothelial cancer, a lymph node count of at least 16 is associated with improved cancer-specific and overall survival. Lymph node yield is presumed to relate directly to extent of dissection and surgical quality, however limited studies have reviewed the impact of the pathological assessment process of lymph nodes on lymph node yield. A retrospective assessment of 139 patients who had radical cystectomy for urothelial cancer between March 2015 and July 2021 from Fiona Stanley Hospital (Perth, Australia) by a single surgeon was assessed. A change in pathological assessment process from assessment of only palpable lymph nodes to microscopic assessment of the entire submitted specimens occurred in August 2018. Patients were divided into two groups accordingly and other relevant demographic and pathological data was recorded. The impact of pathological processing technique on lymph node yield was assessed using the Student T test and logistical regression was used to assess the impact of other demographic variables. The mean lymph node yield was 16.2 nodes (IQR 12-23) in 54 patients in the pre-process change group compared to 22.4 nodes (IQR 15-28.4) in 85 patients in the post-process change group (P< 0.0001). 53.7% had 16 or more nodes in the pre-process change group compared to 71.3% in the post-process change group (P= 0.04). Age, BMI, and gender were not significant predictors of lymph node yield. The current study demonstrates that the microscopic assessment of all lymph node tissue detects significantly more lymph nodes than only examining palpably abnormal tissue. Pathologic assessment protocols should be standardized to this technique to ensure the utility of lymph node yield as a quality metric.

PT1-2 gastric cancer with lymph node metastasis predicted by tumor morphologic features on contrast-enhanced computed tomography

To investigate the value of tumor morphologic features of pT1-2 gastric cancer (GC) on contrast-enhanced computed tomography (CT) in assessing lymph node metastasis (LNM) with reference to histopathological results. Eighty-six patients seen from October 2017 to April 2019 with pT1-2 GC proven by histopathology were included. Tumor volume and CT densities were measured in the plain scan and the portal-venous phase (PVP), and the percent enhancement was calculated. The correlations between tumor morphologic features and the N stages were analyzed. The diagnostic capability of tumor volume and enhancement features in predicting the LN status of pT1-2 GCs was further investigated using receiver operating characteristic (ROC) analysis. Tumor volume, CT density in the PVP, and tumor percent enhancement in the PVP correlated significantly with the N stage (rho: 0.307, 0.558, and 0.586, respectively). Tumor volumes were significantly lower in the LNM- group than in the LNM+ group (14.4 mm3 vs. 22.6 mm3, P = 0.004). The differences between the LNM- and LNM+ groups in the CT density in the PVP and the percent enhancement in the PVP were also statistically significant (68.00 HU vs. 87.50 HU, P < 0.001; and 103.06% vs. 179.19%, P < 0.001, respectively). The area under the ROC curves for identifying the LNM+ group was 0.69 for tumor volume and 0.88 for percent enhancement in the PVP, respectively. The percent enhancement in the PVP of 145.2% and tumor volume of 17.4 mL achieved good diagnostic performance in determining LNM+ (sensitivity: 71.4%, 82.1%; specificity: 91.4%, 58.6%; and accuracy: 84.9%, 66.3%, respectively). Tumor volume and percent enhancement in the PVP of pT1-2 GC could improve the diagnostic accuracy of LNM and would be helpful in image surveillance of these patients.

EARLY RESULTS OF ROBOTIC LOBECTOMY TREATMENT NON-SMALL CELL LUNG CANCER: EXPERIENCE AT CHO RAY HOSPITAL

Objectives: Nowadays, there are numerous ways to configure trocar placements for lobectomy using the Da Vinci Xi system. Cho Ray Hospital conducted robotic video-assisted thoracic surgery (rVATS) lobectomy in July 2018 and obtained satisfactory results. Currently, there is no research on rVATS lobectomy in Vietnam, so we decided to report our initial experiences using rVATS lobectomy in non-small cell lung cancer at our institute. Subjects and methods: rVATS for lobectomy was performed on 79 patients with lung cancer who were treated at Cho Ray Hospital from July 2018 to June 2022. All patients were performed the rVATS lobectomy with triangular port placement. The cardiere, harmonic arms were used as robotic arms in the present study which was further coordinated with thoracic surgical instruments through working support. The early outcomes were: The rate of conversion to open procedure, post-operative complications, and day of post-operation. Results: Out of 79 enrolled patients, the majority of study participants were males and belonged to the 60 - 69 years age group. Most of them had tumor lesions in the left upper lobe, followed by the right upper lobe and right lower lobe, respectively. The mean tumor size was noted to be 3.8 cm. The mean time of operation was 262.2 minutes. The average blood loss was 200 mL. The rate of conversion to open procedure accounted for 8.9%. In intraoperative lymphadenectomy for the mediastinal lymph node, the resection rate was 74.7%. Amongst postoperative complications, prolonged air leak &gt; 7 days was the most common. In the hospital, mortality was found to be 1.3%. Changes in clinical and pathological lymph node assessment via intraoperative lymph node dissection accounted for 32.9%.

A nomogram prediction model for lymph node metastasis risk after neoadjuvant chemoradiotherapy in rectal cancer patients based on SEER database.

Rectal cancer patients who received neoadjuvant chemoradiotherapy (CRT) may have a lower cancer stage and a better prognosis. Some patients may be able to avoid invasive surgery. It is critical to accurately assess lymph node metastases (LNM) after neoadjuvant chemoradiotherapy. The goal of this study is to identify clinical variables associated with LNM and to develop a nomogram for LNM prediction in rectal cancer patients following nCRT. From 2010 to 2015, patients were drawn from the Surveillance, Epidemiology, and End Results (SEER) database. To identify clinical factors associated with LNM, the least absolute shrinkage and selection operator (LASSO) aggression and multivariate logistic regression analyses were used. To predict the likelihood of LNM, a nomogram based on multivariate logistic regression was created using decision curve analyses. The total number of patients included in this study was 6,388. The proportion of patients with pCR was 17.50% (n=1118), and the proportion of patients with primary tumor pCR was 20.84% (n = 1,331). The primary tumor was pCR in 16.00% (n=213) of the patients. Age, clinical T stage, clinical N stage, and histology were found to be significant independent clinical predictors of LNM using LASSO and multivariate logistic regression analysis. The nomogram was developed based on four clinical factors. The 5-year overall survival rate was 78.9 percent for those with ypN- and 66.3 percent for those with ypN+, respectively (P<0.001). Patients over 60 years old, with clinical T1-2, clinical N0, and adenocarcinoma may be more likely to achieve ypN0. The watch-and-wait (WW) strategy may be considered. Patients who had ypN0 or pCR had a better prognosis.

A federated approach to identify women with early-stage cervical cancer at low risk of lymph node metastases

ObjectiveLymph node metastases (pN+) in presumed early-stage cervical cancer negatively impact prognosis. Using federated learning, we aimed to develop a tool to identify a group of women at low risk of pN+, to guide the shared decision-making process concerning the extent of lymph node dissection. MethodsWomen with cervical cancer between 2005 and 2020 were identified retrospectively from population-based registries: the Danish Gynaecological Cancer Database, Swedish Quality Registry for Gynaecologic Cancer and Netherlands Cancer Registry. Inclusion criteria were: squamous cell carcinoma, adenocarcinoma or adenosquamous carcinoma; The International Federation of Gynecology and Obstetrics 2009 IA2, IB1 and IIA1; treatment with radical hysterectomy and pelvic lymph node assessment. We applied privacy-preserving federated logistic regression to identify risk factors of pN+. Significant factors were used to stratify the risk of pN+. ResultsWe included 3606 women (pN+ 11%). The most important risk factors of pN+ were lymphovascular space invasion (LVSI) (odds ratio [OR] 5.16, 95% confidence interval [CI], 4.59–5.79), tumour size 21–40 mm (OR 2.14, 95% CI, 1.89–2.43) and depth of invasion>10 mm (OR 1.81, 95% CI, 1.59–2.08). A group of 1469 women (41%)—with tumours without LVSI, tumour size ≤20 mm, and depth of invasion ≤10 mm—had a very low risk of pN+ (2.4%, 95% CI, 1.7–3.3%). ConclusionEarly-stage cervical cancer without LVSI, a tumour size ≤20 mm and depth of invasion ≤10 mm, confers a low risk of pN+. Based on an international privacy-preserving analysis, we developed a useful tool to guide the shared decision-making process regarding lymph node dissection.

Added Value of Abnormal Lymph Nodes Detected with FDG-PET/CT in Suspected Vascular Graft Infection

Vascular graft and endograft infections (VGEI) cause a serious morbidity and mortality burden. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) imaging is frequently used in the diagnostic workup, but the additional value of abnormal (18F-FDG active and/or enlarged) locoregional lymph nodes is unknown. In this retrospective study, the additional diagnostic value of abnormal locoregional lymph nodes on 18F-FDG PET/CT imaging for VGEI was evaluated, including 54 patients with a culture-proven VGEI (defined according to the Management of Aortic Graft Infection [MAGIC] group classification) and 25 patients without VGEI. 18F-FDG PET/CT was qualitatively and quantitatively assessed for tracer uptake and pattern at the location of the vascular graft, and locoregional lymph node uptake and enlargement (>10 mm). 18F-FDG uptake intensity and pattern independently predicted the presence of VGEI by logistic regression (Χ2: 46.19, p < 0.001), with an OR of 7.38 (95% CI [1.65, 32.92], p = 0.009) and 18.32 (95% CI [3.95, 84.88], p < 0.001), respectively. Single visual assessment of abnormal locoregional lymph nodes predicted the presence of VGEI with a sensitivity of 35%, specificity of 96%, PPV of 95%, and NPV of 41%. The visual assessment of abnormal lymph nodes after qualitative assessment of 18F-FDG uptake intensity and pattern at the vascular graft location did not independently predict the presence of VGEI by logistic regression (Χ2: 3.60, p = 0.058; OR: 8.25, 95% CI [0.74, 63.37], p = 0.096). In conclusion, detection of abnormal locoregional lymph nodes on 18F-FDG PET/CT has a high specificity (96%) and PPV (95%) for VGEI. However, it did not add to currently used 18F-FDG PET/CT interpretation criteria.

Endoscopic ultrasound in patients with resectable perihilar cholangiocarcinoma: impact on clinical decision-making.

Background and study aims Accurate assessment of the lymph node (LN) status is crucial in resectable perihilar cholangiocarcinoma (pCCA) to prevent major surgery in patients with extraregional metastatic LNs (MLNs). This study investigates the added value of preoperative endoscopic ultrasound (EUS) with or without tissue acquisition (TA) for the detection of MLNs in patients with resectable pCCA. Patients and methods In this retrospective, multicenter cohort study, patients with potentially resectable pCCA who underwent EUS preoperatively between 2010-2020, were included. The clinical impact of EUS-TA was defined as the percentage of patients who did not undergo surgical resection due to MLNs found with EUS-TA. Findings of cross-sectional imaging were compared with EUS-TA findings and surgery. Results EUS was performed on 141 patients, of whom 107 (76 %) had suspicious LNs on cross-sectional imaging. Surgical exploration was prevented in 20 patients (14 %) because EUS-TA detected MLNs, of which 17 (85 %) were extraregional. Finally, 74 patients (52 %) underwent surgical exploration followed by complete resection in 40 (28 %). MLNs were identified at definitive pathology in 24 (33 %) patients, of which 9 (38 %) were extraregional and 15 (63 %) regional. Conclusions EUS-TA may be of value in patients with potentially resectable pCCA based on preoperative cross-sectional imaging, regardless of lymphadenopathy at cross-sectional imaging. A prospective study in which a comprehensive EUS investigation with LN assessment and EUS-TA of LNs is performed routinely should confirm this promise.

Pathological features associated with lymph node disease in patients with appendiceal neuroendocrine tumors.

238 Background: Appendiceal neuroendocrine tumors (ANETs) are well known for their benign and slow progression; nonetheless, the presence of lymph node metastasis has been described in up to 50% of all cases. The risk of metastasis is mainly associated with tumor size, and the role of other pathological features remains unclear. Hence, this study was designed to assess the pathologic features of ANETs associated with an increased risk of lymph node metastasis. Methods: Patients ≥18yrs of age with ANETs were identified in the National Cancer Database (NCDB) from 2004 to 2017. Groups were defined based on lymph node status as N(-) (all examined nodes were negative) and N(+) (one or more examined nodes were positive). Multivariable models using demographics and oncological features were used to identify factors independently associated with nodal metastasis (N+). Marginal effects, specifically for tumors &lt;2 cm were also calculated. Results: A total of 2,465 cases were identified and included for data analysis. Among these, 23% had lymph node metastases, including 33 of 979 tumors &lt;1 cm (3.4%), and 145 of 696 tumors ≥1 cm but ≤2 cm (20.8%). Tumor size, depth of tumor invasion, and presence of lymphovascular invasion (LVI) were identified as independent predictors of lymph node metastasis (p &lt;0.001). When evaluating marginal effects, both the depth of tumor invasion and the presence of LVI were associated with increased risk of node metastasis in small tumors (&lt;2 cm), comparable to the mere risk of node metastasis in big tumors (≥2cm). In addition, for small ANETs (&lt;2cm), the true positive rates (TPR) of node metastasis vary according to the number of assessed lymph nodes, differing significantly between patients with at least 12 evaluated lymph nodes vs. those with less than 12 (TPR 4.7% vs. 1.6% for &lt;1 cm [p =0.02], and 40.1% vs. 25.7% in ≤2 cm ANETs, [p &lt;0.001]). Conclusions: In ANETs, the presence of high-risk pathological features, including LVI and tumor depth, increases the risk of node metastasis in addition to tumor size, and should be considered when selecting the optimum management and follow-up in these patients. [Table: see text]

Texture Analysis in Uterine Cervix Carcinoma: Primary Tumour and Lymph Node Assessment.

The conventional magnetic resonance imaging (MRI) evaluation and staging of cervical cancer encounters several pitfalls, partially due to subjective evaluations of medical images. Fifty-six patients with histologically proven cervical malignancies (squamous cell carcinomas, n = 42; adenocarcinomas, n = 14) who underwent pre-treatment MRI examinations were retrospectively included. The lymph node status (non-metastatic lymph nodes, n = 39; metastatic lymph nodes, n = 17) was assessed using pathological and imaging findings. The texture analysis of primary tumours and lymph nodes was performed on T2-weighted images. Texture parameters with the highest ability to discriminate between the two histological types of primary tumours and metastatic and non-metastatic lymph nodes were selected based on Fisher coefficients (cut-off value > 3). The parameters' discriminative ability was tested using an k nearest neighbour (KNN) classifier, and by comparing their absolute values through an univariate and receiver operating characteristic analysis. Results: The KNN classified metastatic and non-metastatic lymph nodes with 93.75% accuracy. Ten entropy variations were able to identify metastatic lymph nodes (sensitivity: 79.17-88%; specificity: 93.48-97.83%). No parameters exceeded the cut-off value when differentiating between histopathological entities. In conclusion, texture analysis can offer a superior non-invasive characterization of lymph node status, which can improve the staging accuracy of cervical cancers.

Measurements of pulse rate using facial video cameras from smart devices in patients diagnosed with atrial fibrillation

Clinical applications of passive long-term heart rate (HR) monitoring in patients with cardiac arrhythmias include adequate drug titration of atrioventricular (AV) nodal drugs and assessment of medical compliance with treatment. A majority of patients treated with beta-blockers, especially patients with atrial fibrillation (AF), require some degree of drug titration during the first 6 months of treatment to ensure that adequate HR control and medicine compliance has been achieved. Failing to achieve adequate rate control in patients with AF can lead to worsening symptoms, heart failure exacerbations, and potentially tachycardia-induced cardiomyopathy. Enabling video-based monitoring during telehealth patient visits could facilitate providers to measure heart rate (HR) without the need for a dedicated home device (smartwatch, SPO2 device, or others). Videoplethysmography (VPG) is a monitoring technology that measures pulse rate by utilizing front-facing cameras embedded in smart devices. VPG provides a remote and contactless cardiac monitoring solution. We conducted a clinical experiment to evaluate the accuracy of VPG in measuring HR while running on two portable devices: Samsung S10 smartphones and S3 tablets. We used a single‑lead ECG to measure the heart rate at the time of the VPG recordings in AF patients. We employed the Bland-Altman method to measure the level of agreement between videoplethysmography and ECG-based measurements of HR. The findings reveal that the mean difference in videoplethysmography and ECG-based heart rate was inferior to 1 bpm across the 2 devices with confidence intervals ranging from 3 to 12 BPM. Our facial video-based HR monitoring solution could assist providers in measuring heart rates in their patients with AF during remote telehealth visits.

Artificial Intelligence for Evaluation of Thyroid Nodules: A Primer.

Background: Artificial intelligence (AI) is broadly defined as the ability of machines to apply human-like reasoning to problem solving. Recent years have seen a rapid growth of AI in many disciplines. This review will focus on AI applications in the assessment of thyroid nodules. Summary: AI encompasses two related computational techniques: machine learning, in which computers learn by observing data provided by humans, and deep learning, which employs neural networks that mimic brain structure and function to analyze data. Some experts believe the way AI systems reach a conclusion should be transparent, or explainable, while others disagree. Most AI platforms in thyroid disease have focused on malignancy risk stratification of nodules. To date, four have been approved by the United States Food and Drug Administration. While the results of validation studies have been mixed, there is ample evidence that AI can exceed the performance of some humans, particularly physicians with less experience. AI has also been applied to assessment of lymph nodes and cytopathology specimens. Conclusions: Adoption of AI in thyroid disease will require vendors to demonstrate that their software works as intended, is readily usable in real-world settings, and is cost effective. AI platforms that perform best in head-to-head comparisons will dominate and spur wider adoption.