Nodal Basins In Patients Research Articles

Sparing of high retropharyngeal nodal basins in patients with unilateral oropharyngeal carcinoma treated with intensity modulated radiation therapy

PurposeThe introduction of intensity modulated radiotherapy (IMRT) has facilitated dose painting and sparing of uninvolved/low-risk nodal basins in head and neck cancers. In oropharynx cancer (OPC), the need for elective coverage of uninvolved high contralateral retropharyngeal (RP) nodes and the risk associated with sparing this region remain unclear. We examined outcomes of OPC patients treated with IMRT and omission of contralateral high RP coverage. Methods and materialsWe identified 102 OPC patients with cN0-N2b disease treated with definitive IMRT with or without concurrent chemotherapy between 2010 and 2013. The contralateral RP nodal basins superior to the vertebral level of C1 were omitted from the elective IMRT field for all patients. Of the 67 patients (66%) with p16 status available, 63 (94%) were p16+. We used the Kaplan-Meier method to estimate overall survival, as well as freedom from local failure, regional failure, distant failure, and retropharyngeal failure. ResultsThe median follow-up was 26.9 months (range, 3.0-59.9 months). There were no failures in the treated ipsilateral RP nodes or the spared contralateral high RP nodes in the entire cohort. In the p16+ cohort and the entire cohort, the 2-year rates of overall survival and freedom from local, regional, distant, and retropharyngeal failure were 98.0% and 95.1%, 98.1% and 97.7%, 96.4% and 96.7%, 98.1% and 95.1%, and 100% and 100%, respectively. ConclusionsOmission of contralateral high RP nodes in patients with p16+ OPC with unilateral disease is safe.

Sonography and Sonographically Guided Needle Biopsy of Internal Mammary Nodes in Staging of Patients With Breast Cancer.

The purpose of this study was to identify the prevalence of occult nodal metastases on routine ultrasound examination of internal mammary (IM) nodal basins in patients with breast cancer. Patients with primary breast cancer (n = 595) underwent breast ultrasound evaluation between September 1, 2011, and April 1, 2012. For all patients, ultrasound examination included a survey of the axillary, infraclavicular, IM, and supraclavicular nodal basins. Patient demographics, breast cancer histopathologic type, and grade, size, location, and presence of metastatic nodes in regional nodal basins were recorded. Fisher exact test and Wilcoxon rank test were used for statistical analysis. Fifty-eight of 595 (10%) patients had positive IM ultrasound finding, with eight (1.3%) patients having isolated IM involvement. Patients with positive IM ultrasound findings were statistically significantly younger than those without such findings (median age, 42 vs 57 years; p < 0.0001). Of the 58 patients with positive IM ultrasound, 29 (50%) underwent ultrasound-guided needle biopsy, which confirmed malignancy in 26 of 29 (90%) patients. Nonlateral (p < 0.001) grade 3 (p < 0.001) tumors larger than 5 cm (p < 0.0006) with the estrogen receptor-negative HER2/neu-negative subtype (p < 0.001) associated with axillary, infraclavicular, or supraclavicular metastases (p < 0.001) were more likely to be associated with positive IM ultrasound findings. IM ultrasound resulted in an N status change for 46 of 595 (8%) patients and of the overall clinical stage for 38 (6.4%) patients. IM ultrasound and ultrasound-guided fine-needle aspiration biopsy are feasible, sensitive, and specific. Application of IM ultrasound and ultrasound-guided needle biopsy in a selected subpopulation of young patients with medial or central estrogen receptor-negative HER2/neu-negative breast cancer may result in a change in clinical stage and modify the treatment plan.

Who Should Be Offered a Sentinel Node Biopsy for Melanoma Less Than 1 mm in Thickness?

Who Should Be Offered a Sentinel Node Biopsy for Melanoma Less Than 1 mm in Thickness?

Surgical Management of Sentinel Lymph Node Biopsy Outside Major Nodal Basin in Patients with Cutaneous Melanoma

To assess the incidence of nonmajor lymphatic basin sentinel nodes in patients with cutaneous melanoma in order to propose a correct nomenclature and inform appropriate surgical management. This was a retrospective review of 1,045 consecutive patients with cutaneous melanoma who underwent sentinel lymph node biopsy and dynamic lymphoscintigraphy to identify sentinel node site. Nonmajor drainage sites were classified as uncommon (located in a minor lymphatic basin along the lymphatic drainage to a major classical nodal basin) or interval (located anywhere along the lymphatics between the primary tumor site and the nearest lymphatic basin) sentinel nodes. Nonclassical sentinel nodes were identified in 32 patients (3.0 %). Uncommon sentinel nodes were identified in 3.2 % (n = 17) of trunk melanoma primary disease and in 1.5 % (n = 7) of upper and lower extremity sites. Interval sentinel nodes were identified in 1.3 % (n = 7) of trunk primary lesions, with none from upper and lower extremities melanomas. The incidence of tumor-positive sentinel nodes was 24.1 % (245 of 1,013) in classical sites and 12.5 % (4 of 32) in uncommon/interval sites. The definition of uncommon and interval sentinel nodes allows the identification of different lymphatic pathways and inform appropriate surgical treatment. Wider experience with uncommon/interval sentinel nodes will better clarify the clinical implications and surgical management to be adopted in the management of uncommon and interval sentinel node sites.

Utility of Lymph Node Assessment for Atypical Spitzoid Melanocytic Neoplasms

Atypical spitzoid melanocytic neoplasms (ASMN) are cutaneous lesions of uncertain malignant potential, which can be difficult to distinguish from cutaneous melanoma. Sentinel lymph node (SLN) biopsy is a safe and useful prognostic tool for staging melanoma, but its role in staging ASMNs is not established nor is the significance of positive SLNs in these patients known. This study attempts to characterize the significance of nodal disease in ASMN. Patients with ASMNs who presented to the melanoma service from 1992 to 2007 were identified from a prospective database. Histological review was performed by two dermatopathologists. Demographic, treatment, and outcome data were reviewed. A total of 58 patients with ASMNs were treated during the time analyzed; 31 (53%) underwent wide local excision and observation (WLE); 27 underwent wide excision and SLN biopsy. Median age was 24 (range, 6-60) years. Mean Breslow thickness was 2.9 (range, 0.5-10) mm. Median follow-up was 56 (range, 1-160) months. Ten of 58 (17%) patients had nodal metastasis. Four (13%) of 31 patients who underwent WLE developed nodal recurrences, and 6 of 27 (22%) patients had a positive SLN biopsy. Of patients with positive SLNs, none have recurred after undergoing completion lymphadenectomy. One patient presented with synchronous brain metastasis and inguinal lymphadenopathy and died of disease. Nodal status does not seem to convey the same prognosis that it does in standard melanoma. There may be a limited ability for progression within the nodal basin in patients with these lesions. This subset of patients would benefit from genetic data complementing histologic analysis.

High-Risk Cutaneous Squamous Cell Carcinoma without Palpable Lymphadenopathy

PURPOSE The beneficial role of elective neck dissection (END) in the management of high-risk cutaneous squamous cell carcinoma (CSCC) of the head and neck remains unproven. Some surgical specialists suggest that END may be beneficial for patients with clinically node-negative (N0) high-risk CSCC, but there are few data to support this claim. We reviewed the available literature regarding the use of END in the management of both CSCC and head and neck SCC (HNSCC). METHODOLOGY The available medical literature pertaining to END in both CSCC and HNSCC was reviewed using PubMed and Ovid Medline searches. RESULTS Many surgical specialists recommend that END be routinely performed in patients with N0 HNSCC when the risk of occult metastases is estimated to exceed 20%; however, patients who undergo END have no proven survival benefit over those who are initially staged as N0 and undergo therapeutic neck dissection (TND) after the development of apparent regional disease. There is a lack of data regarding the proper management of regional nodal basins in patients with N0 CSCC. In the absence of evidence-based data, the cutaneous surgeon must rely on clinical judgment to guide the management of patients with N0 high-risk CSCC of the head and neck. CONCLUSIONS Appropriate work-up for occult nodal disease may occasionally be warranted in patients with high-risk CSCC. END may play a role in only a very limited number of patients with high-risk CSCC.

High-Risk Cutaneous Squamous Cell Carcinoma without Palpable Lymphadenopathy: Is There a Therapeutic Role for Elective Neck Dissection?

The beneficial role of elective neck dissection (END) in the management of high-risk cutaneous squamous cell carcinoma (CSCC) of the head and neck remains unproven. Some surgical specialists suggest that END may be beneficial for patients with clinically node-negative (N0) high-risk CSCC, but there are few data to support this claim. We reviewed the available literature regarding the use of END in the management of both CSCC and head and neck SCC (HNSCC). The available medical literature pertaining to END in both CSCC and HNSCC was reviewed using PubMed and Ovid Medline searches. Many surgical specialists recommend that END be routinely performed in patients with N0 HNSCC when the risk of occult metastases is estimated to exceed 20%; however, patients who undergo END have no proven survival benefit over those who are initially staged as N0 and undergo therapeutic neck dissection (TND) after the development of apparent regional disease. There is a lack of data regarding the proper management of regional nodal basins in patients with N0 CSCC. In the absence of evidence-based data, the cutaneous surgeon must rely on clinical judgment to guide the management of patients with N0 high-risk CSCC of the head and neck. Appropriate work-up for occult nodal disease may occasionally be warranted in patients with high-risk CSCC. END may play a role in only a very limited number of patients with high-risk CSCC.

The role of preoperative lymphoscintigraphy in surgery planning for sentinel lymph node biopsy in malignant melanoma

To evaluate four years of preoperative lymphoscintigraphy experience and the accuracy of sentinel lymph node biopsy in our institution in melanoma patients with various tumor thicknesses. An additional aim was to evaluate the recurrence rate related to pathohistological findings. During the period from February 2002 to November 2005, 201 patients underwent sentinel node biopsy. Lymphoscintigraphy for identification of sentinel nodes was performed four to six hours prior to operation of the patient. Sentinel lymph node biopsy using an intraoperative hand-held gamma probe was performed in all patients, together with wide local excision of biopsy wound or primary lesion (N=56). Immediate complete basin dissection was performed in patients with sentinel node metastases. In four patients delayed complete lymph node dissection was performed after definitive histopathologic examination of sentinel nodes. The accuracy of sentinel node biopsy was determined by comparing the intraoperative rates of sentinel node identification and the subsequent development of nodal metastases in regional nodal basins in patients with tumor-negative sentinel nodes and in those with tumorpositive sentinel nodes. Using preoperative lymphoscintigraphy, we identified sentinel nodes in all but one of the 201 patients (99.0%), and in 248 nodal basins (1.2/patient) we observed 372 sentinel nodes (1.52 sentinels/basin; 1.8 sentinels/patient). The highest number of sentinel nodes was noticed in the groin of patients with melanoma on the lower extremities (1.5/patient), followed by the axilla (1.3/patient). Anomalous lymphatic drainage patterns were observed in 15.0% of all patients. The identification rate of sentinel nodes was 99.0% overall: 100% for the groin basins, and 98.0% for the axilla and head and neck basin. Forty-two patients (20.8%) had tumor-positive sentinel nodes. Ten patients (5.0%) had local or distant recurrences during a median follow-up of 23.1 months (range 2-46). The rate of false-negative lymphatic mapping and sentinel node biopsy as measured by nodal recurrence in patients with tumor-negative sentinel nodes was 1.3%. During the follow-up period, three of 201 patients died from other diseases and three patients died as the result of melanoma metastases, with a median follow-up of 13.5 months (range 12-22). Preoperative lymphoscintigraphy is a sensitive, inexpensive and essential method for the identification of drainage basins, determination of the number and position of sentinel nodes and their location outside the usual nodal basins. Scintigraphic findings may lead to changes in surgical management due to the unpredictability of lymphatic drainage. The low incidence of regional disease recurrence in patients with tumor-negative sentinel nodes supports the use of preoperative lymphoscintigraphy and sentinel node biopsy as a safe and accurate procedure for staging the regional nodal basin in patients with malignant melanoma.

Lymphatic mapping for staging of head and neck cancer

Lymphatic mapping with sentinel lymph node (SLN) biopsy can accurately stage the nodal basins in patients with melanoma of the trunk and extremities and has become a routine, well-accepted diagnostic method for melanoma at these anatomic locations. Melanoma of the head and neck (16% of all cases of melanoma) is complex and difficult to manage because of the rich abundant interlacing lymphatic drainage patterns, as well as watershed areas, which can lead to unusual and unexpected drainage patterns. Radioguided surgery in combination with blue dye facilitates localization of the SLN in the head and neck; however, this type of radioguided surgery is an evolving technique of some difficulty and thus requires careful coordination among the surgeon, nuclear medicine physician, and pathologist. Applications of this technique to other sites in the head and neck are currently being investigated for conditions including squamous cell carcinoma (SCC) of the oral cavity, thyroid cancer, and Merkel cell cancer. More studies of patients with head and neck cancer are needed—and technical issues must be resolved—before radioguided surgery can be recommended as the standard of care for these patients.

Lymph node biopsy does not impair survival after therapeutic dissection for palpable melanoma metastases.

To determine the effects of disrupting a nodal basin in patients with American Joint Committee on Cancer stage III melanoma with clinically palpable lymph nodes, we studied patients who underwent therapeutic lymph node dissection after excisional lymph node biopsy, after fine-needle aspiration (FNA) biopsy, or without a preoperative biopsy. We performed a retrospective review of our patients with American Joint Committee on Cancer stage III melanoma who were treated between January 1972 and June 1995, using data acquired from our 8200-patient database. The study group included 670 patients with melanoma, with known primary tumors, who underwent therapeutic lymph node dissection for palpable nodal metastases diagnosed by open biopsy (227 patients), by FNA (66 patients), or by clinical observation without biopsy (377 patients). Regional node recurrence, 5-year disease-free survival, and overall survival rates were calculated. The same-basin regional node recurrence rates were similar for the three groups (open biopsy, 4.6%; FNA, 3.2%; no biopsy, 4.6%; P = .14). The 5-year disease-free survival rates were 36.8% for the open-biopsy group, 29.6% for the FNA group, and 28.9% for the no-biopsy group (P = .08); corresponding 5-year overall survival rates were 40.6%, 43.9%, and 36.1%, respectively (P = .18). Multivariate analysis failed to identify preoperative biopsy as a significant risk factor. Matched-pair analysis using age, gender, primary tumor site, Breslow thickness, and tumor burden showed no differences in the 5-year disease-free survival rates (33% for the open-biopsy group vs. 27% for the FNA and no-biopsy groups, P = .42) and the 5-year overall survival rates (41% vs. 35%, P = .32). For patients with melanoma with palpable regional adenopathy, histological confirmation of clinical suspicion with either FNA or excisional lymph node biopsy does not adversely affect survival or recurrence rates.

The utility of fine needle aspiration in the diagnosis of melanoma metastatic to lymph nodes

Prompt and accurate diagnosis of melanoma metastatic to the lymph nodes is important with respect to prognosis and treatment. The purpose of this study was to determine the utility and diagnostic reliability of fine needle aspiration (FNA) of enlarged nodules in lymph node basins in patients with melanoma. We retrospectively reviewed the charts of 46 patients with melanoma who underwent a total of 56 FNAs of palpable nodules in lymph node basins. Of the 56 FNAs, 24 showed melanoma, 26 did not demonstrate melanoma, five were inadequate, and one gave inconclusive but suspect results. Findings were confirmed by open biopsy (n = 35) or clinical follow-up (n = 21). Fifty of 56 FNAs (89%) yielded a definitive diagnosis (sensitivity/specificity = 100% in these 50). FNA biopsy of enlarged palpable nodules in nodal basins in patients with melanoma is accurate, rapid, and cost-efficient. An algorithm for management of patients with melanoma who have palpable nodes is provided.