Occult Metastases Research Articles

Practical nomogram based on comprehensive CT texture analysis to preoperatively predict peritoneal occult metastasis of gastric cancer patients.

This study aims to evaluate whether a nomogram based on comprehensive CT texture analysis of primary tumor and peritoneotome combined with conventional CT signs can preoperatively predict peritoneal occult metastasis in gastric cancer patients. A total of 1,251 patients with gastric cancer (GC) were retrospectively analyzed in Fujian Province Hospital between 2008 and 2020. Patients from the occult peritoneal metastasis (PM) group were initially diagnosed as PM-negative on CT and later confirmed as PM-positive through laparoscopy or surgery. The group without PM was randomly sampled from patients without PM. The preoperative CT signs and texture features and clinical characteristics of patients were retrospectively analyzed. Hazard factors of occult PM were identified by univariate analysis and multivariate logistic regression analysis, which were intended for creating prediction models. A nomogram was established based on the model with the highest predictive efficacy and clinical application value. A total of 31 patients with occult PM and 165 patients without PM were enrolled in this study. The maximum size, thickness, enhancement, serous involvement of primary GC tumor and ascites on CT, and texture features such as inhomogeneity of the primary tumor, standard deviation, and inhomogeneity of the peritoneum were determined as independent predictors that could be jointly applied to predict occult PM. We separately constructed five forecast models using CT signs, primary tumor texture, peritoneum texture, primary tumor texture + peritoneum texture, and their combination for predicting occult PM. These five prediction models achieved an AUC value of 0.832, 0.70, 0.784, 0.838, and 0.941, respectively. The DeLong test and Decision Curve Analysis (DCA) showed that the joint model, containing three meaningful CT signs (maximum size, thickness, and ascites) and two meaningful texture parameters (inhomogeneity of the primary tumor and inhomogeneity of the peritoneum), possessed the best predictive performance and clinical application (p<0.05). A forecast nomogram was subsequently established from the model above-mentioned. The calibration curves of the nomogram indicated a good consistency (a concordance index of 0.807) between the projection and the actual observation of occult PM. A practical projection nomogram based on the comprehensive CT texture analysis of a primary tumor and peritoneotome combined with conventional CT signs was constructed in our study, which can be conveniently used in preoperative personalized prediction of occult PM for GC patients, and acts as a recommendation for the optimization of clinical management.

Additional Imaging is of Limited Value in Traumatic Hip Fractures With a History of Distant Malignancy and No Suspicious Lesion on Plain Radiographs.

To determine the value of obtaining additional preoperative imaging in patients with a traumatic hip fracture and a history of malignancy in whom plain radiographs show no lesion suspicious for metastases. Retrospective review. Teaching NHS Trust in the United Kingdom, over an 8-year period treating 4421 hip fractures. Three hundred sixty-seven patients with hip fracture and a history of malignancy at a site distant to the hip. Three hundred thirty patients had a history of trauma and no lesion on the plain radiograph suspicious for metastases. Whether obtaining additional imaging preoperatively (MRI, CT, and bone scan) identified metastases or affected management. 32/330 patients had further preoperative imaging, none of which demonstrated a pathological fracture secondary to malignancy. On follow-up, 3/330 (0.9%) cases were found to have occult metastasis at the hip fracture site. All 3 had only plain radiographs before surgery. In 2, this was identified on histological examination of intraoperative samples, and in 1, radiologically as a metastatic metaphyseal lesion 18 months after a hemiarthroplasty. Only in the latter case, preoperative identification of hip metastasis could have altered surgical management. Patients undergoing further preoperative imaging waited significantly longer for surgery (35 ± 26 vs. 51 ± 26 hours, P = 0.0011). In the absence of a suspicious metastatic lesion on initial plain radiographs, further preoperative imaging is unlikely to identify a lesion that will affect management and confers significant delays to surgery. Sending intraoperative histological samples may help guide postoperative oncological management, but further work is needed to prove its utility. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

PREDICTORS OF LYMPHNODE METASTASIS IN SQAUMOUS CELL CARCINOMA TONGUE

Back Ground:The most important prognostic factor for squamous cell carcinoma (SCC) of oral is the status of cervical lymph nodes. Cure rates drop by 50% with involvement of regional lymph nodes. Cure rates drop by 50% with involvement of regional lymph nodes.The rate of occult metastasis in clinically negative neck for oral tongue cancers ranges from &lt;20% to &gt;30% depending on many predictors. Methods:The relationship clinical and histologic features of the primary tumor of tongue and metastasis to neck nodes was investigated in 90 patients. Results:Histopathologic features of primary tumor showed significant differences in relation to metastasis to neck nodes Conclusion:Tumor stage ,grade. vascular and perineural invasion,morphology ,tumor thickness are important predictors in predicting metastasis to neck nodes.

A Radiomics-Based Nomogram for the Prediction of Occult Lymph Node Metastasis in cN0 Supraglottic Carcinoma

<h3>Purpose/Objective(s)</h3> To develop a radiomics-based nomogram for predicting pathologically occult lymph node metastasis in patients with cN0 supraglottic carcinoma (SGC) to inform the optimal neck treatment. <h3>Materials/Methods</h3> The training set included 131 patients with SGC from 1/2010 to 12/2019 in our hospital, and the validation set included 108 patients from the same time in other hospital. All patents with cN0, defined by computed tomography (CT) and ultrasound or magnetic resonance imaging of the neck, had positive pathologically lymph node. The primary tumors of ROI regions were outlined in each patient's CT image by two radiotherapists. Using the least absolute shrinkage and selection operator (LASSO) method to select radiomics features. The multivariable logistic regression analysis was adopted to develop a radiomics nomogram combining radiomics score and clinical variables. The predictive performance of the model was evaluated by the calibration and decision curve analysis. <h3>Results</h3> Four radiomics features were selected to constitute radiomics signature, which was associated with LNM. Clinical T stage and pathology differentiation were also significant associated with occult metastasis, founded by multivariable logistic analysis. The multiparametric radiomics nomogram incorporate these factors and radiomics signature, which showing better prediction efficacy (C-index 0.805, 95%CI: 0.720-0.890) than radiomics score alone (C-index 0.776, 95%CI: 0.686-0.866) in training set. The area under curve yielded was 0.767 (95%CI: 0.666-0.869) in the validation set. Decision curve analysis showed our model achieved favorable discrimination and calibration. <h3>Conclusion</h3> The radiomics-based nomogram including radiomics signature, clinical T stage, and pathology differentiation has favorable individualized prediction of occult LNM in cN0 SGC patients. This nomogram could offer optimal neck dissection and prophylactic neck irradiation for cN0 SGC patients.

Role of Indocyanine Green in Mapping Sentinel Cervical Lymph Node Involvement in Patients of Oral Squamous Cell Carcinoma - Preliminary Data from a University Hospital

Introduction: Lymph node (LN) positivity is an important determinant in a patient of oral SCC. Sentinel lymph node (SLN) biopsy may aid in minimizing the extent of elective neck dissection (ND). ICG dye facilitates the visualization of lymphatic vessels, sentinel nodes, and provide high penetration during surgery. Methods: It is a prospective observational study in 2021-2022. N = 32 patients of oral SCC were injected with 1mL of ICG submucosally in 4 quadrant fashion (3,6,9 and 12 o’clock). After elevation of platysma flap and posterior retraction of sternocleidomastoid muscle (15 minutes after injecting ICG), fluorescing LNs were detected using NIR (Near Infra-red) fluorescence imaging (STRYKER AIM 1588 camera system) and were sent for frozen section and histopathological examination (HPE). Results: Majority were carcinoma buccal mucosa (53%), followed by tongue (22%) and GB sulcus (12.5%). Most common method of ND was modified radical ND 78%, followed by supraomohyoid 12.5%, extended supraomohyoid 6.25%, radical ND 3.1%. A total of 755 LNs were harvested. 82 lymph nodes were identified as SLN using ICG method. Level Ib was identified as SLN in 26/32 of the cases, followed by level Ia and level IIa (3/32 cases each). 22 out of 82 SLN were positive in frozen section and HPE respectively with a sensitivity of 100%, specificity of 91.8% and NPV (negative predictive value) of 100 %. Routine pathology demonstrated occult metastasis exclusively in SLN in 10 cases (31.25%). Conclusion: NIR using ICG is a feasible and promising method for SLN biopsy in cN0 oral SCC.

Incidence and impact of skip metastasis in the neck in early oral cancer: Reality or a myth?

ObjectivesVarying evidence exists surrounding skip metastasis in clinically node-negative oral cancer. We aim to report its incidence, identify factors predicting its presence, and determine survival outcomes to possibly decide “adequacy” of neck dissection for this select group. MethodsA review of audit records (clinical and pathologic) was undertaken to identify early stage (cT1/T2 cN0) oral squamous carcinoma patients operated between January 2016 and December 2020. Skip metastasis was defined as presence of nodal metastases distant from the primary tumour and at a lower level without metastases at levels above this. The factors predicting its presence were determined using chi-square and multivariate tests. Survival analysis was performed using Kaplan-Meier and regression hazard models. ResultsOccult metastasis rate was 17.9 % among 761 patients, with 47.1 % travelling to level I. Skip metastasis at level III was seen in 1.2 % and level IV was 0.3 %. Presence of PNI predicted the presence of skip metastasis at level III (p = 0.041, OR-0.241, 95 %CI 0.062–0.942) and no significant factors were identified for level IV. The 5-year disease-free survival was significantly reduced with isolated level IV metastasis (50 % vs 79.6 %, p = 0.017). Isolated occult metastasis at level Ia was in 0.3 %, all from tongue cancers. Their presence did not impact the 5-year overall survival (100 % vs 90.7 %, p = 0.628) and disease-specific survival (100 % vs 92.5 %, p = 0.675). ConclusionThe negligible incidence of skip metastasis to level IV in a clinically node negative neck suggests that clearance up to level III might be adequate in a large majority of patients.

The role of staging laparoscopy in pancreatic adenocarcinoma and its effect on patients’ survival

BackgroundPrompt and accurate staging of pancreatic cancer is essential to distinguish patients to benefit from resection with curative intent and those with unresectable disease. A staging laparoscopy is used preoperatively to identify macroscopic or occult metastases not identified on imaging. This single-institution study aims to evaluate the role of staging laparoscopy in patients with pancreatic adenocarcinoma and its effect on overall survival.MethodClinicopathologic data were evaluated for all patients undergoing staging laparoscopy for pancreatic adenocarcinoma from July 2014 to December 2019. The study identified 155 patients eligible for analysis. All patients were followed for at least 2 years. Clinical backgrounds, survival curves and prognostic factors were investigated.ResultsResectability status among the cohort was 62 (40%) upfront resectable, 53 (34%) borderline resectable and 40 (26%) locally advanced disease. The median age was 69, with 44% male patients. Median CA19-9 value was 125 kU/L, and median CA125 value was 22 kU/L. Staging laparoscopy resulted in upstaging nine (15%) upfront resectable patients, five (9%) borderline resectable patients and ten (25%) locally advanced patients. There was positive cytology in 19 (12%), peritoneal deposits in six (4%) and peritoneal liver deposits in seven (5%) patients. Overall, the number needed to treat (NNT) to avoid an unnecessary laparotomy was eight patients.ConclusionStaging laparoscopy continues to be a valuable investigation of pancreatic adenocarcinoma. In this institution, one in every eight patients undergoing a staging laparoscopy was upstaged to metastatic disease, thus avoiding an unnecessary laparotomy or a non-curative resection.

Preoperative platelet-lymphocyte ratio and neutrophil-lymphocyte ratio as predictors of occult lymph node metastasis detected using Desmoglein 3 and Cytokeratin in Indian population.

This study aims to assess whether preoperative platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) can predict occult metastasis in oral squamous cell carcinoma (OSCC). Thirty-five OSCC cases were analyzed for clinicopathological and hematological data. Cases without metastasis (pN0) were checked for micrometastasis immunohistochemically using Desmoglein 3 (DSG3) and Cytokeratin (CK). Mean PLR and NLR were compared and analyzed between the study groups. Metastatic deposits were detected in 9 out of 26 pN0 cases (34.6%) accounting for 11 out of 62 (17%) lymph nodes subjected to immunohistochemistry. The mean PLR was higher in OSCC cases with or without occult metastasis in comparison to controls (P < 0.001). No significant difference was found in the mean PLR and NLR between OSCC cases with and without occult metastasis. Furthermore, we found DSG3+ sinus histiocytes within the lymph nodes in majority of cases which is least reported in literature. A significant percentage of cases showed occult metastasis in this study which led to upstaging of tumor. Although PLR was elevated in OSCC cases, it did not have a positive correlation with the presence of occult metastasis but was able to successfully distinguish OSCC patients from healthy individuals.

Occult metastasis to the superficial level VI lymph nodes in papillary thyroid carcinoma.

This study aimed to evaluate the incidence and risk factors of occult metastasis to superficial level VI, defined as the space anterior to the strap muscles, including the lymph nodes between the sternocleidomastoid and sternohyoid muscles and suprasternal space lymph nodes. We studied 129 patients with papillary thyroid carcinoma who underwent thyroidectomy and neck dissection, including superficial level VI dissection. Of the 129 patients, 62 (48%) had lymph nodes in the harvested specimens of superficial level VI, and the mean number of lymph nodes retrieved was 1.9 ± 1.2. Occult metastasis to superficial level VI occurred in four patients (3.1%). No significant risk factors of superficial level VI occult metastasis were noted in multivariate analysis. Occult metastasis to superficial level VI was rare in patients with papillary thyroid carcinoma. Therefore, prophylactic dissection of superficial level VI may not be necessary for primary papillary thyroid carcinoma.

The Correlation between the Depth of Invasion and Occult Lymph Node Metastasis in Anterior Tongue Cancer

Objective: To determine the correlation between invasion depth and occult lymph node metastasis in anterior tongue cancer, and to establish the optimal tumor-depth cutoff that predicts nodal metastasis. Materials and Methods: Retrospective analyses were done for two groups of patients with T1 and T2 clinical N0 oral squamous cell carcinomas of the tongue who were treated between June 1999 and November 2011. Thirty-nine patients were treated with glossectomy coupled with elective neck dissection as a prophylactic measure (the “END group”). Another 10 patients only had glossectomies as their primary treatment, with at least a 2-year follow-up (the “neck-observation group”). Pathological reports were reviewed for the invasion depths at the tongue lesions. Occult cervical node metastasis was defined by node metastasis in neck specimens in the END group, and by recurrence in the neck-observation group. Results: In the END group, the overall lymph node metastatic rate was 30.8% (n=12/39). The mean invasion depth in positive nodal metastasis was greater than in negative nodal metastasis at 8.68±4.3 mm versus 7.66±3.6 mm, but without significance (p=0.44). As to the neck-observation group, the invasion depth of the 10 patients was 2 to 9 mm (mean 4.4±2.32), and cervical lymph node metastasis occurred in 40%. There was a high incidence of occult metastasis for all tumor depths in the END and neck-observation groups, with minimum depths 2 mm, but no significant correlations were found between nodal metastases and tumor depth. Conclusion: There were no correlations between invasion depth and occult lymph node metastasis in T1 and T2 anterior tongue cancers. A high occult-metastasis incidence occurred for all invasion depth with minimal depth 2.0-mm. Keywords: Cancer; Depth of invasion; Lymph node metastasis; Tongue

Worst Pattern of Invasion as a Predictor of Nodal Metastasis in Early-Stage Oral Squamous Cell Carcinoma.

About one-third of early stage oral cancer patients have occult nodal metastasis. High grade worst pattern of invasion (WPOI) is associated with an increased risk of nodal metastasis and poor prognosis. However, it still remains unanswered whether to perform an elective neck dissection for clinically node-negative disease or not. This study aims to evaluate the role of histological parameters including WPOI in predicting nodal metastasis in early-stage oral cancers. This analytical observational study comprised 100 patients of early-stage, node-negative, oral squamous cell carcinoma, admitted in the Surgical Oncology Department from April, 2018 till the sample size was reached. The socio-demographic data, clinical history, and findings of clinical and radiological examination were noted. The association of nodal metastasis with various histological parameters like tumour size, degree of differentiation, depth of invasion (DOI), WPOI, perineural invasion (PNI), lymphovascular invasion (LVI) and lymphocytic response was determined. SPSS 20.0 statistical tool; student's 't' test and chi-square tests were applied. While the buccal mucosa was the commonest site, the rate of occult metastasis was highest in the tongue. Nodal metastasis was not significantly associated with age, sex, smoking and primary site. While the nodal positivity was not significantly associated with tumour size, pathological stage, DOI, PNI and lymphocytic response, it was associated with LVI, degree of differentiation and WPOI. Increasing WPOI grade correlated significantly with the nodal stage, LVI and PNI, but not with DOI. WPOI is not only a significant predictor of occult nodal metastasis but can also be a novel therapeutic tool in the management of early-stage oral cancers. In patients with an aggressive WPOI pattern or other high-risk histological parameters, the neck can be addressed with either elective neck dissection or radiotherapy after wide excision of the primary tumor; otherwise, an active surveillance approach can be followed.

Predictive factors of occult cervical lymph node metastasis in tongue cancer

AbstractIntroductionCervical lymph node metastasis is the most important prognostic factor in tongue carcinoma. Prophylactic neck dissection improves patient survival, but there are negative impacts on quality of life; consequently, we investigated the predictive factors of occult neck metastasis.ObjectivesFirst, we wanted to identify the rate of occult nodal metastases in patients with squamous cell carcinoma (SCC) of the tongue who had been diagnosed with clinically negative lymph nodes. Second, we explored possible factors that could predict cervical lymph node metastasis.MethodsThe present study was observational and included 62 patients with clinically node‐negative (cN0) oral tongue SCC between September 2019 and December 2020. Clinical presentation, radiological characteristics (tumor size, depth of invasion [DOI], neck lymph node), and pathology (histological grade, DOI, lymphovascular space invasion [LSVI], perineural invasion [PNI], worst patterns of invasion [WPOI‐5], and number of metastasis nodes) were analyzed.ResultsThe rate of occult metastasis was 24.2%. Multivariate analysis indicated WPOI‐5 was an independent prognostic factor. Clinical and histological parameters such as DOI on computerized tomography (CT) (&gt; 7 mm)and DOI on pathology (&gt; 7 mm) showed a significant correlation with the risk of lymph node metastasis but were not strong enough to be independent prognostic factors. The DOI values measured on CT showed a strong correlation with the DOI values on pathology (correlation coefficient = 0.788).ConclusionPatients with positive WPOI‐5, CT‐DOI, and pathological DOI &gt; 7 mm were at high risk of developing cervical lymph node metastasis. We suggest prophylactic neck dissection for these patients.

Nodal Disease and Survival in Oral Cancer: Is Occult Metastasis a Burden Factor Compared to Preoperatively Nodal Positive Neck?

Simple SummaryOccult metastasis in oral squamous cell carcinoma patients is a feared complication. However, there are barely any existing data on survival of patients suffering from occult metastasis. This study aims to compare patients with oral squamous cell carcinoma, considering survival in occult metastases and different treatment approaches.The impact of neck involvement and occult metastasis (OM) in patients with oral squamous cell carcinoma (OSCC) favors an elective neck dissection. However, there are barely any existing data on survival for patients with OM compared with patients with positive lymph nodes detected preoperatively. This study aims to compare survival curves of patients suffering from lymph nodal metastases in a preoperatively N+ neck with those suffering from OM. In addition, clinical characteristics of the primary tumor were analyzed to predict occult nodal disease. This retrospective cohort study includes patients with an OSCC treated surgically with R0 resection with or without adjuvant chemoradiotherapy between 2010 and 2016. Minimum follow-up was 60 months. Kaplan–Meier analysis was used to compare the survival between patients with and without occult metastases and patients with N+ neck to those with occult metastases. Logistic regression was used to detect potential risk factors for occult metastases. The patient cohort consisted of 226 patients. Occult metastases occurred in 16 of 226 patients. In 53 of 226 patients, neck lymph nodes were described as suspect on CT imaging but had a pN0 neck. Higher tumor grading increased the chance of occurrence of occult metastasis 2.7-fold (OR = 2.68, 95% CI: 1.07–6.7). After 12, 24, 48 and 60 months, 82.3%, 73.8%, 69% and 67% of the N0 patients, respectively, were progression free. In the group with OM occurrence, for the same periods 66.6%, 50%, 33.3% and 33.3% of the patients, respectively, were free of disease. For the same periods, respectively, 81%, 63%, 47% and 43% of the patients in the N+ group but without OM remained disease free. The predictors for progression-free survival were a positive N status (HR = 1.44, 95% CI: 1.08–1.93) and the occurrence of OM (HR = 2.33, 95% CI: 1.17–4.64). The presence of occult metastasis could lead to decreased survival and could be a burdening factor requiring treatment escalation and a more aggressive follow-up than nodal disease detected in the preoperative diagnostic imaging.

Occult Neck Metastases in Head and Neck Adenoid Cystic Carcinoma: A Systematic Review and Meta-Analysis.

Introduction: Adenoid cystic carcinoma (AdCC) is a rare tumor whose clinical course is burdened by local recurrence and distant dissemination. Lymph node metastasis is not believed to be common and its clinical impact is controversial. The aim of this study was to determine: (1) the prevalence of occult metastasis at diagnosis in cN0 head and neck AdCC, (2) its prognostic role, and (3) the consequent need to perform elective neck dissection (END). Material and Methods: A systematic review and meta-analyses following PRISMA guidelines was performed. PubMed, Embase, and Central databases were questioned up to July 2021 to identify studies reporting on the prevalence of occult neck metastases in head and neck AdCC. A single-arm meta-analysis was then performed to determine the pooled prevalence of occult lymph node metastases among the retained studies. Results: Of the initial 6317 studies identified, 16 fulfilled the inclusion criteria, and they were included in the meta-analysis. Of a population of 7534 patients, 2530 cN0 patients were treated with END, which revealed 290/2530 cases of occult metastases (pN+/cN0). Meta-analysis of the results of END in the 16 studies estimated an overall prevalence of occult metastases at diagnosis of 17%. No further subgroup analysis was possible to identify factors influencing lymph node involvement and the prognostic role of END. Conclusions: Taking 20% as an historically proposed cut off, a 17% prevalence of occult metastases represents a borderline percentage to get a definitive conclusion about the indication to END for head and neck AdCC. A more advanced UICC stage, an oropharyngeal minor salivary glands origin, and a high-grade transformation are factors to be considered in a comprehensive patient’s tailored therapeutic strategy. Multicenter prospective studies are the key to finding stronger recommendations on this topic.

Optimal timing for lung metastasectomy in patients with colorectal cancer.

OBJECTIVESThe possibility of occult metastasis remains a concern when deciding on lung metastasectomy. This study aimed to evaluate the utility of our two-step determination, which required confirmation that no new metastases had occurred over 3 months before surgery.METHODSPatients who were referred for colorectal lung metastases between 2007 and 2015 were reviewed. Immediate wedge resection was performed for cases with a single peripheral metastasis, whereas surgical indications for others were determined by the two-step determination. Early increase was defined as the emergence of new metastases within 4 months after the diagnosis of lung metastases.RESULTSAmong 369 patients included, 92 were unresectable upon initial diagnosis, and 74 with single peripheral metastasis underwent immediate wedge resection. Surgical indications for the remaining 203 patients were ascertained based on the two-step determination. Surgery was not indicated in 48 patients (24%) due to new metastases or a favourable response to chemotherapy, with a median waiting duration of 4.8 months. Those who did not receive surgery had a worse prognosis than those who did (5-year overall survival: 21% vs 69%, P < 0.001) and were comparable to the initially unresectable group (5-year overall survival: 23%). Thirty-eight patients with early increase had lower surgical resection rates and worse prognoses than those without. Multivariable analysis identified early increase as an independent prognostic factor (hazard ratio: 4.49, P < 0.001).CONCLUSIONSPatients with colorectal lung metastasis who developed new metastasis during the waiting period exhibited poor prognosis, suggesting the utility of the two-step determination of surgical indications.

Sentinel node biopsy in node negative early oral cancers: Solution to the conundrum!

Ideal management of the node-negative neck in early oral cancers is a debated issue. Elective neck dissection (END) is recommended in these patients as it offers a survival benefit. However, about 50–70% of patients who do not harbor occult metastasis are overtreated with this approach. Surgery is associated with morbidity, predominantly shoulder dysfunction. Numerous attempts have been made to identify true node-negative patients through imaging and prediction models but none have high diagnostic accuracy to safely spare the neck dissection. The recent publications of 2 large randomized controlled trials comparing the outcomes of sentinel node biopsy (SNB) and END have spurred interest in SNB. Both the trials reported SNB to be an oncologically safe procedure and spared unnecessary neck dissections. The functional outcomes of the trials showed that SNB limits the morbidity compared to END, which albeit evens out at the end of one-year post-surgery. Despite its benefits, SNB has failed to gain widespread acceptability due to various limitations including the need for infrastructure, equipment costs, staff, and multidisciplinary collaboration of nuclear medicine, surgical, and pathology fraternity. The labor-intensive pathology protocol with serial step sectioning and immunohistochemistry poses a challenge to the feasibility at a high-volume center. This perspective discusses these limitations and propose plausible solutions to the conundrum. To make it widely applicable and feasible across the globe efforts should be directed to understand biology better, find novel solutions, and implement the lessons learned over decades from other sites.

Influence of Site, Size, Depth of Invasion and Histologic Grading on the Occurrence of Cervical Level IIb Metastasis and Extranodal Extension in Clinically N0 Neck of Patients with OSCC: A Single Center Retrospective Analysis.

Depth of Invasion ≥ 4mm, T stage and primary site with more than 20% chances for occult metastasis are currently the accepted indications for elective neck dissection. Nodal metastasis decreases survival by 50%. ENE further reduces the prognosis. Dissection of level IIb lymph nodes in clinically N0 neck does not improve survival. A total of 320 patients were evaluated. Binary and multiple logistic regression and chi-square test were used for data analysis. ROC curve with Youden's J index was used to set up a cutoff value for DOI. The predictor variables were site, size, grading and depth of invasion of primary tumor. Incidence of level IIb metastasis and ENE were the outcomes. The study revealed a significant association and risk stratification between primary tumor characteristics with the occurrence of ENE. The cutoff value for DOI predicting ENE was 12.5mm. Tumors of the oral tongue were an independent risk factor for level IIb metastasis. Size of primary tumor, DOI, tumors of the mandibular alveolus and poor grading are independent risk factors for ENE. Isolated metastasis to level IIb rarely occurs in the absence of concomitant level IIa metastasis. Size, DOI and grading were significantly associated with level IIb metastasis. However, only tumors of the oral tongue were independent risk factor.

Carbonic anhydrase IX stratifies patient prognosis and identifies nodal status in animal models of nasopharyngeal carcinoma using a targeted imaging strategy

Accurate identification of nodal status enables adequate neck irradiation for nasopharyngeal carcinoma (NPC). However, most conventional techniques are unable to pick up occult metastases, leading to underestimation of tumor extensions. Here we investigate the clinical significance of carbonic anhydrase IX (CAIX) in human NPC samples, and develop a CAIX-targeted imaging strategy to identify occult lymph node metastases (LNMs) and extranodal extension (ENE) in animal studies. A total of 211 NPC samples are performed CAIX staining, and clinical outcomes are analyzed. The metastatic murine models are generated by foot pad injection of NPC cells, and a CAIX-targeted imaging agent (CAIX-800) is intravenously administered. We adopt fluorescence molecular tomography and ultrasonography (US)-guided spectroscopic photoacoustic (sPA) imaging to perform in vivo studies. Histological and immunohistochemical characterization are carried out via node-by-node analysis. For clinical samples, 90.1% (91/101) primary tumors, 73.3% (66/90) metastases, and 100% (20/20) local recurrences are CAIX positive. In metastases group, 84.7% (61/72) nodal metastases and 22.2% (4/18) organ metastases are CAIX positive. CAIX expression in primary tumors is significantly associated with NPC stage and prognosis. For animal studies, CAIX-800-based fluorescence imaging achieves 81.3% sensitivity and 93.8% specificity in detecting occult LNMs in vivo, with a minimum detectable diameter of 1.7mm. Coupled with CAIX-800, US-guided sPA imaging could not only detect subcapsular deposits of metastatic cancer cells 2weeks earlier than conventional techniques, but also successfully track pathological ENE. CAIX remarkably expresses in human NPCs and stratifies patient prognosis. In preclinical studies, CAIX-800-based imaging successfully identifies occult LNMs and tracks early stage of pathological ENE. This attractive method shows potential in clinic, allowing medical workers to longitudinally monitor nodal status and helping to reduce unnecessary nodal biopsy for patients withNPC. The schematic diagram for the study. CAIX, carbonic anhydrase IX; NPC, nasopharyngeal carcinoma; US, ultrasonography; sPA, spectroscopic photoacoustic.

The effect of the COVID-19 pandemic on patients with testicular germ cell tumor.

The aim of this study was to investigate the effects of the COVID-19 pandemic on the referral, diagnosis, treatment, and follow-up of germ cell tumor (GCT). A retrospective single-center analysis of all patients who underwent diagnostic and surgical procedures due to GCT was performed from September 2018 to September 2021. 65 patients were enrolled into the study by dividing them into two groups as before pandemic (Pre-CovGCT) and during the pandemic (CovGCT). 33 patients in the Pre-CovGCT group and 32 patients in the CovGCT group were evaluated and compared. A significant increase was observed for symptom duration (p = 0.018), the duration between diagnosis and surgical procedure (p = 0.028), and occult metastasis risk of stage 1 tumors (p = 0.05) during the pandemic period. The duration of symptoms and the duration between the diagnosis and surgical procedure were prolonged in GCT patients diagnosed during the pandemic. Furthermore, an increased risk of occult metastasis has been observed in stage 1 GCT patients. We underline the importance of raising the awareness of patients about admission to the hospital without delay in the presence of testicular cancer symptoms and recommend to be careful not to delay the treatment process.

Analysis of preoperative risk factors for early recurrence after curative pancreatoduodenectomy for resectable pancreatic adenocarcinoma.

ObjectivesTo investigate the risk factors for early recurrence after curative pancreatoduodenectomy for resectable pancreatic ductal adenocarcinoma.MethodsAll data were retrospectively collected from patients with resectable pancreatic ductal adenocarcinoma who had undergone pancreatoduodenectomy at the Department of Surgery, Phramongkutklao Hospital, from January 2015 to December 2020. The preoperative and perioperative risk factors were included into the analysis.ResultsIn total, 34 patients were included in the study. The median time for recurrence and median survival time were 17 and 20 months, respectively. The 1, 3, and 5 year disease-free survival rates were 59.6%, 23.87%, and 23.87%, respectively, while the 1, 3, and 5 year overall survival rates were 81%, 24.7%, and 12.4%, respectively. Seventeen patients (50%) from a total of 34 patients had recurrence, and ten patients (29.41%) had recurrence within 12 months. The independent preoperative risk factor associated with adverse disease-free survival was tumor size > 4 cm (hazard ratio [HR], 14.34, p=0.022). The perioperative risk factors associated with adverse disease-free survival were pathological lymphovascular invasion (HR, 4.31; p=0.048) and non-hepatopancreatobiliary surgeon (HR, 5.9; p=0.022). Risk factors associated with poor overall survival were microscopical margin positive (R1) resection (HR, 3.68; p=0.019) and non-hepatopancreatobiliary surgeon (HR, 3.45; p=0.031).ConclusionsTumor size > 4 cm from the preoperative imaging study was a poor prognostic factor for early recurrence after curative pancreatoduodenectomy for resectable pancreatic adenocarcinoma indicated that they may have radiological occult metastasis, thus, staging laparoscopy may reduce the number of unnecessary laparotomies and avoid missing radiologically negative metastases.