Paracardiac Lymph Nodes Research Articles

Impact of postoperative lymph node status on the prognosis of esophageal squamous cell carcinoma after esophagectomy following neoadjuvant chemoradiotherapy: a retrospective study.

Neoadjuvant chemoradiotherapy (nCRT) and surgery are widely used treatments for locally advanced esophageal squamous cell carcinoma (ESCC). Thus, it is critically important to investigate risk factors that affect patient prognosis after preoperative chemoradiotherapy and surgery. We conducted a retrospective analysis of 77 patients with ESCC who received nCRT and underwent surgery at our center from January 2015 to December 2019. We analyzed the primary clinical data, postoperative pathological results, recurrence, and death results. Among the 77 ESCC patients who received nCRT and surgery, 19 achieved a postoperative pathologic complete response (pCR), and the overall pCR rate was 24.68%. The univariate analysis indicated that postoperative post-neoadjuvant treatment N stage (ypN) metastasis [hazards ratio (HR): 2.908; 95% confidence interval (CI): 0.874-9.676; P=0.082], a high lymph-node ratio [(LNR) >0.1] (HR: 7.149, 95% CI: 1.740-29.369; P=0.006), post-neoadjuvant treatment T3-4 (ypT3-4) (HR: 3.626, 95% CI: 0.824-15.956; P=0.088) affected disease-specific survival (DSS). The multivariate analysis indicated that a high LNR (>0.1) (HR: 6.170; 95% CI: 1.472-25.856; P=0.013) was a significant independent predictor of DSS. The univariate analysis indicated that postoperative ypN metastasis (HR: 2.283; 95% CI: 1.047-4.979; P=0.038) and a high LNR (>0.1) (HR: 4.210; 95% CI: 1.547-11.458; P=0.005) were associated with recurrence-free survival (RFS). The multivariate survival analysis showed that a high LNR (>0.1) (HR: 4.289; 95% CI: 1.538-11.965; P=0.005) was also a significant independent predictor of RFS. In this study, 57 positive lymph nodes were found in 30 of the 77 patients, including 16 left gastric lymph nodes, 9 pericardial lymph nodes, and 7 left supraclavicular lymph nodes. A high LNR (>0.1) in ESCC patients after nCRT is a risk factor of DSS and RFS. ypN metastasis is also an independent predictor of RFS. Left gastric-arterial lymph nodes, para-cardiac lymph nodes, and left supraclavicular lymph nodes are the most common sites of metastasis in ESCC after nCRT.

Phlegmonous Appearance in the Ipsilateral Paracardiac Fat without Paracardiac Lymph Node Enlargement on Chest CT Favors the Diagnosis of Pleural Tuberculosis over Malignant Pleural Effusion.

This study investigated the potential role of paracardiac fat stranding (FS) interspersed with multiple fluid collections (FC) as a clue to differentiate between pleural tuberculosis (pleural TB) and malignant pleural effusion (MPE). The authors retrospectively analyzed chest computed tomography (CT) findings of 428 patients, 351 with pleural TB and 77 with MPE, focusing on the paracardiac fat, and level of pleural adenosine deaminase (ADA) and blood C-reactive protein (CRP). Two radiologists independently evaluated the chest CT findings regarding the paracardiac fat pad ipsilateral to the effusion, including FS, FC, phlegmonous appearance (a combination of the FS and multiple FC), and the presence of lymph node enlargement (>1 cm in short axis diameter). There were significant differences between patients with pleural TB and those with MPE with respect to the prevalence of phlegmonous appearance in the ipsilateral paracardiac fat (47.6% and 10.4%, p < 0.001, OR = 7.8; 95% CI 3.7–16.8) and paracardiac lymph node enlargement (1.4% and 19.5%, p < 0.001, OR = 0.06; 95% CI 0.02–0.2) on CT. In contrast, there was no difference in the prevalence of isolated FS or multiple FC within the ipsilateral paracardiac fat between the two groups. Median pleural ADA and serum CRP level were higher in patients with pleural TB accompanied by phlegmonous appearance in paracardiac fat compared to those without that appearance (ADA: median 104 IU/L versus 90 IU/L, p < 0.001; CRP: 6.5 mg/dL versus 4.2 mg/dL, p < 0.001). In conclusion, phlegmonous appearance in the ipsilateral paracardiac fat without paracardiac lymph node enlargement on chest CT favors a diagnosis of pleural TB over MPE.

Concomitant Laparoscopic and Thoracoscopic Resection of Recurrent High-Grade Ovarian Cancer

Study ObjectiveTo describe the first case of combined endoscopic management of a thoracic and abdominal recurrence of ovarian cancer. DesignAn instructive video showing the combined thoracic and abdominal surgical procedure. SettingDepartment of Gynecological Oncology, Churchill Hospital, Oxford University, UK. PatientsA 64-year-old woman undergoing endoscopic treatment for a third recurrence of ovarian cancer after a full surgical staging in 2007. The disease-free interval from the last recurrence was 31 months. InterventionThe operation was performed by a multidisciplinary team of thoracic and gynecologic oncologist surgeons. Surgery started with thoracoscopic resection of a right enlarged paracardiac lymph node of 24 mm and a small wedge of the right lung, which was attached to the lymph node. At laparoscopy, 2 nodules of 3 and 5 mm were excised from the mesosigmoid and 1 nodule of 20 mm was resected from the right hemidiaphragm. Measurements and Main ResultsThe total operative time was 251 minutes, and no intraoperative complication occurred. No conversion to open surgery was necessary. The estimated blood loss was 50 mL. There was no visible residual disease at the end of the surgery. The patient was discharged 4 days after surgery. The final pathology report confirmed the presence of endometrioid adenocarcinoma in all specimens removed. Adjuvant chemotherapy with carboplatin/paclitaxel was started 2 weeks later. At the 60-day follow-up, no complications were recorded. A computed tomographic scan performed after 6 cycles of chemotherapy did not reveal any evidence of relapse. ConclusionsThe combined endoscopic approach might be feasible in selected patients.

Cirrhosis Related to Hepatic Sarcoidosis in Older Adults

Cirrhosis Related to Hepatic Sarcoidosis in Older Adults

Patterns of lymphatic spread in thoracic esophageal squamous cell carcinoma: a study of 313 cases

We analyzed the lymph node (MLNs) metastasis of thoracic esophageal squamous cell carcinoma (ESCC) to explore the patterns of lymphatic spread and the rational surgical procedure and extent of lymph node dissection for ESCC. We retrospectively evaluated 313 consecutive patients treated in our hospital between January 2010 and May 2014 who underwent minimally invasive esophagectomy (MIE) for ESCC. The information of lymph node status was obtained and the features of lymph node metastasis were analyzed. Of the 313 cases, 122 (39.0%) were found to have lymph node metastasis. In the 4461 dissected lymph nodes, metastasis was identified in 294 (6.6%) lymph nodes. The recurrent laryngeal nerve lymph nodes were the most frequent metastatic nodes with a metastasis rate of 25.2%, followed by the paracardiac and left gastric artery lymph nodes (18.2%). Chi-square test showed that the lymph node metastasis is associated with tumor invasion and tumor differentiation (P<0.001 for both). Metastases were more frequently found in the recurrent laryngeal nerve lymph nodes in patients with tumors in the upper third esophagus and with histologically poor differentiation (P<0.05 for both). The metastasis rate of para-cardiac and left gastric artery lymph nodes was associated with tumor in the lower third of esophagus, T stage and differentiation (all P<0.05). Logistic regression analysis showed that tumor differentiation and location are independent factors affecting the metastasis of recurrent laryngeal nerve lymph nodes (P<0.05 for all). T stage, tumor differentiation and location were independent factors associated with metastasis of para-cardiac and left gastric artery lymph nodes (P<0.05 for all). (1) Metastases of thoracic esophageal carcinoma are often found in the recurrent laryngeal nerve lymph nodes, para-cardiac and left gastric artery lymph nodes. (2) Extensive lymph node dissection should be performed for ESCC with poor differentiation and deep tumor invasion.

The significance of paracardiac lymph-node enlargement in patients with newly diagnosed stage IIIC ovarian cancer

ObjectiveExtra-abdominal metastases in epithelial ovarian cancer (EOC) are relatively rare. Interpreting computed tomography (CT) scans, during initial work-up, little attention is focused on enlargement of paracardiac lymph nodes (PCLN) and their significance is not clear. We aimed to examine whether the presence of PCLN during initial diagnosis of EOC influences prognosis. MethodsA retrospective study comparing patients with stage 3 EOC who were diagnosed with PCLN on CT scan during initial evaluation to stage 3C patients without PCLN. Scans were reviewed by a single radiologist for peritoneal involvement, distal metastases and presence of PCLN. Disease status at diagnosis, results of surgery, chemotherapy and response, disease-free interval (DFI) and overall survival (OS) were recorded. ResultsThirty one patients with stage 3C EOC with PCLN on initial CT scan were included and compared with 41 controls. There was no significant difference between groups in abdominal optimal cytoreduction rate. Lower rates of complete response (CR) to initial treatment were detected in the study group (45.2% vs. 78.0%, p=.004). In survival analysis, the DFI for patients with PCLN was shorter (median 9.0 vs. 24.0months, p=.0097) and overall survival was shorter (median 31.7 vs. 61.3months, p=.001). Multivariate analysis showed that PCLN was significantly associated with a lower rate of CR, a shorter DFI and a shorter OS. ConclusionThe presence of enlarged PCLN at presentation appears to be associated with poor prognosis in stage 3C EOC. Further attention should be given to detection and follow-up of such findings when considering treatment.

Can paracardiac lymphadenopathy predict peritoneal disease in ovarian cancer?

Purpose: An association between paracardiac lymphadenopathy and peritoneal disease in patients with ovarian cancer has been proposed. This study aims to corroborate the relationship between paracardiac lymph nodes and peritoneal disease in ovarian cancer in greater detail.

The significance of paracardiac lymph node enlargement in ovarian cancer

The computed tomography (CT) scans of 78 patients with stage II, stage III and relapsed stage I ovarian carcinoma were reviewed in order to identify the incidence of enlarged paracardiac lymph nodes in this disease, recognize their association, if any, with peritoneal metastases and establish whether they had any bearing on progression free interval and survival. Twenty-two patients (28%) were found to have enlarged paracardiac nodes, nine at initial presentation and a further 13 during the course of follow-up. The association between paracardiac node enlargement and peritoneal metastases was found to be highly significant. Thirty per cent of 27 patients with peritoneal metastases at presentation were found to have enlarged paracardiac nodes whereas of the 51 patients without peritoneal dissemination only 2% had enlarged paracardiac nodes (P < 0.001). In order to determine whether paracardiac nodal status had any independent prognostic value, multivariate analysis using Cox's regression was performed. When status at presentation was considered, the presence of enlarged paracardiac lymph nodes was found to be an independent predictor for survival. (Hazard ratio 3.70, 95% confidence interval (1.18-11.6), P < 0.04.) The hazard ratio for paracardiac nodal status with respect to progression free survival was not significant but in the expected direction. (Hazard ratio 1.85 (0.65-5.25).) When time-dependent covariate analysis was applied, paracardiac nodal status and peritoneal metastases status were found to be independent predictors for both progression free survival and overall survival. The presence of peritoneal metastases indicated a poorer prognosis than the presence of paracardiac lymph nodes, the hazards ratios for progression free survival were 12.9 and 2.58, respectively, and those for survival were 20.7 and 3.62, respectively. We have demonstrated that the presence of paracardiac lymph node enlargement is a significant adverse prognostic factor for both progression free interval and survival. The diagnosis of involved paracardiac lymph nodes is important as it can define patients having stage IV as opposed to stage III disease.

Evaluation of gallbladder function before and after gastrectomy using a double-isotope method.

The motor function of the gallbladder after partial distal gastrectomy for gastric carcinoma (Billroth-I reconstruction) and its relationship to the motor function of the stomach was investigated using a double-isotope method. In this method, [99mTc]N-54-pyridoxyl-5-methyltryptophan ([99mTc]PMT) was utilized as a tracer for the biliary tract and [111In]diethyl-triaminopontacetic acid ([111In]DTPA) mixed with a liquid test meal was used as a tracer for the digestive tract. Gastric emptying half-time (GET1/2) was measured, since this was used historically as the physiologic indicator of gallbladder contractile stimulus. The volume of test meal that emptied from the stomach into the duodenum per minute (VOL/MIN) was measured, as was the gastric emptying duration (GED). A series of gallbladder emptying phenomena were analyzed using three different criteria: gallbladder emptying half-time (GBET1/2), retention rate of bile in the gallbladder (RR), and the start of gallbladder bile ejection into the duodenum after ingestion (TL: time lag). While GET1/2 was reduced (P < 0.01) and VOL/MIN was increased (P < 0.01) after gastrectomy, GED was shortened remarkably (P < 0.01). GBET1/2 showed no significant change, RR increased (P < 0.05), and TL was prolonged (P < 0.01). The postoperative dysfunction of the gallbladder was caused by the short and intense stimulus on the biliary tract during the duodenal phase and by intraoperative injury to the innervation of the gallbladder. In particular, the hepatic branch of the left vagus nerve was injured during the right paracardiac lymph node dissection performed as a component of the radical gastrectomy.

Changes in Paracardiac Lymph Nodes in Portal Hypertension

Because of their proximity to the coronary vein and thoracic duct, the para cardiac lymph nodes are liable to develop both venous and lymphatic conges tion. The authors studied morphologic changes in the paracardiac lymph nodes in patients with portal hypertension. Paracardiac lymph nodes were obtained during surgery from 40 volunteer patients with esophageal varices due to schistosomal portal hypertension (29 nonbleeders, 11 bleeders). Paracardiac lymph nodes from 10 volunteer patients having surgery for correction of incisional hernia served as controls. The main histologic difference found in this study was the lower incidence of necrosis in nonbleeders. This indicates the possible role played by inadequate lymphatic drainage of the excessive lymph produced by the congested varices- bearing area in the bleeder.

Paracardiac adenopathy: CT evaluation.

To establish the normal CT appearance of lymph nodes in the paracardiac area, we reviewed the CT scans of 50 patients without known malignancy or benign causes of lymphadenopathy. Five patients (10%) showed soft-tissue densities in the paracardiac region. The largest of these measured 3.5 mm. No more than two rounded soft-tissue densities were seen in any of the normal CT studies. Forty-five patients with paracardiac adenopathy were subsequently evaluated. In 27 (60%) of these the masses were due to either carcinoma, sarcoma, or benign disease. In 40%, the cause of paracardiac adenopathy was lymphoma. Features that favor a diagnosis of lymphoma are bilateral disease, multiple nodes, nodes greater than 2 cm in diameter, a lobulated or "matted" appearance, and associated pericardial thickening/effusion. Chest radiographs obtained within 2 weeks of the CT scans in 38 patients revealed only nine cases in which a paracardiac mass could be seen. This study suggests that 1 cm is the upper limit for the diameter of lymph nodes in the paracardiac region, and that paracardiac adenopathy may be caused by a wide variety of nonlymphomatous malignant and benign diseases in addition to lymphoma. Compared with CT, chest radiographs are insensitive for detecting paracardiac lymph node enlargement.

Acute and chronic microsphere loss from canine left ventricular myocardium.

We determined the effects of time, type of anesthesia, and myocardial infarction on loss of radioactive microspheres averaging 9 or 15 micrometers diameter from left ventricular myocardium. The principle used to compute losses was comparison of the number of microspheres injected directly into coronary arteries to the numbers remaining in myocardium, appearing within 2-4 min in the coronary sinus, or trapped in the lungs. Losses of 9-micrometers microspheres within 2 min of injection were significantly greater for halothane (mean 6.3%) than nitrous oxide anesthesia (mean 3.3%), and in the next 2 h increased to 11.7 and 7.9%, respectively. Over 5 wk in conscious dogs losses were as high as 40 and 11% for 9 and 15 micrometers microspheres, respectively. Losses were not greater for infarcted than normal muscle, and negligible radioactivity appeared in paracardiac lymph nodes. Microspheres leaving the heart were almost all below 10.3 micrometers diameter, so that microspheres with diameters 10-14 (mean 12) micrometers might be the best size to use for myocardial studies.

Abnormal Cardiac Silhouette in a Patient With Hodgkin's Disease

History Hodgkin's disease, mixed cell type, was diagnosed in a 38-year-old woman after biopsy of an enlarged left supraclavicular lymph node in May 1975. Chest roentgenogram showed right and left paratracheal masses (Fig 1), and her lymphoma was subsequently staged as IIIA after splenic involvement was found at laparotomy. She received external beam irradiation with 4,500 rads to a standard thoracic mantle and 4,000 rads to inverted Y and right and left inguinal fields. The paratracheal adenopathy disappeared after irradiation, but the cardiac silhouette was noted to be abnormal in August 1977 (Fig 2). Diagnosis Recurrent Hodgkin's disease involving the paracardiac lymph nodes at the cardiac apex. Comment Figure 2 shows a mass in the left cardiophrenic angle that was not present on the earlier film. Histological proof of Hodgkin's disease was obtained by a fluoroscopically guided transcutaneous fine-needle aspiration biopsy. Mediastinal lymph node involvement is common in Hodgkin's disease,