Presence Of Skip Metastasis Research Articles

Application of N Descriptors Proposed by the International Association for the Study of Lung Cancer in Clinical Staging.

Background Patients with N1 or N2 non-small cell lung cancer exhibit prognostic heterogeneity. To refine the current N staging system, new N stages were proposed by the International Association for the Study of Lung Cancer. However, those proposed new N stages have not been validated. Purpose To evaluate the prognostic performance of the proposed N descriptors for clinical staging. Materials and Methods Participants with non-small cell lung cancer without distant metastasis from January 2010 to December 2014 were retrospectively included. Each patient's clinical N (cN) stage was assigned to one of seven categories (cN0, cN1a, cN1b, cN2a1, cN2a2, cN2b, cN3). The 5-year overall survival rates were estimated with the Kaplan-Meier method. The adjusted hazard ratios (HRs) and their 95% CIs were estimated by using a multivariable Cox proportional hazard model. Ad hoc analyses according to lymph node (LN) size were performed. Results A total of 1271 patients (median age, 66 years; interquartile range, 59-73 years; 812 men) were included. The 5-year overall survival rates were 77.3%, 53.7%, 36.0%, 29.2%, 34.4%, 18.0%, and 12.4% for stages cN0, cN1a, cN1b, cN2a1, cN2a2, cN2b, and cN3, respectively. Patients with cN2b disease had a worse prognosis than patients with cN2a disease (HR, 1.53; 95% CI: 1.06, 2.22; P = .02). There was no prognostic difference between cN1b and cN1a (HR, 1.13; 95% CI: 0.61, 2.09; P = .71); however, there was a difference between cN1 subgroups when stratified by LN size (≥2 cm; HR, 2.26; 95% CI: 1.16, 4.44; P = .02). Within cN2a disease, there were no differences between cN2a1 and cN2a2 (HR, 0.98; 95% CI: 0.61, 1.56; P = .93) or between subgroups according to LN size (HR, 0.74; 95% CI: 0.40, 1.37; P = .34). Conclusion A survival difference was observed between single- and multistation involvement among cN2 disease. The number of involved lymph node stations in patients with cN1 disease and the presence of skip metastasis in patients with cN2 disease were not associated with survival differences. © RSNA, 2021 Online supplemental material is available for this article.

Minimal invasive surgery in locally advanced N2 non-small cell lung cancer.

Locally advanced lung cancer, defined by nodal involvement in upper mediastinal stations (N2) (stage IIIA–N2), includes a wide spectrum of patients with multiple therapeutic alternatives. Such heterogeneity is explained, at least in part, by tumor size and magnitude of mediastinal nodal involvement. In this setting, many variants can influence the prognosis, such as the specific nodal stations compromised, the burden of mediastinal disease, and the presence of skip metastasis. In the surgical field, the advent of minimally invasive techniques, including video-assisted thoracoscopic and robotic surgery, have revolutionized the management of early-stage lung cancer, but implementations of these approaches in the locally advanced setting have been erratic. This review attempts to highlight the most relevant scientific data of the surgical management of locally advanced lung cancer patients, analyzing not only the medical evidence but also the cost-effectiveness and accessibility.

A LOOK AT THE NAVIGATION SURGERY OF THE GASTRIC CANCER: THE PRESENT STATE OF THE PROBLEM AND OWN EXPERIENCE

Introduction: Concept of sentinel lymph node biopsy has been discussed during several last decades, because this idea seems perspective in terms of modern minimally invasive and organ-preserving era. However, this method has several limitations including complicated anatomy of gastric lymph nodes distribution and presence of skip-metastases. Materials and methods: 66 Patients with early gastric cancer, intermediate risk of lymph node metastases and technical possibility of ESD were included into our investigation. Patients were assigned to either ESD with sentinel lymph node biopsy (54 patients), or underwent distal gastrectomy or total gastrectomy with D1+/D2 lymphadenectomy (12 patients) by chance. Results: 56 (84,6%) Patients had at least one sentinel lymph node. 11 (16,7%) Patients with T1a-T1b had metastases in regional lymph nodes, 9 of them in sentinel lymph nodes (2 false-negative result). So, we calculated sensitivity of 84,6%. In one case, the metastasis was located outside the sentinel lymphatic basin, and in the other case, metastasis was detected in a patient with unlit lymph nodes. Conclusion: Today sentinel lymph node biopsy thechnique is considered as a well investigated and widly used method. The concept itself is promising for organ-preserving gastric cancer surgery.

Do New pN Subclassifications Proposed by IASLC’s Lung Cancer Staging Project Agree with ypN Categories after Trimodality Therapy for Initial N2 Disease?

IntroductionThe International Association for the Study of Lung Cancer's lung cancer staging project has recently proposed a new subclassification of pN1-2 based on multiplicity of involved nodal stations and presence of skip metastasis. The authors investigated whether this new subclassification agrees with the ypN categories after trimodality therapy for initially N2 disease. MethodsFrom March 2001 until June 2014, trimodality therapy consisting of preoperative thoracic radiation therapy concurrent with weekly platinum-based doublet chemotherapy and surgical resection was successfully undertaken in 508 patients after histopathologic confirmation of N2 disease. Data on 481 patients were analyzed and compared with special focus on the current and new pN classification. ResultsThe median duration of overall survival (OS) was 58 months, and the 5-year OS rate of all patients was 48.8%: 62.6% in ypN0; 45.5% in ypN1; 37.6% in ypN2; and 0% in ypN3. Comparisons between neighboring ypN categories showed significant difference between ypN0 and ypN1 (p = 0.028) but not between other categories. The 5-year OS rates according to new ypN subclassification were 48.2% in ypN1a, 39.0% in ypN1b, 52.8% in ypN2a1, 37.9% in ypN2a2, and 32.1% in ypN2b. Although the OS rate of ypN2a1 was numerically higher than those of ypN1b and ypN2b, comparisons between neighboring ypN categories revealed no significant difference. ConclusionsThe current study was specifically intended to investigate whether ypN categories after trimodality therapy agree with International Association for the Study of Lung Cancer's new pN subclassification. Through the current study, the authors have confirmed that ypN downstaging to ypN0-1 from initial N2 stage is a favorable factor with respect to OS and raised the need for refinement of ypN subcategorization after trimodality therapy.

The prognostic value of a combined pattern of mediastinal lymph node metastasis for pIIIa-N2 non-small-cell lung cancer

Objective: To comprehensively investigate the prognostic significance of nodal skip metastasis and lobe-specific metastasis for patients with IIIa-N2 non-small-cell lung cancer (NSCLC). Methods: A total of 218 completely resected pN2-NSCLC cases with systematic lymph node dissections from 2008 to 2009 at Tianjin Medical University Cancer Hospital were enrolled. Mediastinal lymph node metastasis was subdivided into continuous metastasis and skip metastasis according to whether N1 lymph nodes were involved. Mediastinal lymph node metastasis was also classified into extensive metastasis and lobe-specific metastasis on the basis of whether the lymph nodes involved were within or beyond lobe-specific regions. Overall survival (OS) and disease-free survival (DFS) were compared. Results: For the whole cohort, 5-year OS was 21.6% and 5-year DFS was 16.8%. The 5-year OS for patients with skip metastasis or continuous metastasis were 37.6% and 22.0%, respectively (P=0.008). The 5-year DFS of patients with skip metastasis or continuous metastasis were 29.1% and 15.0%, respectively (P=0.022). The 5-year OS of patients with lobe-specific metastasis and extensive metastasis were 38.3% and 20.4%, respectively (P=0.005). The 5-year DFS of patients with lobe-specific metastasis and extensive metastasis were 28.4% and 15.1%, respectively (P=0.009). According to the two patterns, patients were subdivided into three subgroups: Group A (presence of both skip metastasis and lobe-specific metastasis), Group B (presence of skip metastasis only or lobe-specific metastasis only), and Group C (presence of non-skip metastasis and non-lobe-specific metastasis). The 5-year OS of the three subgroups were 47.1% (Group A), 28.1% (Group B), and 16.6% (Group C) (P=0.001), and the 5-year DFS of these subgroups were 35.2% (Group A), 20.8% (Group B), and 11.2% (Group C), respectively (P=0.002). Multivariate analysis demonstrated that the combined pattern was an independent prognostic factor for both OS and DFS. Conclusion: This combined pattern of lymph node metastasis was a 作者单位:1天津医科大学肿瘤医院放疗科,国家肿瘤临床医学研究中心,天津市肿瘤防治重点实验室(天津市300060);2肺部肿瘤科 􀆽本文课题受国家自然科学基金项目(编号:81372518)及天津市抗癌重大专项攻关计划项目(编号:12ZCDZSY15900)资助 通信作者:王平 tjdoctorwang@163.com 1312 中国肿瘤临床 2014年第41卷第20期 Chin J Clin Oncol 2014, Vol. 41, No. 20 www.cjco.cn strong prognostic factor for IIIa-N2 NSCLC. This pattern should be considered when predicting prognoses and during the selection of patients that will receive postoperative treatments.

Invited Commentary

Invited Commentary

Prognostic Evaluation of Nodal Staging Based on the New IASLC Lymph Node Map for Lung Cancer

The purpose of this study was to evaluate the new lymph node map proposed by the International Association for the Study of Lung Cancer (IASLC) from the point of prognosis, and to identify the significant prognostic factors in each pathological N stage. We reviewed 647 consecutive patients with surgically resected non-small cell lung cancers. Survival was analyzed according to N stage and three prognostic subgroups: N1a (single N1 zone), N1b (multiple N1 zones) or N2a (single N2 zone), and N2b (multiple N2 zones). The following prognostic factors were evaluated for each N stage: location of involved zones, number of involved lymph nodes, stations and zones, and the presence of skip metastases. (1) The survival curves showed a stepwise deterioration as the N stage increased. (2) No significant difference was observed in survival between the different locations of involved zones in each N stage. (3) In N2 patients, the presence of skip metastases was a significant prognostic factor in multivariate analysis. The proposed IASLC map is valid for prognostic stratification. The prognostic impact of the presence of skip metastases on N2 disease should therefore be taken into consideration when carrying out the forthcoming revision of the TNM staging system.

A cadaveric study of auricular lymphatics and implications for sentinel lymph node biopsy

Malignant cutaneous tumors of the auricle are known to have a high rate of spread to the regional lymph nodes, and, for this reason, removal of the lymph nodes, for diagnostic or therapeutic purposes, is often required. Recent experience with sentinel node biopsy in cutaneous tumors of the head and neck has questioned the traditional lymphatic pathways and prompted a new study. Lymphatic pathways from the auricle were demonstrated by India ink injection of five auricles in three cadavers followed by block dissection and Spalteholz clearing of en bloc specimens. Lymphatics descend adjacent to the mastoid bone periosteum and lie deep to the insertion of the sternocleidomastoid muscle. There are five different locations for sentinel nodes: superficial parotid, anterior mastoid, infra-auricular parotid, deep to sternocleidomastoid, and lateral mastoid. Two of these nodal locations (anterior and lateral mastoid) may be bypassed by anastomotic pathways. We conclude that, first, echelon lymph nodes lie in five different sites, some bypassed by anastomotic lymphatics. Lymphatics from the ear lie close to the mastoid bone and pass deep to the insertion of sternocleidomastoid where they may be difficult to follow. Sentinel lymph node biopsy for cutaneous tumors of the auricle is possible, but the presence of skip metastases should be considered.

Clinical and prognostic analysis of skip N2 metastases in stage IIIA-N2 non-small cell lung cancer

To investigate the clinicopathologic factors and the distribution pattern of N2 lymph nodes, to analyze the relationship between the survival rate and skip metastasis of non-small cell lung cancer (NSCLC) patients. The clinical data of 478 patients with a pN2 stage who underwent resection for non-small cell lung cancer from January 2000 to December 2004 was retrospectively analyzed. Skip group and non-skip group were defined. Characteristics of tumors, ganglionar involvement and survival were analyzed in both groups. The incidence rate of skip N2 metastasis in stage IIIA-N2 NSCLC patients was 40.6%, which was correlated to sex, smoking and the type of histology (P < 0.05). Squamous carcinoma was the main type of skip group (chi² = 7.602, P = 0.022). The frequency of skip metastasis was higher in patients with a primary tumor in the upper lobe (57%) compared to the lower lobe (43%) (chi² = 5.097, P = 0.024). Superior nodes were more frequently involved by skip group (chi² = 7.046, P = 0.030). Moreover, the relationship between the primary tumor location and N2 positive lymph nodes were described as follows: right upper lobe cancer displayed skip-N2 nodal metastasis mostly in the 2nd, 3rd and 4th station, right middle and lower lobe mostly in the 7th station, left upper lobe mostly in the 5th and 6th station (71.7%), and left lower lobe mostly in the 7th and 9th station. The 5-year survival rate of pN2 patients with skip metastasis was 22.1% compared to 13.6% in patients with involvement of N1 and N2 nodes (P = 0.001). Survival analysis showed that skip N2 metastasis was an independent risk factor of stage IIIA NSCLC. The frequency of skip metastasis was higher in patients with a primary tumor in the upper lobe and in the superior nodes. Skip metastasis is an independent prognostic factor of survival. The presence of skip metastasis seems to be a unique subgroup of pN2 disease in NSCLC.

Role of skip metastasis to mediastinal lymph nodes in non-small cell lung cancer.

Skip metastasis to mediastinal lymph nodes is a well-known phenomenon in non-small cell lung cancer (NSCLC). Little is reported in the literature about its clinical importance. It is still under discussion whether any prognostic differences exist between resected NSCLC with either skip metastases or continuous mediastinal lymph node metastases (N2). We analyzed retrospectively the data of 45 patients with a pN2-stage, who underwent resection for NSCLC. Seventeen of these patients (37.8%), showing no metastatic involvement of hilar (N1) lymph nodes, were compared to the remaining 28 patients with infiltration of hilar nodes (N1) as well as N2 nodes. Multivariate analysis showed no statistically significant difference between the skip metastasis and the continuous N2 group regarding sex, age, histology, T- or M-status. The frequency of skip metastasis was higher in patients with a primary tumor in the upper lobe (n = 12, 71%) compared to the lower lobe (n = 5, 29%). This difference was not statistically significant. In patients with a non-continuous lymph node spread, 29 out of 119 resected mediastinal lymph nodes were infiltrated (1.7 per patient, range: 1-10). Compared to 83 metastatic involved lymph nodes out of 198 resected mediastinal nodes (three per patient, range: 1-10) in patients with involvement of N1 and N2 nodes (P = 0.034, Mann-Whitney test). The 5-year survival rate of pN2 patients with skip metastasis was 41% compared to 14% in patients with involvement of N1 and N2 nodes (P = 0.019). pN2 patients with mediastinal lymph node skip metastasis have a more favorable prognosis compared to pN2 patients with continuous infiltration of the regional lymph nodes. Patients with a continuous lymph node involvement show an increased number of infiltrated mediastinal lymph nodes per patient compared to patients with a non-continuous spread. Skip metastasis is an independent prognostic factor of survival. The presence of skip metastasis seems to be a unique subgroup of pN2 disease in NSCLC.