Propensity For Lymph Node Metastasis Research Articles

Solid-basaloid Variant of Mammary Adenoid Cystic Carcinoma – Report of an Unusual Case with Literature Review

Abstract Introduction/Objective Adenoid cystic carcinoma (AdCC) of breast is a rare subtype of malignancy, constituting approximately 0.1% of all breast carcinomas. The solid-basaloid variant (SB-AdCC) is exceedingly uncommon. Here, we present such an unusual case of SB-AdCC. Methods/Case Report A 64-year-old woman who underwent screening mammography presented with abnormal findings, revealing a hypoechoic ovoid, lobulated nodule at 7:00 of the left breast, which prompted an ultrasound- guided biopsy. Histologically, the biopsy cores demonstrated a 9 mm infiltrative round, solid nests with focal “cribriforming” areas. It was composed of monomorphic basaloid epithelial cells with marked nuclear atypia and high mitotic count. High-grade ductal carcinoma in situ, solid papillary carcinoma, and nonspecific invasive carcinoma were in differentials. Immunohistochemical (IHC) staining expressed positivity for CD117 and CK 5/6, while p63, SMMHC, and synaptophysin were negative. MYB gene rearrangement confirmed by fluorescence in situ hybridization. As expected, the tumor lacked ER, PR, and HER2 expression by IHC. Left breast mastectomy and axillary lymph node dissection have been scheduled. Results (if a Case Study enter NA) NA Conclusion Per literature review, the mean age of SB-AdCC at diagnosis was 68 years (33-84 years) with an average tumor size of 25 mm (12-70 mm). It had more aggressive behavior, with a higher propensity for lymph node metastasis, locally recurrence, and distant metastasis. The median disease-free survival was 46.5 months versus 151.8 months in those with class AdCC. Notably, neovascularization has emerged as a strong independent predictor of outcome in SB-AdCC. Most patients were treated with surgical excision, axillary lymph node dissection, and/or adjuvant chemotherapy. Limited studies demonstrated that neoadjuvant chemotherapy may induce an excellent response. Furthermore, a distinct molecular mutation enriched in NOTCH and CREBBP genes has been identified, which could be novel potential therapeutic target. Thus, awareness of this extremely rare breast cancer subtype and accurate differentiation from other entities are paramount for appropriate management strategies.

Papillary Thyroid Carcinoma: Correlation Between Molecular and Clinical Features.

Thyroid cancer is prevalent worldwide, including in China, where its incidence is on the rise. Papillary thyroid carcinoma (PTC) is the predominant subtype. Investigating the relationship between clinical data associated with PTC and gene mutations is crucial for improving detection and treatment. We collected samples and associated clinical data from 700 PTC patients at Shanxi Provincial People's Hospital. Using a panel of 57 genes linked to thyroid cancer, we sequenced the samples to determine the mutation frequency of thyroid cancer-associated genes in PTC. We further analyzed the correlation between gene variants and clinical information. The mean age of patients in this study was 42.5 years. Females predominated, comprising 507 of the total patient population, resulting in a female-to-male ratio of 2.63 (507:193). Tumor distribution revealed 198, 257, and 142 cases on the left, right, and both sides, respectively. Among the 57 thyroid cancer-related genes analyzed, we identified at least one driver gene in 83.6% of patients. Notably, 76.4% had BRAF mutations, mainly BRAFV600E, which constituted 90.9% of all BRAF mutations, with 535 cases exhibiting these mutations. Other significant driver genes included CHEK2 (n=84), RET (n=42), PIK3CA (n=7), and EGFR (n=7). RET fusions (n=28) were also identified. Notably, patients under 55 years old exhibit a higher tendency towards advanced N staging, suggesting that younger individuals may be more prone to lymph node metastasis. Additionally, male patients were more likely to have advanced N stages. Importantly, a positive correlation was observed between higher BRAF allele frequencies and more advanced T and N stages. Similarly, correlation analysis revealed that a greater frequency of RET fusions correlated with later T and N stages. This study uncovered several significant insights. Younger PTC patients exhibited a higher propensity for lymph node metastasis. An elevated mutation frequency of BRAF was correlated with a higher occurrence of RET fusions, predisposing individuals to lymph node metastasis and potentially indicating a poorer prognosis.

Prognostic factors of resectable anaplastic lymphoma kinase (ALK)-rearranged non-small cell lung cancer (NSCLC) patients: a retrospective analysis based on a single center.

Anaplastic lymphoma kinase (ALK)-rearranged non-small cell lung cancer (NSCLC) exhibited a higher propensity for lymph node metastasis (LNM). This study aimed to investigate risk factors of occult lymph node metastasis (OLNM) and recurrence in resectable ALK-rearranged NSCLC patients. This retrospective analysis included patients with ALK-rearranged NSCLC receiving lung resections at Shanghai Pulmonary Hospital from June 2016 to August 2021. Logistic regression analysis was used to ascertain predictors of OLNM, and Cox regression analysis to identify risk factors of recurrence. A total of 603 resectable ALK-rearranged NSCLC patients were included. The mean age was 55 years old. There were 171 patients (28.4%) pathologically confirmed to have LNM, 51.5% of which were occult. Logistic regression analysis identified clinical tumor size and computed tomography (CT) density as independent factors for OLNM. Cox regression analysis showed that pleural invasion and pathological tumor size were independent prognosticators for recurrence in pathologically nodal negative patients. Among pathologically nodal positive patients, adjuvant ALK-tyrosine kinase inhibitors (TKI) showed a similar recurrence-free survival (RFS) to chemotherapy (hazard ratio, 0.454; 95% confidence interval, 0.111-1.864). Assessing the potential risk of OLNM is required for ALK-rearranged NSCLC patients with large tumors characterized by high CT densities. Patients with large pathological tumor size or pleural infiltration should be closely monitored despite being pathologically nodal negative. Additionally, adjuvant ALK-TKI may present a comparable RFS to chemotherapy in pathologically nodal positive patients.

Comparison of the clinical outcomes of patients with stage IA-IIA2 cervical adenocarcinoma and squamous cell carcinoma after radical hysterectomy: A propensity score-matched real-world analysis.

To compare the pathological findings and survival outcomes of patients with 2009 FIGO stage IA-IIA2 cervical cancer between groups with adenocarcinoma (ADC) and squamous cell carcinoma (SCC) using the Chinese Cervical Cancer Clinical (FOUR-C) study database. Patients from 2004 to 2018 with cervical ADC and SCC who underwent radical hysterectomy were identified through the FOUR-C database. Propensity score matching (PSM) was conducted to balance baseline clinicopathological characteristics. The Kaplan-Meier method and Cox regression analysis were used to evaluate the prognostic effect of ADC on the 5-year overall survival (OS). We identified 1611 (9.8%) patients with ADC and 14 894 (90.2%) patients with SCC. Compared with SCC, ADC was significantly associated with an increased risk of death (odds ratio [OR] 1.40, 95% CI 1.12-1.74) and disease progression (OR 1.34, 95% CI 1.14-1.57). ADC had a greater propensity for lymph node metastasis, uterine corpus invasion, perineural invasion, and ovarian metastases than SCC (P < 0.05). After 1:2 PSM, significant differences were still observed between these two histology subtypes (OS: OR 1.43, 95% CI 1.10-1.86; DFS: OR 1.45, 95% CI 1.19-1.76). The subgroup analysis further showed a worse prognosis for patients with ADC than for patients with SCC among patients with any of the high- or intermediate- risk factors (OR 1.60, 95% CI 1.21-2.12), but no significant differences were observed for the patients with no risk factors (OR 0.71, 95% CI 0.32-1.58). ADC is an independent prognostic factor for shorter survival in surgically treated patients with cervical cancer presenting intermediate- or high-risk factors but does not affect survival outcomes in patients without any risk factors.

Risk factors of additional surgery after non-curative endoscopic submucosal dissection for early gastric cancer

BackgroundThe criteria for surgical intervention after non-curative endoscopic submucosal dissection (ESD) of early gastric cancer are unclear. We aimed to clarify the risk factors for residual cancer and lymph node metastasis after non-curative ESD and to identify recommendations for additional surgery.MethodsWe collected data on 133 consecutive patients who underwent additional surgery after non-curative ESD of early gastric cancer at Nanjing Drum Tower Hospital from January 2013 to July 2022. Univariate and multivariate analyses were performed to seek risk factors of residual cancer and lymph node metastasis.ResultsThe incidence rates of residual cancer and lymph node metastasis were 13.5% (18/133) and 10.5% (14/133), respectively. There was neither residual tumor nor lymph node metastasis in 104 (78.2%) cases. Multivariate analyses elucidated that horizontal margin was an independent risk factor for local residual cancer, whereas lymphatic infiltration was an independent risk factor for lymph node metastasis. Patients with mixed histological types were more likely to suffer lymph node metastasis and further undergo additional surgery after non-curative ESD than pure histological type.ConclusionsAdditional gastrectomy with lymph node dissection was strongly recommended in patients with lymphatic infiltration after non-curative ESD of early gastric cancer. Patients with mixed histological type have a high propensity for lymph node metastasis and should be treated as a separate subtype.

SAT554 Follicular Variant of PTCA Initially Presenting with Widespread Metastases

Abstract Disclosure: N.N. Bisquera: None. R.C. Mirasol: None. Background: Papillary thyroid carcinoma accounts for most cases of thyroid cancer. Most cases of PTC have a good prognosis and low incidence of metastases. The follicular variant is the most common variant. First described in the 1960’s, the understanding of FV-PTC began to evolve with molecular profiling demonstrating a similarity with FTC, and clinical behavior profiling showing that a subtype may behave like PTC with a propensity for lymph node metastases. We are presented with an unusual case of an infiltrative FV-PTC presenting with widespread multiple metastases on diagnosis. Clinical Case: A 64-year-old female, presented with 1-year history of a slowly enlarging mass on the left mandible, which was also associated with an enlarging anterior neck mass. She had no constitutional symptoms and had previously been in good health. On examination, there was a 7x8x3 cm hard, fixed left mandibular mass. There was also a palpable right thyroid nodule measuring 2.5x2 cm. There was no difficulty in swallowing or breathing, but she had some difficulty in eating due to trismus. There were no associated symptoms of hypo/hyperthyroidism. Investigations revealed a euthyroid status. CT scan showed a solid lobulated heterogeneously enhancing mass measuring 4.2x5.1x5.2cm on the body and angle of the left mandible. Ultrasound showed multiple thyroid nodules, the largest - a mixed cystic and solid mass measuring 2.9 x 2.7 x 2.17 cm on the right thyroid lobe, for which FNA was performed. Histopathology showed benign follicular nodules. Incision biopsy of the mandibular mass showed presence of thyroid tissue. Further imaging showed metastases to the left frontal, parietal bone, T7 vertebra, and bilateral lungs. The case was discussed in a multi-disciplinary tumor board meeting. With a pre-operative diagnosis of a primary thyroid malignancy, the patient then underwent a total thyroidectomy with segmental mandibulectomy. Post-operative histopathology showed a metastatic multifocal infiltrative follicular variant of PTC. RAI was administered post-surgery, and she was started on suppressive thyroxine therapy. Steroids were given during RAI, with no untoward events post treatment. Post-ablative whole body scanning revealed increased tracer uptake in multiple areas: left frontal and parietal bone, bilateral thyroidal beds, left supraclavicular lymph node, the sternomanubrial junction, bilateral lung lobes, right humeral head and T7 vertebra. Further doses of RAI was planned and she is currently maintained on suppressive thyroxine therapy. Conclusion: Diagnosis of FV-PTC may be a greater challenge than conventional forms because of possible false-negative results on cytology. The infiltrative subtype has greater metastatic potential and higher recurrence rates. Multidisciplinary team management and careful preparation prior to treatment with RAI is indicated in these cases. Presentation Date: Saturday, June 17, 2023

Correlation of Expression of Androgen Receptors and P16 in Triple Negative Breast Carcinoma - A Five Years Retrospective and Prospective Study

AIM AND OBJECTIVE Triple negative breast carcinoma (TNBC) is an aggressive breast carcinoma, lacking estrogen receptor (ER),progesterone receptor (PR) and human epidermal growth factor receptor 2 (Her2neu receptor) amplification, thereby, unresponsive to conventional hormonal therapy. The aim of present study is to examine androgen receptor (AR) and p16 expression in TNBC cases and explore its clinical significance in view of potential AR and p16 targeted TNBC therapy. MATERIAL AND METHOD A total 94 TNBC patients were included in this 5 years (3 years retrospective and 2 years prospective) study, conducted at Department of Pathology, JNMCH, Aligarh. Immunohistochemical stains for AR and p16 were performed and their relationship with TNBC clinicopathological data were analyzed. Positive AR expression was defined as ≥1% nuclear staining wheras positive p16 expression was defined as score of ≥1which in turn calculated as product of intensity score and extent of positivity score of cytoplasmic and nuclear stained cells. RESULT Out of 94 TNBC patients, 92 cases were of invasive carcinoma (NST) and 2 cases were invasive lobular carcinoma.AR was expressed in 38/94 (40.4%) cases, all of which were of invasive carcinoma (NST) type. We observed higher expression rate in postmenopausal women i.e.43.2% (16/37) cases and in patients with age ≥60 years i.e. 66.7% (8/12) cases. Statistical analysis showed significant association of AR + TNBC cases with larger tumor size (p= 0.017412) and lymph node metastases (p= 0.033119). Higher expression rate was found in lower grade and stage III, however statistically insignificant.p16 protein was positively expressed in 72.3% (68/94) of the total TNBC cases. We observed higher expression rate in premenopausal women i.e.78.9%(48/57) cases and in patients with age 40-49 years i.e. 84.4% (27/32) . Significantly higher p16 expression rate was found in grade II (90%) followed by grade I (66.7%) and grade III (65%) (p= 0.04). CONCLUSION TNBC was more common in older age group and had a higher propensity for lymph node metastases. AR positive and p16 positive TNBC cases may represent a breast cancer subtype with unique features that may be amenable to treatment with alternative targeted therapy.

Worst Pattern of Invasion as an Independent Predictor of Lymph node Metastasis and Prognosis in oral Cavity Squamous cell carcinoma - A Retrospective Cohort Study.

Although Worst pattern of invasion (WPOI) is one of the histopathological (HP) markers that has been utilized in risk stratification of oral squamous cell carcinoma (OSCC) patients, its potential as an independent predictive factor for lymph node metastasis (LNM) and prognosis is least analyzed. Aim of the study is to analyze the relationship of various HP parameters to WPOI, their propensity for lymph node metastasis and prognostic value. This retrospective study included 140 patients diagnosed with resectable OSCC who underwent definitive surgery. Multiparametric HP risk assessment was done on the postoperative specimen and patients were categorized as low-risk WPOI (Type 1-3), and high-risk group (type 4 and 5). After categorization, 36.1% patients had low-risk WPOI and 63.9% had high-risk WPOI. Significant association was noted between WPOI and patient's age (p = 0.001), nodal stage (p = 0.001), lymphovascular invasion (LVI) (p = 0.006) and neural invasion (p = 0.001). 87% patients with nodal metastasis had high risk WPOI. LVI (p = 0.014) and WPOI (p < 0.001) had significant predictive role in LNM. High-risk WPOI and bone involvement were found to be predictive factors for overall survival, and only high risk WPOI had strong correlation with disease free survival having significant poor prognosis. Analyzing WPOI is essential in reporting HP specimens in OSCC. High-risk WPOI can act as an independent predictor for LNM, early recurrence and poor prognosis. Incorporation of WPOI into TNM staging is recommended to improve clinician's ability to prognosticate and individualize treatment strategies.

Glassy cell carcinoma of the cervix (GCCC): a single institution review of treatment patterns and outcomes (184)

Glassy cell carcinoma of the cervix (GCCC): a single institution review of treatment patterns and outcomes (184)

P53 and p16ink4a As Predictive and Prognostic Biomarkers for Nodal metastasis and Survival in A Contemporary Cohort of Penile Squamous Cell Carcinoma.

Human papilloma virus (HPV) infection is implicated in a proportion of invasive squamous cell carcinoma of the penis (PC). A subset of PC involves dysregulation of the p53 pathway. HPV in situ hybridization (ISH) and p16ink4a positivity are surrogate markers for HPV infection, and p53 immunohistochemistry (IHC) denotes abnormality in the p53 pathway. There remains an ambiguity with regard to the contribution of both the pathways in the prognosis of PC. We sought to analyze the clinicopathologic characteristics of a cohort of Indian PC patients with respect to p16 ink4a and p53 expression. A cohort of 123 PC patients was studied for p16ink4aand p53IHC and HPVISH. The results of these biomarkers were correlated with various clinicopathologic parameters. p16ink4a and HPV ISH were positive in 47% and 53% of the tumors, respectively. The proportion of warty, basaloid, or mixed warty-basaloid tumor subtypes showed significant p16ink4apositivity (P< .0001) compared to other subtypes. Twenty-eight patients were dual negative (p53- /p16ink4a-), 32 were dual positive (p53+/p16ink4a+), 38 were p53+/p16ink4a-, and 25 were p53-/p16ink4a +. In patients where p16ink4a was negative, a p53-positive phenotype had a higher propensity for lymph node metastases (OR, 5.42; 95% CI, 1.75-16.80; P=.003). Similarly, p53 positivity dictates nodal involvement in the p16ink4a-positive subset of tumors (OR, 5.00; 95% CI, 1.23-20.17; P=.024). On multivariate analyses, pathologic subtypes (warty, warty-basaloid, and basaloid) (P < .0001), p16ink4aexpression (P < .0001), and absence of nodal metastasis (P < .0001) were significant predictors of improved overall (OS) and cancer specific survival (CSS). In Kaplan-Meier analysis, the OS was significantly longer in patients with p16ink4a+tumors (P < .0001), as was the CSS (P < .0001). Patients with dual positive tumors had a significantly higher OS (P < .001) and CSS (P=.012), in the entire cohort. In the node positive patients, dual positivity was associated with significantly higher OS (P < .0001); however, the median CSS for p53+/p16ink4a+tumors were not significantly different compared to p53- /p16ink4a- tumors (P=.064), although there was a trend towards improved CSS. There is a strong concordance between p16ink4aIHC and HPV ISH results. p16ink4a status is an independent predictor of survival (OS and CSS) in our cohort of PCs. p53 is a predictor of nodal metastasis irrespective of p16 status. Dual positive tumors have a significantly better outcome in comparison to dual negative tumors.

4MO p53 and p16ink4a as predictive and prognostic biomarkers for nodal metastasis and survival in a contemporary cohort of penile squamous cell carcinoma

Human papilloma virus (HPV) infection is implicated in a proportion of invasive squamous cell carcinoma of the penis (PC). A subset of PC involves dysregulation of the p53 pathway. HPV in situ hybridization (ISH) and p16 ink4a positivity are surrogate markers for HPV infection, and p53 immunohistochemistry (IHC) denotes abnormality in the p53 pathway. Clinicopathologic characteristics of a cohort of Indian PC patients with respect to p16 and p53 expression were analyzed. 123 PC patients were studied for p16 and p53 IHC and HPV ISH and the results were correlated with various clinicopathologic parameters. p16 and HPV ISH were positive in 47% and 53% of the tumors, respectively. The proportion of warty, basaloid, or mixed warty-basaloid tumor subtypes showed significant p16 positivity (p < 0.0001) compared to other subtypes. In patients where p16 was negative, a p53-positive phenotype had a higher propensity for lymph node metastases (OR, 5.4; 95% CI, 1.7 to16.8; p=0.003). Similarly, p53 positivity dictates nodal involvement in the p16-positive subset of tumors (OR, 5; 95% CI, 1.2 to 20.1; p=0.024). On multivariate analyses, pathologic subtypes (warty, warty-basaloid, and basaloid) (p<0.0001), p16 expression (p<0.0001), and absence of nodal metastasis (p<0.0001) were significant predictors of improved overall (OS) and cancer specific survival (CSS). The OS was significantly longer in patients with p16+ tumors (p<0.0001), as was the CSS (p<0.0001). Patients with dual positive tumors had a significantly higher OS (p<0.001) and CSS (p=0.01), in the entire cohort. In the node positive patients, dual positivity was associated with significantly higher OS (p<0.0001); however, the median CSS for p53+/p16+tumors was not significantly different compared to p53- /p16- tumors (p=0.064), although there was a trend towards improved CSS. There is a strong concordance between p16 IHC and HPV ISH results. p16 status is an independent predictor of survival (OS and CSS) in our cohort of PCs. p53 is a predictor of nodal metastasis irrespective of p16 status. Dual positive tumors have a significantly better outcome in comparison to dual negative tumors.

Prognosis of lymphotropic invasive micropapillary breast carcinoma analyzed by using data from the National Cancer Database

BackgroundInvasive micropapillary carcinoma (IMPC) is an uncommon subtype of breast cancer. Previous studies of this subtype demonstrated a higher propensity for lymph node metastases as compared with invasive ductal carcinoma (IDC). The purpose of the present study was to determine the clinical characteristics, outcomes, and propensity for lymph node metastasis of patients with IMPC of the breast recorded in the National Cancer Database (NCDB).MethodsRecords of patients with IMPC diagnosed between 2004 and 2014 were retrieved from the NCDB. Log-rank test was performed to evaluate associations of clinical characteristics with overall survival (OS). Cox proportional hazards model was used to determine variables associated with OS.ResultsOverall, 2660 patients with IMPC met the selection criteria; the 5-year OS rate was 87.5% and 24.9% of patients had nodal involvement at presentation. Patients with ≥ 4 positive lymph nodes had shorter OS than node-negative patients, whereas patients with 1–3 positive nodes had similar OS to node-negative patients. Age < 65 years, receipt of radiotherapy, and estrogen receptor positivity were also associated with prolonged OS. The benefit of radiotherapy was limited to IMPC patients undergoing lumpectomy; there was no benefit for the patients undergoing mastectomy (regardless of nodal positivity/negativity).ConclusionsFavorable prognostic factors of IMPC patients included age < 65 years, < 4 positive lymph nodes, receipt of radiotherapy, and estrogen receptor positivity. The results presented herein suggest a survival benefit associated with radiotherapy in IMPC treatment, though this may be limited to the patients treated with lumpectomy.

1202 Long Term Outcomes Following Surgical Resection of Gastric Neuroendocrine Tumors

INTRODUCTION: Gastric neuroendocrine tumors vary in propensity for lymph node metastases, and this principle has guided management towards endoscopic, surgical or pharmacologic therapy. However, no consensus on optimal type of gastric surgery for gastric carcinoid and rate of recurrence or survival has been reached in North America. The goal of our study is to determine mortality and incidence of tumor recurrence among different surgical interventions for gastric neuroendocrine tumors. METHODS: All consecutive patients encountered at a tertiary referral center who underwent gastric surgery or endoscopic submucosal dissection (ESD) for biopsy proven gastric neuroendocrine tumor from April 1988 to January 2019 were entered into the study. Patients were categorized by proximal/wedge, distal/subtotal, total gastric resection, and ESD as well as by lymphadenectomy: none (D0), D1, or D2. Tumor grading was characterized as high (poorly differentiated, WHO 3) or low (well differentiated, WHO 1 &amp; 2) as some patients preceded WHO classification. Recurrence and lymph node metastases were based on biopsy. Patient follow-up was determined by most recent encounter with gastroenterology or oncology provider within our health system. Date of decease was determined by Social Security Death Index query of all patients. RESULTS: Thirty patients were enrolled. Mean age of diagnosis was 63.9 ± 12.3 years old. Lymph node dissection practices were provider dependent but at least 62% did not have any lymphadenectomy. Mean follow up after surgery was 42.8 ± 12.8 months. Of those who underwent distal gastrectomy and ESD, no evidence of recurrence was noted. Two of 3 patients with recurrence had low grade tumors without lymphadenectomy. Mortality did not significantly vary with lymphadenectomy status (Figure 2). One 78-year-old patient did not survive post operatively after distal/subtotal gastrectomy with D1 lymphadenectomy due to sudden cardiac arrest 9 days after surgery. CONCLUSION: In our cohort, fewer gastric resections for GNETS include lymphadnectomy. Interestingly, recurrence was not statistically significantly associated with positive and negative lymph nodes or performance of lymphadenectomy. One limitation of this study is the scarcity of lymph node positive GNET.

The application of selective neck dissection while preserving the cutaneous branches of cervical plexus in the surgical treatment of differentiated thyroid cancer-experiences from thousands of cases.

Differentiated thyroid cancer (DTC) is associated with the highest propensity for lymph node metastases, given the significant morbidity associated with sacrificing the spinal accessory nerve, surgeons increasingly looked to minimizing functional deficits while maintaining oncologic outcome. We have detailed the technique of a selective neck dissection with more attention to preserving the cervical sensory nerves since 1999 in Fudan University Shanghai Cancer Center. We found that the radical dissection with preservation of the cutaneous branches including the great auricular nerve, the less occipital nerve and the supraclavicular nerve can maximally decrease the complications of paresthesia and dysesthesia postoperatively in the lower neck, the shoulders and the area around the ear in DTC cases when indications were allowed. As long as the principles of cancer surgery are strictly followed, our approach guarantees radical tumor removal and exhibit more functional preservation.

Sentinel lymph node biopsy in Merkel cell carcinoma: The Mayo Clinic experience of 150 patients

BackgroundMerkel cell carcinoma (MCC) is a rare cutaneous malignancy of neuroendocrine origin with a high propensity for lymph node metastasis. Sentinel lymph node (SLN) status is important for accurate staging; however, the optimal treatment following SLN biopsy, regardless of nodal status, remains unclear. Methods150 patients with MCC who underwent SLN biopsy from 1995 to 2011 at 3 Mayo Clinic sites were reviewed. ResultsOf 150 patients with MCC who underwent SLN biopsy, 39 (26%) were positive and 111 (74%) were negative. There was no significant difference between the sex, age, tumor location, or size of primary in the positive and negative SLN groups. While there was no difference in the cumulative incidence of any regional recurrence between SLN groups, the rate of in-transit recurrences was significantly higher in patients with a positive SLN (p = 0.022). The disease-specific survival for MCC was 97.0%, 82.4%, and 82.4% at 1, 3, and 5 years with a positive SLN and 99.0%, 94.9%, and 86.8% with a negative SLN (p = 0.31). Among those alive at last follow up, the median follow up was 3.8 years (IQR, 2.1–8.4) and 2.9 years (IQR, 1.8–6.1) for positive and negative SLN cohorts respectively. ConclusionsOccult nodal metastasis is common in MCC(26%). No tumor or patient characteristics were identified to predict SLN positivity. Patients with a positive SLN have a higher risk of in-transit recurrence and may benefit from adjuvant radiation with inclusion of the in-transit field in amenable cases. When patients with a positive SLN receive additional treatment to the at-risk nodal basin, both OS and DSS are similar to patients with a negative SLN.

Lymph node metastasis and the physicochemical micro-environment of pancreatic ductal adenocarcinoma xenografts.

Pancreatic ductal adenocarcinoma (PDAC) patients develop lymph node metastases early and have a particularly poor prognosis. The poor prognosis has been shown to be associated with the physicochemical microenvironment of the tumor tissue, which is characterized by desmoplasia, abnormal microvasculature, extensive hypoxia, and highly elevated interstitial fluid pressure (IFP). In this study, we searched for associations between lymph node metastasis and features of the physicochemical microenvironment in an attempt to identify mechanisms leading to metastatic dissemination and growth. BxPC-3 and Capan-2 PDAC xenografts were used as preclinical models of human PDAC. In both models, lymph node metastasis was associated with high IFP rather than high fraction of hypoxic tissue or high microvascular density. Seven angiogenesis-related genes associated with high IFP-associated lymph node metastasis were detected by quantitative PCR in each of the models, and these genes were all up-regulated in high IFP/highly metastatic tumors. Three genes were mutual for the BxPC-3 and Capan-2 models: transforming growth factor beta, angiogenin, and insulin-like growth factor 1. Further comprehensive studies are needed to determine whether there is a causal relationship between the up-regulation of these genes and high IFP and/or high propensity for lymph node metastasis in PDAC.

Cervical Lymph Node Metastasis in High-Grade Transformation of Head and Neck Adenoid Cystic Carcinoma: A Collective International Review.

Adenoid cystic carcinoma (AdCC) is among the most common malignant tumors of the salivary glands. It is characterized by a prolonged clinical course, with frequent local recurrences, late onset of metastases and fatal outcome. High-grade transformation (HGT) is an uncommon phenomenon among salivary carcinomas and is associated with increased tumor aggressiveness. In AdCC with high-grade transformation (AdCC–HGT), the clinical course deviates from the natural history of AdCC. It tends to be accelerated, with a high propensity for lymph node metastasis. In order to shed light on this rare event and, in particular, on treatment implications, we undertook this review: searching for all published cases of AdCC-HGT. We conclude that it is mandatory to perform elective neck dissection in patients with AdCC-HGT, due to the high risk of lymph node metastases associated with transformation.Electronic supplementary materialThe online version of this article (doi:10.1007/s12325-016-0298-5) contains supplementary material, which is available to authorized users.

Multifocal Papillary Thyroid Cancer Increases the Risk of Central Lymph Node Metastasis.

Papillary thyroid cancer (PTC) is the most common thyroid malignancy, with a strong predilection for lymph node metastasis, most commonly to the central neck compartment (level VI). Few studies have evaluated lymph node metastasis in multifocal PTC, and the role of level VI dissection in the management of PTC remains controversial. This retrospective analysis evaluated the rate of level VI lymph node positivity in multifocal PTC, as compared with unifocal disease, in order to inform surgical decision making better. Patients with PTC who underwent total or hemi-thyroidectomy plus level VI lymph node dissection at the authors' institution between January 2008 and June 2014 were included (N=227). The number and laterality of PTC foci, lymphovascular invasion (LVI), extrathyroidal extension (ETE), and positive/total number of level VI lymph nodes were recorded. Fisher's exact test was used to determine univariate associations, and multivariate analysis was done by logistical regression. There was an association between the number of PTC foci and level VI node positivity (p<0.001), with an odds ratio (OR) of 2.355 in patients with three or more tumor foci (p=0.026). The OR for central neck metastasis was 1.088 with each additional focus of PTC (p=0.018). The risk of level VI node positivity in the presence of one or two foci was only 19%, with no appreciable difference between one and two foci. This risk increased in the presence of between three and nine foci (38%), and 10 or more foci (88%). Level VI node positivity was associated with ETE (p<0.001), LVI (p<0.001), and size of the largest focus (p<0.001). There was no association between level VI lymph node positivity and male sex (p=0.089), bilaterality (p=0.276), or age (p=0.076). There is a significant association between multifocal PTC and level VI lymph node positivity, increasing proportionally with the number of foci. These findings recognize multifocality as a sign of tumor aggressiveness, as evidenced by a higher propensity for lymph node metastasis.

Treatment of eccrine porocarcinoma with Mohs micrographic surgery: a cases series and literature review.

Eccrine porocarcinoma (EPC) is a rare malignant tumor of the eccrine sweat gland. It is a potentially fatal neoplasm that is locally aggressive and commonly recurs. Wide surgical excision has traditionally been the treatment of choice and is curative in approximately 70-80% of cases. The disease is metastatic to lymph nodes and distant sites in 20% and 10% of cases, respectively. Metastatic EPC has not shown any great response to adjuvant chemotherapy or radiation. The purpose of this study was to evaluate the efficacy of Mohs micrographic surgery (MMS) for EPC as an alternative to wide local excision. Five patients diagnosed with EPS between 2011 and 2014 at the University of Louisville and treated with MMS were studied. Recurrence-free periods subsequent to the treatment of EPC with MMS were measured. The five patients with EPC treated by MMS remained recurrence-free for a mean of 11 months (range: 2-26 months). Mohs micrographic surgery is a highly effective treatment for EPC. Given the high rate of recurrence, propensity for lymph node metastases, and the often ineffective options for treating advanced disease, MMS should be considered in the treatment of all cases of EPC.

Invited Commentary

Invited Commentary