Resection Of Metastatic Lymph Nodes Research Articles

Solitary lymph-nodal para-aortic recurrence in a patient with High Grade Serous Ovarian Cancer

Ovarian cancer is the second most common cause of gynecologic cancer death. The most common histologic category of epithelial ovarian cancer is High Grade Serous Ovarian Cancer (HGSOC). The initial management usually involves appropriate staging and debulking surgery. Otherwise, patients with unresectable disease receive neoadjuvant chemotherapy, and then undergo Interval Debulking Surgery (IDS). However, even cases with complete clinical response often experience a recurrence. While the primary debulking surgery is the standard of treatment, the role of secondary debulking surgery for recurrent ovarian cancer is still debatable. The most common sites of recurrences are pelvis and abdomen, whereas recurrence confined solely to lymph node is a rare event. Secondary cytoreductive surgery (SCS) for recurrent ovarian cancer presenting as isolated lymph node metastases has been associated with favorable long-term survival, although the resection of aortic metastatic lymph nodes could be related to severe intraoperative complications. In this article, we report a case of a 72-year-old patient with an isolated lymph-nodal para-aortic recurrence with a history of primary debulking surgery for high grade serous ovarian cancer FIGO stage IV, four years before, followed by received adjuvant chemotherapy, and maintenance therapy. The patient presented with a lymph node relapse down the ileocolic artery and submitted to radical resection of the metastatic lymph nodes.

Quantification and Pattern of Central Compartment Lymph Nodes in pN1a Papillary Thyroid Cancer Patients.

Background: The background is to investigate the results of central compartment lymphadenectomy for pN1a papillary thyroid carcinoma (PTC) with regard to quantification and pattern of resected lymph nodes thereby providing basis for future compartment VI surgical intervention. Methods: The study comprised 443 pN1a PTC patients whose clinicopathological characteristics and central compartment lymphadenectomy results were compared and correlated with the primary thyroid cancer and lymph node metastasis (LNM) features. Ultimately, multivariate analysis was conducted to identify statistically significant impact factors for a high metastatic ratio (MR). Results: Dissected lymph nodes (DLNs) were more frequently identified in right level VI than left (P < .05) although there was no difference in in the number of resected metastatic lymph nodes (MLNs). Male sex, multifocality, extrathyroidal extension (ETE), and fewer DLNs were related to a high MR. There was a positive correlation between DLN and MLN, and a negative correlation between DLN and MR. Disease multifocality and ETE were identified more frequently in the left than the right thyroid lobe. Conclusion: The outcome of central compartment lymphadenectomy in pN1a PTC patients is associated with several factors, and a thorough dissection of lymph nodes improves the rate of metastatic lymph node resection.

陰圧閉鎖療法が奏効した大腸癌鼠径リンパ節転移術後難治性リンパ漏の2例

陰圧閉鎖療法が奏効した大腸癌鼠径リンパ節転移術後難治性リンパ漏の2例

Lymph node ratio predictive of recurrence, distant metastasis, and survival in submandibular gland carcinoma patients

Submandibular gland (SMG) carcinoma has an unfavorable clinical course and a low survival rate. Specific tumor and nodal findings might help predict posttreatment recurrence and survival in SMG carcinoma patients. This study evaluated factors predictive of posttreatment recurrence and survival in SMG carcinoma patients. This study enrolled 99 consecutive patients with previously untreated SMG carcinoma. All patients underwent tumor and metastatic lymph node resection along with or without radiation/chemo-radiation. The predictive clinical and pathological factors for disease-free survival (DFS), distant metastasis-free survival (DMFS), disease-specific survival (DSS), and overall survival (OS) were determined using univariate and multivariate Cox proportional hazards regression analyses. The median tumor size was 2.7cm and 53 patients (53.5%) had high-grade tumors. The rates of initial nodal and distant metastasis at initial presentation or follow-up were 45.5% and 42.4%, respectively. The actuarial 5-year DFS, DMFS, DSS, and OS rates were 46.4%, 55.9%, 61.5%, and 59.7%, respectively. The independent factors associated with poor DFS, DMFS, DSS, and OS outcomes (all p < 0.05) were T3-T4 classification and lymph node ratio. A histological high-grade tumor was an independent prognostic factor predictive of poor DMFS, DSS, and OS outcomes (all p < 0.05). A high rate of distant site failure is associated with SMG carcinoma, resulting in a poor survival rate. Lymph node ratio might help predict recurrence, distant metastasis, and death due to SMG carcinoma.

Prostate-specific membrane antigen-guided salvage lymph node dissection in recurrent prostate cancer: a novel technology to detect lymph node metastases.

With Gallium (Ga)-prostate-specific membrane antigen (PSMA) PET/computed tomography (CT) as emerging imaging technique offering superior detection rates in biochemical recurrent prostate cancer, salvage lymph node dissection has gained increasing interest in localized oligometastatic prostate cancer. Currently, PSMA-targeting small molecules cannot only be linked to positron-emitting isotopes for imaging but also be labelled with γ-radiation emitting isotopes. These modified PSMA agents are evaluated for intraoperative guidance for resection of metastatic lymph nodes. This review aims to review current knowledge on the novel technique of PSMA-radioguided surgery. Recently radiolabeling of PSMA ligands with Indium and Technetium as γ emitter has been established. After preoperative intravenous injection of these novel PSMA agents single photon emission computed tomography/CT imaging can be performed using the γ-emitting properties. Although its diagnostic performance seems to be inferior to Ga-PSMA PET/CT, intraoperative guidance by the use of a γ probe was reported to facilitate detection and resection of tumour-infiltrated soft tissue. First follow-up data suggests favourable outcomes concerning prostate-specific antigen progression and treatment-free survival in a subset of patients. Although current knowledge is still limited and published data is sparse salvage surgery in recurrent prostate cancer facilitated by γ-emitting PSMA agents seems feasible. However, careful identification of ideal candidates for those procedures is mandatory.

Prognostic impact of incomplete surgical clearance of radioiodine sensitive local lymph node metastases diagnosed by post-operative (124)I-NaI-PET/CT in patients with papillary thyroid cancer.

Nodal involvement is an independent risk factor of recurrence in papillary thyroid cancer (PTC). Neither the international guidelines nor the recently introduced ongoing risk adaptation concept consider the extent of initial surgical clearance of radioiodine sensitive lymph node metastases in their stratification systems. We investigated the prognostic relevance of incomplete initial surgical clearance in patients with purely lymphogeneous metastatic PTC (pN1 M0) despite successful radioiodine therapy. Accurate assessment of pre-ablative nodal status was attempted using PET/CT studies with both (124)I-NaI and (18)F-FDG along with high-resolution cervical ultrasound. Sixty-five patients with histologically diagnosed lymph node metastases (pN1 M0) were retrospectively analyzed. Patients with iodine-negative lymph node metastases diagnosed by (18)F-FDG PET/CT or distant metastases were excluded from the analysis. The association of disease recurrence with the pre-ablative nodal status, as well as other baseline characteristics, were examined applying nonparametric tests for independent samples and multiple regression analysis. Patients with persistent lymph node metastases in (124)I-NaI PET/CT were further divided according to the additional presence or absence of FDG-uptake in (18)F-FDG PET/CT. Survival analyses were performed using Kaplan-Meier curves and the Cox proportional hazards model for uni- and multivariate analyses to assess the influence of prognostic factors on progression free survival (PFS). Incomplete metastatic lymph node resection captured by (124)I-NaI PET/CT (n = 33) was an independent risk factor for recurrence (61% vs 25%, p = 0.006) and shorter PFS (46months vs not reached, HR 4.0 [95%-CI, 1.7-9.2], p = 0.001). Ultrasound could detect lymph node metastases only in 19/33 patients (58%). Among patients with positive nodal status, FDG-avidity of metastatic iodine positive lymph nodes worsened the outcome (16 vs 69months, p = 0.047). From all other investigated factors including age, N-stage (N1a vs N1b), and T-Stage (T4 vs T1-3), only large tumor size (pT4) had a significant impact on PFS (HR 2.9 [95%-CI, 1.3-6.4], p = 0.007). Incomplete initial surgical clearance of lymph node metastases even after successful radioiodine therapy may increase the chances of recurrence and is an independent risk factor for impaired survival of patients with PTC. Pre-ablative (dual tracer PET/CT) imaging with (124)I-Na and (18)F provides a prognostic tool for these patients and may considerably complement the current risk stratification systems.

Role of near-infrared fluorescence imaging in the resection of metastatic lymph nodes in an optimized orthotopic animal model of HNSCC

ObjectivesTo study the role of near-infrared fluorescence imaging in the detection and resection of metastatic cervical lymph nodes in head and neck cancer. Materials and methodsCAL33 head and neck cancer cells of human origin were implanted in the oral cavity of nude mice. The mice were followed up after tumor resection to detect the development of lymph node metastases. A specific fluorescent tracer for αvβ3 integrin expressed by CAL33 cells was injected intravenously in the surviving mice between the second and the fourth month following tumor resection. A near-infrared fluorescence-imaging camera was used to detect tracer uptake in metastatic cervical lymph nodes, to guide of lymph-node resection for histological analysis. ResultsLymph node metastases were observed in 42.8% of surviving mice between the second and the fourth month following orthotopic tumor resection. Near-infrared fluorescence imaging provided real-time intraoperative detection of clinical and subclinical lymph node metastases. These results were confirmed histologically. ConclusionNear infrared fluorescence imaging provides real-time contrast between normal and malignant tissue, allowing intraoperative detection of metastatic lymph nodes. This preclinical stage is essential before testing the technique in humans.

Clinical significance of surgical resection of metastatic lymph nodes from hepatocellular carcinoma.

The clinical significance of the surgical resection of metastatic lymph nodes (LN) from patients with hepatocellular carcinoma (HCC) remains controversial. The aim of this study was to evaluate the significance of the surgical resection of LN metastasis of HCC. Among 961 patients who underwent surgical resection for HCC in our hospital, LN metastasis was identified in 38 patients. In these patients, the metastatic LN were removed completely in 22 patients (complete removal group), and incompletely or not removed in 16 patients (control group). The long-term prognosis after LN metastasis was compared between the two groups. The overall survival rate after LN metastasis was significantly better in the complete removal group (1-, 3- and 5-year: 71.2, 58.0 and 49.7%, respectively) than in the control group (45.9, 23.0 and 15.3%, respectively, p = 0.0477). LN metastasis was not the cause of death in any of the patients in the complete removal group, whereas it was a cause in some patients in the control group. No local LN recurrence was identified in the complete removal group. The present results suggest that the complete removal of metastatic LN from HCC is clinically beneficial in selected patients.

Analysis of clinicopathological features of the echinoderm microtubule-associated protein-like-4-anaplastic lymphoma kinase fusion gene in Chinese patients with advanced non-small-cell lung cancer.

The echinoderm microtubule-associated protein-like-4-anaplastic lymphoma kinase (EML4-ALK) fusion gene defines a novel molecular subset of non-small-cell lung cancer (NSCLC). However, the clinicopathological features of patients with the EML4-ALK fusion gene have not been defined completely. Clinicopathological data of 200 Chinese patients with advanced NSCLC were analyzed retrospectively to explore their possible correlations with EML4-ALK fusions. The EML4-ALK fusion gene was detected in 56 (28.0%) of the 200 NSCLC patients, and undetected in 22 (11.0%) patients because of an insufficient amount of pathological tissue. The median age of the patients with positive and negative EML4-ALK was 48 and 55 years, respectively. Patients with the EML4-ALK fusion gene were significantly younger (P< 0.001). The detection rate of the EML4-ALK fusion gene in patients who received primary tumor or metastatic lymph node resection was significantly higher than in patients who received fine-needle biopsy (P= 0.003). The detection rate of the EML4-ALK fusion gene in patients with a time lag from obtainment of the pathological tissue to EML4-ALK fusion gene detection ≤48 months was significantly higher than in patients >48 months (P= 0.020). The occurrence of the EML4-ALK fusion gene in patients with wild-type epidermal growth factor receptor (EGFR) was significantly higher than in patients with mutant-type EGFR (42.5% [37/87] vs. 6.3% [1/16], P= 0.005). Younger age and wild-type EGFR were identified as clinicopathological characteristics of patients with advanced NSCLC who harbored the EML4-ALK fusion gene. The optimal time lag from the obtainment of the pathological tissue to the time of EML4-ALK fusion gene detection is ≤48 months.

The prognostic significance ofBRAFmutation status in stage IIIB–C melanoma

Evaluation of: Moreau S, Saiag P, Aegerter P et al. Prognostic value of BRAF (V600) mutations in melanoma patients after resection of metastatic lymph nodes. Ann. Surg. Oncol. 19(13), 4314–4321 (2012).Recently introduced systemic agents have shown promising results in melanoma patients with distant metastases. However, the durability of the effect of these agents is still disappointing. In melanoma patients with palpable regional lymph node metastases, these new systemic drugs might induce longer efficacy as tumor load is low compared to patients with distant metastases. However, before administering these potentially toxic and still very expensive systemic drugs the selection of patients who will most probably benefit from them is important. In this key paper evaluation, the use of BRAF mutation status as a prognostic marker in stage III melanoma is discussed.

Incidentally Discovered Primary Malignant Melanoma of the Trachea

Primary malignant melanoma of the trachea is extremely rare. We report here the first case of primary tracheal malignant melanoma in the asymptomatic stage. Incidentally, this 73-year-old man was found to have a flat tumor at the upper trachea on chest computed tomography scans. The tumor was surgically resected with end-to-end anastomosis and was diagnosed to be primary malignant melanoma of the trachea. Four months after the surgical resection, cervical lymph node metastasis was found. Despite the resection of metastatic lymph nodes and six courses of chemotherapy, he died of cachexia approximately two years after the discovery of the tracheal tumor.

Resection of metachronous lymph node metastases from hepatocellular carcinoma after hepatectomy: report of four cases.

We report 4 cases of surgical resection of metachronous lymph node (LN) metastases from hepatocellular carcinoma (HCC) following hepatectomy. Clinicopathological features and results of LN dissection were investigated in the 4 patients. One patient was found to have a single metastasis in the mediastinal LNs, another had multiple metastases in the mediastinal and abdominal LNs, and the other 2 had single metastases in the abdominal LN. The locations of the abdominal LN metastases were behind the pancreas head in 2 patients and around the abdominal aorta in 1 patient. They all underwent surgical resection of metastatic LNs and had no postoperative complications. The 3 patients whose LN metastases were solitary have been alive for more than 2 years after LN resection, and one of them is free from recurrence. The patient with multiple LN metastases died 13 months after LN resection due to carcinomatosis. With the expectation of long-term survival, a single metachronous LN metastasis from HCC after hepatectomy should be resected in patients without uncontrollable intrahepatic or extrahepatic tumors.

Resolution of Pulsatile Tinnitus Following an Upper Mediastinal Lymph Node Resection

External compression of extracranial/mediastinal vessels has not been reported as an etiology of pulsatile tinnitus. We present a case in which compression of extracranial vasculature led to long term pulsatile tinnitus which resolved completely with surgical resection of metastatic lymph nodes. This should be included in the list of differential diagnoses when dealing with any patient with a complaint of pulsatile tinnitus. Patients with advanced carcinoid cancer often present with distant metastases to their left superior mediastinum and supraclavicular lymph node chain. We believe a careful search for nodal metastases compressing vascular structures in such patients is warranted as debilitating pulsatile tinnitus may be cured by a simple surgical procedure.

Optimizing lymphadenectomy in laparoscopic surgery for colon cancer

Complete tumor resection (R0) for stages I to III, if feasible, has been essential as the basis of multimodal treatment of solid cancer [1–5]. However, the adequate extent of lymph node dissection for solid tumors, including colorectal cancer (CRC), has not been established to date [6–14]. Over recent decades there have been two main treatment trends. The first trend considers an appropriate lymphadenectomy to be an important part of an R0 resection. The main argument is that local and nodal control is important not only for recurrence-free survival but also for overall survival. Such lymphadenectomy requires resection and examination of at least 12 lymph nodes CRC [6]. The National Quality Forum has endorsed the examination of at least 12 lymph nodes for patients undergoing colon cancer surgery as a means of improving staging and survival. Using data from the National Cancer Data Base, researchers have shown that patient survival increases when 12 or more nodes are examined [6]. The second trend contends that the number of lymph nodes harvested does not have an impact on survival. In a retrospective cohort study using the national Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database (1995–2005), the data for 30,625 U.S. patients undergoing colectomy for nonmetastatic colon cancer were analyzed. Emphasis was given to whether more or less than 12 lymph nodes were examined. Wong et al. [7] concluded that the number of lymph nodes hospitals examine after colectomy for colon cancer is not associated with staging, use of adjuvant chemotherapy, or patient survival. These too large retrospective contrasting studies reemphasize that well-designed, randomized, phase III, controlled trials are important in the approach to the truth. Until high-quality evidence becomes available, a R0 resection, including the resection of metastatic lymph nodes, via surgical endoscopy appears to be a rational approach to the prevention of nodal recurrence. Can laparoscopic surgery result in such a quality R0 surgery with adequate lymphadenectomy? To highlight this issue, El-Gazzaz et al. [15] report in a recent issue of Surgical Endoscopy the number of lymph nodes harvested after laparoscopic and open colorectal cancer resections. Of the 729 patients who underwent surgical resection with curative intent between 1996 and 2007, 243 patients had laparoscopic surgery, and 486 had open surgery. The number of nodes harvested did not differ significantly between laparoscopic and open surgery. In this retrospective study, the mean number of lymph nodes retrieved and examined was high: 24.8 ± 20.6 per patient. The lymph nodes obtained were twice the number recently recommended, reflecting the quality of laparoscopic surgery. Although no conclusion can be drawn from the study whether this appropriate lymphadenectomy may provide a survival benefit, it reflects a rational approach accepted by most surgeons. Laparoscopic colectomy has become the standard of care for colon cancer patients with potentially curable disease (stages I to III). To achieve optimal R0 resection, metastatic lymph nodes also should be removed. Given that preoperative or operative nodal staging is inaccurate in distinguishing node-positive from node-negative disease, a standardized lymphadenectomy determined by more than 12 lymph nodes harvested appears to be beneficial for patients with node-positive colon cancer. This surgical approach is adequate for local and nodal control C. Hottenrott (&) St. Elisabethenkrankenhaus, Chirurgische Klinik, Frankfurt, Germany e-mail: info@gastricbreastcancer.com

Retroperitoneal lymph node resection in patients with cervical cancer

To determine predictive factors precluding complete resection of metastatic lymph nodes identified by pre-operative imaging in patients with cervical cancer. Retrospective clinical review of patients with cervical cancer with suspected metastases to pelvic and/or periaortic lymph nodes who underwent lymph node dissection by laparotomy at The University of Texas M.D. Anderson Cancer Center from September 1990-December 2004. A total of 104 patients were the subject of this analysis. Post-operatively, 25 patients (24%) had negative lymph nodes, 62 patients (60%) had macroscopically positive lymph nodes, one patient had microscopically positive (1%) and 16 patients (15%) had unresectable lymph nodes. Body mass index did not have any impact on successful resection of lymph nodes. On univariate analysis age (p=0.049) and size and location of the largest lymph node were associated with resection status (p=0.001 and 0.020). Logistic regression confirmed that chance of achieving a successful resection decreases with increasing age (p=0.046) and size of largest lymph node (0.002). The ability to completely resect suspected metastatic lymph nodes at the time of extraperitoneal lymph node dissection in patients with cervical cancer is associated with size and location of largest lymph node.