Total Nodes Research Articles

The localization of thyroid cancers on the thyroid gland is a new risk factor for metastases of perithyroidal, peritracheal and central lymph nodes

Lymph node metastasis is frequently detected in differentiated thyroid cancers. Central dissection is performed to the lymph nodes in patients with microscopic metastases in the intraoperative evaluation. Other indications for central dissections are tumor size and cervical lateral lymph node metastasis. We consider that the localization of thyroid cancer in the thyroid lodge may be another risk factor for central lymph node metastasis. For this reason, the purpose of the present study was to investigate the relations between thyroid cancer localization and lymph node metastasis in differentiated thyroid cancer patients who had no preoperative cervical metastases and who underwent total thyroidectomy, and peritracheal, perithyroidal, and central lymph node dissection. A total of 213 differentiated thyroid cancer cases followed in our general surgery and endocrinology clinic between September 2016 and May 2020 were evaluated retrospectively. Based on the data in the files, the patients who underwent total thyroidectomy, and central, perithyroidal, and peritracheal lymph node dissection were included in the study. The patients were divided into four Groups according to tumor localizations, those with tumors adjacent to the trachea (Group 1), upper thyroid pole (Group 2), thyroid middle part (Group 3), thyroid inferior (Group 4). The demographic characteristics, laboratory parameters, cancer types, and lymph node metastasis rates of the Groups were evaluated. A total of 84% (179) of the cases had thyroid papillary cancer, 11.73% (25) had thyroid follicular cancer, and 4.2% (9) had poorly differentiated thyroid cancer. The mean age of all patients was found to be 49 ± 8.3years, and the female/male ratio was 2.4. It was found that the differentiated thyroid cancers metastasized to the perithyroidal, peritracheal, and central lymph nodes at a rate of 57.74%. The distribution of these metastases according to the Groups was; 62.85% in Group 1, 11.53% in Group 2, 43.9% in Group 3, and 88.57% in Group 4. It was also found that 80.32% of the papillary cancer cases and 57.14% of the follicular cancer cases metastasized to central (level VI) lymph nodes in Group 4. The localization of differentiated thyroid cancers is a new risk factor for perithyroidal metastases.

Predictors of Lateral Pelvic Lymph Node Metastasis in Advanced Low Rectal Cancer Treated With Neoadjuvant Chemotherapy.

This retrospective study used magnetic resonance imaging to identify clinicopathological predictors of lateral pelvic lymph node metastasis in patients with advanced low rectal cancer treated with neoadjuvant chemotherapy; only few such studies have been reported. Sixty-one patients with advanced low rectal cancer who underwent total mesorectal excision and lateral pelvic lymph node dissection after neoadjuvant chemotherapy between April 2013 and December 2019 were included in this study. Univariate and multivariate analyses were used to analyze the relationship between lateral pelvic lymph node metastasis and clinicopathological factors, such as lateral pelvic lymph node size, measured before and after neoadjuvant chemotherapy using magnetic resonance imaging. The short-axis diameter of lateral pelvic lymph nodes before neoadjuvant chemotherapy (p=0.003, odds ratio: 2.898, 95% confidence interval=1.534-9.143) was the only identified independent preoperative predictor. Based on the receiver operating characteristic curve analysis, the cut-off value of the short-axis diameter of lateral pelvic lymph nodes before neoadjuvant chemotherapy was 6.8 mm. The area under the curve was 0.761 (95% confidence interval=0.723-0.932). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 77.8%, 72.1%, 53.8%, 88.6%, and 73.8%, respectively. The preoperative predictor of lateral pelvic lymph node metastasis in advanced low rectal cancer treated with neoadjuvant chemotherapy was the short-axis diameter of lateral pelvic lymph nodes before neoadjuvant chemotherapy. When lateral pelvic lymph nodes with short-axis diameters above 6.8 mm are present, lateral pelvic lymph node dissection may be necessary.

Early Recurrence of Cromophobic Renal Cell Carcinoma with Sarcomatoid and Rhabdoid Differentiation: About a Case

Chromophobic renal cell carcinoma with sarcomatoid differentiation is a rare tumor characterized by a biphasic tumor with both classic epithelial components and sarcomatoid components with poor prognostic factors, usually in association with the rhabdoid contingent which has the potential to behave aggressively and metastasize. We report a particular case of recurrence of this entity in a male patient in which the diagnosis was suspicious preoperatively for the tumor evolution time and the size of the mass and the imaging data performed. The patient underwent extensive left total nephrectomy and lymph node dissection. The postoperative follow up was marked by early appearance of recurrence within 6 weeks after surgery.

Prognostic Value of Lymph Node Evaluation in Stage II Small Bowel Adenocarcinoma: An Updated Analysis of Surveillance, Epidemiology, and End Results Database.

BackgroundDue to the lack of large-scale clinical trials, the treatment strategies of small bowel adenocarcinoma (SBA) are controversial, especially for stage II patients. According to the National Comprehensive Cancer Network (NCCN) guideline, few lymph nodes (LNs) examined (<5 for duodenum or <8 for jejunal/ileal primary location) are one of the high-risk features for stage II patients, for whom adjuvant chemotherapy is recommended. This consensus is originally drawn from data in the Surveillance, Epidemiology, and End Results Database (SEER) between 1988 and 2010. However, the surgical modalities and chemotherapy strategies changed a lot after 2004 for SBA patients. The previous data may not represent a true picture of current therapeutics. Thus, we reanalyzed the SEER database and updated the cutoff point of LN numbers resected with respect to cancer-specific survival (CSS) using the latest SEER information.MethodsPatients diagnosed with stage II SBA and who underwent curative surgery between 2004 and 2018 were extracted from the SEER database. CSS was calculated using the Kaplan–Meier method and compared by log-rank test. Maximum survival differences based on total LNs examined for duodenal and jejunoileal tumors were determined separately with the cut-point analysis and maximum log-rank χ2 statistic. A nomogram model was constructed based on the multivariate Cox analysis to predict 5‐ and 10‐year CSS and was then validated with an internal cohort.ResultsA total of 935 stage II SBA patients met the inclusion criteria. The greatest difference in survival was found in patients who had removal of at least 5 LNs for duodenal and 12 LNs for jejunoileal tumors. Multivariate Cox analysis showed that age, T stage, histology grade, primary site, and LN numbers were independent prognostic factors for survival. The C index of nomogram model was 0.701 (95% CI, 0.661–0.741, p < 0.001).ConclusionsThe number of LNs harvested is an important prognostic factor for survival in stage II SBA patients. LN number examined <5 remains a high-risk factor for duodenum, but the cutoff point for jejunal/ileal tumors should rise from 8 to 12. Appropriate radical lymphadenectomy should be performed in stage II SBA surgery.

Two-lung ventilation or one-lung ventilation for esophagectomy: maybe the more is better from the evidence of meta-analysis.

One-lung ventilation (OLV) is the most commonly used ventilation strategy during esophagectomy. However, two-lung ventilation (TLV) with artificial pneumothorax has been applied in recent years during esophagectomy. It is unclear whether TLV takes advantages over OLV for esophagectomy. Here, we conducted a meta-analysis to compare the effects of TLV and OLV for esophagectomy. We searched relevant studies from the Cochrane Central Register of Controlled Trials, Pubmed, and Embase in November 2020. We included studies that compared the effects of TLV with OLV in esophagectomy and provided sufficient perioperative and postoperative data. We extracted data of postoperative outcomes (postoperative pulmonary complications, anastomotic leak, hospital stay) and surgical variables (thoracic phrase time, blood loss, the number of total resected thoracic lymph nodes). We calculated the risk ratio (RR) for dichotomous data and the weighted mean differences (WMDs) for continuous data. Six studies with 1725 patients were included in this meta-analysis. TLV was associated with significantly lower incidence of postoperative pulmonary complications [RR = 0.714; 95% confidence interval (CI) = (0.534, 0.956); P = 0.023], shorter hospital stay [WMD = - 0.148; 95% CI = (- 0.246, - 0.051); P = 0.003], less blood loss [WMD = - 0.352; 95% CI = (- 0.528, - 0.176); P < 0.001] and more resected thoracic lymph nodes [WMD = 0.207; 95% CI = (0.003, 0.4120); P = 0.047] than OLV. Moreover, TLV consumed similar time for thoracic phrase [WMD = - 0.289; 95% CI = (- 0.661, 0.083); P = 0.128], and yielded a comparable rate of anastomotic leak [RR = 1.086; 95% CI = (0.842, 1.400); P = 0.525] compared with OLV. TLV with artificial pneumothorax resulted in less trauma than OLV. TLV with artificial pneumothorax is safe and could be a choice of ventilation strategy for esophagectomy.

448 Evaluation of cases of total laparoscopic radical hysterectomy and pelvic lymph node dissection for early-stage cervical cancer

Introduction and aim: Cervical cancer ranks the 16thleading cause of female cancer in Malta, with about 12 new cases diagnosed annually. Patients with early stage, FIGO IA2 or IB1, are offered a radical hysterectomy and pelvic lymph node dissection (PLND). We examine the cases of total laparoscopic radical hysterectomy (TLRH) and PLND done in 2017 and 2018. Method: The cases performed were audited, comparing them to quality indicators proposed by the European Organization for Research and Treatment of cancer – Gynaecological Cancer Group (EORTC-GCG).

Bilateral inguinal lymphadenectomy using simultaneous double laparoscopies for penile cancer: A retrospective study.

To assess the feasibility, safety, and efficiency of bilateral inguinal lymphadenectomy using simultaneous double laparoscopies for penile cancer. We reviewed retrospectively the records of 65 patients who underwent inguinal lymph nodes dissection (ILND) for penile cancer from January 2012 to May 2019. Treatments included open ILND (OILND, 19 patients), video-endoscopic inguinal lymphadenectomy (VEIL) using single laparoscopy (S-VEIL, 24 patients), and VEIL using double laparoscopies (D-VEIL, 22 patients). We evaluated the peri-operative and short-term oncological outcomes of the three groups. The mean operative time of D-VEIL (105.91 ± 10.87 minutes) was significantly shorter than the other two groups, OILND shorter than S-VEIL (160.47 ± 13.74 minutes, 191.67 ± 17.80 minutes, respectively) (P < 0.001). Intraoperative blood loss in the S-VEIL and D-VEIL groups were 53.54 ± 8.78 and 48.41 ± 13.22 ml, respectively; they were significantly lower than that of the OILND group (99.74 ± 9.64 ml; P < 0.001). The numbers of unilateral and total lymph nodes harvested were similar in all groups. The complication rates in the S-VEIL group (4.2%) and the D-VEIL group (4.5%) were significantly lower than that in the OILND group (63.2%; P < 0.001). Compared with open surgery (13.53 ± 1.74 days for hospitalization; 11.37 ± 1.92 days for the left side of drain, 11.95 ± 1.84 days for the right side), the two VEIL groups had significantly shorter drainage tube residence time (7.42 ± 2.02 and 7.32 ± 1.52 days, respectively for the left side; 7.63 ± 1.81 and 7.27 ± 1.58 days, respectively for the right side), shorter postoperative hospitalization (9.46 ± 1.64 and 9.00 ± 1.83 days, respectively) (P < 0.001). There were no statistically significant differences in rates of regional recurrence and short-term survival among the three groups. Bilateral inguinal lymphadenectomy using double laparoscopies simultaneously can provide adequate oncological outcomes safely and efficiently, and carry significantly lower morbidity than OILND, at a median follow-up of 33.5 months. It is a more time-saving surgical approach for penile cancer patients who need bilateral ILND.

A Population-Based Study to Evaluate the Associations of Nodal Stage, Lymph Node Ratio and Log Odds of Positive Lymph Nodes with Survival in Patients with Small Bowel Adenocarcinoma.

Purpose: This study aimed to determine the real-world prognostic significance of lymph node ratio (LNR) and log odds of positive lymph nodes (LOPLN) in patients with non-metastatic small bowel adenocarcinoma. Methods: Patients diagnosed with early-stage small bowel adenocarcinoma between January 2007 and December 2018 from a large Canadian province were identified. We calculated the LNR by dividing positive over total lymph nodes examined and the LOPLN as log ([positive lymph nodes + 0.5]/[negative lymph nodes + 0.5]). The LNR and LOPLN were categorized at cut-offs of 0.4 and −1.1, respectively. Multivariable Cox proportional hazards models were constructed for each nodal stage, LNR and LOPLN, adjusting for measured confounding factors. Harrell’s C-index and Akaike’s Information Criterion (AIC) were used to calculate the prognostic discriminatory abilities of the different models. Results: We identified 141 patients. The median age was 67 years and 54.6% were men. The 5-year overall survival rates for patients with stage I, II and III small bowel adenocarcinoma were 50.0%, 56.6% and 47.5%, respectively. The discriminatory ability was generally comparable for LOPLN, LNR and nodal stage in the prognostication of all patients. However, LOPLN had higher discriminatory ability among patients with at least one lymph node involvement (Harrell’s C-index, 0.75, 0.77 and 0.82, and AIC, 122.91, 119.68 and 110.69 for nodal stage, LNR and LOPLN, respectively). Conclusion: The LOPLN may provide better prognostic information when compared to LNR and nodal stage in specific patients.

Impact of lymph node yield at prostatectomy on outcomes in NRG/RTOG 9601.

265 Background: A recent study ( Fossati et al, 2018) found that higher lymph node count at radical prostatectomy was associated with improved outcomes in patients treated with salvage radiation for elevated prostate-specific antigen (PSA) after surgery. We sought to validate these results in NRG/RTOG 9601, a randomized controlled trial of men with pT2/T3 disease who underwent either radiation (RT) alone or RT+antiandrogen (bicalutamide) therapy for PSA elevation following radical prostatectomy from 1998-2003. Methods: We reviewed available pathology reports for all patients in NRG/RTOG 9601 to determine the nodal count at radical prostatectomy. Clinical data was as of 11/5/2015, same as the primary endpoint for the trial. Cox proportional hazards models were used to assess the effect of number of positive lymph nodes, treatment arm (RT alone or RT+bicalutamide), Gleason score, positive margins, and seminal vesicle invasion on the following endpoints: times to local and distant failure and overall and disease specific survival. Results: Out of the 760 patients originally eligible in the trial, 552 (73%, 276 in each arm) had complete data available. Median node count in the entire cohort was 6 (range 0-33, Q1-Q3 3-9). There were no significant differences between treatment arms in terms of patient demographic or clinical characteristics, including total lymph nodes removed in either arm (RT alone vs RT+bicalutamide median 5 vs 6, p = 0.11). There was no significant association between total lymph nodes and overall survival with both arms combined (HR = 1.00, 95% CI:0.97-1.03, p = 0.87) or in the individual arms alone (RT+Casodex: HR = 1.01, 95% CI:0.97-1.05, p = 0.65; RT+Placebo: HR = 0.98, 95% CI: 0.94-1.03, p = 0.45). There was also no significant association between total lymph nodes and disease-specific survival with both arms combined (HR = 1.00, 95% CI:0.95-1.04, p = 0.84) and in the arms alone (RT+Casodex: HR = 1.00, 95% CI:0.95-1.05, p = 0.92; RT+Placebo: HR = 0.99, 95% CI: 0.92-1.07, p = 0.86). In multivariable analysis performed on the two arms, Gleason score was the only feature associated with worse overall and disease-specific survival, seen only in the RT alone arm. Similar findings were seen when evaluating times to local and distant failure. Conclusions: Lymph node yield in NRG/RTOG 9601 did not show any association with adverse outcomes in the entire cohort, or in either treatment arm alone. The therapeutic benefit of an extensive lymph node dissection in this population remains uncertain. Clinical trial information: NCT00002874.

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer.

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex procedures. The high-quality 3-D visual, multijoint arm and natural tremor filtration allow the surgeon to expose and dissect more accurately with minimal invasion. Total mesorectal excision is the standard surgical technique for the treatment of resectable rectal cancer. To reduce the lateral recurrence rate, lateral pelvic lymph node dissection can be performed, as it is a safe and feasible procedure for locally advanced middle-low rectal cancer with a high possibility of metastasis to the lateral lymph nodes. However, the complexity of the anatomic structures and the high postoperative complication rate limit its application. Recently, several surgeons have increasingly used robotic techniques for total mesorectal excision and lateral pelvic lymph node dissection. Compared with open and laparoscopic surgery, the robotic technique has several advantages, such as less blood loss, fewer blood transfusions, minimal trauma, shorter postoperative hospitalization, and quicker recovery. A robotic approach is generally regarded as a reasonable alternative for complicated procedures such as lateral pelvic lymph node dissection, although there are a limited number of high-quality prospective randomized controlled studies reporting direct evidence. Here, we provide the detailed steps of robot-assisted total mesorectal excision and lateral pelvic lymph node dissection performed at the First Affiliated Hospital of Xi'an Jiaotong University.

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

Representativeness of the Index Lymph Node for Total Nodal Basin in Pathologic Response Assessment After Neoadjuvant Checkpoint Inhibitor Therapy in Patients With Stage III Melanoma

Neoadjuvant checkpoint inhibition in patients with high-risk stage III melanoma shows high pathologic response rates associated with a durable relapse-free survival. Whether a therapeutic lymph node dissection (TLND) can be safely omitted when a major pathologic response in the largest lymph node metastasis at baseline (index lymph node; ILN) is obtained is currently being investigated. A previous small pilot study (n = 12) showed that the response in the ILN may be representative of the pathologic response in the entire TLND specimen. To assess the concordance of response between the ILN and the total lymph node bed in a larger clinical trial population. Retrospective pathologic response analysis of a multicenter clinical trial population of patients from the randomized Study to Identify the Optimal Adjuvant Combination Scheme of Ipilimumab and Nivolumab in Melanoma Patients (OpACIN) and Optimal Neo-Adjuvant Combination Scheme of Ipilimumab and Nivolumab (OpACIN-neo) trials. Included patients were treated with 6 weeks neoadjuvant ipilimumab plus nivolumab. Patient inclusion into the trials was conducted from August 12, 2015, to October 24, 2016 (OpACIN), and November 24, 2016, and June 28, 2018 (OpACIN-neo). Data were analyzed from April 1, 2020, to August 31, 2021. Concordance of the pathologic response between the ILN and the TLND tumor bed. The pathologic response of the ILN was retrospectively assessed according to the International Neoadjuvant Melanoma Consortium criteria and compared with the pathologic response of the entire TLND specimen. A total of 82 patients treated with neoadjuvant ipilimumab and nivolumab followed by TLND (48 [59%] were male; median age, 58.5 [range, 18-80] years) were included. The pathologic response in the ILN was concordant with the entire TLND specimen response in 81 of 82 patients (99%) and in 79 of 82 patients (96%) concordant when comparing the ILN response with the response in every individual lymph node. In the single patient with a discordant response, the ILN response (20% viable tumor, partial pathologic response) underestimated the entire TLND specimen response (5% viable, near-complete pathologic response). Two other patients each had 1 small nonindex node that contained 80% viable tumor (pathologic nonresponse) whereas all other lymph nodes (including the ILN) showed a partial pathologic response. In these 2 patients, the risk of regional relapse might potentially have been increased if TLND had been omitted. The results of this study suggest that the pathologic response of the ILN may be considered a reliable indicator of the entire TLND specimen response and may support the ILN response-directed omission of TLND in a prospective trial.

Does lymph node ratio (metastasis/total lymph node count) affect survival and prognosis in gastric cancer?

Objectives:To investigate the influence of the metastatic lymph node/total lymph node ratio (N-ratio) on survival and prognosis in surgically treated gastric carcinomas.Methods:A retrospective review of 73 patients who underwent curative resection at the Department of General Surgery, Hitit University Faculty of Medicine, Turkey. Receiver operating characteristic analysis was used to calculate the cut-off value for the N-ratio of the patients. The N-ratio cut-off value was determined to be 0.32. Patients were divided into 2 groups: below 0.32 (Group 1) and 0.32 and above 0.32 (Group 2).Results:Group 2 patients had a total lymph node mean of 25.10±13.64 while Group 1 patients had a total lymph node mean of 18.77±9.36 (p=0.04). In Group 2, the mean of metastatic lymph node was 15.97±10.30 (p<0.001). The mortality rate of Group 1 was 18% while Group 2 was 51.7%, and were statistically significant (p=0.0039). The estimated survival duration of Group 2 was 24.22 months, and Group 1 was 48.01 months (p=0.001). The mean estimated survival time for the entire group was 40.92 months. We differentiated patients from the development of mortality cut-off value in ROC analysis with 65.2% sensitivity and 72% specificity. This ratio was found to be 0.32, which was statistically significant (p=0.003). Ratios greater than 0.32 raised the risk of mortality by 4.8 times, which was statistically significant (p=0.003).Conclusion:The N-ratio could be a new metric to evaluate prognosis following curative gastrectomy and improve the existing tumor lymph node metastasis staging system.

Long-term management of recurrent papillary thyroid carcinoma treated with lenvatinib for over 5\xa0years: a case report

BackgroundFew reports exist of the long-term management of recurrent and progressive papillary thyroid carcinoma (PTC) with a tyrosine kinase inhibitor for over 5 years.Case presentationA 57-year-old woman was referred to a psychiatric hospital for the treatment of schizophrenia. The patient had been diagnosed with a PTC at the age of 40 and subsequently underwent a left thyroid lobectomy. At 47, completion total thyroidectomy and lymph node dissection were performed and the patient assessed as radioactive iodine refractory postoperatively. External radiation therapy was performed for Rouviere lymph nodes. At 57, neck and mediastinal lymph nodes, and lung metastases had progressed, and the trachea became narrowed by para-tracheal lymph node compression. After 2 weeks of sorafenib therapy on an outpatient basis, the patient was discovered unconsciousness at home and transferred to hospital by ambulance; sorafenib therapy was stopped. The patient was diagnosed with reversible posterior leukoencephalopathy syndrome by brain magnetic resonance imaging. External radiation therapy to the site of the tracheal stenosis in the neck and mediastinum was performed. The patient’s mental symptoms worsened, and she was referred to a psychiatric hospital, Kachi Memorial Hospital, in July 2015. In September, the patient’s mental state stabilized and in November, after computed tomography revealed rapid disease progression, lenvatinib was commenced at a daily dose of 24 mg. Measurable solid recurrence sites were neck lymph nodes in the pre-laryngeal subcutaneous space, right lobe of the lung, and left adrenal. After 3 months, the tumors shrank in a partial response (PR). Because of several adverse events, occasional dose reductions or discontinuations of lenvatinib were sometimes necessary. Since re-starting lenvatinib, treatment with this for 51 consecutive months was achieved while maintaining a PR. Although a new bone metastasis was noted after 57 months of lenvatinib, treatment was continued for another 9 months. The patient subsequently passed away in June 2021.ConclusionsThe long-term treatment of recurrent PTC with lenvatinib was feasible, with manageable adverse events, for more than 5 years.

Comparison of the long-term oncologic outcomes of robotic-assisted and video-assisted thoracoscopic lobectomy for resectable non-small cell lung carcinoma

The current oncologic outcomes of robotic-assisted lobectomy compared to video-assisted thoracoscopic lobectomy are currently not well defined. This study compares the overall survival and recurrence-free survival rates between the two approaches for patients with resectable non-small cell lung carcinoma. This is a retrospective review of 200 patients diagnosed with resectable primary lung carcinoma who underwent minimally invasive lobectomy from March 2014 to May 2018. A total of 100 patients underwent thoracoscopic lobectomy and 100 patients underwent robotic-assisted lobectomy by a single surgeon. The data collected included patient demographics, tumor characteristics, surgical margin status, total number of lymph nodes harvested, lymph node upstaging rate, and overall survival and recurrence-free survival. The patients in each group were similar in age, gender, smoking status, pulmonary function, tumor histology, and pathologic stage. The postoperative mortality and complication rates were similar as well. The median number of total lymph nodes and N2 lymph nodes were significantly higher in the robotic lobectomy group (p < 0.0001). The Kaplan-Meier survival rates of overall survival (p = 0.097) and recurrence-free survival (p = 0.769) were similar between the two surgical approaches. The results of this report suggest that thoracoscopic and robotic-assisted lobectomy have similar long-term oncologic outcomes. There may be an advantage for robotic-assisted lobectomy in the total number of lymph nodes harvested during lobectomy.

Comparison of National Comprehensive Cancer Network and American College of Surgeons Commission on Cancer Lymph Node Sampling Guidelines for Non-Small Cell Lung Cancer

<h3>Purpose/Objective(s)</h3> Current guidelines conflict regarding adequate lymph node sampling during lung cancer surgery. The National Comprehensive Cancer Network (NCCN) guidelines recommend sampling at least 3 N2 and 1 N1 stations while the American College of Surgeons Commission on Cancer (CoC) guidelines recommend sampling at least 10 total lymph nodes. We sought to compare these guidelines in a cohort of Veterans with clinical stage I non-small cell lung cancer (NSCLC). <h3>Materials/Methods</h3> We performed a retrospective cohort study using a uniquely compiled dataset from the Veterans Health Administration (VHA) consisting of adults with clinical stage I NSCLC receiving surgery (2006-2016). We assembled a team of researchers who extracted lymph node sampling information from pathology reports and operative notes over a period in excess of 20 months. We defined sampling adequacy based on current guidelines from the NCCN (≥3 N2 + 1 N1 station) and CoC (≥10 lymph nodes). Our primary outcomes of interest were pathologic upstaging, disease-free survival, and overall survival. <h3>Results</h3> A total of 9575 patients were included in the current study. Of these, 3556 (37.1%) patients met NCCN guidelines and 3250 (33.9%) patients met CoC guidelines. Upstaging was observed in 1236 (12.9%) individuals. Adherence to either NCCN (adjusted odds ratio [aOR] 1.299, 95% CI 1.130-1.492) or CoC (aOR 1.637, 95% CI 1.425-1.881) guidelines was associated with higher likelihood of upstaging. With a median follow-up of 6.14 years, recurrence was observed in 2260 (23.6%) patients. While adherence to NCCN guidelines was associated with lower risk of recurrence (adjusted hazard ratio [aHR] 0.867, 95% CI 0.785-0.958), adherence to CoC guidelines was not associated with disease recurrence (aHR 0.928, 95% CI 0.839-1.028). Adherence to NCCN (aHR 0.932, 95% CI 0.874-0.994) or CoC (aHR 0.931, 95% CI 0.871-0.996) guidelines were associated with improved overall survival. <h3>Conclusion</h3> These data suggest that adherence to NCCN sampling guidelines may mitigate the risk of recurrence in clinical stage I NSCLC. Improving adherence to either guideline, however, may significantly improve long-term survival in patients with clinical stage I NSCLC undergoing surgical treatment.

Effects of standard and total two-field lymph node dissection on prognosis of patients undergoing Esophagectomy.

Objectives:To investigate the effects of standard two-field lymph node dissection (2FLND) and total 2FLND on the short-term and long-term clinical efficacy and complications of patients undergoing esophagectomy.Methods:The clinical data of 268 patients undergoing radical Ivor-Lewis esophagectomy in our hospital from January 2008 to November 2015 were analyzed retrospectively. According to different methods of lymph node dissection (LND), the patients were divided into standard 2FLND group (n = 121) and total 2FLND group (n = 147). The LND status, postoperative complications, survival rate and lymph node recurrence of the two groups were analyzed.Results:Lymph node metastasis rate showed no statistically significant difference between the standard 2FLND group and the total 2FLND group (71.1% and 63.3%, respectively, P > 0.05). The incidence of postoperative complications was 5.8% (7/121) in the standard 2FLND group, which was lower than that in the total 2FLND group [17.0% (25/147)], with a statistically significant difference (χ2 = 7.948, P < 0.01). The 5-year survival rate of the standard 2FLND group and the total 2FLND group was 29.8% and 28.6%, respectively, without statistically significant difference (χ2 = 0.005, P > 0.05). The lymph node recurrence rate in the standard 2FLND group was 41.3% (50/121), which was higher than 19.0% (28/147) of the total 2FLND group (χ2 = 15.959, P < 0.01).Conclusion:Compared with standard 2FLND, total 2FLND does not improve the postoperative survival of patients with esophageal carcinoma, and the risk of complications is higher.

Lymphadenopathy subsequent to Covishield (ChAdOx1 nCoV-19) Corona virus vaccine: ultrasound findings and clinical implications.

Introduction:Post anti-COVID-19 vaccine lymphadenopathies have been recently described in literature, from different parts of the world. Although there have been studies on lymphadenopathy following mRNA vaccines, there is a paucity of studies on lymphadenopathy following inactivated viral vaccines, such as Covishield.Aim:In this study, we explored lymphadenopathy subsequent to Covishield vaccine in terms of its various ultrasound parameters in the Indian population.Methods:This hospital-based longitudinal study was conducted among 50 adult beneficiaries of Covishield vaccine. Sociodemographic details and relevant clinical history were recorded using a semi-structured performa. Detailed ultrasound (USG) examination of the bilateral axillae was done on the day of vaccination and after 6–12 days post vaccination. Vaccine beneficiaries were evaluated for the presence of any vaccine-associated lymphadenopathy and described the presence, number, size, morphology, cortical thickness, and presence or absence of echogenic hilum.Results:Out of total (63) lymph nodes evaluated sonologically, majority (80.9%) of lymph nodes showed the features of benign lymphadenopathy. However, 12.6% (8/63) lymph nodes showed diffusely thickened cortex with preserved central echogenic hilum, 4.76% (3/63) lymph nodes showed eccentric cortical thickness with preserved hilar pattern, while only one lymph node showed diffuse cortical thickening with loss of central echogenic hilum.Conclusion:With an increase in vaccination coverage, clinicians are likely to confront increasing cases of vaccine-associated axillary lymphadenopathy. Therefore, they should exercise care, that contemporary anti-COVID-19 vaccination can present an aetiology of axillary lymph nodes with suspicious USG features.

The potency of multiple synchronous ipsilateral tumours on quantity of axillary lymph node involvement in clinical early stage breast cancer

Abstract Objective: The purpose of this study was to compare multiple synchronous ipsilateral breast cancer (MSIBC) with unifocal breast cancer (UBC) in terms of the quantity of axillary lymph node involvement (ALNI) and to examine the factors that increase the number of ALNI in MSIBC. Materials and Methods: Patients who were diagnosed with clinical early-stage breast cancer (stage I, II) with cN0 were included in the study. Results: Patients were divided into two groups according to multifocality (MSIBC, n=142, 26.2%; UBC, n=400, 73.8%). Statistically significant differences in ALNI were found between the two groups (p &lt; 0.001). Patients with MSIBC had significantly higher number of total positive lymph nodes, involvement of three or more axillary lymph nodes, tumor size, intermediate-high grade tumor, microcalcification, lymphovascular invasion (LVI), and accompanying ductal carcinoma in situ (DCIS) than patients with UBC (p &lt; 0.001, p &lt; 0.001, p &lt; 0.001, p = 0.041, p &lt; 0.001, p &lt; 0.001, p = 0.035, respectively). Out of the 142 patients who had MSIBC, 107 (75.4%) had ≤ 2 ALNI and 35 (24.6%) had &gt; 2 ALNI. Presence of pT2 tumor, grade 2/3 tumor, C-erbB2 positivity, microcalcification, and LVI for MSIBC patients with &gt; 2 ALNI were significantly higher than patients with ≤ 2 ALNI (p = 0.003, p &lt; 0.001, p = 0.048, p &lt; 0.001, p = 0.002, respectively). Presence of pT2 tumor, microcalcification, LVI, and grade 2/3 tumor were found to be significant after multivariate analysis for &gt; 2 ALNI in MSIBC patients. Conclusion: These results show that MSIBC not only increases ALNI in breast cancer patients, but also increases the number of involved lymph nodes. In MSIBC, limited axillary sampling can be performed more safely by identifying subgroup patients that may have increase number of ALNI.

Oncologic Benefit of Adjuvant Therapy in Lateral Pelvic Lymph Node Metastasis following Neoadjuvant Chemoradiotherapy and Lateral Pelvic Lymph Node Dissection.

Background: It remains controversial whether the addition of adjuvant chemotherapy (ACT) to total mesorectal excision (TME) plus lateral pelvic lymph node dissection (LLND) can provide a survival benefit after neoadjuvant chemoradiotherapy (nCRT) in patients with clinically suspected lateral pelvic lymph node metastasis (LPNM). We aim to investigate the effectiveness of ACT after nCRT with TME plus LLND for patients with clinically suspected LPNM.Methods: From January 2015 to December 2021, 138 patients with clinically suspected LPNM who were treated with nCRT followed by TME plus LLND at three institutions were enrolled in this study. The patients were categorized into the ACT group (n = 95) and the non‐ACT group (n = 43).Results: The mean follow-up period was 37 months. The 3-year disease-free survival (DFS) rate for the entire cohort was 74.8%. Ninety-five patients (68.8%) received ACT, without any oncologic benefit (3-year DFS rates for the ACT and non-ACT groups were 67.0% and 80.5%, respectively, P = 0.130). Additionally, multivariate analysis showed that lymphatic invasion (hazard ratio [HR]: 6.26, P = 0.005) was an independent risk factor for DFS. Subgroup analyses revealed that for patients ≥ 64 years and those with ypStage 0, the distribution of 95% confidence interval (CI) values tended to focus on the non-ACT strategy.Conclusion: The efficacy of the addition of ACT to TME plus LLND after nCRT in LARC patients with clinically suspected LPNM was not confirmed in this study. Moreover, patients with age ≥ 64 years and those with ypStage 0 may not receive benefit from ACT after nCRT followed by TME plus LLND.