Pulmonary T2N0 adenocarcinoma with metastasis to a lymph node in the thoracic wall

We experienced a rare case of lung cancer without hilar/mediastinal nodal involvement or direct invasion to the thoracic wall, but with metastasis to a lymph node in the thoracic wall. A 72-year-old woman with lung cancer was admitted to our hospital for the surgical therapy. She had suffered from right pleuritis in her childhood. During the dissection of the pleural adhesion around the whole lung, one small black lymph node was found in the thoracic wall and resected. Then, right middle and lower lobectomy and systematic nodal dissection were performed. The postoperative pathological examination revealed that nodal involvement was not observed in all samples except in the lymph node in the thoracic wall. In lung cancer patients with broad pleural adhesion, we should pay attention to lymph nodes in the thoracic wall. If we find them, the nodes should be resected for accurate staging.     

A prospective trial of systematic nodal dissection for lung cancer by video-assisted thoracic surgery: can it be perfect?

BACKGROUND: There have been no reports evaluating the completeness of systematic nodal dissection with video-assisted thoracic surgery (VATS). In order to elucidate the completeness of the dissection, we have conducted a prospective trial with patients having primary lung cancer. METHODS: Patients with clinical stage I lung cancer were the candidates for this study. Thoracotomy was performed with a small skin incision of 7 cm to 8 cm in length. Through these small wounds and two trocars, pulmonary resection was performed and then hilar and mediastinal lymph nodes were dissected. After that, a standard thoracotomy was carried out by another surgeon to complete systematic nodal dissection. RESULTS: Video-assisted thoracic surgery lobectomy with lymph node dissection was accomplished in 17 right lung cancer patients and 12 left lung cancer patients. On the right side, the average numbers of resected lymph nodes by VATS and remnant lymph nodes were 40.3 and 1.2, respectively. The average weights of dissected tissues by VATS and remnant tissues were 10.0 g and 0.2 g, respectively. On the left side, there were 37.1 and 1.2 lymph nodes and 8.3 g and 0.2 g of weight of dissected tissues. No nodal involvement was observed in the remnant lymph nodes. CONCLUSIONS: The lymph node dissection with VATS was technically feasible and the remnant ("missed" by VATS) lymph nodes and tissues were 2% to 3%, which seems acceptable for clinical stage I lung cancer.     

Mediastinal lymph node involvement as the initial manifestation of occult thyroid cancer in the surgical treatment of lung cancer: Report of a case

A 63-year-old man was referred to our institute for the treatment of squamous cell carcinoma of the upper lobe of his right lung. A right upper lobectomy of the lung was performed with a mediastinal lymph node dissection. The postoperative pathological examination of the dissected specimens revealed one of the superior mediastinal lymph nodes to be morbid with micrometastasis of occult thyroid cancer, while no node involvement was seen due to lung cancer. A right lobectomy of the thyroid gland with a modified radical neck dissection was done 4 years later after the confirmation of the absence of any recurrent sign of lung cancer. In the resected specimen, papillary thyroid microcarcinoma was observed with several intraglandular metastases and right regional lymph node involvement. Eight months later, a new primary lung cancer developed in the left lung, and a left upper lobectomy of the lung with a mediastinal lymph node dissection was performed. At that time, the absence of mediastinal lymph node metastasis from lung cancer or thyroid cancer was confirmed. Mediastinal lymph node involvement as the initial manifestation of occult thyroid cancer in surgical treatment for lung cancer is rare, but it is important to be aware of the possibility of incidentally detecting occult thyroid cancer in surgical dissections in this area for lung cancer. The appropriate surgical treatment should be determined while carefully considering the prognosis of the lung cancer as well as that of any coexisting malignancy.     

Assessment of systematic nodal dissection by VATS lobectomy for lung cancer

The feasibility of the complete systematic nodal dissection by the video-assisted thoracic surgery was prospectively assessed in 22 cases of clinical stage I lung cancer (16 right, 6 left cases). Resection of the designated lobe with the mediastinal lymph node dissection was carried out by the small thoracotomy with the aid of the thoracoscope, followed by the standard surgery to verify the completeness of systematic nodal dissection. Although residual lymph nodes were found in 14 of 22 cases, the residual rate was 2.9% and 2.7% by the number and 2.3% and 2.1% by the weight in right and left cases, respectively. Average time and hemorrhage for performing the procedure were 196 minutes, 216.7 minutes and 157.5 g, 145 g in right and left cases, respectively. As a consequence, sufficient systematic nodal dissection in lung cancer was suggested to be feasible by VATS lobectomy.     

ESTS guidelines for intraoperative lymph node staging in non-small cell lung cancer.

The European Society of Thoracic Surgeons (ESTS) organized a workshop dealing with lymph node staging in non-small cell lung cancer. The objective of this workshop was to develop guidelines for definitions and the surgical procedures of intraoperative lymph node staging, and the pathologic evaluation of resected lymph nodes in patients with non-small cell lung cancer (NSCLC). Relevant peer-reviewed publications on the subjects, the experience of the participants, and the opinion of the ESTS members contributing on line, were used to reach a consensus. Systematic nodal dissection is recommended in all cases to ensure complete resection. Lobe-specific systematic nodal dissection is acceptable for peripheral squamous T1 tumors, if hilar and interlobar nodes are negative on frozen section studies; it implies removal of, at least, three hilar and interlobar nodes and three mediastinal nodes from three stations in which the subcarinal is always included. Selected lymph node biopsies and sampling are justified to prove nodal involvement when resection is not possible. Pathologic evaluation includes all lymph nodes resected separately and those remaining in the lung specimen. Sections are done at the site of gross abnormalities. If macroscopic inspection does not detect any abnormal site, 2-mm slices of the nodes in the longitudinal plane are recommended. Routine search for micrometastases or isolated tumor cells in hematoxylin-eosin negative nodes would be desirable. Randomized controlled trials to evaluate adjuvant therapies for patients with these conditions are recommended. The adherence to these guidelines will standardize the intraoperative lymph node staging and pathologic evaluation, and improve pathologic staging, which will help decide on the best adjuvant therapy.     

Strategy for surgical treatment for small peripheral carcinoma of the lung especially on systemic nodal dissection

The diagnosis of small-sized (< or = 2 cm) non-small cell lung cancer (NSCLC) has increased with the development of computed tomography (CT), whereas unexpected extensive mediastinal involvement has been occasionally detected in such a small-sized lung cancer. We retrospectively analyzed the clinicopathological features to determinate the predictors for lymph node involvement in patients with a small-sized adenocarcinoma. One hundred and eighty one patients who underwent pulmonary resection and systematic nodal dissection for a peripheral small-sized adeno-carcinoma were reviewed. Of these, 24 patients (13.3%) had lymph node involvement. These patients were divided into 2 groups according to the existence of lymph node involvement, and the predictors for lymph node involvement were determined using univariate analysis and multivariate regression analysis. Univariate analysis revealed GGOR (ground glass opacity area/tumor area at the level of the greatest dimension of the lesion on chest computer tomography) > or = 25% (p = 0.0137) and pleural lavage fluid involvement (p = 0.0467) as predictors for lymph node involvement. No patients had lymph node involvement if their GGOR was higher than 50%. Multivariate regression analysis revealed GGOR > or = 25% (p = 0.0274), pleural tags on the lesion on chest CT (p = 0.0138) and pleural lavage fluid involvement (p = 0.0415) as predictors. We recommend performing systemic nodal dissection even if small peripheral adeno-carcinoma's maximal diameter is 20 mm or less. Systemic nodal dissection is unnecessary if the patients' GGOR > or = 50% or they do not have pleural tags or pleural lavage fluid involvement.     

Relationship of lymph node metastasis to primary tumor size and microscopic appearance of roentgenographically occult lung cancer

We investigated the relationship of lymph node metastasis to primary tumor size and microscopic appearance in 92 resected specimens obtained from patients with roentgenographically occult lung cancer (ROLC) located at a site along the airway between the main bronchus and the sub-subsegmental bronchi. Most of the patients were discovered by mass screening. All were treated surgically after bronchoscopic localization of cancer. The bronchial tree of the resected specimens was serial-sectioned into 2-mm thick blocks from the margin of resection to the sub-subsegmental bronchi. Bronchial wall invasion was noted in some blocks of all the specimens. The length of longitudinal extension (LLE) was defined as the product of the thickness and the number of consecutive blocks involved, counting from the most proximal to the most distal block. LLE was used as primary tumor size. Hilar and mediastinal lymph nodes were examined in 84 patients who underwent lymph node dissection. No nodal involvement was found in 59 cancers with LLE of less than 20 mm. Of 25 cancers with LLE of 20 mm or more, six showed nodal involvement. Eleven in situ carcinomas and four cancers of the "suspicious for invasion" type showed no lymph node metastasis. We contend that no lymph node dissection is required when pulmonary resection is performed for patients with ROLC if it is in situ carcinoma, if it is of the "suspicious for invasion" type, or if the LLE is smaller than 20 mm.     

Preoperative imaging of the lung sentinel lymphatic basin with computed tomographic lymphography: a preliminary study

BACKGROUND: Preoperative localization of the sentinel node basin would guide selective lymph node dissection. We tried to identify these nodal stations with indirect computed tomographic lymphography using a conventional extracellular contrast agent, iopamidol. METHODS: Eleven consecutive patients scheduled to undergo anatomic resection of suspected lung cancer, without lymphadenopathy, were given a peritumoral injection of undiluted iopamidol under computed tomography guidance, and lymphatic migration was assessed by multidetector-row helical computed tomography. RESULTS: There were no complications such as bleeding, pneumothorax, or allergic reactions. Enhanced nodes were detected in all but 1 patient who had diffuse lymph nodal calcification. Enhanced nodes were identified at 32 ipsilateral intrathoracic nodal stations (20 hilar stations and 12 mediastinal stations). The average length of the longer axis of the enhanced nodes was 4.8 mm (range, 3 to 8 mm), and the average attenuation of the enhanced nodes was 132 (range, 46 to 261) Hounsfield units. In 9 patients with confirmed lung cancer, enhanced nodes appeared at 26 nodal stations, and all apparent enhanced nodes were identified as actual lymph nodes at appropriate position during lymphadenectomy. None of the resected lymph nodes had metastatic involvement. CONCLUSIONS: Indirect computed tomographic lymphography with the peritumoral injection of iopamidol effectively depicts the drainage nodes unless they are diffusely calcified. Although further study is required, this method could guide selective lymph node dissection.     

Video-assisted thoracic surgery for left lung cancer in a patient with a right aortic arch

We report a rare case of left lung cancer in a patient with a right aortic arch. A 65-year-old woman was diagnosed to have an adenocarcinoma in the left upper lobe (S3) in addition to a right aortic arch (type II), with the left subclavian artery originating from the descending aorta. Left upper lobectomy and lymph node dissection was performed by video-assisted thoracic surgery (VATS). For the mediastinal dissection, the upper mediastinal lymph nodes were easily resected after verifying the location of the arterial ligament and the recurrent laryngeal nerve (RLN). This is the first report of using VATS to remove a lung cancer from a patient with a right aortic arch.     

Clinical outcome after video-assisted thoracic surgery (VATS) for clinical stage I lung cancer with pathologically nodal involvement

The lymph node dissection with video-assisted thoracic surgery( VATS) was technically feasible and the remnant lymph nodes and tissues were 2% to 3%, which seems acceptable for clinical stage I lung cancer. Surgical outcome after VATS for clinical stage I lung cancer with pathologically nodal involvement, however, remains unclear. Medical records of 72 patients who had clinical stage I non small cell lung cancer with pathologically nodal involvement( pN1:21 patients, pN2:51 patients) and underwent VATS lobectomy or segmentectomy with mediastinal dissection between January 2005 and December 2010, were retrospectively reviewed. Postoperative recurrence and survival were studied. Remnant nodal recurrence occurred in 8 patients with pN1 (recurrence rate 38%) and 15 patients with pN2 (recurrence rate 29%). The 1- and 3-year disease free survival rate was 87% and 68%. The 1- and 3-year survival rate was 100% and 79%. This study suggested that VATS is acceptable for patients with clinical stage I lung in terms of survival rate, cancer with pN1. In a view point of remnant nodal recurrence, a more skillful dissection procedure is required.     

The spread of metastatic lymph nodes to the mediastinum from left upper lobe cancer: results of superior mediastinal nodal dissection through a median sternotomy.

BACKGROUND: This study endeavored to clarify the location, frequency, and prognostic value of metastatic lymph nodes in the mediastinum among patients with left upper lung cancer who underwent complete dissection of the superior mediastinal lymph node through a median sternotomy. METHODS: Forty-four patients with left upper lobe cancer underwent extended radical mediastinal nodal dissection (ERD), all of whom were analyzed in this retrospective study. The group comprised 12 females and 32 males, with ages ranging from 28 to 70 years (median age, 60 years). Mediastinal nodal status was assessed according to the systems of Mountain/Dresler 7 and Naruke 8. The clinicopathological records of each patient were examined for prognostic factors, including age, sex, histology, tumor size, c-N number, preoperative serum CEA level, metastatic stations and distribution of metastatic nodes according to Naruke's system 8. The superior mediastinal lymph nodes which cannot be dissected through a left thoracotomy (bilateral #1 and #2, #3, right #3a, and right #4 according to Naruke's map 8 were defined as extra-superior mediastinal nodes for left lung cancer (ESMD). RESULTS: Fourteen patients had one or more metastases to mediastinal lymph nodes, among whom the most common metastatic station was the aortic nodes: 71.4% had metastasis to #5 or #6 (57.1% to #5 and 50% to #6). The next most common metastatic station was the left tracheobronchial nodes (42.8%). Metastasis to the ESMD occurred in 7 of the 44 study subjects (16%), representing a 50% rate of occurrence (7/14) among those with mediastinal nodal involvement. Univariate analysis found that CN factor and aortic nodal involvement (#5, #6) were significant predictive factors for ESMD metastasis. Multivariate analysis determined that only aortic nodal involvement was significant (p = 0.008). Furthermore, ESMD metastasis was rare (5.8%) in the absence of aortic node metastasis. The overall survival rate at 5 years was 50% among the patients without ESMD metastasis. However, the survival rate was 32% at 3 years and 0% at 5 years among the seven patients with ESMD metastasis. CONCLUSIONS: The aortic lymph node is the most common site of metastasis from left upper lobe cancer. Multivariate analysis demonstrated that aortic nodal involvement was a significant predictive factor for ESMD metastasis. Based upon the rates of metastasis and the post-operative prognosis in our study patients, dissection of aortic nodes and left tracheobronchial nodes may be important for patients with left upper lobe cancer. Whether ESMD dissection has a beneficial effect on prognosis remains controversial.     

Lymph node staging in non-small cell lung cancer: evaluation by [18F]FDG positron emission tomography (PET)

BACKGROUND: A study was undertaken to investigate the accuracy of positron emission tomography (PET) with 2-[18F]-fluoro-2-deoxy-D- glucose (FDG) in the thoracic lymph node staging of non-small cell lung cancer (NSCLC). METHODS: Forty six patients with focal pulmonary tumours who underwent preoperative computed tomographic (CT) and FDG- PET scanning were evaluated retrospectively. Thirty two patients had NSCLC and 14 patients had a benign process. The final diagnosis was established by means of histopathological examination at thoracotomy, and the nodal classification in patients with lung cancer was performed by thorough dissection of the mediastinal nodes at surgery. RESULTS: FDG-PET was 80% sensitive, 100% specific, and 87.5% accurate in staging thoracic lymph nodes in patients with NSCLC, whereas CT scanning was 50% sensitive, 75% specific, and 59.4% accurate. The absence of lymph node tumour involvement was identified by FDG-PET in all 12 patients with NO disease compared with nine by CT scanning. Lymph node metastases were correctly detected by FDG-PET in three of five patients with N1 disease compared with two by CT scanning, in nine of 11 with N2 disease compared with six by CT scanning, an in all four with N3 nodes compared with two by CT scanning. CONCLUSIONS: FDG-PET provides a new and effective method for staging thoracic lymph nodes in patients with lung cancer and is superior to CT scanning in the assessment of hilar and mediastinal nodal metastases. With regard to resectability, FDG-PET could differentiate reliably between patients with N1/N2 disease and those with unresectable N3 disease.     

Solitary Nodal Recurrence in the Dorsal Area of the Thoracic Aorta After a Curative Resection of Esophageal Cancer: Report of Two Cases

Although locoregional recurrence is often observed in the cervicothoracic area even after an esophagectomy with three-field lymph node dissection (3FL), recurrence in the mediastinal lymph nodes is relatively rare. We experienced two cases of solitary recurrence in a posterior mediastinal node (No 112-ao) after a curative resection for thoracic esophageal cancer. The lymph node recurrence was located in the connective tissue adjacent to the left posterior wall of the thoracic aorta, and thus could not have been removed by the conventional approach of an esophagectomy through a right thoracotomy. These two patients underwent surgical removal of the tumor through left thoracotomy, and survived for 5 years and 1 year without recurrence, respectively. Because the rate of metastasis in this area appears to be low, it is not always necessary to perform complete nodal dissection of the left side of the descending aorta at the initial surgery in cases of thoracic esophageal cancer. However, our experience suggests the importance of periodic computed tomography scans to check for any nodal recurrence in this area, since a surgical resection may be effective when the recurrence is detected as a solitary metastasis.     

Peripheral small-sized (2 cm or less) non-small cell lung cancer with mediastinal lymph node metastasis; clinicopathologic features and patterns of nodal spread

Objective: The diagnosis of small-sized (2 cm or less) non-small cell lung cancer (NSCLC) has increased with the development of computed tomography (CT), whereas unexpected extensive multiple-level mediastinal involvement has been occasionally detected in this small-sized lung cancer. To establish the optimal surgical strategy, we retrospectively analyzed the clinicopathologic features, efficacy of preoperative investigations and lobe specific patterns of nodal spread in small-sized NSCLC with mediastinal involvement. Methods: Among 1550 resected lung cancer cases between 1981 and 2000, 267 (17.2%) had peripheral small-sized NSCLC. Of these, 29 patients (10.8%) with mediastinal lymph node involvement who underwent pulmonary resection and systematic nodal dissection were reviewed. Results: Among 29 patients, 27 patients (93.1%) were adenocarcinoma, and 51.7% (15/29) showed no lymph node enlargement on CT (cN0). Surgical pathology revealed multiple-level mediastinal involvement in 65.5% (19/29) of all patients and 60.0% (9/15) of cN0 patients. All of right upper lobe tumors (n=11) showed multiple-level involvement. Thallium-201 single photon emission computed tomography (201Tl-SPECT) was positive for increased focal uptake in the mediastinum in 72.7% (8/11) of patients. Conclusions: The vast majority of cases were adenocarcinoma, and two thirds of them showed multiple-level mediastinal involvement, even in cN0 patients. We thus recommend to perform systematic nodal dissection or meticulous sampling for accurate intrathoracic staging, especially for right upper lobe tumor. 201Tl-SPECT appears to be more sensitive preoperative investigation for mediastinal metastasis compared with CT scan.     

Combined resection of the aorta for an esophageal carcinoma invading the aorta through a right transthoracic approach.

The prognosis of esophageal carcinoma invading the thoracic aorta has been extremely poor, as it has been either not resected or only palliatively resected. In recent years a remarkable improvement in survival has been achieved in advanced esophageal carcinoma through an aggressive dissection of the upper mediastinal lymph nodes. This implied that resection only of the aorta without lymph node dissection in these patients was not adequate for curability. Although a resection of the aorta would seem to be performed more easily through a left thoracotomy than through a right thoracotomy, the upper mediastinal lymph node dissection was unsatisfactory through a left thoracotomy. Therefore, we performed combined resection of the aorta using a temporary aorta-aorta bypass together with upper mediastinal lymph node dissection through a right thoracotomy for four patients with the esophageal carcinoma invading the thoracic aorta. This operative procedure was performed safely, and had the advantage that full observation on the extent of the carcinoma was attained together with subsequent radical lymph node dissection in the same field through only the right thoracic approach. This operation may provide a possibility for cure to patients with an esophageal carcinoma invading the aorta, who would otherwise receive only palliative treatment.     

Combined resection of the aorta for an esophageal carcinoma invading the aorta through a right transthoracic approach

The prognosis of esophageal carcinoma invading the thoracic aorta has been extremely poor, as it has been either not resected or only palliatively resected. In recent years a remarkable improvement in survival has been achieved in advanced esophageal carcinoma through an aggressive dissection of the upper mediastinal lymph nodes. This implied that resection only of the aorta without lymph node dissection in these patients was not adequate for curability. Although a resection of the aorta would seem to be performed more easily through a left thoracotomy than through a right thoracotomy, the upper mediastinal lymph node dissection was unsatisfactory through a left thoracotomy. Therefore, we performed combined resection of the aorta using a temporary aorta-aorta bypass together with upper mediastinal lymph node dissection through a right thoracotomy for four patients with the esophageal carcinoma invading the thoracic aorta. This operative procedure was performed safely, and had the advantage that full observation on the extent of the carcinoma was attained together with subsequent radical lymph node dissection in the same field through only the right thoracic approach. This operation may provide a possibility for cure to patients with an esophageal carcinoma invading the aorta, who would otherwise receive only palliative treatment.     

Squamous cell carcinoma caused by dysplasia on the bullous wall

We experienced a squamous cell lung carcinoma caused by dysplasia around the bullous wall after right upper lobectomy by tuberculosis. A case is 70 years old male who was resected right upper lobe caused by tuberculosis 50 years ago. He was pointed out an abnormal shadow on the chest X-ray in March 2002. There were bullous change in right lung field on the chest computed tomography (CT). There was appeared a tumor contiguous to the bullous wall. A part of bullous wall surrounding the tumor was thickened bronchio-alveolar lavage gave proof of squamous cell carcinoma. Right basal segmentectomy and subcarinal lymph node dissection was done, because of severe adhesion a right middle lobe. Radiation therapy at the mediastinum is performed, because of positive subcarinal lymph nodes. It is rare case of squamous cell carcinoma caused by dysplasia, we reported.     

Lobectomy with extended lymph node dissection by video-assisted thoracic surgery for lung cancer

Background: Between September 1992 and September 1996, we performed 88 VATS (video-assisted thoracic surgery) lobectomies and two VATS pneumonectomies. Methods: The indications for surgery were 68 cases of lung cancer, nine cases of bronchiectasis, six cases of tuberculosis, and seven cases of benign lesions. Of the 68 cases of lung cancer, 36 were treated by VATS lobectomy with extended lymph node dissection for clinical stage I lung cancer, making full use of recently developed devices for thoracoscopic surgery, such as roticulating endoscissors, miniretractors, endoclips, and harmonic scalpels. Results: Twenty-four lymph nodes were resected on average (range, 10 to 51) by VATS. This number was comparable to lymph nodes resected in open thoracotomy during the same period. Among the 36 patients who underwent extended lymph node dissection, 20 showed no lymph node metastasis postoperatively (stage I), while 16 had N1 or N2 cancer. All patients with stage I cancer have survived 4 to 36 months (median: 17 months) with no signs of recurrence. Conclusions: This survival of stage I lung cancer after VATS is comparable to that of open thoracotomy. We thus believe that VATS lobectomy with extended lymph node dissection can be an alternative to standard posterolateral thoracotomy for stage I lung cancer. Received: 10 May 1996/Accepted: 19 November 1996     

Pattern of lymph node metastases in patients with squamous cell carcinoma of the thoracic esophagus who underwent three-field lymphadenectomy

BACKGROUND/AIMS: Lymph nodes in patients with squamous cell carcinoma of the thoracic esophagus might be involved with metastases at cervical, mediastinal, and abdominal sites. The range of lymph node dissection is still controversial. The pattern of lymph node metastasis and factors that are correlated with lymph node metastasis affect the surgical procedure of lymph node dissection. The purpose of the present study was to explore the pattern of lymph node metastasis and factors that are correlated with lymph node metastasis in patients with esophageal cancer who underwent three-field lymphadenectomy. METHODS: Lymph node metastases in 230 patients who underwent radical esophagectomy with three-field lymphadenectomy were analyzed. The metastatic sites of lymph nodes were correlated with tumor location by chi-square test. Logistic regression was used to analyze clinicopathological factors related to lymph node metastasis. RESULTS: Lymph node metastases were found in 133 of the 230 patients (57.8%). The average number of resected lymph nodes was 25.3 +/- 11.4 (range 11-71). The proportions of lymph node metastases were 41.6, 19.44, and 8.3% in neck, thoracic mediastinum, and abdominal cavity, respectively, for patients with upper thoracic esophageal carcinomas, 33.3, 34.7, and 14%, respectively, in those with middle thoracic esophageal carcinomas, and 36.4, 34.1, and 43.2%, respectively, for patients with lower thoracic esophageal carcinomas. We did not observe any significant difference in lymph node metastatic rates among upper, middle, and lower thoracic carcinomas for cervical or thoracic nodes. The difference in lymph node metastatic rates for nodes in the abdominal cavity was significant among upper, middle, and lower thoracic carcinomas. The lower thoracic esophageal cancers were more likely to metastasize to the abdominal cavity than tumors at other thoracic sites. A logistic regression model showed that depth of tumor invasion and lymphatic vessel invasion were factors influencing lymph node metastases. CONCLUSIONS: Based on our data, cervical and mediastinal node dissection should be performed independent of the tumor location. Abdominal node dissection should be conducted more vigorously for lower thoracic esophageal cancers than for cancers at other locations. Patients with deeper tumor invasion or lymphatic vessel invasion were more likely to develop lymph node metastases.     

Size of metastasis in the sentinel node predicts additional nodal involvement in penile carcinoma

PURPOSE: The majority of patients with penile cancer with a tumor positive sentinel node do not benefit from complementary lymph node dissection because of absent additional involved nodes. We analyzed factors that may determine the involvement of additional nodes. MATERIALS AND METHODS: A total of 158 patients with clinically node negative penile carcinoma underwent sentinel node biopsy. Complementary inguinal lymph node dissection was performed when the sentinel node was tumor positive. The size of the sentinel node metastasis was measured and classified as micrometastasis--2 mm or less, or macrometastasis--more than 2 mm. Sentinel and dissection specimen nodes were step-sectioned. Factors were analyzed for their association with additional nodal involvement, including stage, diameter, grade, absence or presence of vascular invasion of the primary tumor, and sentinel node metastasis size. RESULTS: Tumor positive sentinel nodes were found in 46 groins and complementary lymph node dissection was performed. Nine of these 46 groins (20%) contained additional involved lymph nodes. On univariate and multivariate analyses the size of the sentinel node metastasis proved to be the only significant prognostic variable for additional lymph node involvement (each p = 0.02). None of the 15 groins with only micrometastasis in the sentinel node contained additional involved nodes. CONCLUSIONS: In penile carcinoma additional nodal involvement was related to the size of the metastasis in the sentinel node. Sentinel node micrometastasis was not associated with other involved lymph nodes. This finding suggests that these patients can be spared complementary lymph node dissection.