Long-term efficacy of percutaneous tibial nerve stimulation for faecal incontinence and a new approach for partial responders

Background

The aim of the present study was to evaluate the long-term efficacy of percutaneous tibial nerve stimulation (PTNS) for patients with faecal incontinence (FI) refractory to conservative treatment. Secondary aims were to identify predictors of response and validate new treatment pathways for partial responders.

Methods

A prospective, interventional study was carried out in a specialist defecatory disorder unit from a university hospital between January 2010 and June 2017 on patients > 18 years old with FI refractory to conservative treatment. Thirty-minute PTNS sessions were performed in three phases (weekly, biweekly and monthly) up to a year, with clinical reassessment at 3, 6, 12 and 36 months.

Patients were classified as optimal responders when their pretreatment Wexner score decreased > 50%; partial responders when it decreased 25–50%; and insufficient responders if it decreased < 25%. Only optimal and partial responders progressed into successive phases.

Results

Between 2010 and 2017, 139 patients (110 women, median age 63 years [range 22–82 years]) were recruited. After the first phase, 4 patients were optimal responders, 93 were partial responders and 36 were insufficient responders. At 6 and 12 months, 66 and 89 patients respectively were optimal responders, with an optimal response rate of 64% at the end of treatment. A total of 93.3% patients with a partial response initially finally became optimal responders. Furthermore, at 36 months, 71.9% of patients were still optimal responders without supplementary treatment, although their quality of life did not improve significantly. Baseline Wexner scores ≤ 10 and symptom duration < 1 year were identified as predictive factors for positive responses to PTNS.

Conclusions

Patients undergoing PTNS for 1 year following this protocol had optimal long-term responses. PTNS sessions for up to 1 year in patients who were partial responders prevents a high percentage of them from needing more invasive treatments, and maintains long-term continence in patients who were optimal responders.

     

A retrospective observational study of benign anthracotic lymphadenitis and its association with PET avid lymph nodes in patients undergoing cancer evaluation

BackgroundAccurate staging of newly diagnosed or recurrent malignancy is essential for effective treatment. An important first step in staging involves the use of PET/CT to identify areas of FDG avidity. PET/CT however has limitations, including false positive FDG uptake from benign causes. In this paper we characterize an uncommon yet clinically important cause of false positive PET/CTs, that of benign anthracotic lymphadenitis (BAL). We examine the clinical, radiographic and histologic characteristics of BAL in patients referred for endobronchial ultrasound (EBUS) guided biopsies and discuss its context in relation to existing literature.MethodsWe performed a retrospective observational case series of 20 patients who were referred for EBUS guided biopsies of PET positive mediastinal and hilar lymph nodes during the work-up or treatment of suspected malignancy.ResultsTo be included, all patients received PET imaging as well as an EBUS guided biopsy of FDG avid lymph nodes which demonstrated anthracotic pigment as the only histologic abnormality. The key findings were that 90% of patients in this cohort were born outside of the US, 90% had bilateral FDG avid lymph nodes with an average standardized uptake value (SUV) of 7.9±2.2. Most patients, based on their history, had a likely exposure to biomass fuel or urban pollution.ConclusionsBAL may be an underrecognized cause for PET positive lymph nodes in patients undergoing work-up for malignancy. These findings support the importance of sampling mediastinal and hilar lymph nodes even when SUVs are highly suggestive of malignancy.     

Tuberculous pleural effusion and lymphadenitis treated with rifampin-containing regimen

Rifampin, isoniazid, and ethambutol were administered in single daily dose for nine months to 91 patients with pleural effusion and 45 patients with lymphadenitis, both of tuberculous etiology. Clinical and roentgenographic clearance of pleural effusion was successfully achieved in all cases at the end of nine months of treatment. Followup of 80 cases of pleural effusion up to nine months, in 55 cases up to one year, and up to two years in 30 cases after completion of therapy, showed no recurrence. In the cases of tuberculous lymphadenitis, resolution of lymph nodes occurred in 31 cases (68.8 percent) at the end of nine months of treatment. Therapy had to be extended for varying periods for achieving successful response, and in five cases, medical treatment had to be supplemented with surgical drainage and excision of the nodes. Short course chemotherapy can be used to treat pleural effusion, but the same mode of treatment is less effective for cases of tuberculous lymphadenitis.     

Management of lymphadenitis in childhood: the role of percutaneous needle aspiration

Bacterial lymphadenitis occurs commonly during childhood, but the preferred initial therapy has not been clearly established. We studied lymphadenitis in children to determine the course of patients with fluctuant and nonfluctuant infections, and to assess the role of percutaneous needle aspiration as a form of therapy. Of 32 patients diagnosed as having lymphadenitis, 30 were followed successfully (26 with initially nonfluctuant and four with initially fluctuant infections). Fluctuance subsequently developed in four of 26 lymph nodes that were initially firm to palpation. In all eight children with fluctuant lesions the infections were resolved following percutaneous needle aspiration and antibiotic therapy, and 25 of 26 with initially nonfluctuant infections were cured with antibiotic therapy alone or with antibiotics accompanied by percutaneous aspiration when fluctuance developed (four cases). Thus we recommend initial percutaneous aspiration for the treatment of lymphadenitis whenever abscess formation is detected clinically.     

Problem of differential diagnosis of tuberculosis of peripheral lymph nodes and malignant neoplasms]

A total of 386 patients admitted with the diagnosis of tuberculous lymphadenitis were subjected to a differential diagnosis of tuberculosis of peripheral lymph nodes and malignant tumours. A histological examination of the removed lymph nodes demonstrated malignant tumours in 22 (5.7%) patients. Difficulties encountered in differentiating between tuberculous lymphadenitis and malignant tumours are due to changes in the clinical course of the process which are manifested in the enlargement of one or several nodes in 80% of patients in the absence of intoxication, which is also typical of primary malignant tumours of the lymph nodes. Histological and bacteriological studies of the removed nodes proved to be more informative for the differential diagnosis of tuberculous lymphadenitis and malignant tumours.     

A retrospective analysis of 1019 cases of tuberculous cervical lymphadenitis in a rural setup in 20 years

BackgroundThis article is to review cervical lymphadenitis due to tuberculosis (TB), their presentation, their aetiology, the methods used to diagnose them, the treatment modalities offered and the response to treatment.Methods1019 patients were diagnosed and treated for TB of the lymph nodes of the neck from 1st November 2001 to 31st August 2020 at a tertiary ENT hospital, Nadiad, Gujarat, India. Study consisted about 61% males and 39% females with the mean age being 37.3 years.ResultCommonest factor or habit among those diagnosed for tuberculous cervical lymphadenitis was consumption of unpasteurized milk. HIV and diabetes were the most common co-morbid conditions found with this disease. Swelling in the neck was most common clinical feature followed by loss of weight, formation of abscess, fever and fistula. Rifampicin resistance was found in 1.5% of patients among those tested for the same.ConclusionThe most commonly affected site for extra pulmonary TB is posterior triangle of neck than the anterior triangle. Patients with HIV and diabetes are at higher risk for the same. Testing for drug susceptibility has to be done due to increased resistant of drugs for extra pulmonary TB. GeneXpert and histopathological examination are important for its confirmation.     

颈部淋巴结结核发生结核性脓肿的危险因素分析

目的 探讨颈部淋巴结结核患者发生结核性脓肿的相关危险因素。方法 分析2013年7月至2016年6月于同济大学附属上海市肺科医院住院确诊的符合纳入标准的280例颈部淋巴结结核患者临床资料,分析颈部结核性淋巴结脓肿发生的危险因素。结果 280例颈部淋巴结结核患者中有52例(18.6%)患者在治疗中出现淋巴结脓肿、自行破溃或需要淋巴结切开引流。发生脓肿者中不规范治疗者占38.5%(20/52)、肿大淋巴结直径≥2cm者占76.9%(40/52)、年龄≤45岁者占90.4%(47/52);未发生脓肿者中不规范治疗者占24.6%(56/228)、肿大淋巴结直径≥2cm者占55.3%(126/228)、年龄≤45岁者占77.6%(177/228);差异均有统计学意义(χ²值分别为4.14、8.23、4.30,P值均<0.05)。多因素logistic回归分析显示,不规范治疗(OR=2.53,95%CI:1.31~4.89)、肿大淋巴结直径≥2cm(OR=2.29,95%CI:1.12~4.66)和年龄≤45岁(OR=3.68,95%CI:1.21~11.17)为发生颈部结核性淋巴结脓肿的危险因素。结论颈部淋巴结结核患者治疗不规范、肿大淋巴结直径≥2cm及年龄≤45岁为发生结核性脓肿的独立危险因素,当颈部淋巴结结核患者出现上述危险因素时要警惕发生结核性脓肿的可能。     

A systematic review and meta-analysis of predictors of recurrence in patients with Solid Pseudopapillary Tumors of the Pancreas

BackgroundThe recurrence rates and predictors of recurrence in patients with Solid Pseudopapillary tumors (SPT) are unclear, which makes it challenging to determine the duration of follow-up. The aim of the current study was to perform a systematic review and meta-analysis to determine the recurrence rates and pathologic factors associated with recurrence in patients with SPT.MethodsA PubMed, Scopus, and Web of Science search was conducted to identify studies of SPT published during the last 15 years: (09/2002–09/2017). Studies reporting on patients with SPT and follow-up of >5 years were included. The search strategy was conducted per 2009 PRISMA guidelines.ResultsA total of 103 studies reporting on 2599 non-metastatic SPT patients were identified. Sixty-nine patients (2.6%) developed recurrence during follow-up. Pooled estimates from studies with a sample size >20 (N = 33) noted an overall recurrence rate of 2% (95% CI 1–2%). Male gender (OR 1.960), positive lymph nodes (OR 11.9), R1 margins (OR 11.1), and LVI (OR 5.5), were associated with a significantly (all p < 0.05) increased risk of recurrence.ConclusionCurrent meta-analysis suggests that only 2% of patients with SPT experience recurrence after resection. These data will guide the treating physicians and patients regarding recurrence rates and help identify patients at increased risk of recurrence during follow-up.     

The use of the artificial neural network for three-month prognosis in diabetic foot syndrome

AimsMaking a reliable prognosis in new patients with diabetic foot syndrome (DFS) is challenging. We used the artificial neural network (ANN) to identify the patients who didn't heal in three months. We provided data for an application which helps predict the course of healing in DFS.Methods175 in-patients (213 limbs) with DFS ulcerations were enrolled in this prospective observational study and were followed up for three months. Thirty-five clinical variables were included in the statistical analysis.ResultsSix significant variables predicting the outcome of DFS treatment were identified: probe-to-bone test, presence of blood flow in Doppler probe, prior amputation within the foot, erythrocyte sedimentation rate, the area and duration of the ulceration. ANN was created with nine input neurons, six hidden nodes and two output neurons. The area under the ROC curve was 0.85. The total accuracy was 82.21 %, sensitivity 91.6 %, specificity 66.18 %.ConclusionsANN as a new prognosis method in DFS ulcers can be reliably used in the prediction, helping physicians and patients predict the course and outcome of the treatment. The algorithm can be particularly useful in identifying individuals who fail to be healed.     

Volume of surgical activity and lymph node evaluation for patients with colorectal cancer in France

BackgroundThe correct examination of lymph nodes is decisive for tumour classification into stage 2 and stage 3. The aim of this specialised population-based study was to investigate the influence of clinical factors and volume of surgical activity on lymph node assessment in France for patients diagnosed with localised colorectal cancer.MethodsFrom 1997 to 2004, French digestive cancer registries recorded a total of 4197 cases of colorectal cancer. The volume of surgical activity was appreciated by the annual number of digestive surgery admissions in 2004. The probability of having at least 12 lymph nodes examined after surgical resection was analysed using a multilevel logistic regression model.ResultsOnly 1900 patients had more than 12 lymph nodes examined (45.2%). The percentage of patients with at least 12 lymph nodes examined after tumour resection is directly associated with the volume of surgical activity within care centres for patients diagnosed between 1997 and 2000. This association was no longer significant during the second period study (2001–2004).Conclusion(s)This population-based study reports that only 55% of colorectal patients have a sufficient number of lymph nodes examined. This insufficient number of examined lymph nodes could be considered as a potential prospect for increasing treatment quality in cancer patients in France.     

A comparison of the accuracy of echo features during endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration for diagnosis of malignant lymph node invasion

Background: The purpose of this study was to re-evaluate echo features of lymph nodes during endoscopic ultrasound and assess the utility of these echo features and endoscopic ultrasound–guided fine-needle aspiration in predicting malignant lymph node invasion. Methods: Thirty-five lymph nodes in 25 patients with lung, esophageal, and pancreatic cancer were evaluated by endoscopic ultrasound. Endoscopic ultrasound examinations were performed with a radial scanning echoendoscope. Confirmation of benign lymph nodes was obtained by surgical resection while malignant lymph nodes were confirmed by real-time endoscopic ultrasound–guided fine-needle aspiration with a linear array echoendoscope. Results: Nineteen benign lymph nodes and 16 malignant lymph nodes in the mediastinum, celiac axis, and the peripancreatic area were included in the study. The following echo features were compared between benign and malignant lymph nodes: size greater than 1 cm, hypoechoic, distinct margins, and round shape. No single feature independently predicted malignant invasion. When all four of the above features were present in the same lymph node, the accuracy for predicting malignant invasion was 80%. However, all four features of malignant involvement were present in only 25% (4 of 16) of malignant lymph nodes. Our study also suggests that the above echo features may be a less reliable predictor of malignant invasion in pulmonary malignancies when compared to gastrointestinal cancers. Endoscopic ultrasound–guided fine-needle aspiration of lymph nodes in 22 patients revealed malignant lymph node invasion in 16 and benign cells in 6 patients. Conclusion: Endoscopic ultrasound–guided fine-needle aspiration is an important adjunct for accurate lymph node assessment for malignancy. (Gastrointest Endosc 1997;45:474-9.)     

Relationship of apical lymph node involvement to survival in resected colon carcinoma

In a prospective study of 197 patients with resected colon carcinoma treated between 1974 and 1985, we explored the relationships between pathologic parameters, and the effect of the latter on survival, to identify the parameter whose systematic measurement would improve the predictive capacity of pathologic staging. Prognostic characteristics were studied by univariate analysis. The results showed significant relationships between the location and number of lymph nodes involved, blood vessel invasion, depth of tumor penetration, and metastases. The five-year survival rates were 45 percent and 17 percent (P < 0.001) for patients without and with apical lymph node involvement, respectively, and 44 percent and 6 percent (P <0.05) for those with four or less nodes involved and more than four involved, respectively. Among the patients treated by incomplete resection, the respective survival rates of those resected for metastases and of those resected for apical lymph node involvement did not differ significantly. We conclude that the involvement of apical lymph nodes has a significant effect on prognosis and suggest systematic pathologic examination of these nodes to allow simpler and more reproducible selection of patients for treatment by incomplete resection who are at high risk of disease-related death.     

Necrotizing and suppurative lymphadenitis in Leishmania major infections

The pathology of lymph nodes and subcutaneous nodules in 6 patients with cutaneous leishmaniasis (Oriental sore) due to Leishmania major is described in this paper. In 3 patients enlarged epitrochlear lymph nodes were found to be associated with primary skin lesions in the forearm. The lymph node in one patient showed a necrotizing granulomatous reaction that simulated tuberculous lymphadenitis. Leishmania parasites were, however, found in sections of the node, and staining for mycobacteria was negative. The second patient presented with an abscess and a discharging sinus in the epitrochlear region. Parasites were found in smears of the pus and cultures for bacteria were negative. The lesion healed with antimonial therapy. In the third patient the lesion resembled cat-scratch disease and showed stellate abscesses and granulomas. Leishmania parasites were also identified in the sections. Sections of a subcutaneous nodule from the fourth patient showed a necrotizing granuloma. The lesion healed spontaneously and the patient became leishmanin-positive. In two other patients fine needle aspiration of the subcutaneous nodules showed parasites, granuloma and necrosis. We concluded that L. major disseminates from the primary cutaneous lesion via the lymphatics to the subcutaneous tissues and the regional lymph nodes. The subcutaneous nodules and lymphadenopathy may persist long after the primary lesion had healed. The primary lesion is sometimes inconspicuous. Necrotizing and suppurative lymphadenitis due to L. major have to be distinguished from other causes of necrosis and suppuration such as tuberculosis and cat-scratch disease.     

Spontaneous resolution of post‐transplant localized cytomegalovirus lymphadenitis mimicking tumor recurrence

Compromised T‐cell immunity persists for up to 1 year after autologous stem cell transplantation (ASCT), and patients treated with ASCT are more likely to develop atypical lymphoid hyperplasia that mimics tumor recurrence. Here, we present a case of cervical lymphadenitis due to cytomegalovirus (CMV) reactivation in a patient who had undergone ASCT for Burkitt lymphoma, which mimicked tumor recurrence on computed tomography and positron emission tomography‐computed tomography 6 months after ASCT. This lesion was confined to the regional lymph nodes and was not accompanied by signs of systemic involvement, such as fever, splenomegaly, an elevated C‐reactive protein level, or viremia. The localized CMV lymphadenitis resolved spontaneously without treatment after 6 months (12 months after ASCT) and the elevated CMV immunoglobulin‐M titer normalized 6 months after resolution. Our experience with this case suggests that cautious follow‐up without anti‐CMV treatment should be considered in cases of post‐ASCT localized CMV lymphadenitis without systemic involvement in patients with complete engraftment.     

Kikuchi Fujimoto disease secondary to Entamoeba histolytica: case report

Kikuchi Fujimoto disease (KFD) is a rare histiocytic necrotizing lymphadenitis which has a benign self-limiting clinical course. Its origin is unknown, but an abnormal autoimmune reaction has been suggested and infection is often considered to be an inciting agent. A 50-year-old man presented with fever, malaise, fatigue and sweat of 7 days duration, and diarrhea for 2 days. Physical examination revealed five mobile and painless cervical adenopathies. Entamoeba histolytica trophozoites and cysts were detected by microscopy of feces. Parenteral ornidazole treatment was commenced. Thorax computerized tomography showed lymph node sizes congruent with infection in the mediastinum, right hilus and right axillary region. Axillary lymph node biopsy and immunohistochemical analyses were then performed, and the results were consistent with histiocytic necrotizing lymphadenitis. From day 4 of antibiotic treatment the patient's body temperature decreased and reached a normal level on day 10. After discharge the patient returned for follow-up twice and was asymptomatic; his lymph nodes were either unpalpable or were decreased in size. We could not find any previous study or case report about a probable role for E. histolytica. Amebiasis can be a triggering factor in KFD or alternatively it is possible that its occurrence is coincidental.     

Analysis of C-reactive protein levels and febrile tendency after joint surgery in rheumatoid arthritis patients treated with a perioperative 4-week interruption of tocilizumab

Abstract

We evaluated the safety and efficacy of tocilizumab in polyarticular-course juvenile idiopathic arthritis (pJIA) with polyarticular or oligoarticular onset. Patients received 8 mg/kg tocilizumab every 4 weeks in the open-label studies: initial study (to week 12) and then an extension study (at least 48 weeks). Nineteen patients intractable to conventional methotrexate therapy were enrolled. Seventeen patients had polyarticular-onset pJIA; two had oligoarticular-onset pJIA. Mean age was 11.6 years; mean disease duration 5.3 years. American College of Rheumatology Pediatric (ACR Pedi) 30, 50, 70, and 90 response rates, respectively, were 94.7%, 94.7%, 57.9%, and 10.5% at week 12, and 100%, 94.1%, 88.2%, and 64.7% at week 48. Mean disease activity score (DAS28) remained below the remission level (2.6) from week 24. Administration was discontinued in two patients during the extension study because the ACR Pedi 50 response was judged insufficient (one patient) and antitocilizumab antibodies developed (one patient). Adverse events were generally mild, and the four serious adverse events resolved spontaneously or with treatment. In conclusion, tocilizumab showed early and sustained efficacy and tolerability for treating intractable pJIA, which suggests that it is a promising new treatment for this disease.     

Tuberculous lymphadenitis: a clinical study of 23 cases

INTRODUCTION: Tuberculous lymphadenitis is a relatively rare disease in adults. In the absence of pulmonary tuberculosis, tuberculous lymphadenitis is very difficult to differentiate from other diseases. We described our experiences of patients with tuberculous lymphadenitis. RESULTS: We diagnosed 23 patients with tuberculous lymphadenitis out of 207 patients with tuberculosis. Their ages ranged from 18 to 99 years (mean, 45.7 years), and the male-to-female ratio was 7:16. The most common complaints were cervical mass and fever. With the exception of two patients, all diagnosed patients had a strong positive skin test to tuberculin. Observing the site of affected lymph nodes, 16 patients had cervical node involvement, 3 patients had axillary node involvement, 7 patients had mediastinal node involvement, 3 patients had hilar node involvement, 3 patients had abdominal node involvement, and 1 patient had inguinal node involvement. Fifteen patients had neither hilar nor mediastinal node involvement. Eleven patients had no tuberculous lesions other than lymphadenitis. Seven patients underwent biopsy of the lymph nodes. Four of these patients had the evidence of acid-fast bacilli. The remaining three patients were also diagnosed histologically. Five patients underwent fine needle aspiration. Two of them had the evidence of acid-fast bacilli. Acid-fast bacilli were detected in 10 out of 16 sputum samples and in 1 out of 2 pleural effusion samples. Five patients were diagnosed clinically by image (Computed tomography etc.) and by therapeutic effect. Eleven cases underwent contrast-enhanced computed tomography (CT) of the lymph nodes. Seven cases showed central low attenuation with peripheral rim enhancement, whereas the other four cases showed homogeneous attenuation. All patients received chemotherapy for a mean duration of 14.5 months (range, 6-30 years) with apparent improvement, but 1 patient relapsed. CONCLUSION: Tuberculous lymphadenitis remains one of important targets for the differential diagnosis of lymphadenopathy. It is essential that a peripheral lymph node biopsy be performed and examined either histologically and/or microbiologically. A tuberculin skin test and contrast-enhanced CT imaging should also be performed.     

Mycobacterial lymphadenitis in Western Australia.

The records of 172 patients with culture-positive mycobacterial lymphadenitis in Western Australia between January 1972 and December 1989 inclusive have been reviewed. Of the 118 children under 7 years of age, the disease was caused by M. tuberculosis in 4%, the M. avium complex in 74% and M. scrofulaceum in 20%, whereas in the 54 adults aged 15 years and over, the same organisms were responsible for 89%, 2% and 4% respectively of their diseases. Tuberculous (TBC) lymphadenitis affected mainly adult Asian migrants (71%), while non-tuberculous mycobacterial (NTM) lymphadenitis predominantly affected non-Aboriginal Australian children (92%). The two conditions differed significantly in their distribution of disease in the lymph nodes (P < 0.001). Patients with the TBC disease had a longer (P < 0.001) duration of symptoms before diagnosis but less common (P < 0.02) local complications at presentation than those with the NTM disease. The response of TBC lymphadenitis to medical treatment was excellent with no failure or relapse in the 43 patients followed up to 12 months. Total excision was curative for NTM lymphadenitis although in 10% a second excision was needed because of relapse or residual disease. In a selected group of children, the double Mantoux test was shown to have a 79% sensitivity and a 69% specificity in the diagnosis of the NTM disease. Over the last decade, the prevalence of NTM lymphadenitis in Western Australia decreased while that of TBC lymphadenitis remained steady.     

Lymphadenitis due to nontuberculous mycobacteria in children: presentation and response to therapy.

The most common manifestation of infection due to nontuberculous mycobacteria (NTM) in children is cervical lymphadenitis in an otherwise healthy patient. We identified and reviewed 19 cases of proven or presumptive lymphadenitis due to NTM seen at our hospital over the course of 13 months. Nine patients underwent initial surgical excision of involved lymph nodes. Ten children did not have involved lymph nodes excised initially and were treated with macrolide-containing antibiotic regimens. Of these patients, five required subsequent surgical excision and five were cured with combination chemotherapy. Six patients underwent radiographic imaging of the head and neck that revealed asymmetrical adenopathy with ring-enhancing masses but minimal inflammatory stranding of the subcutaneous fat, a finding that may distinguish adenitis caused by NTM from staphylococcal and streptococcal adenitis. Our data suggest that if surgical excision is not considered feasible, antimicrobial therapy for adenitis due to NTM may be beneficial for some patients.     

Prognostic value of positive lymph nodes in rectal cancer

Abdominal curative resections for rectal cancer in 109 patients with positive lymph nodes were prospectively studied. The best subdivision of patients for predicting outcome was into 1–3 and >3 positive lymph node groups. Comparison with patients with >3 positive lymph nodes demonstrated that patients with 1–3 positive nodes had less local (35.0 percent vs. 13.0 percent;P =0.007) and less distant recurrences (45.0 percent vs.26.0 percent;P =0.04) and had much better crude five-year survival (58.2 percent vs.17.0 percent; P < 0.0001). For predicting postsurgical outcome in patients with positive lymph nodes, the results justify subdividing patients into the following two prognostic subgroups: 1) those with 1–3 involved lymph nodes and 2) those with metastatic tumor in four or more lymph nodes.