Pelvic lymph node dissection for penile carcinoma: extent of inguinal lymph node involvement as an indicator for pelvic lymph node involvement and survival

PURPOSE: We identified pathological parameters of inguinal lymph node involvement with the aim of predicting pelvic lymph node involvement and survival. MATERIALS AND METHODS: A total of 308 patients with penile carcinoma and adequate followup were included in this study. The outcome of 102 patients who underwent lymphadenectomy for lymph node metastases was analyzed further. Histopathological characteristics of the regional lymph nodes were reviewed including unilateral or bilateral involvement, the number of involved nodes, pathological tumor grade of the involved nodes, and the presence of extracapsular growth. RESULTS: Tumor grade of the involved inguinal lymph nodes (OR 6.0, 95% CI 1.2-30.3) and the number of involved nodes (2 or less vs more than 2) (OR 12.1, 95% CI 3.0-48.1) were independent prognostic factors for pelvic lymph node involvement. Extracapsular growth (OR 2.3, 95% CI 1.1-4.8), bilateral inguinal involvement OR 3.4, 95% CI 1.2-9.4) and pelvic lymph node involvement (OR 3.1, 95% CI 1.4-6.6) were independent prognostic factors for disease specific survival. CONCLUSIONS: Patients with only 1 or 2 inguinal lymph nodes involved without extracapsular growth and no poorly differentiated tumor within these nodes are at low risk of pelvic lymph node involvement and have a good prognosis with a 5-year survival rate of approximately 90%. Pelvic lymph node dissection seems to be unnecessary in these cases.     

Extent of pelvic lymph node dissection in penile cancer may impact survival

Introduction

Current guidelines on management of penile carcinoma (PC) recommend ipsilateral pelvic lymph node dissection (PLND) in patients with inguinal lymph node metastasis (LNM) who meet specific criteria. The aim of this article was to assess outcomes in patients treated with bilateral PLND in the presence of unilateral metastatic pelvic nodes.

Methods

After IRB approval, four international centers contributed to this study. Men with PC and unilateral inguinal LNM and pelvic node metastases were retrospectively analyzed. Estimates of overall survival (OS) and cancer-specific survival were provided by the Kaplan–Meier method. Comparisons between subgroups were made using the log-rank test, and Cox regression analysis was used to adjust comparisons for covariates of interest.

Results

From 1978 to 2012, fifty-one men with unilateral inguinal LNM and positive pelvic nodes on PLND were identified. Thirty-eight (75 %) had ipsilateral and 13 (25 %) had bilateral PLND. Except the extent of the PLND, patients were comparable with respect to disease and therapeutic interventions. The Kaplan–Meier estimated median OS was significantly longer in the bilateral PLND patients (21.7 vs. 13.1, p = 0.051). On Cox regression analysis, bilateral PLND [HR 0.25, (95 % CI 0.10–0.64)], multiple pelvic node involvement [HR 2.12 (95 % CI 1.02–4.43)], neoadjuvant chemotherapy [HR 0.01, (95 % CI 0.02–0.44)] and adjuvant therapies [HR 0.16, (95 % CI 0.06–0.45)] (compared to no additional therapy) were independent predictors of OS.

Conclusions

Men with PC and pelvic node metastases may benefit from a bilateral PLND. This hypothesis requires further confirmation.

     

Preoperative Prediction of Central Lymph Node Metastasis in Thyroid Papillary Microcarcinoma Using Clinicopathologic and Sonographic Features

Background

The purpose of the present study was to evaluate the clinicopathologic factors and ultrasound (US) features predictive of central lymph node metastasis (LNM) in patients diagnosed with papillary thyroid microcarcinoma (PTMC).

Methods

From March 2008 to August 2008, the clinicopathologic features and preoperative US features of 483 patients who were diagnosed with conventional PTMC were included. Medical records, US features, and pathology reports of all patients were retrospectively reviewed. Univariate and multivariate analysis was performed to identify clinicopathological prognostic factors associated with central LNM. Odds ratios (OR) with relative 95 % confidence intervals (95 % CI) were calculated to determine the relevance of all potential predictors of central LNM.

Results

Among the 483 patients with PTMC, 139 (28.8 %) patients had central LNM. The OR of significant independent factors were 2.055 (95 % CI, 1.137–3.716), 2.075 (95 % CI, 1.27–3.39), 1.71 (95 % CI, 1.073–2.724), and 15.897 (95 % CI, 4.173–60.569), respectively, for bilaterality, larger tumor size (>5 mm), extracapsular invasion, and lateral LNM. No significant association was seen among the US features of PTMC with central LNM.

Conclusions

Central lymph node metastasis in patients with PTMC was significantly associated with various clinicopathological factors, including larger tumor size (>5 mm), bilaterality, extracapsular invasion, and lateral LNM. When these features are detected on preoperative US, selective central compartment dissection may be helpful in patients diagnosed with PTMC.     

Factors Associated with Lymph Node Metastasis in Radically Resected Rectal Carcinoids: a Systematic Review and Meta-analysis

Background

Although various guidelines regarding neuroendocrine tumors were released, treatment for rectal neuroendocrine tumors with size between 1 and 2 cm has not been explicitly elucidated. The determinant factor of the choice between endoscopic resection and radical surgery is whether lymph node involvement exists.

Aim

This study aims to explore factors associated with lymph node involvement in rectal neuroendocrine tumors by conducting a meta-analysis.

Methods

A broad literature research of Pubmed, Embase&Medline, and The Cochrane Library was performed, and systematic review and meta-analysis about factors associated with lymph node involvement were conducted.

Results

Seven studies were included in this meta-analysis. Tumor size?>?1 cm (odds ratio (OR) 6.72, 95 % confidence interval (CI) [3.23, 14.02]), depth of invasion (OR 5.06, 95 % CI [2.30, 11.10]), venous invasion (OR 5.92, 95 % CI [2.21, 15.87]), and central depression (OR 3.00, 95 % CI [1.07, 8.43]) were significantly associated with lymph node involvement.

Conclusion

The available clinical evidence suggests that tumor size?>?1 cm, invasion of muscularis properia, venous invasion, and central depression could be risk factors of lymph node involvement, while other factors reported by few studies need further research.     

Distribution of Lymph Node Metastasis Sites in Endometrial Cancer Undergoing Systematic Pelvic and Para-Aortic Lymphadenectomy: A Proposal of Optimal Lymphadenectomy for Future Clinical Trials

Purpose

The aim of this study was to demonstrate the precise mapping of lymph node metastasis (LNM) sites in endometrial cancer.

Methods

A total of 266 patients who underwent primary radical surgery including systematic pelvic and para-aortic lymphadenectomy for endometrial cancer from 1993 to 2010 were enrolled in this study. We removed lymph nodes from the femoral ring to the para-aortic node up to the level of renal veins. We analyzed the distribution of positive-node sites according to their anatomical location.

Results

Overall, 42 of 266 patients (15.8 %) showed LNM. The median number of nodes harvested was 62.5 (range 40–119) in pelvic nodes (PLN), and 20 (range 3–47) in para-aortic nodes (PAN). Among 42 cases with positive-nodes, 16 cases (38.1 %) showed positive PLN alone, 7 cases (16.7 %) in PAN alone, and 19 cases (45.2 %) in both PLN and PAN. The most prevalent site of positive-nodes was PAN (9.8 %) followed by obturator nodes (9.4 %), internal iliac nodes (7.1 %), and common iliac nodes (5.6 %). Six of 19 cases (31.6 %) of positive PAN above the inferior mesenteric artery (IMA) showed negative PAN below IMA. Metastasis to the deep inguinal nodes was found to be extremely rare (0.38 %). Single-site LNM was the most frequently observed in obturator nodes, followed by PAN above IMA.

Conclusion

Routine resection of deep inguinal nodes is not recommended, whereas para-aortic lymphadenectomy should be extended up to the level of renal veins for endometrial cancer.     

Pattern of initial metastasis in the cervical lymph node from papillary thyroid carcinoma

Purposes

This study attempted to reveal the pattern of initial lymphatic spread in order to investigate the clinical significances of lymph node metastasis in papillary thyroid carcinoma (PTC) since such information has yet to be elucidated in previous studies.

Methods

This study reviewed 501 consecutive patients with PTC who had been surgically treated, accompanied by routine node dissection of the central, and lateral compartments. Thirty-eight cases were found to have only one metastatic node, and 62 cases were found to have 2 or 3 metastatic nodes. The locations of these metastatic nodes were mapped, and evaluated.

Results

The initial lymph node metastasis occurred equally in the lateral and central compartments (19 vs. 19 nodes). Metastatic nodes were more frequently found in the central compartment (60 and 65 %) in cases with 2- and 3-node involvements. Twenty-two (60 %) and 33 (65 %) cases had at least one instance of lateral node involvement in those cases, respectively.

Conclusions

The current results demonstrated the pattern of initial lymphatic spread in PTC cases, and indicated the importance of evaluating the lateral nodes of at least compartments III and IV for accurate pathological staging, as well as for investigating the nature of the disease.     

A novel predictive model for pelvic lymph node metastasis in patients with penile cancer: A multi-institutional study

PurposeWe determined whether a clinicopathological nomogram is able to predict the risk of pelvic lymph node metastasis (LNM) in penile cancer patients after inguinal lymph node dissection (ILND).MethodsNinety-eight patients with bilateral ILND who underwent pelvic lymphadenectomy at 10 centers were retrospectively analyzed. The most predictive features in the nomogram were selected by the stepwise logistic regression method and then tested and verified by multivariate logistic regression analyses. The nomogram was assessed using concordance indices and calibration curves.ResultsOf the 181 pelvic basins, pelvic LNM was observed in 52 packages (43 patients). Bilateral pelvic LNM was present in 9 patients (9/43, 20.9%). There was no crossover metastatic spread from one inguinal side to the other pelvic side. Age, previous resection, the biopsy procedure for inguinal lymph nodes, vascular invasion, and ipsilateral inguinal lymph node status were all independent risk factors for pelvic LNM (all P < 0.05) in the multivariate logistic regression analysis. The nomogram exhibited a good probability for survival agreement, with a concordance index of 0.868 (95% CI: 0.813–0.922).ConclusionsA novel nomogram suggests that the risk of pelvic LNM can be effectively predicted in penile carcinoma patients and may provide a useful guide for clinicians. Further external validation is needed.     

Pathologic predictive factors for lymph node metastasis in submucosal invasive (T1) colorectal cancer: a systematic review and meta-analysis

Background

Colorectal adenocarcinoma with depth of invasion ≤1,000 μm from the muscularis mucosa and favorable histology is now considered for local resection. We aimed to examine the strength of evidence for this emerging practice.

Methods

We searched Medline, Scopus, and Cochrane (1950–2011), then performed a meta-analysis on the risk of lymph node metastasis in nonpedunculated (sessile and nonpolypoid) T1 colorectal cancers. We included studies with nonpedunculated lesions, actual invasion depth, and pathologic factors of interest. Synchronous, polyposis or secondary cancers, and chemoradiation studies were excluded. Our primary outcome was the risk of LNM. We analyzed using Review Manager; we estimated heterogeneity using Cochran Q χ² test and I ². We generated summary risk ratios using a random effects model, performed sensitivity analyses, and evaluated the quality of evidence using GRADEPro.

Results

We identified 209 articles; 5 studies (n = 1213 patients) met the inclusion criteria. The risk of LNM in nonpedunculated ≤1,000 μm is 1.9 % (95 % confidence interval 0.5–4.8 %). The risk for all T1 is 13 % (95 % confidence interval 11.5–15.4 %). Characteristics protective against LNM were ≤1,000 μm invasion, well differentiation, absence of lymphatic and vascular invasion, and absence of tumor budding. We did not detect significant study heterogeneity. The quality of evidence was poor.

Conclusions

Well-differentiated nonpedunculated T1 colorectal cancer invasive into the submucosa ≤1,000 μm, without lymphovascular involvement or tumor budding, has the lowest risk of nodal metastasis. Importantly, the risk was not zero (1.9 %), and the qualitative formal analysis of data was not strong. As such, endoscopic resection alone may be adequate in select patients with submucosal invasive colorectal cancers, but more studies are needed. Overall, the quality of evidence was poor; data were from small retrospective studies from limited geographic regions.     

Race/Ethnicity Is Predictive of Lymph Node Status in Patients with Early Gastric Cancer

Background

Race/ethnicity has long been suspected to affect survival in patients with gastric adenocarcinoma. However, the clinicohistopathological impact of race or ethnicity on early gastric cancer (EGC) is not known.

Methods

From 2000 to 2013, 286 patients underwent gastrectomy and 104 patients had pathological confirmation of EGC. A retrospective analysis of pathological and clinical prognostic indicators was performed.

Results

The study population consisted of 38 (37 %) Asian Americans and 66 (63 %) non-Asian Americans. Of these, 2 (5.3 %) Asian Americans and 19 (28.8 %) non-Asian Americans had pathological confirmation of lymph node metastasis (LNM) (p?=?0.004). Univariate analysis comparing the clinicohistopathological characteristics in each group did not reveal significant difference regarding histotype, tumor size, grade, location, morphology, or lymphovascular invasion, except for the LNM rate and mean body mass index (23.2 versus 26.6, p?p?=?0.038), younger age (OR, 1.11; 95 % CI, 1.01–1.12; p?=?0.046), and lymphovascular invasion (OR, 13.9; 95 % CI, 2.40–79.99; p?=?0.003) were significant predictors for LNM.

Conclusions

This study demonstrated that Asian American race in EGC is associated with a significantly decreased rate of LNM in comparison to non-Asian Americans, despite similar histopathological characteristics of each group.     

Predicting the Extent of Nodal Disease in Early-Stage Breast Cancer

Background

The role of regional nodal ultrasound (US) has been questioned since publication of the American College of Surgeons Oncology Group (ACOSOG) Z0011 data. The goal of this study was to determine if imaging and clinicopathologic features could predict the extent of axillary nodal involvement in breast cancer.

Study Design

Patients with T1–T2 tumors who underwent regional nodal US and axillary lymph node dissection from 2002 to 2012 were identified from a prospective database excluding those who received neoadjuvant chemotherapy. Patients whose metastases were identified by US confirmed by needle biopsy were compared with those identified by sentinel lymph node dissection (SLND) after a negative US.

Results

Metastases were identified by US in 190 patients, and by SLND in 518 patients. SLND patients had fewer positive nodes (2.2 vs. 4.1; p < 0.0001), smaller metastases (5.3 vs. 13.8 mm; p < 0.0001), and a lower incidence of extranodal extension (24 vs. 53 %; p < 0.0001) than the US group. Even when US identified ≤2 abnormal nodes, patients were still more likely to have ≥3 positive nodes (45 %) than SLND patients (19 %; p < 0.001). After adjusting for tumor size, receptor status, and histology, multivariate analysis revealed that metastases identified by US [odds ratio (OR) 4.01; 95 % confidence interval (CI) 2.75–5.84] and lobular histology (OR 1.77; 95 % CI 1.06–2.95) predicted having ≥3 positive nodes.

Conclusions

Imaging and clinicopathologic features can be used to predict the extent of nodal involvement. Patients with US-detected metastases, even if small volume, have a higher burden of nodal involvement than patients with SLND-detected metastases and may not be comparable with patients in the ACOSOG Z0011 trial.     

Der Einfluss des T-Stadiums auf das Metastasierungsrisiko des Peniskarzinoms: T1 vs. T2

Background

Controversies persist over the therapeutic approach to T1 penile carcinoma, particularly in patients with negative inguinal lymph nodes. Available data on lymph nodes metastases (LNM) in T1 carcinoma are contradictory. The aim of this study was to evaluate the metastatic risk of T1 carcinoma and to compare it with that of T2 carcinoma.

Material and methods

A total of 37 patients (pts) with T1 or T2 tumors were reviewed. Assessment of the inguinal lymph node condition was based on node dissection in 29 pts and surveillance in eight pts (mean 62 months, range 22–162).

Results

Grading was classified as good (G1), moderate (G2) and poor (G3) in seven, 26 and four pts, respectively. Tumor stage was T1 in 21 and T2 in 16 pts. LNM were observed in eight of 21 T1 (38%) and six of 16 T2 tumors (38%). No G1 and all G3 tumors developed LNM independently of tumor stage. Ten of the 26 G2 carcinomas (38%) harboured LNM and seven of these pts (70%) had a T1 tumor.

Conclusions

According to our data, the metastatic potential of T1 penile carcinoma has been underestimated in the recent literature. Tumor grading has a substantially stronger impact on the metastatic risk in T1 and T2 penile carcinoma than tumor stage, indicating a surgical lymph node staging starting at the pT1G2 stage.     

Surgical techniques of laparoscopic peritonectomy plus paraaortic lymph node dissection for the treatment of patients with positive lymph node metastasis and peritoneal seeding from rectosigmoid cancer

Background

This multimedia article demonstrates the surgical techniques of laparoscopic pelvic peritonectomy plus aggressive lymph node dissection over the abdominal aorta and inferior vena cava for the treatment of rectosigmoid cancer.

Methods

The surgical procedures are detailed in the attached video.

Results

This study enrolled 17 patients. All the patients successfully underwent surgery by the described surgical technique and had a zero conversion rate, an acceptable operation time (median 284 min, range 240–360 min), and moderate blood loss (median 294 ml, range 140–740 ml) through five small wounds (four 1-cm wounds for 5–12-mm abdominal ports and one 5-cm wound for tumor retrieval). The number of dissected lymph nodes was adequate (median 44, range 32–68). The operative complications represented 29.4% of all cases including anastomotic leakage in two cases, wound infection in two cases, and urinary retention followed by repeated urinary tract infection in one case. The patients had quick functional recovery, as evaluated by the length of the postoperative ileus (median 72 h, range 36–144 h), the hospital stay (median 14 days, range 12–28 days), and the degree of postoperative pain (visual analog scale median 4.0, range 3–6).

Conclusion

Laparoscopic surgery can be performed safely for rectosigmoid cancer patients with pelvic peritoneal seeding and extensive abdominal paraaortic lymph node metastases requiring an extended abdomino-iliac lymphadenectomy plus curative pelvic peritonectomy.     

Outcomes of patients receiving additional esophagectomy after endoscopic resection for clinically mucosal, but pathologically submucosal, squamous cell carcinoma of the esophagus

Purpose

This study investigated the actual rate or extent of lymph node metastasis or the survival outcomes among patients that underwent esophagectomy with lymph node dissection after ESD for clinical mucosal, but pathological submucosal, esophageal cancer.

Methods

Seventeen patients that received esophagectomy with two- or three-field lymph node dissection as additional treatment after ESD for clinical mucosal, but pathological submucosal, esophageal cancer between 2006 and 2010 were analyzed. The rate and extent of lymph node metastasis and the patient outcomes were determined.

Results

The tumor depths were diagnosed as SM1 in 8 (47 %) patients and SM2 in 9 (53 %), based on the analyses of resected specimens. Lymphatic invasion was evident in 13 (76 %) patients, while venous invasion was detected in 5 (29 %). Five (29 %) patients had pathologically detected lymph node involvement. Seven (0.8 %) of the 890 dissected nodes showed cancer involvement. Three patients had one involved node in the mediastinum or abdomen, and 2 patients had 2 involved nodes in the abdomen. The patients were followed up for 11–71 months (median 23 months), and all were alive without recurrence at the final follow-up.

Conclusion

Twenty-nine percent of the patients diagnosed with clinically mucosal, but pathologically submucosal, thoracic squamous cell esophageal cancer after ESD had 1–2 cancer-involved lymph nodes in the lower mediastinum and abdomen. Esophagectomy with lymph node dissection is therefore considered to be a necessary and effective additional treatment for these patients.     

Is there a relationship between the number of lymph nodes and disease parameters in patients who underwent retropubic prostatectomy

Purpose

We aimed to establish the relationship between lymph nodes (LNs) counts that were removed with standard pelvic lymph node dissection (sPLND) and different disease parameters in patients who underwent radical prostatectomy (RP).

Materials and methods

A total of 70 patients who underwent sPLND during RP were scanned retrospectively. The scanned parameters were levels of serum PSA, the total weight of the removed prostate, the amount as a percentage of the tumor in the prostate tissue, the stage of the tumor, the total Gleason score (GS) and the number of standard pelvic lymph nodes that were removed from both right and left sides.

Results

The average age of the patients was 59 years. A positive correlation was found between the total GS and the number of lymph nodes; while this correlation was significant (p = 0.0038), there was no significant difference between lymph nodes counts and other scanned parameters. The average pelvic lymph node numbers of patients with GS of 6–7 and 8 were 10.4–11.5 and 13.2, respectively. Lymph nodes metastases were found in 3 (4.2 %) patients whose average pelvic lymph node number was 17.3.

Conclusion

The chance of cure or decreased recurrence is much more possible in patients who had received extended PLND or at least standard one, because of the removal of much more lymph node tissues that have a high probability of disseminating cancer cells. This position can especially be considered in patients with high GS.     

Modified concept for radioisotope-guided sentinel lymph node dissection in prostate cancer

Purpose

To present a modified concept for sentinel lymph node (SLN)-guided pelvic lymph node dissection in prostate cancer.

Methods

A total of 463 patients with histologically proven prostate cancer underwent SLN-guided lymph node dissection. The day before surgery patients received intraprostatic injection of Tc-99 m-labeled nanocolloid (Tc-NC) under transrectal ultrasound guidance. At the time of surgery, the lymph nodes of the obturator fossa were dissected routinely in all patients. After meticulous testing with a handheld gamma probe, all lymphatic tissues in predefined anatomic regions (external iliac, internal iliac, common iliacal and presacral) with Tc-NC uptake were additionally resected.

Results

In 146 (12.8%) patients, SLN were located exclusively in the obturator fossa, but 317 patients (87.2%) underwent resection of additional sentinel regions. In 28 (6.1%) patients, 62 lymph node metastases were detected, and 32 (51.6%) of these were located outside the obturator fossa. Eight (28.6%) patients displayed lymph node metastases exclusively outside the obturator fossa and had been resected only because of positive SLN probing.

Conclusions

The obturator fossa comprises the major landing site of lymph node metastases, but more than half of the metastases are located outside this anatomic region. Routine resection of the obturator fossa with additional resection of positive sentinel regions improves staging accuracy compared to resection of the obturator fossa only.     

Papillary Thyroid Carcinoma Located in the Isthmus or Upper Third is Associated with Delphian Lymph Node Metastasis

Background

Delphian lymph node (DLN) metastasis is a recognized indicator of further lymph node involvement in papillary thyroid carcinoma (PTC). The aim of this study was to evaluate the clinicopathological significance of and risk factors for DLN metastasis.

Methods

The medical records of 1,436 patients who underwent primary thyroidectomy for classical PTC with a tumor size of 2 cm or less were reviewed. Of these, 370 patients from whom the DLN was harvested were enrolled. Metastasis in DLN was present in 46 patients and absent in 324 patients. Clinicopathological features were compared according to DLN metastasis.

Results

In univariate analysis, DLN metastasis was associated with suspected lymph node metastasis on preoperative ultrasonography, tumor location in the isthmus or upper third of the thyroid, larger tumor size, extrathyroid extension, lymphovascular invasion, and further lymph node metastasis. Multivariable analysis revealed that DLN metastasis was associated with tumor location in the isthmus or upper third of the thyroid (odds ratio [OR] = 2.420; 95 % confidence interval [CI] 1.193–4.910) and further lymph node metastasis (OR = 4.746; 95 % CI 2.065–10.908).

Conclusions

DLN metastasis in PTC is associated with tumor location in the isthmus or upper third of the thyroid and unfavorable clinicopathological characteristics. Careful consideration and patient management are warranted when preoperative ultrasonography indicates that the tumor is located in the isthmus or upper third of the thyroid.     

Ilioinguinal lymph node dissection for palpable metastatic melanoma to the groin

Background: Block dissection of the inguinal lymph nodes is the routine management for palpable metastatic melanoma confined to this node basin. Involvement of the next tier external iliac and obturator lymph nodes in the pelvis is common, and untreated pelvic nodal disease can become advanced before becoming clinically apparent. We have routinely performed combined inguinal and pelvic (ilioinguinal) lymph node block dissection to avoid this morbid outcome. Methods: A retrospective analysis of all patients undergoing ilioinguinal lymph node dissection for melanoma between January 1998 and January 2006 was carried out. Results: There were 72 patients with a median age of 52.7 years (19.7–75.2 years) who were followed up for a median of 28.9 months (1.0–115.0 months) after ilioinguinal lymph node dissection. There were 22 (30.6%) of 72 patients with histologically involved pelvic lymph nodes. Preoperative computed tomography (CT) scanning accuracy for pelvic lymph node involvement was as follows: sensitivity 60.0%, specificity 100.0%, positive predictive value 100.0% and negative predictive value 86.2%. Lymphoedema was reported in 32 (44.4%) of 72 patients. Median time to first recurrence was 8.7 months (0.8–69.7 months). Regional recurrence occurred in 6 (8.3%) of 72 patients at a median of 4.9 months (0.9–32.0 months). Extranodal spread was the only factor adversely associated with disease‐free survival. In all patients, 5‐year disease‐free survival was 38% (95% confidence interval (CI) 26–50) and overall survival 47% (95% CI 33–60). Conclusion: Palpable metastatic melanoma in the groin is commonly associated with pelvic lymph node involvement, is not well predicted by CT scanning and is appropriately managed by ilioinguinal lymph node block dissection.     

Depth of Submucosal Tumor Infiltration and its Relevance in Lymphatic Metastasis Formation for T1b Squamous Cell and Adenocarcinomas of the Esophagus

Background

Surgery for early esophageal carcinoma has been challenged by less invasive endoscopic approaches. Selecting patients in need for surgical intervention according to their risk of lymphatic spread is mandatory.

Objective

The aim of this study was to evaluate risk factors for lymphatic metastasis formation in T1b esophageal carcinomas.

Methods

Histopathological specimens following surgical resection for T1b esophageal carcinomas were reevaluated for overall submucosal layer thickness, depth of submucosal tumor infiltration, tumor length as well as lymphatic and vascular infiltration. Depth of tumor infiltration to overall submucosal thickness was divided in thirds (SM1, SM2, and SM3) and factors influencing lymphatic metastasis formation were assessed.

Results

A total of 67 patients with pT1b tumors were analyzed, including 36 adenocarcinomas (53.7 %) and 31 squamous cell carcinomas (46.3 %). Lymph node involvement was seen in 22.4 % (15/67) patients without significant differences between SM1 3/11 (27.3 %), SM2, 4/18 (22.2 %), and SM3 (8/38) (21.8 %) (p?=?0.909) carcinomas. On binomial log-regression models, only lymphangioinvasion and tumor length >2 cm was significantly associated with lymph node involvement.

Conclusion

As depth of submucosal tumor infiltration did not correlate with the formation of lymph node metastases and in regard of the risk of lymphatic spread in these cases, surgical resection is warranted in pT1b carcinomas.     

Risk of lymph node metastases in multifocal papillary thyroid cancer associated with Hashimoto's thyroiditis

Aims

The aim of this study was to evaluate the risk factors of lymph nodes metastases (LNM) in patients with papillary thyroid cancer (PTC) and coexisting Hashimoto’s thyroiditis (HT).

Patients and methods

This was a retrospective cohort study of patients with PTC and HT who had undergone total thyroidectomy (TT) with central neck dissection (CND) over an 11-year period (between 2002 and 2012). Pathological reports of all eligible patients were reviewed. Multivariable analysis was performed to identify risk factors of LNM.

Results

During the study period, PTC was diagnosed in 130 patients with HT who had undergone TT with CND (F/M ratio?=?110:20; median age, 52.4?±?12.7 years). Multifocal lesions were observed in 28 (21.5 %) patients. LNM were identified in 25 of 28 (89.3 %) patients with multifocal PTC and HT versus 69 of 102 (67.5 %) patients with a solitary focus of PTC and HT (p?=?0.023). In multivariable analysis, multifocal disease was identified as an independent risk factor for LNM (odds ratio, 3.99; 95 % confidence interval, 1.12 to 14.15; p?=?0.033).

Conclusions

Multifocal PTC in patients with HT is associated with an increased risk of LNM. Nevertheless, the clinical importance of this finding needs to be validated in well-designed prospective studies.     

The impact of lymph node status and features on oncological outcomes in urothelial carcinoma of the upper urinary tract (UTUC) treated by nephroureterectomy

Purpose

Prognostic impact of lymphadenectomy during radical nephroureterectomy (RNU) for urothelial carcinoma of the upper urinary tract (UTUC) is controversial. Our aim was to assess the impact of lymph node status (LNS) on survival in patients treated by RNU.

Methods

In our multi-institutional, retrospective database, 714 patients with non-metastatic UTUC had undergone RNU between 1995 and 2010. LNS was tested as prognostic factor for survivals through univariate and multivariable Cox regression analysis.

Results

Median age was 70 years [interquartile range (IQR), 60–75] with median follow-up of 27 months (IQR, 10–50). Overall, lymphadenectomy was performed in 254 patients (35.5 %). Among these patients, 204 (80 %) had negative lymph nodes (pN0) and 50 (20 %) had positive lymph nodes (pN1/2). The 5-year cancer-specific survival (CSS) was 81 % [95 % confidence interval (CI), 73–88 %] for pN0 patients, 85 % (95 % CI, 80–90 %) for pNx patients and 47 % (95 % CI, 24–69 %) for pN1/2 patients (p < 0.001). Metastasis-free survival (MFS) and overall survival (OS) rates were significantly lower in pN1/2 patients than in pN0 and pNx patients (p < 0.05). On multivariable analysis, LNS did not appear as an independent prognostic factor for CSS, OS or MFS (p > 0.05). In case of lymph node involvement, extra-nodal extension was marginally associated with worse CSS (log rank p = 0.07). The retrospective design was the main limitation.

Conclusion

LNS is helpful for survival stratification in patients treated with RNU for UTUC. However, LNS did not appear as an independent predictor of survival in this retrospective series and needs to be investigated in a large multicentre, prospective evaluation.