Patients with sentinel lymph node positive melanoma: Who needs completion lymph node dissection?

Introduction

Completion lymph node dissection (CLND) for melanoma after positive sentinel lymph node biopsy (SLNB) was recently shown to improve regional but not overall survival, likely due to the majority of patients harboring no further nodal disease. We sought to determine predictors of non-sentinel node (NSN) positivity.

Autologus groin lymph node transfer for “sentinel lymph network” reconstruction after head-and-neck cancer resection and neck lymph node dissection: a case report

Local or distant metastatic recurrence after therapy is observed in 20–30% of cases of head-and-neck cancer. An unfavorable course may occur after cervical lymph node dissection due to loss of immunoprotective lymph nodes in the head-and-neck region. To overcome this problem, we performed autologous lymph node transplantation from the groin after head-and-neck cancer resection and cervical lymph node dissection. The patient was a 63-year-old man with squamous cell carcinoma in the mesopharyngeal lateral wall. After tumor resection and right cervical lymph node dissection, a lymph node-containing superficial circumflex iliac artery perforator flap was transplanted from the left groin. Pathological examination showed that cancer had invaded the primary tumor tissue stump. Thus, radiotherapy (66 Gy) was performed for the residual tumor from days 28 to 84 after surgery. At 12 months after surgery, no recurrent lesion or has developed. The biopsy of flap and lymphatic vessel endothelial hyaluronan receptor-1 (LYVE1) immunostaining shows creditable lymph network in the flap, compared with normal free flap. This case suggests that autologous lymph node transplantation may keep watch on cancer recurrence by reconstruction of the lymph node system in the resected region, and we suggest that this approach may be very useful in cancer therapy.     

Extended lymph node dissection in robot-assisted radical prostatectomy： lymph node yield and distribution of metastases

In this study, we reported our experience performing robotic extended lymph node dissection （eLND） in patients with prostate cancer. A total of 147 patients with intermediate and high-risk prostate cancer who underwent robotic eLND from May 2008 to December 2011 were included in this analysis. The dissection template extended to the ureter crossing the iliac vessels. We assessed lymph node yield, lymph node positivity, and perioperative outcomes. Lymph node positivity was also evaluated according to the number of lymph nodes （LNs） removed （〈22 vs 〉22）. The median number of LNs removed was 22 （11-51）, and 97 positive LNs were found in 24 patients （16.3%）. While the obturator fossa was the most common site for LN metastases （42.3%, 41/97）, the internal iliac area was the most common area for a single positive LN packet （20.8%, 5/24）. Eight patients （33.3%, 8/24） had positive LNs at the common iliac area. The incidence of positive LNs did not differ according to the number of LNs removed. Complications associated with eLND occurred in 21 patients （14.3%） and symptomatic lymphocele was found in five patients （3.4%）. In conclusion, robotic eLND can be performed with minimal morbidity. Furthermore, LN yield and the node positive rate achieved using this robotic technique are comparable to those of open series. In addition, the extent of dissection is more important than the absolute number of LNs removed in eLND, and the robotic technique is not a prohibitive factor for performing eLND.     

Ultrasound guided percutaneous axillary lymph node core biopsy: How often is the sentinel lymph node being biopsied?

Patients with breast cancer now frequently undergo axillary ultrasound and core biopsy (CB) in an attempt to reduce the number of unnecessary sentinel lymph node (SLN) biopsies. This study aimed to establish the frequency of successful targeting of the SLN by ultrasound guided biopsy. A total of 137 patients had axillary ultrasound of which 121 underwent CB. 73 (60%) patients proceeded to SLN after negative CB. All SLNs were examined for evidence of metastases and previous CB. Of the 73 patients, 51 had no evidence of malignancy in the SLN (true negative=70%). However nodal deposits were found in the remaining 22 patients, representing a false negative rate for CB of 30%. Overall histopathological evidence of previous CB was identified in 47 (64%) of 73 patients undergoing SLN biopsy. The reason for false negative findings in the 22 (30%) patients was failure to sample the sentinel lymph node in 10 (45%) and failure to sample the metastatic disease in the sentinel node in 11 (55%). This study suggests that both better methods of identifying the sentinel lymph node and more adequate sampling are required.     

Intramammary lymph nodes and breast cancer: a marker for disease severity, or just another lymph node?

BACKGROUND: Axillary lymph node status is still considered the most significant prognostic factor for breast cancer outcome, and treatment decisions are based on the presence or absence of nodal disease. Intramammary lymph nodes (IMLNs) can be a site of regional spread. Is this a marker for more aggressive disease? METHODS: We reviewed the cancer center pathology database from 1991 to 2005 for all cases of breast cancer with IMLNs. RESULTS: IMLNs were identified in 64 breast cancer patients, with metastatic spread in 20 patients, and benign IMLNs described in 44 patients. Positive IMLNs were associated with more aggressive disease, including higher rates of invasive versus noninvasive cancers (5% ductal carcinoma-in-situ [DCIS] with positive IMLNs vs. 23% with negative IMLNs), lymphovascular invasion (55% vs. 11%), and a higher rate of axillary lymph node involvement (72% vs. 18%). Patients with positive IMLNs were also more likely to undergo mastectomy (75% vs. 54%). CONCLUSIONS: IMLN metastases are a marker for disease severity; recognition of this may influence choice of adjuvant therapy. The presence of metastatic disease in an IMLN is associated with a high rate of axillary nodal involvement, and should mandate axillary dissection. Preoperative lymphoscintigraphy may help identify these extra-axillary metastases.     

High body mass index predicts multiple prostate cancer lymph node metastases after radical prostatectomy and extended pelvic lymph node dissection

Our aim is to evaluate the association between body mass index(BMI)and preoperative total testosterone(TT)levels with the risk of single and multiple metastatic lymph node invasion(LNI)in prostate cancer patients undergoing radical prostatectomy and extended pelvic lymph node dissection.Preoperative BMI,basal levels of TT,and prostate-specific antigen(PSA)were evaluated in 361 consecutive patients undergoing radical prostatectomy with extended pelvic lymph node dissection between 2014 and 2017・Patients were grouped into either nonmetastatic,one,or more than one metastatic lymph node invasion groups.The association among clinical factors and LNI was evaluated.LNI was detected in 52(14.4%)patients:28(7.8%)cases had one metastatic node and 24(6.6%)had more than one metastatic node.In the overall study population,BMI correlated inversely with TT(r=-0.256;P<0.0001).In patients without metastases,BMI inversely correlated with TT(r=-0.282;P<0.0001).In patients with metastasis,this correlation was lost.In the overall study population,BMI(odds ratio[OR]=1.268;P=0.005)was the only in dependent clinical factor associated with the risk of multiple metastatic LNI compared to cases with one metastatic node.In the nonmetastatic group,TT was lower in patients with BMI>28 kg m^2(P<0.0001).In patients with any LNI,this association was lost(P=0.232).The median number of positive nodes was higher in patients with BMI>28 kg m^2(P-0.048).In our study,overweight and obese patients had a higher risk of harboring multiple prostate cancer lymph node metastases and lower TT levels when compared to patients with normal BMI.     

Does the greater number of lymph nodes removed during standard lymph node dissection predict better patient survival following radical cystectomy?

Purpose

To determine whether the number of lymph nodes (LNs) removed during radical cystectomy (RC) and pelvic LN dissection (LND) is associated with patient survival.

Methods

Data on 450 patients who underwent RC and standard bilateral pelvic LND for urothelial bladder cancer without receiving neoadjuvant chemotherapy were reviewed. The extent of LND included common iliac artery bifurcation proximally, genitofemoral nerve laterally and the pelvic floor caudally. The impact of the number of LNs removed, analyzed as both continuous and categorical variables, on cancer-specific survival (CSS) and recurrence-free survival (RFS) was analyzed.

Results

The median number of LNs removed was 18 (mean 19.6, range 10?C94). Of total 450 patients, 129 (28.7%) had node-positive (N?+) disease. For entire patients, the number of LNs removed was not associated with CSS and RFS in the analysis with continuous variable (P?=?0.715; P?=?0.442, respectively), quartiles (P?=?0.924; P?=?0.676, respectively), or <18 versus ??18 LNs removed (5-year CSS rates: 67.0% vs. 69.4%, P?=?0.679; 5-year RFS rates?=?59.4% vs. 60.6%, P?=?0.725, respectively). Similarly, the number of LNs removed was not associated with CSS and RFS in both N0 and N?+?patients, and in each T stage. Multivariate analyses showed that T stage and lymphovascular invasion were significant predictors for survival in N0 patients, whereas adjuvant chemotherapy and LN density were predictors for survival in N?+?patients.

Conclusions

If meticulous LND was performed based on standardized LND template during RC, the number of LNs removed was not associated with patient survival.     

Critical analysis of the 2010 TNM classification in patients with lymph node–positive bladder cancer: Influence of lymph node disease burden

ObjectivesIn 2010, a new TNM staging system was published by American Joint Committee on Cancer, changing the nodal classification to include the presence of common iliac lymph node (LN) involvement as N3 category. The objective of this study was to define the capability of the current TNM nodal classification to separate patients with different prognostic stages and to evaluate the effect of LN disease burden.Methods and materialsA total of 93 patients with metastatic LNs after radical cystectomy and extended LN dissection for urothelial carcinoma of the bladder between 1999 and 2012 were included. The median follow-up was 21.5 months. The correlation between N3 and indicators of LN disease burden was analyzed using the Spearman correlation coefficient. Recurrence-free survival (RFS) and overall survival (OS) analysis was performed using the Kaplan-Meier and Cox proportional hazards methods.ResultsThe presence of N3 disease was associated with higher number of metastatic LNs (7 vs. 2, P<0.01); however, this was highly variable and correlation coefficients between common iliac metastatic LNs and other lymphatic disease burden indicators demonstrated weak association (0.39–0.63). Patients with N1 lesions were found to have a distinct RFS and OS (P<0.01 and P = 0.01, respectively). A trend toward worse RFS (P = 0.07) and OS (P = 0.08) was observed in patients with N3 lesions. However, no difference in RFS or OS was found between patients with N2 and N3 lesions (P = 0.83 and 0.50, respectively).ConclusionsThe N3 category in the current TNM classification defines a group of patients with high but heterogeneous disease burden. This may be the explanation for its lack of prognostic stratification when compared with N2 category bladder cancer.     

Endosalpingiosis of the axillary lymph nodes--primary or metastatic tumour?

The involvement of extra-abdominal sites by serous ovarian tumours of low malignant potential is extremely rare. In this paper we present the case of a 33 years old woman, diagnosed with atypical endosalpingiosis in the axillary lymph nodes before the diagnosis of a bilaterally ovarian serous tumour of low malignant potential. The occurrence of axillary lymph nodes involvement associated with serous tumours of the ovary could be explained by the presence of circulating serous cells that remained dormant for a period of time or by the development of an independent primary tumour from glandular inclusions in axillary lymph nodes. The recognition of the occurrence of axillary atypical endosalpingiosis in association with serous tumours of the ovary is important to avoid misdiagnosis. It is better to define these lesions as secondary serous papillary involvement.     

Impact of number of retrieved lymph nodes and lymph node ratio on the prognosis in patients with stage Ⅱ and Ⅲ colorectal cancer

Objective To discuss the impact of number of retrieved lymph nodes and lymph node ratio (LNR) on the prognosis in patients with stage Ⅱ and Ⅲ colorectal cancer.Methods Clinicopathological data of 507 patients with stage Ⅱ and Ⅲ colorectal cancer were analyzed retrospectively. Follow-up was available in all the patients. Results The total number of retrieved lymph nodes was 5801, of which 1122 had metastasis. There was a positive correlation between metastatic lymph nodes and retrieved lymph nodes (r=0. 171, P＜0.01). In stage Ⅱ colorectal cancer there was a significant difference in 5-year survival rate between patients with more than 12 lymph nodes retrieved and those with less than 12 lymph nodes retrieved (P＜0.01). LNR also affected the 5-year survival rate of patients with stage Ⅱ and Ⅲ colorectal cancer (P＜0.05). In patients with similar LNR, the 5-year survival rate differed significantly among different regions of lymph node metastasis(P＜0.05). LNR influenced the prognosis independent of the number of lymph nodes retrieved. Conclusions The number of retrieved lymph nodes is a prognostic factor for stage Ⅱ and Ⅲ colorectal cancer. More than 12 lymph nodes should be retrieved for better staging and prognosis. LNR is also a prognostic factor in stage Ⅱ and Ⅲ colorectal cancer. Regions of lymph nodes metastasis should be considered when evaluating the prognosis of patients using LNR.     

Does lymph node dissection during nephroureterectomy affect oncological outcomes in upper tract urothelial carcinoma patients without suspicious lymph node metastasis on preoperative imaging studies?

Purpose

This study aimed to investigate the effects of lymph node dissection (LND) on upper tract urothelial carcinoma (UTUC) without suspicious lymph node (LN) metastasis on preoperative imaging studies.

Methods

From 1998 to 2012, 418 UTUC patients without suspicious LN metastasis on preoperative imaging studies were included. Patients were divided into two groups according to the performance of LND. The effects of LND on oncological outcomes were assessed after adjusting other variables. The mean follow-up duration was 69 months.

Results

Among the 132 patients who underwent LND, LN metastasis was pathologically identified in 16 patients (12.1 %). The median number of resected LNs for patients who underwent LND was 7. On multivariate analysis, the number of resected LNs and pathologic T stage was significant predictors of LN metastasis. The 5-year recurrence-free survival was 76.4 % for patients without LND and 65.4 % for patients with LND (p = 0.126). In addition, there was no difference in 5-year overall survival between the 2 groups (without LND; 71.7 % vs. with LND; 72.1 %, p = 0.756). Multivariate analysis showed that pathologic T stage, tumor grade, and lymphovascular invasion were risk factors for recurrence. Age at surgery, tumor size, pathologic T stage, tumor grade, and lymphovascular invasion were significantly associated with overall survival. However, performance of LND was not associated with recurrence and survival.

Conclusions

LND could be selectively performed in patients with clinically LN-negative UTUC based on patient/tumor characteristics and operative findings although sufficient LNs should be removed if LND is to be performed.

     

Elective lymph node dissection in stage I melanoma--necessary or not?

The management of patients with malignant melanoma is somewhat controversial. The most important prognostic factor is depth of invasion. Criteria by both Clark and Breslow are of value. Therapy must not be "standardized," but individualized for each patient.     

Does obesity impact lymph node retrieval in colon cancer surgery?

Background

Evaluation of lymph nodes is important for the optimal treatment of colon adenocarcinoma. Few studies have assessed whether lymph node harvest is compromised by obesity. We hypothesized that lymph node retrieval in colon cancer resection would be reduced in obese patients.

Methods

Patients undergoing resection for colon adenocarcinoma diagnosed from 2000 to 2007 were reviewed retrospectively and stratified by body mass index (BMI). Lymph node harvest was evaluated.

Results

A total of 401 patients were included. Their mean age was 72.8 years, and 44% were men. Their mean BMI was 28.2 kg/m². Mean lymph node recovery among BMI groups was as follows: BMI less than 18.5 was 20.6; BMI of 18.5 to 24.9 was 25.1; BMI of 25 to 29.9 was 23.1; BMI of 30 to 34.9 was 22.4; BMI of 35 to 39.9 was 19.0; and BMI of 40 or greater was 21.1 nodes (P = .321). Surgical time increased with increasing BMI (P = .005). Adequacy of node harvest differed by stage (P = .007), left-sided versus right-sided resections (P = .001), and pathology technician (P = .001).

Conclusions

Lymph node retrieval was not affected by BMI.