Biomedical subjects

Akira Tangoku

Publications and source records attributed to Akira Tangoku.

At least 19 recordsLinked to original sources

PubMed2006

The reduced expression and aberrant methylation of p16(INK4a) in chromate workers with lung cancer.

STUDY OBJECTIVES: It is known that chromium is one of the important inhaled carcinogens that cause lung cancer. Our previous studies revealed a variety of genetic changes in lung cancers from chromate-exposed workers (chromate lung cancer). However, the epigenetic effects of chromium are not understood. MATERIALS AND METHODS: We investigated the methylation of the p16 gene using a methylation-specific PCR method in 30 chromate lung cancers and 38 non-chromate lung cancers, and the expression of the p16 protein using immunohistochemistry in 25 chromate lung cancers. RESULTS: Ten (33%) chromate lung cancers showed methylation of the p16 promoter region. On the other hand, 10 (26%) of the non-chromate lung cancers also showed it. The frequency of p16 methylation in non-chromate lung cancer was 0%, 33% and 30% for low (< or =600), moderate (<600, >1000) and high (> or =1000) Brinkman indexes, respectively. However, the frequency of p16 methylation in chromate lung cancer was constant, irrespective of the Brinkman index. In chromate lung cancer, patients with chromate exposure of less than 15 years never had p16 methylation, while 40% (> or =25 years) or 43% (> or =15, <25 years) of patients with chromate exposure of more than 15 years did. In chromate lung cancer, chromate exposure, not smoking, mainly influenced the p16 methylation. Most of the chromate lung cancers with p16 methylation (85.7%) showed repression of the p16 protein. CONCLUSIONS: We speculate that not only genetic but also epigenetic alterations are involved in the carcinogenesis due to chromium.

Adult↗

PubMed2006

Fluoroscopy-assisted thoracoscopic resection of pulmonary nodules after computed tomography--guided bronchoscopic metallic coil marking.

OBJECTIVE: To localize small and deeply situated pulmonary nodules during thoracoscopy with roentgenographic fluoroscopy, we developed a marking procedure that uses a metallic coil. METHODS: Nine patients underwent video-assisted thoracoscopic surgery for the removal of 11 pulmonary lesions. Fluoroscopy-assisted thoracoscopic surgery after computed tomography-guided bronchoscopic metallic coil marking was performed with an ultrathin bronchoscope, with simulation by means of virtual bronchoscopy. During thoracoscopy, a C-arm-shaped roentgenographic fluoroscope was used to detect the radiopaque nodules. RESULTS: The marking procedure took 15 to 60 minutes from insertion to removal of the bronchoscope. There were no complications from the marking, and all 11 nodules were easily localized by means of thoracoscopy. The metallic coil showed the nodules on the fluoroscopic monitor, which aided in nodule manipulation. Nodules were completely resected under thoracoscopic guidance, except in one case in which a minithoracotomy was performed at an early stage of the trial. The pathologic diagnosis was primary adenocarcinoma in 9 patients, pulmonary metastasis from colon cancer in 1 patient, and pulmonary lymph node in 1 patient. Two cases of bronchioloalveolar adenocarcinoma with an invasive component and a well-differentiated adenocarcinoma were converted to open thoracotomy to perform curative lobectomy. CONCLUSIONS: In this pilot study computed tomography-guided transbronchial metallic coil marking with an ultrathin bronchoscope with virtual bronchoscopic simulation might be a useful method for the fluoroscopy-assisted thoracoscopic resection of pulmonary nodules.

Adult↗

PubMed2006

Lung regeneration: implantation of fetal rat lung fragments into adult rat lung parenchyma.

OBJECTIVE: The capability of regeneration of lung tissues in adults is limited after chronic destruction. Bone marrow-derived stem cells, retinoic acid, growth factors, and other approaches have been attempted to promote or facilitate this process. We hypothesized that fetal lung tissues, with great potential for growth and differentiation, could be used for lung regeneration. METHODS: Day 17 fetal lung tissue fragments at the pseudoglandular stage of lung development from Lewis rats were implanted into adult Lewis rat lungs. For group 1, fetal lung fragments were injected into the adult left lung parenchyma; for group 2, fetal fragments were injected with the left lung partially resected; for group 3, adult fragments were injected; and for groups 4 and 5, fetal fragments were implanted into the omentum and subcutaneous tissue, respectively. RESULTS: The grafts implanted into pulmonary parenchyma were differentiated with opening of the alveolar space after 4 weeks and were advanced further with morphologic features similar to those of neonatal lungs after 8 and 12 weeks. The implants were connected with pulmonary circulation determined by means of perfusion with India ink. These changes appeared to be further enhanced in animals with partial lung resection that might have facilitated the maturation of implanted fetal lung tissues through mechanical factors, soluble factors, or both. Fetal lung tissues did not mature when implanted into the omentum or subcutaneous tissue. Adult lung fragments did not expand after being reimplanted back into the same animal. CONCLUSIONS: Fetal lung tissue might be an option for further investigation into lung regeneration.

Age Factors↗

PubMed2006

CT lymphography-navigated sentinel lymph node biopsy in patients with superficial esophageal cancer.

BACKGROUND: To evaluate experimentally and clinically the feasibility of a newly developed technique of endoscopic computed tomography (CT) lymphography with endoscopic submucosal injection of iopamidol for esophageal sentinel lymph node (SLN) mapping and biopsy examination. METHODS: Nine anesthetized dogs underwent CT after endoscopic submucosal injection of 2 mL iopamidol; 1.25-mm thick CT images were obtained before and at 1, 3, 5, 7, and 10 minutes after contrast injection. Clinically, 12 patients with superficial esophageal cancer (preoperative imaging stage: cT1, cN0) underwent CT lymphography in a similar fashion at 1, 5, and 10 minutes after peritumoral injection, followed by radical esophagectomy and regional lymph node dissection under CT lymphography guidance. RESULTS: CT lymphography visualized the draining lymphatic vessels and SLNs within 5 minutes after contrast injection. All 14 SLNs in dogs (average, 1.5 nodes per animal; range, 1-2) and 28 SLNs in patients (average, 2.3 nodes per patient; range, 1-4) were found intraoperatively at the correct location under CT lymphography guidance. Lymph node metastasis could be detected with excellent sensitivity and accuracy in this small number of patients with no false-negative findings; metastasis was positive only in the preoperatively identified SLNs in 4 patients and in both SLNs and distant nodes in 1 patient, and was negative in all resected nodes in the remaining 7 patients. CONCLUSIONS: Endoscopic CT lymphography appears to allow accurate identification of direction and locations of lymph flow and SLNs, and has the potential clinical applicability for esophageal SLN mapping and biopsy examination, but will require a large study to determine its accuracy and usefulness.

Aged↗

PubMed2006

A case of early relapsed multiple lung metastases after esophagectomy successfully treated with S-1/cisplatin therapy after docetaxel/5-fluorouracil/cisplatin therapy.

A 55-year-old-male patient underwent subtotal esophagectomy for esophageal cancer (pT1b, N0, M0, stage II) in April 2005. The patient received postoperative chemotherapy (docetaxel 40 mg/body, 5-fluorouracil 750 mg/body, cisplatin 10mg/body: administered every 4 weeks) for 3 months. Six months postoperatively, routine follow up CT demonstrated multiple metastatic tumors in the bilateral lungs. Under the diagnosis of multiple lung metastases, the patient was hospitalized and received intensive chemotherapy with docetaxel 40 mg/week (day 1), 5-fluorouracil 500 mg/day (days 1-5), cisplatin 10 mg/day (days 1-5). After two weeks administration, the patient eagerly hoped for outpatient treatment. The treatment was changed to outpatient chemotherapy with S-1 100 mg/day (continuous administration for 3 weeks followed by rest for 1 week) and cisplatin 20 mg/every week. The treatment enabled the patient to keep working. Follow up CT showed disappearance of all tumors two months after TS-1/cisplatin chemotherapy. There were no obvious signs of recurrence 5 months after chemotherapy. The S-1/cisplatin therapy in the outpatient was thought to be one of the effective treatments in maintaining quality of life for the patient.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2006

Problems in histological grading of malignancy and its clinical significance in patients with operable breast cancer.

Although the histological grading of malignancy in patients with operable breast cancer, typically consisting of three factors: tubular formation, mitotic counts, and nuclear atypia, plays an important role in identifying patients at high risk of recurrence, the most effective combination of factors is still not completely clear. In assessing prognosis, the problems of clinical application of the grade of malignancy are not only related to the assemblage of the factors employed, but also to the heterogeneity within the tumor and interobserver variations. In a review of the correlation between the histological grading system for malignancy in operable breast cancer patients and the recurrence rate, only the grade of nuclear atypia statistically correlated with the rate of recurrence. Furthermore, a grading system consisting of mitotic counts and nuclear atypia was more significantly correlated to the risk of recurrence than was the system based on the three factors described above. Concerning the heterogeneity of histologic features within the primary tumor, a system based on the grade of mitotic counts or nuclear atypia showed a high degree of heterogeneity, but a system based on the grade of tubular formation showed low heterogeneity and bimodal distribution.

Breast Neoplasms↗

PubMed2006

[Evaluation of safety and efficacy for bi-weekly Docetaxel and 5'-DFUR combination therapy in patients with advanced or recurrent breast cancer--Phase I study].

BACKGROUND: A clinical trial of Docetaxel was performed by tri-weekly administration in patients with advanced or recurrent breast cancer. However, careful observation is necessary for outpatients because serious neutropenia often occurs during the therapy. A bi-weekly schedule is recommended since weekly administration requires more visits to the hospital. Docetaxel is proved to express synergistic efficacy in combination with 5'-DFUR by induced dThdPase in vivo. But there are no clinical trials to evaluate efficacy of bi-weekly Docetaxel and 5'-DFUR combination therapy. PURPOSE: To evaluate safety, the recommended dose of Docetaxel and the efficacy of biweekly Docetaxel and 5'-DFUR combination therapy. PATIENTS AND METHODS: Patients with advanced or recurrent breast cancer within 1 regimen of prior chemotherapy and without prior use of both Docetaxel and 5'-DFUR were enrolled. 5'-DFUR was orally administered by 600 mg/day. Docetaxel was intravenously given for at least 2 cycles (8 weeks) by 30 mg/m(2) for level 1, 40 mg/m(2) for level 2 and 50 mg/m(2) for level 3. At each level with 3 cases enrolled,the maximum tolerated dose (MTD) level was defined as that in which 2 or 3 cases showed dose limiting toxicity (DLT). The recommended dose was defined as the dose before MTD level. Therapeutic safety was evaluated by analyses of adverse events with the recommended dose. RESULTS: MTD was in level 3 and the recommended dose of Docetaxel was 40 mg/m(2) of level 2. No DLT was observed in level 2, and this combination therapy seemed safe and feasible for outpatients. In addition, all 6 cases for whom therapeutic efficacy was evaluated expressed a clinical response.

Administration, Oral↗

PubMed2005

Breast sentinel lymph node navigation with three-dimensional interstitial multidetector-row computed tomographic lymphography.

OBJECTIVE: Three-dimensional multidetector-row computed tomographic lymphography (3D MDCT-LG) with interstitial injection of a widely available nonionic monometric contrast medium iopamidol was used for navigation of breast sentinel lymph node (SLN) biopsy. METHODS: 3D MDCT-LG was obtained after massage of the interstitially injection sites of a total of 4-5 mL undiluted iopamidol at periareolar and peritumoral areas in 68 consecutive patients with early-stage breast cancer, using a 4 detector-row CT scanner. Drainage lymphatic patterns and SLN anatomy were assessed on 3D MDCT-LG images. 3D MDCT-LG-navigated SLN biopsy with combined use of blue dye was followed by backup axillary lymph node dissection to evaluate accuracy of SLN biopsy. RESULTS: The 3D MDCT-LG images clearly localized primary SLNs by visualizing the direct connection between these nodes and their afferent lymphatic vessels on detailed anatomy of the surrounding structures in all patients. Drainage lymphatic pathways on these images were classified into 4 patterns: single route/single SLN (39 cases, 57%), multiple routes/multiple SLNs (10 cases, 15%), single route/multiple SLNs (9 cases, 13%), and multiple routes/single SLN (10 cases, 15%). Under 3D MDCT-LG navigation, SLNs was found at the accurate location in all patients. With backup axillary lymph node dissection, metastasis was found in 14 (20%) patients, and 8 of these patients had metastasis only in the preoperatively identified SLNs. In other 5 positive patients, metastasis was found both in the SLN and non-SLNs. However, micrometastasis eventually was found only in non-SLN in an elderly patient. Overall, the sensitivity, false-negative rate, and accuracy of 3D CT-L-navigated SLN biopsy were 92% (13/14 patients), 7% (1/14 patients), and 98% (67/68 patients), respectively. CONCLUSIONS: Topographic 3D interstitial MDCT-LG can be a widely available and reliable navigator for breast SLN biopsy.

Adult↗

PubMed2005

Lymphatic drainage from esophagogastric tract: feasibility of endoscopic CT lymphography for direct visualization of pathways.

PURPOSE: To evaluate the feasibility of an endoscopic computed tomographic (CT) lymphography technique with submucosal injection of iopamidol for direct visualization of lymphatic drainage pathways in dogs and in patients with operable esophageal cancer. MATERIALS AND METHODS: With institutional animal committee approval, a total of 2 mL of undiluted iopamidol was injected into the esophageal (n = 6) or gastric (n = 3) submucosa in nine dogs by using a flexible endoscope. Multi-detector row CT images (section thickness, 1.25 mm) were obtained before contrast material injection and during the 10 minutes after injection. The animals were euthanized so that their lymphatic anatomy could be examined. With ethical committee approval and patient informed consent, nine patients with esophageal cancer also underwent CT lymphography with peritumoral injection of 2 mL of iopamidol, followed by esophagectomy and regional lymph node dissection with CT lymphographic guidance. The histopathologic features of dissected nodes, including sentinel lymph nodes (SLNs), were examined. RESULTS: CT lymphography depicted the direct connection of lymphatic drainage vessels with enhanced and/or unenhanced nodes (ie, SLNs) as early as within 5 minutes after contrast material injection in all subjects. All 13 SLNs in dogs (1.4 nodes per animal) and 18 SLNs in patients (two nodes per patient) were found and dissected at the correct location by using CT lymphographic guidance. In patients, histopathologic examination revealed the high predictive value of CT lymphographic-guided SLN biopsy: Only one of the preoperatively identified SLNs in three patients and both SLNs and adjacent nodes in two patients were positive for metastasis; all resected nodes in the remaining four patients were negative. CONCLUSION: Endoscopic CT lymphography is a feasible method for visualizing the direct connection between and the accurate anatomic location of SLNs and lymphatic drainage vessels.

Aged↗

PubMed2005

Photodynamic therapy for submucosal tumor of the central bronchus.

A 75-year-old man was referred to our hospital because of the emphysema and tumor of the right intermediate bronchus. Thoracic CT scan and bronchoscopic examination demonstrated a spherical tumor of the right intermediate bronchus covering a normal mucosa. The biopsy specimen obtained from this tumor was histologically diagnosed as "glandular type of adenocarcinoma in the bronchus". Surgical treatment was not feasible because of poor pulmonary function. Therefore, the patient underwent Photodynamic therapy (PDT) using porfimer sodium (Photofrin) and an excimer dye laser. After 4 months, the tumor disappeared and there has been no recurrence for 3 years 3 months. PDT can affect a submucosal tumor of the central airway, and is safe for patients with poor pulmonary function. Our report recommends that PDT should be applied not only to early lung cancer but also submucosal tumor of the central bronchus.

Adenocarcinoma↗

PubMed2005

Lower axillary dissection in breast cancer surgery may be candidate for cases with early breast cancer.

Lower axillary lymph node dissection (lower parts of both the level I and II elements below the second intracostobrachial nerve) and level I and II lymph node dissection were performed on breast cancer patients (n = 54), and the results with the two methods were compared in terms of the status of detected lymph node metastases. For Stage I, N0 cases, the results for pathological classification lymph node metastases (pN) were in agreement between the two dissection methods. And, the occurrence of operated arm swelling wasn't recognized when a side effect was examined with the case (n = 28) that only lower axillary dissection was carried out in case of an operation for breast cancer. Accordingly, it was surmised that lower axillary dissection provides accurate pN information for Stage I, N0 cases. These results indicate that lower axillary dissection has the potential to become an effective, standard surgical procedure for breast cancer patients whose preoperative disease stage is Stage I.

Adult↗

PubMed2005

[Evaluation of host immunity and side effects in breast cancer patients treated with adjuvant chemotherapy (FEC therapy)].

BACKGROUND: FEC (5-FU+epirubicin+cyclophosphamide) therapy has been used as adjuvant chemotherapy for breast cancer patients with nodes positive. The aim of this study was to evaluate host immunity and side effects of the FEC therapy. The effect of oral administration of Lentinus edodes mycelia (LEM) was also observed. METHODS: Ten patients were enrolled in this study. The treatment with 5-FU (500 mg/m2), epirubicin (75 mg/m2) and cyclophosphamide (500 mg/m2) was administered every 21 days for 2 cycles, and LEM (9 g/day po) was administered during the 2nd cycle. RESULTS: NK cell activity and the number of white blood cells decreased on the 7th day after the therapy, and they recovered on the 21st day. However, this NK cell activity and the number of white blood cells didn't decrease when the FEC therapy was used with LEM po. CONCLUSIONS: FEC 75 therapy has made some impacts on host immunity, and LEM with the FEC 75 therapy might have prevented host immunity.

Adult↗

PubMed2004

Molecular signature linked to acquired resistance to cisplatin in esophageal cancer cells.

To clarify the molecular basis of acquired cisplatin (CDDP) resistance in esophageal squamous cell carcinoma (ESCC), we used cDNA microarray technology. A CDDP-resistant cell line (YES-2/CDDP), which shows a 7.5-fold increase in resistance to CDDP and a 3-fold decrease in CDDP accumulation compared with the parental YES-2 ESCC cell line, was generated from YES-2 by exposure to increased concentrations of CDDP. By cDNA microarray analysis, we identified 44 genes with significantly different expression levels between YES-2/CDDP and YES-2 cells. Interestingly, 15 of these 44 genes encoded ribosome-related proteins, almost all of which were underexpressed in YES-2/CDDP cells. Our present data suggest that many ribosome-related genes may be involved in the acquired resistance to CDDP in ESCC and that such information may allow us to better understand the mechanism of CDDP resistance.

Antineoplastic Agents↗

PubMed2004

Sentinel lymph node biopsy using computed tomography-lymphography in patients with breast cancer.

BACKGROUND: The sentinel lymph node biopsy (SLNB) technique is established in the treatment of breast cancer. The current technique of mapping the SLN with blue dye or radiotracers requires a learning period. Tracer and injection site selection and intraoperative pathologic examination have been discussed. METHODS: We developed a three-dimensional computed tomography lymphography (3D CT-LG) technique with commercially available iopamidol. SLNB and backup dissection were performed in 40 patients with T1 and T2 breast cancer. Feasibility and efficacy of CT-LG were examined. RESULTS: In all patients, lymph flow and the surrounding anatomical environment were visualized with 3D CT-LG. SLNB was successful because of accurate navigation by 3D CT-LG. SLN was detected in all patients, whereas dye navigation failed in seven fatty axilla and two patients with prior excisional biopsy. Backup dissection confirmed the accuracy of CT-LG-guided SLNB. A false negative result was found in only one patient. Preoperative prediction was feasible in cases of SLN metastasis. CONCLUSIONS: CT-LG allowed accurate SLN localization by quickly and adequately visualizing the direct connection between the SLN and its afferent lymphatic vessels. Detailed cross-sectional images of lymphatic anatomy during CT resulted in successful SLNB with shortening of the presurgical examination schedule.

Adult↗

PubMed2004

Analysis of DNA copy number aberrations in hepatitis C virus-associated hepatocellular carcinomas by conventional CGH and array CGH.

To clarify the genetic aberrations involved in the development and progression of hepatitis C virus-associated hepatocellular carcinoma (HCV-HCC), we investigated DNA copy number aberrations (DCNAs) in 19 surgically resected HCCs by conventional CGH and array CGH. Conventional CGH revealed that increases of DNA copy number were frequent at 1q (79% of the cases), 8q (37%), 6p (32%), and 10p (32%) and that decreases were frequent at 17p (79%), 16q (58%), 4q (53%), 13q (42%), 10q (37%), 1p (32%), and 8p (32%). In general, genes that showed DCNAs by array CGH were usually located in chromosomal regions with DCNAs detected by conventional CGH analysis. Increases in copy numbers of the LAMC2, TGFB2, and AKT3 genes (located on 1q) and decreases in copy numbers of FGR/SRC2 and CYLD (located on 1p and 16q, respectively) were observed in more than 30% of tumors, including small, well-differentiated carcinomas. These findings suggest that these genes are associated with the development of HCV-HCC. Increases of MOS, MYC, EXT1, and PTK2 (located on 8q) were detected exclusively in moderately and poorly differentiated tumors, suggesting that these alterations contribute to tumor progression. In conclusion, chromosomal and array CGH technologies allow identification of genes involved in the development and progression of HCV-HCC.

Aged↗

PubMed2004

Molecular signature in three types of hepatocellular carcinoma with different viral origin by oligonucleotide microarray.

Chronic infection with hepatitis B or C virus (HBV or HCV) is the most clearly established risk factor for hepato-cellular carcinoma (HCC). One type of HCC (non-B, non-C HCC) also appears to develop in patients negative for both HBV and HCV. Using a supervised learning method, we investigated gene expression in 11 non-B, non-C HCCs with high-density oligonucleotide microarrays, and compared the patterns of gene expression with those of HBV-infected HCCs (B-type HCCs) and HCV-infected HCCs (C-type HCCs) in the previous dataset. Our gene selection identified 112 and 64 genes that were differentially expressed in non-B, non-C HCC in comparison with B- and C-type HCCs, respectively. In both gene selections, we found that the false discovery rate, the percentage of genes identified by chance, was less than 5%. Additionally, in combination with the previous data, our present data revealed a set of genes specific to each type of B- and C-type HCCs and non-B, non-C HCC. Among these, an interferon-induced gene, IFI27, was differentially expressed among all three types of HCCs, and this result was confirmed by RT-PCR. Thus, our present study provides a framework to characterize the molecular features in the three subtypes of HCC with different viral origin.

Carcinoma, Hepatocellular↗

PubMed2004

[A case of disseminated tumor from cecal cancer with survival for over 5 years after twice surgical resection and systemic chemotherapy].

A 66-year-old man underwent a curative operation for cecal cancer on the 30th of November, 1998. Since his CEA level rose in January 2001, computed tomography (CT) revealed a tumor in the abdomen. He underwent a resection of this tumor and disseminated tumors that were diagnosed during the operation. He received systemic chemotherapy (5'-DFUR 600 mg 3x everyday, CPT-11 80 mg/body div every 2 weeks), but the CEA level rose again in August 2003. He was diagnosed with spleen metastasis and underwent splenectomy. The tumor disseminated in the left diaphragm was also resected. After that, he received systemic chemotherapy (5-FU 500 mg/body/week div, levofolinate calcium 250 mg/body/week i.v.) as an outpatient. Peritoneal carcinomatosis from colorectal cancer with distant metastasis, in general, has no indication for an operation. However, if dissemination is located after a sufficient observation period, its resection may be recommended.

Adenocarcinoma↗

PubMed2003

Breast sentinel lymph node mapping at CT lymphography with iopamidol: preliminary experience.

PURPOSE: To evaluate sentinel lymph node (SLN) mapping with interstitial computed tomographic (CT) lymphography with small volumes of iopamidol for direction of SLN biopsy in breast cancer. MATERIALS AND METHODS: Thin-section transverse and three-dimensional CT images that included the breast and axilla were acquired at multi-detector row helical CT in 17 patients with operable breast cancer before subcutaneous injection of 2 mL of undiluted iopamidol into peritumoral and periareolar areas and 1-5 minutes after massage of injection sites. Location and size of SLNs were assessed at CT lymphography and were compared with SLNs at standard axillary lymph node dissection with blue dye staining. RESULTS: CT lymphography allowed localization of SLNs in all patients by means of visualization of a direct connection between an SLN and its afferent lymphatic vessels draining from the injection sites. Afferent vessels were joined and drained into a single axillary SLN, except in four patients with two or three SLNs, including a parasternal one. SLNs did not enhance because of rerouting of lymph flow in four patients. At surgery, SLNs that were stained or not stained with blue dye were easily found with CT lymphographic guidance. Tumoral infiltration was not evident in any resected nodes, except for infiltration in one patient with micrometastasis in SLN alone and infiltration in four patients with massive metastasis in both SLN and distant nodes. CONCLUSION: Because preoperative CT lymphography-guided SLN mapping provides SLN position with detailed lymphatic anatomy, it may be useful for the direction of breast SLN biopsy.

Adult↗