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PubMed1995

Lymph node dissection for thoracic esophageal carcinoma. Two- and 3-field lymph node dissection.

Patients' records were analyzed to evaluate the effect of lymph node dissection on the survival of patients with thoracic esophageal carcinoma. Patients who underwent incomplete resection of the tumor were excluded from this study. A conventional lower mediastinal and abdominal lymph node dissection (conventional 2-field dissection) had been performed in 410 patients. A complete dissection of the upper mediastinal nodes was performed in addition in 121 patients (extended 2-field dissection). Sixty-four patients underwent a further dissection of the cervical periesophageal lymph nodes through the thoracic cavity (super-extended 2-field dissection). A cervical, mediastinal, and abdominal lymph node dissection was carried out in another 100 patients (3-field dissection). Background factors in the latter three groups were similar. Mean numbers of dissected lymph nodes in extended 2-field, super extended 2-field, and 3-field dissections were 32, 57, and 77, respectively. Operative mortality rates were 11%, 9%, and 3%, respectively. The five-year survival rates for patients who underwent extended 2-field or 3-field dissection were 43% and 61%; the difference was statistically significant (P = 0.000113). The four-year survival rate for super-extended 2-field dissection was 53%. Among those patients who underwent 3-field dissection, 58 (58%) had histologically positive lymph nodes. Their five-year survival rate was 47%. The patients' survival has been improved by increasing the field of lymph node dissection without deterioration of operative mortality.

Adenocarcinoma↗
PubMed2004

Should decisions on internal mammary lymph node irradiation be based on current lymphoscintigraphy techniques for sentinel lymph node identification?

BACKGROUND: Treatment of internal mammary lymph node (IMN) metastases remains controversial because of the difficulty in predicting involvement, potential treatment-related morbidity, and questionable efficacy. Lymphoscintigraphy with sentinel lymph node biopsy offers a means to identify occult involvement of IMN, allowing appropriate patient selection for IMN treatment. METHODS: The authors retrospectively reviewed 262 lymphoscintigraphies (LS) of 248 patients treated at the University of Florida (Gainesville, FL) between 1998 and 2002. Tumor characteristics were assessed for their value in predicting IMN drainage and their association with IMN radiation. RESULTS: Lymph flow to the IMN was documented with LS in 23 of 262 tumor specimens (9%). Flow to the IMN was not correlated with any of the five factors: tumor location, tumor size, lymphovascular invasion, pathologic lymph node status, and laterality of the involved breast (right vs. left breast). Identification of IMN flow increased from 5.7% to 10.1% with the use of a deep injection technique. IMN radiotherapy was used more frequently in patients with larger tumors (15 of 188 in Tis/T1 vs. 31 of 70 in T2-T4; P<0.0001) and positive lymph nodes (17 of 91 in lymph node-negative patients vs. 28 of 66 in lymph node-positive patients; P<0.0001). In patients with T2N0 tumors (n=32), IMN radiotherapy was used more frequently with medial tumors (5 of 11 [45%]) than with lateral tumors (4 of 21 [19%]). CONCLUSIONS: The incidence of flow to the IMN documented with the current LS technique was low compared with other LS and extended radical mastectomy series. Histopathologic information was obtained for the sentinel IMN when IMN flow was identified on the LS. In the absence of histopathologic information, treatment decisions should continue to be based on clinical factors known to be correlated with occult IMN involvement.

Adult↗
PubMed1982

Transabdominal fine needle aspiration of retroperitoneal lymph nodes in staging of genitourinary tract cancer (correlation with lymphography and lymph node dissection findings).

Percutaneous fine needle aspiration of retroperitoneal pelvic and abdominal lymph nodes was done in 100 patients with clinically localized bladder, prostatic, testis and penile cancer. A diagnosis of metastases to regional lymph nodes was detected by this method in 20 patients. Fine needle aspiration revealed evidence of regional lymph node involvement in 6 of 40 patients (15 per cent) with negative findings on lymphography and computerized tomography scan. Lymph node aspiration was followed by lymph node dissection in 50 patients. The correlation between aspiration and dissection was 68 per cent. The accuracy of obtaining representative material from the lymph node aspiration was 83 per cent. Negative results of lymph node aspiration cannot be used in clinical management. However, positive aspiration results provide the clinician with valuable information obtainable otherwise only by laparotomy or lymph node dissection. Positive aspiration results may spare patients with prostatic and bladder cancer an unnecessary radical operation, and may indicate early chemotherapy or surgery in patients with testis and penile cancer.

Biopsy, Needle↗
PubMed2003

Evaluation of lymph node status in male breast cancer patients: a role for sentinel lymph node biopsy.

Sentinel lymph node (SLN) biopsy is rapidly emerging as an alternative to axillary lymph node dissection (ALND) for many female breast cancer patients. In contrast, ALND remains the standard of care for male breast cancer patients with similar tumors. We evaluated the results of SLN biopsy in male breast cancer patients with clinically negative axillae. This study included all male breast cancer patients who underwent SLN biopsy at our institution between October 1999 and 2000. All patients had negative axillae on clinical examination and sonography. All patients underwent preoperative lymphoscintigraphy followed by SLN biopsy performed using a combination of isosulfan blue dye and technetium Tc 99m sulfur colloid. Tc 99m sulfur colloid was injected at a dose of 2.5 mCi 24 h before surgery (four patients) or 0.5 mCi 2-4 h before surgery (three patients). Intraoperatively, 5 ml of 1% isosulfan blue was injected adjacent to the breast tumor or biopsy cavity prior to SLN biopsy. A gamma probe was used intraoperatively in order to localize SLNs. Any node that was blue or associated with ex vivo radioactivity counts at least 10 times higher than the axillary background counts was defined as a SLN. SLNs were assessed intraoperatively using touch preparation cytologic examination. Completion ALND was performed if nodal metastases were identified. Seven patients, 44-76 years of age, were included in the study. Preoperative lymphoscintigraphy identified SLNs in five patients. Intraoperatively, SLNs were identified in all seven patients. SLNs were identified in six patients using the gamma probe and in all seven patients using blue dye. The mean number of SLNs encountered was 2.9. Findings on touch preparation cytology correlated with findings on the final pathological analysis examination in all patients. One patient had a positive SLN, this patient had three additional positive nodes identified in his completion ALND specimen. Three patients with negative SLNs had been elected preoperatively to undergo ALND regardless of findings on SLN biopsy, no positive lymph nodes were identified in the ALND specimens from these patients. These findings compare favorably with findings reported in the literature regarding SLN biopsy in female breast cancer patients. Blue dye injection and radioisotope injection were complementary. SLN biopsy should be considered for axillary staging in male breast cancer patients with clinically negative axillae.

Adult↗
PubMed2003

Gene therapy to target dendritic cells from blood to lymph nodes.

Peripheral lymph nodes (PLN) are strategic microenvironments where antigen-presenting dendritic cells (DC), loaded with environmental antigens, and naive lymphocytes meet to initiate immune responses. The unique capacity of DC to induce primary immune responses has led to their use in clinical medicine; however, delivering DC to lymph nodes is problematic. Intravenously injected DC cannot access to PLN, while DC injected into tissue migrate inefficiently through lymphatics to PLN. We achieved DC targeting to T-cell areas of PLN by endowing DC with a novel receptor for peripheral node addressin (PNAd), an adhesion molecule present on the lymph node venular endothelium. This novel receptor is a chimeric E/L-selectin (ELS) that, we have previously shown, binds to PNAd. DC were genetically modified by retroviral transduction to express ELS. ELS expression was targeted to tips of microvilli, and mediated rolling of DC on PNAd both in vivo and in vitro. Such genetically engineered DC could extravasate directly from blood through the lymph node endothelium as opposed to nontransduced DC. This study provides evidence that the trafficking of DC can be modified using gene transfer technologies. More efficient delivery of DC to PLN should assist the development of improved vaccination strategies.

Adoptive Transfer↗
PubMed2004

Paradigm of metastasis for melanoma and breast cancer based on the sentinel lymph node experience.

Lymph node status is the most reliable prognostic indicator for patients with melanoma and breast cancer. Because it is the first node draining the primary cancer, the sentinel lymph node (SLN) is most likely to harbor metastatic cancer cells. The Breslow thickness of the primary melanoma and the size of primary breast cancer are highly correlated with SLN metastasis. If the SLN is negative, its negative predictive value for the remaining nodal basin exceeds 95%; thus, survival rates for melanoma and breast cancer increase when the SLN is negative. The rate of SLN identification is more than 95%, and the false-negative rate is about 5%. SLN data from melanoma and breast cancer are so convincing that they have been incorporated into the new American Joint Committee on Cancer classification of these cancers. The therapeutic value of additional lymph node dissection after a positive SLN for melanoma or breast cancer is still controversial. In melanoma, a 3-year follow-up may confirm better survival when the SLN is negative. However, about 25% of histologically negative SLNs may be upstaged by molecular techniques, and patients whose SLNs are positive by polymerase chain reaction (PCR) assay may develop recurrence. In most cases, melanoma and breast cancer follow an orderly progression of metastasis to the SLN; however, a small subgroup may develop systemic dissemination without SLN involvement. Current SLN experience has confirmed that the earlier the cancer, the less its potential for metastasis. Since treatments for metastatic cancer are still limited, early detection and resection are imperative. Better understanding of the molecular and genetic mechanisms of metastasis will be critical to select high-risk patients for adjuvant therapy.

Breast Neoplasms↗
PubMed1999

[A case of multiple hepatocellular carcinoma complicated with N3 regional lymph node metastases preventing tumor progression by gradual introduction of lymph node excision and high-dose chemotherapy using percutaneous isolated hepatic perfusion].

We experienced a case of multiple hepatocellular carcinoma (HCC) complicated with N3 regional lymph node metastases. The gradual introduction of lymph node excision and high-dose chemotherapy using percutaneous isolated hepatic perfusion (PIHP) was effective in preventing progress of the tumor. The patient was a 63-year-old male who underwent a thorough medical examination because of elevated AFP at a local hospital. He was referred to our hospital. The preoperative laboratory results showed the elevation of AFP (729 ng/ml) and PIVKA-II (2,110 mAU/ml). CT scan of the liver revealed tumors in segment 4, 5 and 6, and lymph node metastases from the pancreas to the hepato-duodenal ligament. The enlarged lymph nodes were excised and the tumor in segment 5 was resected for pathological examination. Adriamycin was administered in doses of 100 mg/m2 and 80 mg/m2 using PIHP two and three months after the operation. According to the results of laboratory studies conducted 14 months after the operation, AFP was 12 ng/ml and PIVKA-II was within the normal range. CT scan of the liver showed the liquefaction degeneration of the remaining HCC. Although surgery is not generally indicated in a patient with multiple HCC complicated with N3 regional lymph node metastases, it should be considered in combination with PIHP in those with resectable extrahepatic lesion.

Antineoplastic Agents↗
PubMed2002

Lymph node recoveries from 2427 pT3 colorectal resection specimens spanning 45 years: recommendations for a minimum number of recovered lymph nodes based on predictive probabilities.

This study investigates the relationship between the number of recovered lymph nodes and lymph node metastases in colorectal resection specimens. All of the slides from 2427 pT3 colorectal resection specimens from patients operated on at William Beaumont Hospital during the 45 years from 1955 through 2000 were reviewed. Lymph node metastases were present in 333 of 1499 (22.2%) specimens with fewer than 15 recovered lymph nodes, compared with 789 of 928 (85.0%) specimens with 15 or greater recovered lymph nodes (p <0.01). The proportion of lymph node metastases increased as a function of the number of recovered lymph nodes (p <0.01). Similarly, in patients without lymph node metastases, survival increased as a function of the number of recovered lymph nodes. Among these patients, the 5-year overall survival rate was 62.2% among patients with seven or fewer recovered lymph nodes and 75.8% among patients with 18 or more recovered lymph nodes (p = 0.018). Statistical analysis found the predictive probability of identifying the single lymph node metastasis in a theoretical specimen with a single lymph node metastasis is 0.25 if 12 lymph nodes are recovered and 0.46 if 18 lymph nodes are recovered. The predictive probability increased as the number of recovered lymph nodes increased, suggesting there is no minimum number that reliably or accurately stages all patients. Thus, all palpable lymph nodes should be recovered, including those that are 1 or 2 mm.

Adenocarcinoma↗
PubMed2001

Characteristics of the sentinel lymph node in breast cancer predict further involvement of higher-echelon nodes in the axilla: a study to evaluate the need for complete axillary lymph node dissection.

BACKGROUND: Sentinel lymph node (SLN) biopsy techniques provide accurate nodal staging for breast cancer. In the past, complete lymph node dissection (CLND) (levels 1 and 2) was performed for breast cancer staging, although the therapeutic benefit of this more extensive procedure has remained controversial. HYPOTHESIS: It has been demonstrated that if the axillary SLN has no evidence of micrometastases, the nonsentinel lymph nodes (NSLNs) are unlikely to have metastases. OBJECTIVE: To determine which variables predict the probability of NSLN involvement in patients with primary breast carcinoma and SLN metastases. METHODS: An analysis of 101 women with SLN metastases and subsequent CLND was performed. Variables included size of the primary tumor, tumor volume in the SLN, staining techniques used to initially identify the micrometastases (cytokeratin immunohistochemical vs hematoxylin-eosin), number of SLNs harvested, and number of NSLNs involved with the metastases. Tumor size was determined by the invasive component of the primary tumor. Patients with ductal carcinoma in situ who were upstaged with cytokeratin staining were considered to have stage T1a tumors. RESULTS: Sentinel lymph node micrometastases (<2 mm) detected initially by cytokeratin staining were associated with a 7.6% (2/26) incidence of positive CLND compared with a 25% (5/20) incidence when micrometastases were detected initially by routine hematoxylin-eosin staining. Sentinel lymph node micrometastases, regardless of identification technique, inferred a risk of 15.2% (7/46) for NSLN involvement. As the volume of tumor in the SLN increased (ie, <2 mm, >2 mm, grossly visible tumor), so did the risk of NSLN metastases (P<.001). CONCLUSIONS: Our study demonstrated that patients with micrometastases detected initially by cytokeratin staining had low-volume disease in the SLN with a small chance of having metastases in higher-echelon nodes in the regional basin other than the SLN. Characteristics of the SLN can provide information to determine the need for a complete axillary CLND. Complete lymph node dissection may not be necessary in patients with micrometastases detected initially by cytokeratin staining since the disease is confined to the SLN 92.4% of the time. However, the therapeutic value of CLND in breast cancer remains to be determined by further investigation.

Axilla↗
PubMed2001

Sentinel lymph node biopsy as an alternative to routine axillary lymph node dissection in breast cancer patients.

Sentinel lymph node (SLN) biopsy is a useful way of assessing axillary nodal status and obviating axillary lymph node dissection (ALND) in patients with node-negative breast cancer. Because SLN technology is evolving rapidly, however, variation in technique is widespread, and no standardization has yet been accomplished. This review discusses the feasibility and accuracy of this procedure and suggests the optimal method for identifying the SLN and detecting micrometastases. Although the SLN can be successfully identified by either the dye-guided or gamma probe-guided method in experienced hands, identification is facilitated when the two techniques are used together. In the gamma probe-guided method, the use of a large-sized radiotracer (particle size, 200-1000 nm) may be preferred because only one or two SLNs are identified. To increase the chance of finding metastases in SLN, it is desirable to make step sections with hematoxylin and eosin staining on permanent and frozen sections. The addition of immunohistochemistry may improve the accuracy of SLN diagnosis. The intraoperative examination of imprint cytology may be useful in determining the status of the SLNs, but further studies are needed to establish whether it has additional value when combined with the frozen section. In practice, routine ALND can be avoided when there is documentation of extensive experience and a low false-negative rate with the technique in the hands of a particular surgeon and hospital team. Particularly, SLN biopsy is more successful and has a lower false-negative rate in patients with smaller tumors. However, investigation of long-term regional control and survival in a prospective randomized trial is necessary, before SLN biopsy can replace routine ALND as the preferred staging operation for women with breast cancer.

Breast↗
PubMed2004

[Sentinel lymph node negative breast cancer larger than 30 mm: is axillary lymph node dissection constantly necessary?].

Benefits provided by sentinel lymph node biopsy (SLNB) include improvement of pathologic examination and lower rate of sequels. The aim of this study was to assess the accuracy of this procedure in large tumors. From march 1999 and december 2003, 663 patients were operated for a breast cancer and underwent a SLNB. All patients with tumor larger than 30 mm and/or with involved SLNB underwent a complete axillary dissection (AD). One hundred and sixteen patients (17.5%) with a tumor larger than 30 mm underwent an AD. Identification rate of SLNB was 94% (109/116). Among the 43 cases with non metastatic SLNB, the AD was negative in 39 cases (90.7%). In four cases a palpable non sentinel lymph node discovered during the SLNB procedure was found to be involved. In one case the lymphoscintigraphy found only one lymph node with a very low fixation and an AD was performed because of low efficiency of the lymphoscintigraphy procedure. SLNB false negative rate was 1.4 % (1/72) among the 72 cases with lymph node involvement. AD was performed in 66 cases (60.5%) during the same operating time than the SLNB. AD showed a lymph node involvement in 30 cases (30/72, 41.7%): in 5 cases among 24 cases with microscopic disease (20.8%) and in 25 cases among 48 cases with macroscopic disease (52%). This series results suggest than AD could be avoided for negative SLNB tumors up to 50 mm at pathologic examination in patients with clinically-measured tumor smaller than 30 mm.

Adult↗
PubMed1995

Sentinel lymph node status as an indicator of the presence of metastatic melanoma in regional lymph nodes.

The value of elective lymph node dissection (ELND) for melanoma patients with clinically uninvolved regional nodes remains controversial. However, it has been proposed that selective 'sentinel' lymph node biopsy reliably identifies individuals with micrometastases, who are most likely to benefit from full ELND. The aim of this study was to confirm that metastatic melanoma cells travelling in lymphatics do not bypass the sentinel node. After preoperative lymphoscintigraphy and intraoperative injection of blue dye around the primary melanoma site, sentinel node biopsy was performed in 118 melanoma patients for whom full ELND was planned as part of their definitive surgical treatment. A confidently identified sentinel node was tumour positive in 22 out of 105 regional lymph node fields (21%). In 18 cases the sentinel node was the only node found to be involved and in four cases, additional nodes were positive. In two other patients a positive node was found when the sentinel lymph node had been negative. However, in each case an avoidable error of technique had occurred and definite blue staining indicated that the positive node was in fact another sentinel node. This study thus confirms that sentinel lymph node status reliably indicates whether metastatic melanoma is present in regional lymph nodes.

Adolescent↗
PubMed1976

Lymph node involvement by direct extension in adenoid cystic carcinoma. Absence of classic embolic lymph node metastasis.

Thirty-four cases of adenoid cyctic carcinoma seen at the University of Virginia Hospital from 1946 to 1974 were reviewed, with special emphasis on lymph node involvement by tumor. Lymph node involvement was found in three cases of primary tumors of the submaxillary gland, and all of the affected lymph nodes were in the immediate vicinity of the primary tumor. Two lymph nodes were involved in two of the cases, and one node was involved in the third case. In all of these lymph nodes, adenoid cystic carcinoma was present in the soft tissue surrounding the node, and the tumor extended into the node. No metastatic tumors were observed in 46 lymph nodes removed incidentally at the time of local excision of the primary tumors in 10 additional cases or in 212 lymph nodes examined after unilateral radical neck dissections in six other cases. Five autopsies in this series showed no lymph node metastases. In this series of cases adenoid cystic carcinoma only invades lymph nodes in the immediate vicinity of the primary tumor. When lymph node involvement does occur, it does not result from embolic lymph node metastasis; rather, a direct invasion of the lymph node from tumor in the perinodal soft tissue occurs. Obviously, this small study does not completely exclude the possibility of embolic metastasis; however, if it does occur, it must be extremely rare.

Carcinoma, Adenoid Cystic↗
PubMed1984

Prognostic significance of morphology of tumor and retroperitoneal lymph nodes in epithelial carcinoma of the ovary. I. Correlation with lymph node metastasis.

The prognostic indices based on a morphologic study of tumor and retroperitoneal lymph nodes in 63 patients with epithelial carcinoma of the ovary are reported. The purpose of the study was to identify those variables most frequently related to nodal involvement. The cases in the series consisted of 11 Stage I, 10 Stage II, 34 Stage III, and 8 Stage IV. Histologic distribution was 60.4% serous type, 11.1% mucinous, 6.3% endometrioid, 6.3% clear cell, and 15.9% unclassified. All patients had maximal surgery and selective biopsy of para-aortic and pelvic lymph nodes. The results showed statistically significant variables associated with nodal metastasis in both primary tumor and regional lymph nodes. The indices in primary tumor were grade of tumor, vascular invasion, lymphocytic infiltration, and stromal fibrosis; those in lymph node were type of lymph node reaction, sinus histiocytosis, and fibroblastic proliferation. The nodes with lymphocyte depletion were associated with nodal spread in 81.3% of cases. It is concluded that morphologic study of tumor and lymph node could identify prognostic factors predicting regional nodal metastasis in ovarian carcinoma.

Female↗
PubMed1992

[A suspected case of perforation of a lymph node into the bronchus during the treatment of adult hilar lymph node tuberculosis].

A 27-year old patient was diagnosed as having post-primary hilar lymph node tuberculosis. First being admitted to the hospital with a high fever, a chest x-ray examination revealed a swelling of the left hilar lymph nodes and a sputum smear tested positive for acid-fast bacilli. Neither regular clinical examination or investigation had reported abnormality. The acid-fast bacilli was successfully treated through treatment using INH RFP SM. However, after two months, swelling was observed in the right para-tracheal lymph nodes, Further, a bronchoscopic examination revealed polyp-like tumors at the left upper and lower bifurcation. The swelling of the para-tracheal lymph nodes was considerably reduced and the tumors non-existent after five months. These lymph node reactions could have likely been a part of the so called early exacerbation. The polyp-like tumors were not found during the bronchoscopy performed during admission to the hospital. It is therefore suspected that the cause was perforation of the hilar lymph node into the bronchus.

Adult↗
PubMed2001

Intraoperative pathologic evaluation of a breast cancer sentinel lymph node biopsy as a determinant for synchronous axillary lymph node dissection.

BACKGROUND: Intraoperative pathologic evaluation of a breast cancer sentinel lymph node (SLN) biopsy permits synchronous axillary lymph node dissection (ALND), but frozen section is time consuming and potentially inaccurate. This study evaluated intraoperative gross examination and touch prep analysis (TPA) of a breast cancer SLN biopsy as determinants for synchronous ALND. METHODS: Intraoperative gross examination/TPA were performed on the SLN of consecutive breast cancer patients from 1997 to 2000. Patients with an intraoperative "positive" SLN underwent synchronous ALND. Intraoperative results were compared with the final pathology. RESULTS: Thirty-seven of 150 patients had a positive SLN on final pathology. Intraoperative gross examination/TPA identified 54% (20 of 37) of these patients. All intraoperative "positive" patients underwent synchronous ALND. Of 17 "false-negative" findings, 53% (9 of 17) had micrometastatic disease. There were no "false-positive" results. Overall sensitivity and specificity were 54% and 100%, respectively. CONCLUSIONS: Gross examination/TPA are simple, rapid techniques for the intraoperative evaluation of a breast cancer SLN. As there were no false-positive results, the rationale behind SLN biopsy was preserved. These techniques permitted synchronous ALND in over half of all patients with a positive SLN. This represents a potential benefit to the patient by eliminating a second hospitalization for delayed ALND.

Adult↗