Magnetic resonance imaging - evaluation of mesorectal lymphadenopathy in patients with rectal cancer

INTRODUCTION

Multidisciplinary management of patients with rectal cancer presents a gold standard of care; neoadjuvant therapy indications are based on magnetic resonance imaging (MRI) description of the local stage of the carcinoma. Although the accuracy of MRI-based assessment of cancer depth of invasion is satisfactory, its accuracy in the assessment of mesorectal lymphadenopathy is very questionable.

METHODS

This was a prospective, single-centre, cohort study focused on the accuracy of preoperative MRI in the assessment of mesorectal lymph nodes (LN). MRI findings of each patient were compared with detailed histopathological examination of rectal specimens.

RESULTS

Forty patients with rectal cancer, undergoing rectal resection with total mesorectal excision were enrolled in the study. MRI assessment of the T-stage was correct in 22 of the 40 study patients (55.0%). T-stage overstaging was noted in 14 (35.0%), and understaging in 4 (10.0%) study patients. According to preoperative MRI (using Horvat's criteria), there were 50 suspicious/malignant lymph nodes. Only 13 of these 50 LNs (26.0%) were proved malignant on histopathology examination. In total, our study group included 18 patients with suspicious/positive LNs (according to preoperative MRI) who were classified as cN+. MRI diagnosis of malignant lymphadenopathy was correct in only 33.3% of these patients.

CONCLUSION

MRI shows very low accuracy in the evaluation of mesorectal lymph nodes in patients with rectal cancer. Therefore neoadjuvant therapy should be offered particularly with respect to MRI description of the depth of carcinoma invasion (T-stage and relationship to fascia propria of the rectum).

Using machine learning to predict lymph node metastasis in patients with renal cell carcinoma: A population-based study

Background

Lymph node (LN) metastasis is strongly associated with distant metastasis of renal cell carcinoma (RCC) and indicates an adverse prognosis. Accurate LN-status prediction is essential for individualized treatment of patients with RCC and to help physicians make appropriate surgical decisions. Thus, a prediction model to assess the hazard index of LN metastasis in patients with RCC is needed.

Methods

Partial data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Data of 492 individuals with RCC, collected from the Southwest Hospital in Chongqing, China, were used for external validation. Eight indicators of risk of LN metastasis were screened out. Six machine learning (ML) classifiers were established and tuned, focused on predicting LN metastasis in patients with RCC. The models were integrated with big data analytics and ML algorithms. Based on the optimal model, we developed an online risk calculator and plotted overall survival using Kaplan-Meier analysis.

Results

The extreme gradient-boosting (XGB) model was superior to the other models in both internal and external trials. The area under the curve, accuracy, sensitivity, and specificity were 0.930, 0.857, 0.856, and 0.873, respectively, in the internal test and 0.958, 0.935, 0.769, and 0.944, respectively, in the external test. These parameters show that XGB has an excellent ability for clinical application. The survival analysis showed that patients with predicted N1 tumors had significantly shorter survival (p < 0.0001).

Conclusion

Our study shows that integrating ML algorithms and clinical data can effectively predict LN metastasis in patients with confirmed RCC. Subsequently, a freely available online calculator (https://xinglinyi.shinyapps.io/20221004-app/) was built, based on the XGB model.

Safety and Efficacy of Carbon Nanoparticle-Labeled Lymph Node Dissection in Radical Resection of Gastric Cancer: A Systematic Review and Meta-Analysis

Objective: In this meta-analysis, we investigated the safety and efficacy of carbon nanoparticle (CNP) trace-guided lymph node (LN) dissection during radical gastrectomy. Methods: Literature on CNP tracing compared with non-CNP tracing in radical gastric cancer (GC) surgery was searched from PubMed, EMBASE (Ovid platform), Web of Science, and the Cochrane Library from the establishment of the library until October 2022. This meta-analysis was performed according to the preferred reporting items for systematic reviews and meta-analysis guidelines. Available data regarding the number of LNs dissected, number of metastatic LNs dissected, other surgical outcomes, and postoperative complications were analyzed in a pooled manner. Stata software (version 12.0) was used for the present meta-analysis. Results: This analysis included 7 studies with a total of 1827 GC patients (551 and 1276 in the CNP and non-CNP groups, respectively). The results of the meta-analysis showed that the CNP group had more intraoperative LNs detected [weighted mean difference (WMD) = 6.67, 95% confidence interval (CI): 3.71-9.62], more LN metastases (WMD = 1.60, 95% CI: 0.09-3.12), and less intraoperative bleeding (WMD = 11.33, 95% CI: 6.30-16.37) than the non-CNP group, all with statistically significant differences (P < .05). For postoperative complications (odds ratio [OR] = 0.88, 95% CI: 0.52-1.48) and operative time (WMD = -11.60, 95% CI: -40.53-17.34), there was no statistically significant difference between the 2 groups (P > 0.05). Conclusions: CNP was a significant tracer for the LNs of GC. It increased the number of LNs harvested while reducing intraoperative blood loss, without increasing the operative time or postoperative complications. CNP tracer-guided lymphadenectomy is considered safe and effective for gastrectomy.

Spontaneous regression of an human papillomavirus-positive oropharyngeal squamous cell carcinoma

BACKGROUND

Spontaneous regression (SR) of cancer is an exceedingly rare phenomenon. While SR is well-documented for some cancers, very few reports exist in oropharyngeal squamous cell carcinomas (OPSCCs) and none in human papillomavirus (HPV)-positive OPSCCs.

METHODS

A 67-year old man presented with a left-sided neck mass. Neck CT, PET, and biopsies showed a SCC in a left-sided lymph node without a primary lesion. Immunohistochemistry confirmed HPV16. Six weeks after biopsy, the patient underwent left selective tonsillectomy and neck dissection.

RESULTS

Surgery revealed a left tonsillar SCC and no lymph nodes with tumor. Histology revealed homogenous fibrosis and intermixed immune cells indicative of tumor regression analogous to reports of immune-related pathologic responses. AE1/AE3 immunostain was also negative for tumor. All lymph nodes remained negative at 1 year follow-up.

CONCLUSION

We described a spontaneously regressed lymph node in a tonsillar HPV-positive SCC. The unique immune environment of HPV-positive OPSCCs, and unknown environmental or host factors, may have played a role in our patient's SR which requires future studies to elucidate.

Internal mammary node involvement in patients with axilla-negative early breast cancer: a narrative review

Early breast cancer staging involves radiological and pathological evaluation of the tumour and regional lymph nodes. The internal mammary nodes (IMN) are an important site of possible metastasis and influence disease stage and prognosis. However, the recommendation for routine IMN assessment remains unclear. Internal mammary sentinel lymph node biopsy (SLNB) is associated with increased morbidity and an unknown survival benefit. Furthermore, the IMN are traditionally thought to be involved only synchronous with, or following, axillary node (AXN) metastasis. The aim of this review is to determine the prevalence of IMN metastasis in patients with axilla-negative early breast cancer. A narrative review of studies assessing IMN metastasis was performed. The literature search was completed using the database Medline (Ovid). Twenty-two retrospective studies were identified. The studies included data from SLNB, US, MRI, PET/CT and opportunistic biopsy during free-flap reconstruction (FFR). The prevalence of isolated IMN metastasis ranged from 1.2% to 17.9%.

Myeloid sarcoma incidentally found in lymph nodes dissected for advanced gastric cancer

Myeloid sarcoma (MS) is a condition characterized by a tumor mass of myeloid blasts in any site of the body other than the bone marrow, with or without acute myeloid leukemia. A 93-year-old man underwent laparoscopy-assisted distal gastrectomy with D1 lymphadenectomy for advanced gastric cancer. Other than metastatic foci of gastric cancer cells, some dissected lymph nodes showed destructive architecture with proliferation of small- to medium-sized atypical hematopoietic cells. Those cells were focally positive for naphthol AS-D chloroacetate esterase. Immunohistochemically, positive results were obtained for CD4, CD33, CD68 (KP1), Iba-1, lysozyme, myeloperoxidase, and PU.1, with focally positive results for CD13, CD14, CD68 (PGM1), CD163, and CD204, and negative results for AE1/AE3, CD1a, CD3, CD20, and S-100 protein. These results suggested MS with phenotypically myelomonocytic differentiation. We report a rare case of MS incidentally found in specimens resected for other purposes. Careful diagnosis and consideration of differential diagnoses including MS using an adequate panel of antibody markers for dissected lymph nodes is warranted.

Diagnostic Efficacy of Ultrasonography, Doppler Ultrasonography and Elastography in the Evaluation of Suspected Malignant Lymph Nodes

Aim

In this prospective study, the efficiency of imaging findings was investigated by comparing the histopathological results of lymph nodes with Doppler and ultrasound features and elasticity scores.

Material and method

A total of 100 cervical or axillary lymph nodes with a suspected malignancy or whose size did not decrease after treatment were examined. In addition to the demographic data of the patients, B-mode ultrasound, Doppler ultrasound, and elastography features of the lymph nodes were evaluated prospectively. The irregular shape, increased size, pronounced hypoechogenicity, presence of micro/macro calcification, short axis/long axis ratio >2, increased size of the short axis, increased cortex thickness, obliterated hilus or increased cortex thickness >3.5 mm were evaluated on ultrasound. Resistivity index, pulsatility index, acceleration rate and time were evaluated for intranodal arterial structures on color. Doppler ultrasound, strain ratio value and elasticity score were recorded on ultrasound elastography. After sonographic examination, patients underwent ultrasound-guided fine needle aspiration cytology or tru-cutting needle biopsy. Histopathological examination results of the patients were compared with the B-mode ultrasound, Doppler ultrasound, and ultrasound elastography.

Results

When the individual and combined effects of the ultrasound, Doppler ultrasound, and ultrasound elastography were evaluated, the combination of all three imaging methods was found to have the highest sensitivity and the highest overall accuracy (90.4% and 73.9%). As an individual method Doppler ultrasound had the highest specificity (77.8%). B-mode ultrasound was found to have the lowest accuracy (56.7%) both in individual and combined evaluations.

Conclusion

Addition of ultrasound elastography to the combination of B-mode and Doppler ultrasound findings increases diagnostic sensitivity and accuracy in the differentiation of benign and malignant lymph nodes.

Optimal extent of lymph node dissection in gastric cancer

Gastric cancer still remains a major cause of cancer-related deaths globally. Stage-adapted, individualized treatment is crucial to achieving optimal oncological outcomes. Postoperative morbidity and accurate nodal staging are heavily influenced by the extent of lymph node dissection. On one hand, insufficient lymphadenectomy may result in understaging and undertreatment of a patient, on the other hand, unnecessary lymph node dissection may result in a higher rate of postoperative complications. Approximately one-third of patients with gastric cancer undergoes an avoidable lymph node dissection. Many of the recent treatment updates in the management of gastric cancer have a major influence on both surgical and oncological approaches. Currently, a wide range of endoscopic, minimally invasive, and hybrid surgical techniques are available. The concept of sentinel node biopsy and utilization of the Maruyama Computer Program are significant components of stage-adapted gastric cancer surgery. Likewise, centralization and application of national guidelines, widespread use of neoadjuvant therapy, and the stage migration phenomenon are serious concerns to be discussed. Our goal is to review the available surgical strategies for gastric cancer, with a primary focus on lymphadenectomy.

An unusual pseudolymphoma in the context of necrotizing fasciitis: A case report

RATIONALE

The diagnosis of lymphoma in routine diagnostics can be challenging due to clinical, morphological and immunphenotypical overlap with unusual reactive processes termed "pseudolymphomas."

PATIENT CONCERNS

45-year-old male that underwent surgical debridement for a necrotizing fasciitis of the thigh with concomitant excision of a regional lymph node.

DIAGNOSES

The lymph node demonstrated an architecture-effacing activation and proliferation of lymphoblasts and was initially misdiagnosed as an aggressive lymphoma. Only in consideration of the clinical context and with the help of additional immunohistochemical and molecular analyses the final diagnosis of a reactive lymphadenopathy could be made.

INTERVENTIONS

No further therapy was required after the final diagnosis of a reactive lymphadenopathy was made.

OUTCOMES

The clinical follow-up was unremarkable, with no evidence of residual disease after 6 months.

LESSONS

This case report adds the parafollicular activation and proliferation of blasts and plasmablasts in the drainage area of an active infection to the spectrum of "pseudolymphomas" and reiterizes the importance of placing histopathological findings in the proper context.

Retroperitoneal malignant solitary fibrous tumor with second recurrence and lymphatic metastases: A case report

Malignant solitary fibrous tumor (SFT) in the retroperitoneum is rare. The present study reported on the case of a 67-year-old man who had retroperitoneal SFT for ~13 years, which resulted in two recurrences and lymphatic metastases. After the second recurrence, the patient presented with hematochezia and multiple retroperitoneal masses were found through computed tomography (CT). Histopathological examination showed that the tumor was mainly comprised of short spindle cells, arranged into sparse and dense areas. Mitotic figures were observed, generally 6-8 mitoses/10 high power fields, along with local necrosis. The tumor invaded the circumferential liver, intestines, lymphatic vessels and lymph nodes. Combined with the immunohistochemical results, it was diagnosed as a malignant SFT, which regrew just 2 months after the latest surgery. Retroperitoneal SFTs with repeated relapses, infiltrative growth and lymphatic metastasis suggest the need for careful and long-term follow-up.

Pattern of nodal metastasis of cutaneous squamous cell carcinoma involving the temporal bone

Objective

The objective of this study was to explore the pattern of lymph-node spread of SCCs involving the temporal bone.

Methods

We retrospectively reviewed all cutaneous SCCs involving the temporal bone over a 20-year time-period. Forty-one patients were eligible.

Results

Mean age was 72.8 years. The diagnosis was cutaneous SCC in all cases.All patients underwent a temporal bone resection, 70.7% had a neck-dissection and 78.0% a parotidectomy.Level 2 was the most common area of neck metastasis, and occurred in 12.2%. The parotid had disease in 34.1%. 51.2% of patients underwent free-flap reconstruction.Mean overall survival of the cohort was 4.2 years.

Conclusions

Overall, the rate of cervical nodal metastasis was 22.0% and 13.5% in the occult setting. The parotid was involved in 34.1% and 10.0% in the occult setting. Results from the present study support consideration for performing a parotidectomy at the time of temporal bone resection, while a neck dissection can be performed for adequate staging of the nodal basin.

Level of Evidence

3.

Immunohistochemical Algorithm for the Classification of Muscle-Invasive Urinary Bladder Carcinoma with Lymph Node Metastasis: An Institutional Study

Muscle-invasive urothelial carcinoma represents 20% of newly diagnosed cases of bladder cancer, and most cases show aggressive biological behavior with a poor prognosis. It is necessary to identify biomarkers that can be used as prognostic and predictive factors in daily clinical practice. In our study, we analyzed different antibodies in selected cases of muscle-invasive urinary bladder carcinoma and lymph node metastasis to identify immunohistochemical types and their value as possible prognostic factors. A total of 38 patients were included, 87% men and 13% women, with a mean age of 67.8 years. The most frequent histopathological type was urothelial carcinoma. In the primary lesion, the mixed type was the most common. In unilateral metastasis, the mixed type was the most frequently found. In cases of primary lesions and bilateral metastasis, the luminal and mixed types were observed. The luminal subtype was the most stable in immunohistochemical expression across primary tumors and metastases. The basal type showed a better prognosis in terms of disease-free survival. In conclusion, immunohistochemical studies are useful in assessing primary and metastatic lesions in patients with urothelial carcinoma. Immunohistochemical classification can typify muscle-invasive urothelial carcinoma, and the immunophenotype seems to have prognostic implications.

Diffusion-weighted imaging and apparent diffusion coefficient mapping of head and neck lymph node metastasis: a systematic review

AIM

Head and neck squamous cell cancer (HNSCC) is the ninth most common tumor worldwide. Neck lymph node (LN) status is the major indicator of prognosis in all head and neck cancers, and the early detection of LN involvement is crucial in terms of therapy and prognosis. Diffusion-weighted imaging (DWI) is a non- invasive imaging technique used in magnetic resonance imaging (MRI) to characterize tissues based on the displacement motion of water molecules. This review aims to provide an overview of the current literature concerning quantitative diffusion imaging for LN staging in patients with HNSCC.

METHODS

This systematic review performed a literature search on the PubMed database (https://pubmed.ncbi.nlm.nih.gov/) for all relevant, peer-reviewed literature on the subject following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) criteria, using the keywords: DWI, MRI, head and neck, staging, lymph node.

RESULTS

After excluding reviews, meta-analyses, case reports, and bibliometric studies, 18 relevant papers out of the 567 retrieved were selected for analysis.

CONCLUSIONS

DWI improves the diagnosis, treatment planning, treatment response evaluation, and overall management of patients affected by HNSCC. More robust data to clarify the role of apparent diffusion coefficient (ADC) and DWI parameters are needed to develop models for prognosis and prediction in HNSCC cancer using MRI.

Cytology Smears: An Enhanced Alternative Method for Colorectal Cancer pN Stage-A Multicentre Study

Stage II colorectal cancer (CRC) recurrence remains a clinical problem. Some of these patients are true stage III CRC with a pN0 pathology stage. This large prospective multicentre cohort study aimed at evaluating the diagnostic ability of lymph node (LN) cytology smears to perform the pN stage and compare it with the conventional haematoxylin and eosin (H&E) pathology pN stage. Additionally, we used the One-Step Nucleic Acid Amplification (OSNA), a high-sensitive molecular method of LN staging. A total of 3936 fresh LNs from 217 CRC surgical specimens were examined by three methods, H&E, LN cytology smears, and OSNA. H&E detected 29% of patients with positive LNs, cytology smears 35%, and OSNA 33.2% (p < 0.0001). H&E and cytology concordantly classified 92.2% of tumours, and 88.5% between OSNA and H&E. Cytology had 96.8% sensitivity and 90.3% specificity to discriminate positive/negative patients compared to H&E (p = 0.004), and 87.3% sensitivity and 89% specificity when compared to OSNA (p = 0.56). Patients with positive LNs detected by any of the three methods had significantly worse disease-free and overall survival. We conclude that pN stage accuracy for detecting positive LNs is superior with LN cytological smears than with conventional H&E, which would enable a better pN stage and management of early-stage CRC patients.

Assessment of lymph node metastasis of ≤20 mm non-small cell lung cancer originating from superior segment compared to basal segment

BACKGROUND

Segmentectomy with curative intention is occasionally performed for early non-small cell lung cancer (NSCLC). However, a major problem has been pointed out, in that the rate of locoregional recurrence is higher after segmentectomy than after lobectomy. This study aimed to investigate differences in rates of lymph node metastasis between segment 6 and basal segment NSCLC as potential candidates for segmentectomy and to explore factors associated with locoregional recurrence of segmentectomy.

METHODS

We retrospectively analyzed 461 patients with lower lobe NSCLC who underwent segmentectomy or lobectomy with mediastinal lymph node dissection between 2011 and 2021. Among these, 122 patients with clinical N0 NSCLC, diameter ≤ 20 mm, and consolidation tumor ratio >0.5 were analyzed.

RESULTS

The 122 patients were divided into a segment 6 group (n = 51) and a basal segment group (n = 71). Frequency of lymph node metastasis was significantly higher in the segment 6 group (17.7%) than in the basal segment group (4.2%; p = 0.01). Metastases to lymph node station 7 were seen in five of 122 patients (4.1%). Hilar lymph node metastasis occurred in nine of 122 patients (7.4%). Notably, metastases to station 11, 11i and 11 s lymph nodes were the most frequent patterns for hilar lymph nodes (41.7%).

CONCLUSIONS

Station 11 lymph nodes are adjacent to the remaining lung segment or pulmonary artery in S6 segmentectomy or basal segmentectomy. Part of the NSCLC in segment 6 patients may thus be considered for lobectomy owing to the difficulty of complete dissection of station 11 lymph nodes.

Lymphoid tissue residency: A key to understand Tcf-1+PD-1+ T cells

During chronic antigen exposure, a subset of exhausted CD8+ T cells differentiate into stem cell-like or progenitor-like T cells expressing both transcription factor Tcf-1 (T cell factor-1) and co-inhibitory receptor PD-1. These Tcf-1+ stem-like or progenitor exhausted T cells represent the key target for immunotherapies. Deeper understanding of the biology of Tcf-1+PD-1+ CD8+ T cells will lead to rational design of future immunotherapies. Here, we summarize recent findings about the migratory and resident behavior of Tcf-1+ T cells. Specifically, we will focus on TGF-β-dependent lymphoid tissue residency program of Tcf-1+ T cells, which may represent a key to understanding the differentiation and maintenance of Tcf-1+ stem-like CD8+ T cells during persistent antigen stimulation.

Kimura's disease presenting with intraparotid and neck nodes: A case report and review of literature

Kimura's disease (KD) is a rare chronic inflammatory disorder of unknown etiology. The purpose of this article is to increase the awareness of clinicians regarding KD presenting with intraparotid and neck nodes which can mimic various inflammatory and neoplastic conditions. A 22-year-old man presented with a slow-growing left parotid swelling for 3 years. Ultrasound and computed tomography showed multiple enlarged intraparotid and neck nodes. Fine needle aspiration results showed lymphoid tissue hyperplasia. A diagnosis of KD was based on characteristic histopathological findings after a superficial parotidectomy in conjunction with peripheral eosinophilia. KD should be included in the differential diagnosis especially in young Asian men with slow-growing lesions and peripheral eosinophilia. Cytology by fine needle aspiration is useful to exclude malignancy but the results may be inconclusive. Surgical excision is best for definitive histopathological diagnosis, and has been the mainstay of treatment of KD.

Utility of Whole Body 18F-FDG PET/CT in Comparison to Pelvic MRI in Evaluation of Local Staging of Early-Stage Carcinoma Cervix

OBJECTIVE

This prospective comparative study aimed to investigate the applied value of whole body 2-deoxy-2[fluorine-18]fluoro- D-glucose positron emission tomography integrated with computed tomography (¹⁸F-FDG PET/CT) in comparison to pelvic magnetic resonance imaging (MRI) in early cervical cancer patients.

MATERIAL AND METHODS

A prospective study was performed on 47 clinically early-stage cervical cancer patients evaluated with positron emission tomography/computed tomography (PET/CT) and MRI before surgery. The final postoperative histopathology report served as the reference standard. Both PET/CT and MRI images were analyzed and correlated with histopathologic findings concerning parametrial and lymph node involvement.

RESULTS

Sensitivity, specificity, and negative predictive value (NPV) of PET/CT were 33.3%, 81.8%, and 94.7%, respectively, for parametrium assessment. And the corresponding values of pelvic MRI were 33.3%, 63.6%, and 93.3%, respectively (PET/CT versus MRI, p > 0.05). The positive predictive value (PPV) of PET/CT (11.1%) was higher than MRI (5.9%) for parametrial assessment (p < 0.05). The sensitivity, specificity, PPV, and NPV of PET/CT were 75%, 83.7%, 30%, and 97.3%, respectively, for lymph node assessment. And the corresponding values of MRI were 75%, 81.3%, 27.3%, and 97.2%, respectively (PET/CT versus MRI, p > 0.05). There was no significant difference between MRI and PET/CT concerning stage migration (p = 0.4276).

CONCLUSION

The PET/CT had no additional utility (compared to MRI) in the evaluation of local staging of clinically early cervical carcinoma patients.

Association between fat-infiltrated axillary lymph nodes on screening mammography and cardiometabolic disease

Objective

Ectopic fat deposition within and around organs is a stronger predictor of cardiometabolic disease status than body mass index (BMI). Fat deposition within the lymphatic system is poorly understood. This study examined the association between the prevalence of cardiometabolic disease and ectopic fat deposition within axillary lymph nodes (LNs) visualized on screening mammograms.

Methods

A cross-sectional study was conducted on 834 women presenting for full-field digital screening mammography. The status of fat-infiltrated LNs was assessed based on the size and morphology of axillary LNs from screening mammograms. The prevalence of cardiometabolic disease was retrieved from the electronic medical records, including type 2 diabetes mellitus (T2DM), hypertension, dyslipidemia, high blood glucose, cardiovascular disease, stroke, and non-alcoholic fatty liver disease.

Results

Fat-infiltrated axillary LNs were associated with a high prevalence of T2DM among all women (adjusted odds ratio: 3.92, 95% CI: [2.40, 6.60], p-value < 0.001) and in subgroups of women with and without obesity. Utilizing the status of fatty LNs improved the classification of T2DM status in addition to age and BMI (1.4% improvement in the area under the receiver operating characteristic curve).

Conclusion

Fat-infiltrated axillary LNs visualized on screening mammograms were associated with the prevalence of T2DM. If further validated, fat-infiltrated axillary LNs may represent a novel imaging biomarker of T2DM in women undergoing screening mammography.

Early Pregnancy Modulates Expression of the Nod-like Receptor Family in Lymph Nodes of Ewes

NOD receptors (NLRs) mediate adaptive immune responses and immune tolerance. Nevertheless, it is not clear if gestation modulates the NLR signaling pathway in lymph nodes of ewes. In this study, lymph nodes of ewes were collected at day 16 of the estrous cycle, and at days 13, 16 and 25 of gestation (n = 6 for each group). RT-qPCR, Western blot and immunohistochemistry analysis were used to analyze the expression of the NLR family, including NOD1, NOD2, CIITA, NAIP, NLRP1, NLRP3 and NLRP7. The data showed that early gestation enhanced expression of NOD1, CIITA, NLRP1, NLRP3 and NLRP7 mRNA, as well as proteins at day 16 of gestation, and the expression levels of NOD2, CIITA, NLRP1 and NLRP7 were higher at days 13 and 25 of gestation than day 16 of the estrous cycle. However, NOD1 expression was lower on days 13 and 25 of gestation compared to day 16 of the estrous cycle, and early gestation suppressed NAIP expression. In summary, early pregnancy modulated expression of the NLR family in ovine lymph nodes, which participates in immune regulation, and this modulation may be necessary for pregnancy establishment in ewes.

Postnatal expansion of mesenteric lymph node stromal cells towards reticular and CD34+ stromal cell subsets

Gut-draining mesenteric lymph nodes (LN) provide the framework to shape intestinal adaptive immune responses. Based on the transcriptional signatures established by our previous work, the composition and immunomodulatory function of LN stromal cells (SC) vary according to location. Here, we describe the single-cell composition and development of the SC compartment within mesenteric LNs derived from postnatal to aged mice. We identify CD34⁺ SC and fibroblastic reticular stromal cell (FRC) progenitors as putative progenitors, both supplying the typical rapid postnatal mesenteric LN expansion. We further establish the location-specific chromatin accessibility and DNA methylation landscape of non-endothelial SCs and identify a microbiota-independent core epigenomic signature, showing characteristic differences between SCs from mesenteric and skin-draining peripheral LNs. The epigenomic landscape of SCs points to dynamic expression of Irf3 along the differentiation trajectories of FRCs. Accordingly, a mesenchymal stem cell line acquires a Cxcl9⁺ FRC molecular phenotype upon lentiviral overexpression of Irf3, and the relevance of Irf3 for SC biology is further underscored by the diminished proportion of Ccl19⁺ and Cxcl9⁺ FRCs in LNs of Irf3^-/- mice. Together, our data constitute a comprehensive transcriptional and epigenomic map of mesenteric LNSC development in early life and dissect location-specific, microbiota-independent properties of non-endothelial SCs.

Clockwise Anterior-to-Posterior-Double Isolation (CAP-DI) Approach for Portal Lymphadenectomy in Biliary Tract Cancer: Technique, Yield, and Outcomes

Background: Portal lymphadenectomy (PLND) is the current standard for oncologic resection of biliary tract cancers (BTCs). However, published data show it is performed infrequently and often yields less than the recommended 6 lymph nodes. We sought to identify yield and outcomes using a Clockwise Anterior-to-Posterior technique with Double Isolation of critical structures (CAP-DI) for PLND. Methods: Consecutive patients undergoing complete PLND for BTCs using CAP-DI technique were identified (2015−2021). Lymph node (LN) yield and predictors of LN count were examined. Secondary outcomes included intraoperative and postoperative outcomes, which were compared to patients having hepatectomy without PLND. Results: In total, 534 patients were included; 71 with complete PLND (36 gallbladder cancers, 24 intrahepatic cholangiocarcinomas, 11 perihilar cholangiocarcinomas) and 463 in the control group. The median PLND yield was 5 (IQR 3−8; range 0−17) and 46% had at least 6 nodes retrieved. Older age was associated with lower likelihood of ≥6 node PLND yield (p = 0.032), which remained significant in bivariate analyses with other covariates (p < 0.05). After adjustment for operative factors, performance of complete PLND was independently associated with longer operative time (+46.4 min, p = 0.001), but no differences were observed in intraoperative or postoperative outcomes compared to the control group (p > 0.05). Conclusions: Yield following PLND frequently falls below the recommended minimum threshold of 6 nodes despite a standardized stepwise approach to complete clearance. Older age may be weakly associated with lower PLND yield. While all efforts should be made for complete node retrieval, failure to obtain 6 nodes may be an unrealistic metric of surgical quality.

Assessing Whether Morphological Changes in Axillary Lymph Node Have Already Occurred Prior to Metastasis in Breast Cancer Patients by Ultrasound

Background and Objectives: Whether the morphological changes in axillary lymph node (ALN) have occurred prior to metastasis remains unclear in breast cancer (BC) patients. The aim of this study is to investigate the influence of BC for the morphology of non-metastasis ALN (N−) and, further, to improve the performance of ultrasound (US) examination for metastasis ALN (N+). Materials and Methods: In this retrospective study, 653 patients with breast mass were enrolled and divided into normal group of 202 patients with benign breast tumor, N− group of 233 BC patients with negative ALN and N+ group of 218 BC patients with positive ALN. US features of ALN were evaluated and analyzed according to long (L) and short (S) diameter, the (L/S) axis ratio, cortical thickness, lymph node edge, replaced hilum and color Doppler flow imaging (CDFI). Results: ALN US features of short diameter, replaced hilum, cortical thickness and CDFI have significant statistical differences in N− group comparing with normal group and N+ group, respectively (p < 0.05). Conclusions: Therefore, BC can affect ALN and lead to US morphological changes whether lymph node metastasis is present, which reduces the sensitivity of axillary US. The combination of US and other examination methods should be applied to improve the diagnostic performance of N+.

Human lymphoid tissue sampling for vaccinology

Long-lived plasma cells (LLPCs) - largely resident in the bone marrow - secrete antibody over months and years, thus maintaining serum antibody concentrations relevant for vaccine-mediated immunity. Little is known regarding factors that can modulate the induction of human LLPC responses in draining lymph node germinal centres, or those that maintain LLPCs in bone marrow niches following vaccination. Here, we review human and non-human primate vaccination studies which incorporate draining lymph node and/or bone marrow aspirate sampling. We emphasise the key contributions these samples can make to improve our understanding of LLPC immunology and guide rational vaccine development. Specifically, we highlight findings related to the impact of vaccine dosing regimens, adjuvant/vaccine platform selection, duration of germinal centre reactions in draining lymph nodes and relevance for timing of tissue sampling, and heterogeneity in bone marrow plasma cell populations. Much of this work has come from recent studies with SARS-CoV-2 vaccine candidates or, with respect to the non-human primate work, HIV vaccine development.

1.5 T MR-Guided Daily Adapted SBRT on Lymph Node Oligometastases from Prostate Cancer

Introduction: The aim of our study was to evaluate the efficacy and toxicity of a daily adaptive MR-guided SBRT on 1.5 T MR-linac in patients affected by lymph node oligometastases from PCa. Materials and Methods: The present study is a prospective observational study conducted in a single institution (protocol n°: MRI/LINAC n. 23748). Patients with oligometastatic lymph nodes from PCa treated with daily adaptive MR-guided SBRT on 1.5 T MR-linac were included in the study. There was a minimum required follow-up of 3 months after SBRT. The primary end-point was local progression-free survival (LPFS). The secondary end-points were: nodal progression-free survival (NPFS), progression-free survival (PFS), and toxicity. Results: A total of 118 lymph node oligometastases from PCa were treated with daily adaptive 1.5 T MR-guided SBRT in 63 oligometastatic patients. Of the patients, 63.5% were oligorecurrent and 36.5% were oligoprogressive. The two-year LPFS was 90.7%. The median NPFS was 22.3 months and the 2-year NPFS was 46.5%. Receiving hormone therapy before SBRT was correlated with a lower NPFS at the multivariate analysis (1 y NPFS 87.1% versus 42.8%; p = 0.002-HR 0.199, 95% CI 0.073-0.549). Furthermore, the oligorecurrent state during ADT was correlated with a lower NPFS than was the oligoprogressive state. The median PFS was 10.3 months and the 2-year PFS was 32.4%. Patients treated with hormone therapy before SBRT had a significantly lower 1-year PFS the others (28% versus 70.4%; p = 0.01-HR 0.259, 95% CI 0.117-0.574). No acute and late toxicities occurred during treatment. Conclusions: The present study is the largest prospective study of 1.5 T lymph node SBRT on MR-linac in patients with PCa. Lymph node SBRT by 1.5 T MR-linac provides high local control rates with an excellent toxicity profile.

The diagnostic utility of ultrasound elastography to differentiate tuberculosis and sarcoidosis during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)

Introduction

Elastography is a non-invasive tool that may allow differentiation between benign and malignant lymph nodes during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). In tuberculosis (TB) endemic areas, clinicoradiological features of mediastinal TB and sarcoidosis often overlap, rendering an accurate diagnosis challenging. There is interest in the identification of modalities to aid in this differentiation. There are currently no published data on the utility of EBUS-elastography in differentiating between TB and sarcoidosis.

Methods

Subjects undergoing EBUS-TBNA were prospectively enrolled, and elastography features were observed. Subjects with definitive diagnosis of TB or sarcoidosis were enrolled. The elastography features recorded included the three-colour classification patterns and strain ratio.

Results

We enrolled 96 subjects with a definitive diagnosis (53 with TB and 43 with sarcoidosis). Of the 27 patients in whom the lymph nodes were classified as type 1 on endobronchial ultrasound elastography colour pattern, 17 had a diagnosis of TB (62.9%), while 10 were sarcoidosis (37%). For type 2 lymph nodes, 20/45 (44.4%) were TB and 25/45 (55.6%) were sarcoidosis. Type 3 lymph nodes were TB in 16/24 (66.7%) and sarcoidosis in 8/24 (33.3%). In classifying type 1 as 'sarcoidosis' and Type 3 as 'tubercular', the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were 48.5%, 55.6%, 66.7%, 37%, and 0.51, respectively. The strain ratio (Median [IQR]) was 1.29 (0.37-5.98) in TB and 2.10 (0.83-4.52) in sarcoidosis group (P = 0.48).

Conclusion

Ultrasound elastographic lymph node characteristics have a poor diagnostic utility to differentiate between TB and sarcoidosis during EBUS-TBNA.

A roadmap for a comprehensive diagnostic approach to fine needle cytology of lymph node metastases

OBJECTIVE

Fine needle cytology (FNC) is widely used as a first-line procedure in the diagnostic algorithm of lymphadenopathies. In a metastatic setting, a first-line diagnostic approach identifies non-haematopoietic malignancy; however, cytopathologists could also provide a second diagnostic level, identifying the origin of the primary tumour. This paper outlines a comprehensive and practical approach to the cytological diagnosis of lymph node metastases.

METHODS

Cytological diagnoses of lymph node metastases performed over a 10-year period were selected and divided into two groups. The first group, labelled "oncological," comprised patients with a previous history of malignancy; the second group, labelled "naïve," included patients with no relevant history. Pathology records were retrieved to record microscopic findings, namely, background appearance, group architecture, and specific cell features; data from cell block (CB) preparations were also collected.

RESULTS

Overall, 982 cases were selected: 497 cases (50.61%) in the naïve group, and 485 (49.39%) in the oncological group. Overall, a second diagnostic level was achieved in 834/982 cases (84.92%); cases diagnosed as carcinoma not otherwise specified were more frequent in the naïve group than in the oncological group (17.51% vs. 8.04%, P &lt; 0.01). Notably, although CB material was available in only 44.87% of the naïve cases, we were able to achieve a second diagnostic level thanks to the integration of clinical and cytomorphological findings, plus lymph node topography, in 82.49% of the cases.

CONCLUSION

Our results confirmed that in a metastatic setting, FNC can reliably lead to the identification of the origin of the primary tumour.

Incidental Finding of Microfilaria in Lymph Node Cytology: A Case Report

Filariasis is a global public health problem. We routinely examine it in peripheral smears made from samples collected during the night. Though the prevalence is high, microfilariae are rarely found in cytology smears. A lymph node presenting as a filarial nodule is an unusual occurrence. Also, lymph node fine needle aspiration cytology (FNAC) with a finding of microfilariae is uncommon. We would like to report the case of incidental microfilariae finding in a patient who presented with a supraclavicular lymph node mass. The patient presented with a right supraclavicular lymph node mass of size 2 cm × 2 cm and severe fever during the night for six months. The USG-neck region revealed enlarged lymph nodes in the right supraclavicular region. She was provisionally diagnosed as a case of cervical lymph node swelling under evaluation. However, on ultrasound-guided FNAC of the lymph node, microfilariae were found incidentally. In cases where clinical presentations of filariasis are absent, FNAC may aid in the diagnosis of microfilariae in the lymph node.

A predictive model based on site-specific risk factors of recurrence regions in endometrial cancer patients

Objective

This study investigated site-specific differences in clinical factors for recurrence in patients who were newly diagnosed and treated for endometrial cancer. A model for predicting recurrence sites was generated.

Methods

Electronic medical records’ data were retrieved from January 2006 to December 2018 for patients who were diagnosed with endometrial cancer at the National cancer center in Korea. Recurrence sites were classified as local, regional, or distant. We used multinomial logistic regression models that modeled the log-odds for the three recurrence sites relative to non-recurrence as a linear combination of possible risk factors for the recurrence of endometrial cancer.

Results

The data of 611 patients were selected for analysis; there were 20, 12, and 25 cases of local, regional, and distant recurrence, respectively, and 554 patients had no recurrence. High-grade disease was associated with local recurrence; non-endometrioid histology and parametrial invasion were risk factors for regional recurrence; additionally, parametrial invasion and no lymphadenectomy were associated with distant metastasis.

Conclusion

We identified different risk factors specific for each type of recurrence site. Using these risk factors, we suggest that individually tailored adjuvant treatments be introduced for patients.

Axillary Lymphadenopathy as an Initial Presentation of Systemic Amyloidosis: A Case Report and Literature Review

Amyloidosis rarely presents as localized lymphadenopathy. Various studies have elucidated the varied presentation and manifestations of this interesting disease. We reviewed the literature and found 36 cases of primary amyloidosis with lymph node enlargement as a presentation, and 17 of the 36 cases (47%) had systemic involvement on further work up. We describe a patient who presented with an isolated right axillary mass. Clinical examination and radiology were indicative of a lymph node enlargement with no evidence of malignancy in the breasts or lungs. Histopathological examination was indicative of amyloidosis. A further work up including serum, urine biochemistry, cardiac work up, bone marrow examination, and a kidney biopsy revealed systemic amyloidosis. Patient was treated with daratumumab and CyBorD (cyclophosphamide, bortezomib, and dexamethasone) followed by a stem cell transplantation. Patient is in remission for 1 year, at the time of submission of this report. Therefore, we conclude (1) systemic amyloidosis presenting as an isolated lymph node enlargement is rare, (2) a structured systemic work up is imperative for early diagnosis and proper management of amyloidosis, when there is an index of suspicion, and (3) use of novel therapeutic options such as CD38 + antibody (daratumumab) and stem cell transplant have positive impact on disease outcomes.

Comparisons of minimally invasive esophagectomy and open esophagectomy in lymph node metastasis/dissection for thoracic esophageal cancer

BACKGROUND

The study aimed to clarify the characteristics of lymph node metastasis (LNM) and to compare the oncologic outcomes of minimally invasive esophagectomy (MIE) with open esophagectomy (OE) in terms of lymph node dissection (LND) in thoracic esophageal cancer patients.

METHODS

The data from esophageal cancer patients who underwent MIE or OE from January 2016 to January 2019 were retrospectively reviewed. The characteristics of LNM in thoracic esophageal cancer were discussed, and the differences in numbers of LND, LND rate, and LNM rate/degree of upper mediastinum between MIE and OE were compared.

RESULTS

For overall characteristics of LNM in 249 included patients, the highest rate of LNM was found in upper mediastinum, while LNM rate in middle and lower mediastinum, and abdomen increased with the tumor site moving down. The patients were divided into MIE ( n  = 204) and OE groups ( n  = 45). In terms of number of LND, there were significant differences in upper mediastinum between MIE and OE groups (8 [5, 11] vs. 5 [3, 8], P  < 0.001). The comparative analysis of regional lymph node showed there was no significant difference except the subgroup of upper mediastinal 2L and 4L group (3 [1, 5] vs. 0 [0, 2], P  < 0.001 and 0 [0, 2] vs. 0, P  = 0.012, respectively). Meanwhile, there was no significant difference in terms of LND rate except 2L (89.7% [183/204] vs. 71.1% [32/45], P  = 0.001) and 4L (41.2% [84/204] vs . 22.2% [10/45], P  = 0.018) groups. For LNM rate of T3 stage, there was no significant difference between MIE and OE groups, and the comparative analysis of regional lymph node showed that there was no significant difference except 2L group (11.1% [5/45] vs . 38.1% [8/21], P  = 0.025). The LNM degree of OE group was significantly higher than that of MIE group (27.2% [47/173] vs . 7.6% [32/419], P  < 0.001), and the comparative analysis of regional LNM degree showed that there was no significant difference except 2L (34.7% [17/49] vs . 7.7% [13/169], P  < 0.001) and 4L (23.8% [5/21] vs . 3.9% [2/51], P  = 0.031) subgroups.

CONCLUSION

MIE may have an advantage in LND of upper mediastinum 2L and 4L groups, while it was similar to OE in other stations of LND.

An unusual isolated anterior mediastinal lesion

Malignant pleural mesothelioma (MPM) is an infrequent tumour of poor prognosis with a strong association with asbestos exposure. Pleural effusion or thickening is the most common radiological finding. Thoracoscopic biopsy is the diagnostic modality of choice. In our report, we present the case of a career welder who consulted with vocal cord palsy and an atypical anterior mediastinal lesion. An EBUS-TBNA-guided biopsy and a thorough cytological assessment led to an unexpected diagnosis of epithelioid MPM. A localized anterior mediastinal lesion is an extremely infrequent presentation of MPM that deserves clinical recognition.

The Applications and Potential Developments of Ultrasound in Oral Cancer Management

Oral cancer is endemic and causes a great burden in Southern Asia. It is preferably treated by surgery with/without adjuvant radiotherapy (RT) or chemoradiation therapy, depending on the stage of the disease. Close or positive resection margin and cervical lymph node (LN) metastasis are important prognostic factors that have been presented to be related to undesirable locoregional recurrence and poor survival. Ultrasound (US) is a simple, noninvasive, time-saving, and inexpensive diagnostic modality. It can depict soft tissues very clearly without the risk of radiation exposure. Additionally, it is real-time and continuous image is demonstrated during the exam. Furthermore, the clinician can perform US-guided fine needle aspiration (FNA) or core needle biopsy (CNB) at the same time. US with/without US-guided FNA/CNB is reported to be of value in determining tumor thickness (TT), depth of invasion (DOI), and cervical LN metastasis, and in aiding the staging of oral cancer. DOI has a relevant prognostic value as reported in the eighth edition of the American Joint Committee on Cancer staging of oral cancer. In the present review, we describe the clinical applications of US in oral cancer management in different phases and potential applications in the future. In the pretreatment and surgical phase, US can be used to evaluate TT/DOI and surgical margins of oral cancer in vivo and ex vivo. The prediction of a malignant cervical LN (nodal metastasis) by the US-based prediction model can guide the necessity of FNA/CNB and elective neck dissection in clinical early-stage oral cancer. In the posttreatment surveillance phase, US with/without US-guided FNA or CNB is helpful in the detection of nodal persistence or LN recurrence, and can assess the possibility and extent of carotid artery stenosis after irradiation therapy. Both US elastography and US swallowing assessment are potentially helpful to the management of oral cancer.

Synthesis of a Dual-Color Fluorescent Dendrimer for Diagnosis of Cancer Metastasis in Lymph Nodes

Detection of cancer metastasis spread in lymph nodes is important in cancer diagnosis. In this study, a fluorescence imaging probe was designed for the detection of both lymph node and tumor cells using always-ON and activatable fluorescence probes with different colors. Rhodamine B (Rho), a matrix metalloproteinase-2 (MMP-2)-responsive green fluorescence probe, and a tumor-homing peptide were conjugated to a carboxy-terminal dendrimer that readily accumulates in lymph nodes. The activatable green fluorescence signal increased in the presence of MMP-2, which is secreted by tumor cells. Both the always-ON Rho signal and the activatable green fluorescence signal were observed from tumor cells, but only the weak always-ON Rho signal was from immune cells. Thus, this type of dendrimer may be useful for non-invasive imaging to diagnose cancer metastasis in lymph nodes.

Estimation of colon cancer grade and metastatic lymph node involvement using DWI/ADC sequences

BACKGROUND

The potential benefit of neoadjuvant chemotherapy (NAC) in colon cancer is under evaluation. There is a need to improve preoperative non-invasive diagnostics using techniques that provide more accurate staging information in assessing patient eligibility for NAC.

PURPOSE

To investigate the link between the tumor grade (pathohistological confirmed) and the N status (corresponding to lymph node involvement) with apparent diffusion coefficient (ADC) values.

MATERIAL AND METHODS

A total of 17 patients planned for surgical resection had a biopsy confirming colon carcinoma and participated in the study. Abdominal magnetic resonance imaging with diffusion-weighted imaging/ADC sequence was recorded before surgery. The tumor and all visible lymph nodes were manually delineated directly on a grayscale ADC map for every single slice and detected to access the total tumor and summarized lymph node volume. The mean ADC value was further calculated for the mean tumor and mean lymph node values.

RESULTS

Low-grade tumors had a mean ADC equivalent to 1225 ± 170×10^-6 mm²/s, and the coefficient of high-grade tumors was 1444 ± 69×10^-6 mm²/s. The group of patients with positive lymph nodes in operative tissue samples (N+) exhibited lower mean ADC values (1023 ± 142×10^-6 mm²/s) as opposed to the group without metastatic lymph nodes (N-) with ADC values of 1260 ± 231×10^-6 mm²/s.

CONCLUSION

The mean whole-tumor ADC is associated with the histological tumor grade, and the mean ADC value of whole-volume abdominal lymph nodes could assume real nodal infiltration.

Evaluation of the 8th Edition AJCC Staging System for the Clinical Staging of Pancreatic Cancer

The 8th edition of the American Joint Committee on Cancer (AJCC) staging system for pancreatic cancer (PC) has been validated for pathological staging; however, its significance for clinical staging remains uncertain. We validated the prognostic performance and suitability of the current staging system for the clinical staging of PC. We identified 1043 patients from our PC registry who were staged by imaging according to the 8th edition staging system and conducted analysis, including overall survival (OS) comparison. Gradual prognostic stratification according to stage hierarchy yielded significant OS differences between stage groups, except between stage I and II (p = 0.193). A substage comparison revealed no survival differences between IB (T2N0) and IIA (T3N0), which were divided by the T3 criterion only (p = 0.278). A higher N stage had significantly shorter OS than a lower N stage (all pairwise p < 0.05). However, among the 150 patients who received upfront surgery, the pathological stage was more advanced than the clinical stage in 86 (57.3%), mostly due to a false-negative cN0 (70.9%). Our results suggest that the new definition of T3 and the number-based N criteria in the 8th edition AJCC staging system may be not adequate for clinical staging. Establishing separate criteria more suitable for clinical staging should be considered.

Prognostic Value of Porta-Hepatis Lymphadenopathy in Children with Hepatitis A

Background

The present study aimed to investigate the prognostic value of porta-hepatis lymphadenopathy (PHL) in children with hepatitis A virus.

Methods

The present prospective cohort study included 123 pediatric patients with a definite diagnosis of hepatitis A who were divided into two groups based on the presence or absence of PHL in their abdominal ultrasound: Group A included the patients with a porta-hepatis lymph node of >6 mm in diameter, whereas the patients with a porta-hepatis lymph node of <6 mm in diameter were classified in Group B. The patients were also classified based on the presence or absence of para-aortic lymphadenopathy: Group C had bisecting para-aortic lymph nodes, whereas Group D did not have such findings in their ultrasound. Afterward, the groups were compared in laboratory investigation results and hospital stay.

Results

According to our results, Group A (n = 57) was significantly higher in aspartate and alanine aminotransferase and alkaline phosphatase levels compared to Group B (P < 0.05), whereas these two groups were not significantly different in the hospital stay. Furthermore, except bilirubin, all laboratory test results were significantly higher in Group C (n = 3) than in Group D. However, there was no significant correlation between the patients' prognosis with the absence or presence of porta-hepatis or para-aortic lymphadenopathy.

Conclusion

We concluded that there was no significant relationship between porta-hepatis or para-aortic lymphadenopathy and the prognosis of the children with hepatitis A. However, ultrasound findings can help determine the disease severity in pediatric patients with hepatitis A.

Leveraging the Dynamic Immune Environment Triad in Patients with Breast Cancer: Tumour, Lymph Node, and Peripheral Blood

During the anti-tumour response to breast cancer, the primary tumour, the peripheral blood, and the lymph nodes each play unique roles. Immunological features at each site reveal evidence of continuous immune cross-talk between them before, during and after treatment. As such, immune responses to breast cancer are found to be highly dynamic and truly systemic, integrating three distinct immune sites, complex cell-migration highways, as well as the temporal dimension of disease progression and treatment. In this review, we provide a connective summary of the dynamic immune environment triad of breast cancer. It is critical that future studies seek to establish dynamic immune profiles, constituting multiple sites, that capture the systemic immune response to breast cancer and define patient-selection parameters resulting in more significant overall responses and survival rates for breast cancer patients.

Clinical target volume automatic segmentation based on lymph node stations for lung cancer with bulky lump lymph nodes

Background

The lack of standardized delineation of lymph node station in lung cancer radiotherapy leads to nonstandard clinical target volume (CTV) contouring, especially in patients with bulky lump gross target volume lymph nodes (GTVnd). This study defines lymph node region boundaries in radiotherapy for lung cancer and automatically contours lymph node stations based on the International Association for the Study of Lung Cancer (IASLC) lymph node map.

Methods

Computed tomography (CT) scans of 200 patients with small cell lung cancer were collected. The lymph node zone boundaries were defined based on the IASLC lymph node map, with adjustments to meet radiotherapy requirements. Contours of lymph node stations were confirmed by two experienced oncologists. A model (DiUNet) was constructed by incorporating the contours of GTVnd to precisely contour the boundaries. Quantitative evaluation metrics and clinical evaluations were conducted.

Results

The mean 3D Dice similarity coefficient (Dice similarity coefficient) values of DiUNet in most lymph node stations was greater than 0.7, 98.87% of the lymph node station slices are accepted. The mean DiUNet score was not significantly different from that of the man contoured in the evaluation of lymph node stations and CTV.

Conclusion

This is the first study to propose a method that automatically contours lymph node regions station by station based on the IASLC lymph node map with bulky lump GTVnd. Delineation of lymph node stations based on the DiUNet model is a promising strategy to obtain accuracy and efficiency for CTV delineation in lung cancer patients, especially for bulky lump GTVnd.

LPS- and LTA-Induced Expression of TLR4, MyD88, and TNF-α in Lymph Nodes of the Akkaraman and Romanov Lambs

Toll-like receptor (TLR)-mediated inflammatory processes play a critical role in the innate immune response during the initial interaction between the infecting microorganism and immune cells. This study aimed to investigate the possible microanatomical and histological differences in mandibular and bronchial lymph nodes in Akkaraman and Romanov lambs induced by lipopolysaccharide (LPS) and lipoteichoic acid (LTA) and study the gene, protein, and immunoexpression levels of TLR4, myeloid differentiation factor 88 (MyD88), and tumor necrosis factor-α (TNF-α) that are involved in the immune system. Microanatomical examinations demonstrated more intense lymphocyte infiltration in the bronchial lymph nodes of Akkaraman lambs in the LPS and LTA groups compared to Romanov lambs. TLR4, MyD88, and TNF-α immunoreactivities were more intense in the experimental groups of both breeds. Expression levels of MyD88 and TNF-α genes in the bronchial lymph node of Akkaraman lambs were found to increase statistically significantly in the LTA group. TLR4 gene expression level in the mandibular lymph node was found to be statistically significantly higher in the LTA + LPS group. In conclusion, dynamic changes in the immune cell populations involved in response to antigens such as LTA and LPS in the lymph nodes of both breeds can be associated with the difference in the expression level of the TLR4/MyD88/TNF-α genes.

A Malignant Mimicker: Features of Kikuchi-Fujimoto Disease in the Pediatric Population

BACKGROUND

Kikuchi-Fujimoto disease (KFD) is a rare, benign, and self-limited disease that presents with cervical lymphadenopathy and systemic symptoms. Histologic evaluation is often necessary to differentiate KFD from other entities.

METHODS

Electronic medical records and diagnostic material were reviewed for 14 children diagnosed with KFD and 6 children diagnosed with infectious mononucleosis (IM) from 2013-2021. Four cases of KFD were further characterized using targeted DNA-based next-generation sequencing.

RESULTS

Systemic symptoms were present in 86% (n = 12/14) of KFD patients, the most common being fever. Laboratory values worrisome for malignancy included cytopenia(s) (n = 9/12), elevated ESR and/or CRP (n = 9/12), elevated ferritin (n = 7/7), and elevated LDH (n = 7/10). Histologically, lymph nodes showed characteristic necrotic foci without neutrophils surrounded by MPO+ "crescentic" histiocytes. Immunoblasts and CD123+ plasmacytoid dendritic cells (pDCs) were also increased surrounding the necrosis. IM lymph nodes showed similar features when necrosis was present but increases in pDCs were patchy and rare neutrophils were seen in the necrotic foci. Molecular analysis of 4 KFD cases did not identify pathogenic variants.

CONCLUSION

While the signs/symptoms of KFD are worrisome, there are pathologic features that help differentiate it from potential mimics. We did not identify characteristic molecular features to aid in the work-up of these cases.

High endothelial venules as potential gateways for therapeutics

High endothelial venules (HEVs) are specialized blood vessels that support the migration of lymphocytes from the bloodstream into lymph nodes (LNs). They are also formed ectopically in mammalian organs affected by chronic inflammation and cancer. The recent arrival of immunotherapy at the forefront of many cancer treatment regimens could boost a crucial role for HEVs as gateways for the treatment of cancer. In this review, we describe the microanatomical and biochemical characteristics of HEVs, mechanisms of formation of newly made HEVs, immunotherapies potentially dependent on HEV-mediated T cell homing to tumors, and finally, how HEV-targeted therapies might be used as a complementary approach to potentially shape the therapeutic landscape for the treatment of cancer and immune-mediated diseases.

ADC Values of Cytologically Benign and Cytologically Malignant 18 F-FDG PET-Positive Lymph Nodes of Head and Neck Squamous Cell Carcinoma

Simple Summary

In squamous cell carcinoma of the head and neck, 18F-fluordeoxyglucose positron emission tomography (FDG-PET), diffusion-weighted magnetic resonance imaging (DW-MRI) and ultrasound-guided fine needle aspiration are commonly used imaging tools for nodal staging (N-staging). Although FDG-PET has good performance in nodal detection, it is still difficult to distinguish between PET-positive reactive and malignant nodes for the purpose of selecting nodes to be aspirated. DW-MRI can help to detect small lymph node metastases, and an inverse correlation with FDG uptake is expected. We found a mild negative correlation between SUVmax and ADC. Comparing the apparent diffusion coefficient (ADC) values between PET-positive and PET-negative nodes, ADC was significantly higher in PET-negative nodes. Whereas no significantly lower ADC value of cytological malignant nodes could be found overall, in the subgroup of non-HPV-related nodes, the ADC values of cytologically malignant PET-positive nodes were significantly lower than in cytologically benign nodes. This finding might be helpful in selecting nodes for puncture.

Abstract

Nodal staging (N-staging) in head and neck squamous cell carcinoma (HNSCC) is essential for treatment planning and prognosis. 18F-fluordeoxyglucose positron emission tomography (FDG-PET) has high performance for N-staging, although the distinction between cytologically malignant and reactive PET-positive nodes, and consequently, the selection of nodes for ultrasound-guided fine needle aspiration cytology (USgFNAC), is challenging. Diffusion-weighted magnetic resonance imaging (DW-MRI) can help to detect nodal metastases. We aim to investigate the potential of the apparent diffusion coefficient (ADC) as a metric to distinguish between cytologically reactive and malignant PET-positive nodes in order to improve node selection criteria for USgFNAC. PET-CT, real-time image-fused USgFNAC and DW-MRI to calculate ADC were available for 78 patients offered for routine N-staging. For 167 FDG-positive nodes, differences in the ADC between cytologically benign and malignant PET-positive nodes were evaluated, and both were compared to the ADC values of PET-negative reference nodes. Analyses were also performed in subsets of nodes regarding HPV status. A mild negative correlation between SUVmax and ADC was found. No significant differences in ADC values were observed between cytologically malignant and benign PET-positive nodes overall. Within the subset of non-HPV-related nodes, ADC_b0-200-1000 was significantly lower in cytologically malignant PET-positive nodes when compared to benign PET-positive nodes. ADC_b0-1000 and ADCb_0-200-1000 were significantly lower (p = 0.018, 0.016, resp.) in PET-negative reference nodes than in PET-positive nodes. ADC was significantly higher in PET-negative reference nodes than in PET-positive nodes. The non-HPV-related subgroup showed significantly (p = 0.03) lower ADC values in cytologically malignant than in cytologically benign PET-positive nodes, which should help inform the node selection procedure for puncture.

Spatial delivery of immune cues to lymph nodes to define therapeutic outcomes in cancer vaccination

Recently approved cancer immunotherapies - including CAR-T cells and cancer vaccination, - show great promise. However, these technologies are hindered by the complexity and cost of isolating and engineering patient cells ex vivo. Lymph nodes (LNs) are key tissues that integrate immune signals to coordinate adaptive immunity. Directly controlling the signals and local environment in LNs could enable potent and safe immunotherapies without cell isolation, engineering, and reinfusion. Here we employ intra-LN (i.LN.) injection of immune signal-loaded biomaterial depots to directly control cancer vaccine deposition, revealing how the combination and geographic distribution of signals in and between LNs impact anti-tumor response. We show in healthy and diseased mice that relative proximity of antigen and adjuvant in LNs - and to tumors - defines unique local and systemic characteristics of innate and adaptive response. These factors ultimately control survival in mouse models of lymphoma and melanoma. Of note, with appropriate geographic signal distributions, a single i.LN. vaccine treatment confers near-complete survival to tumor challenge and re-challenge 100 days later, without additional treatments. These data inform design criteria for immunotherapies that leverage biomaterials for loco-regional LN therapy to generate responses that are systemic and specific, without systemically exposing patients to potent or immunotoxic drugs.

Lymph-derived chemokines direct early neutrophil infiltration in the lymph nodes upon Staphylococcus aureus skin infection

A large number of neutrophils infiltrate the lymph node (LN) within 4 h after Staphylococcus aureus skin infection (4 h postinfection [hpi]) and prevent systemic S. aureus dissemination. It is not clear how infection in the skin can remotely and effectively recruit neutrophils to the LN. Here, we found that lymphatic vessel occlusion substantially reduced neutrophil recruitment to the LN. Lymphatic vessels effectively transported bacteria and proinflammatory chemokines (i.e., Chemokine [C-X-C motif] motif 1 [CXCL1] and CXCL2) to the LN. However, in the absence of lymph flow, S. aureus alone in the LN was insufficient to recruit neutrophils to the LN at 4 hpi. Instead, lymph flow facilitated the earliest neutrophil recruitment to the LN by delivering chemokines (i.e., CXCL1, CXCL2) from the site of infection. Lymphatic dysfunction is often found during inflammation. During oxazolone (OX)-induced skin inflammation, CXCL1/2 in the LN was reduced after infection. The interrupted LN conduits further disrupted the flow of lymph and impeded its communication with high endothelial venules (HEVs), resulting in impaired neutrophil migration. The impaired neutrophil interaction with bacteria contributed to persistent infection in the LN. Our studies showed that both the flow of lymph from lymphatic vessels to the LN and the distribution of lymph in the LN are critical to ensure optimal neutrophil migration and timely innate immune protection in S. aureus infection.

Reevaluation of regional lymph nodes in patients with pancreatic ductal adenocarcinoma in the pancreatic body and tail

Introduction

In patients with pancreatic ductal adenocarcinoma (PDAC) in the pancreatic body (Pb) and tail (Pt), the appropriate area for lymphadenectomy is controversial. This study aimed to reevaluate the extent of lymph node (LN) metastasis in Pb- and Pt-PDAC, and to define the optimal area of LN dissection.

Patients and methods

This single-center retrospective study evaluated patients with Pb- and Pt-PDAC who underwent distal pancreatectomy with extended lymphadenectomy between 2006 and 2020. LN metastasis in >3.0% of patients were defined as new regional LN.

Results

The study cohort included 135 patients with Pb-PDAC and 42 patients with Pt-PDAC. In patients with Pb-PDAC, LNs around the splenic artery (SPA) had the highest metastasis-positive rate (54.1%). LNs along the left gastric artery, common hepatic artery, celiac axis (CA), superior mesenteric artery (SMA), and splenic hilus were defined as new regional LNs. In patients with Pt-PDAC, LNs at the splenic hilum had the highest metastasis-positive rate (38.1%). The station and LN around the SPA were defined as new regional LNs in those with Pt-PDAC. Metastasis beyond the newly defined regional LNs was not associated with survival. The incidence of LN metastasis was lower in patients who received preoperative chemotherapy than in those who underwent upfront surgery in both Pb- and Pt-PDAC.

Conclusion

Although it needs to be verified in future multicenter studies, LN of both the CA and SMA systems should be dissected in patients with Pb-PDAC. However, only those around the SPA and splenic hilus should be dissected routinely in those with Pt-PDAC.

Lymph node homeostasis and adaptation to immune challenge resolved by fibroblast network mechanics

Emergent physical properties of tissues are not readily understood by reductionist studies of their constituent cells. Here, we show molecular signals controlling cellular, physical, and structural properties and collectively determine tissue mechanics of lymph nodes, an immunologically relevant adult tissue. Lymph nodes paradoxically maintain robust tissue architecture in homeostasis yet are continually poised for extensive expansion upon immune challenge. We find that in murine models of immune challenge, cytoskeletal mechanics of a cellular meshwork of fibroblasts determine tissue tension independently of extracellular matrix scaffolds. We determine that C-type lectin-like receptor 2 (CLEC-2)-podoplanin signaling regulates the cell surface mechanics of fibroblasts, providing a mechanically sensitive pathway to regulate lymph node remodeling. Perturbation of fibroblast mechanics through genetic deletion of podoplanin attenuates T cell activation. We find that increased tissue tension through the fibroblastic stromal meshwork is required to trigger the initiation of fibroblast proliferation and restore homeostatic cellular ratios and tissue structure through lymph node expansion.

Primary Osseous Leiomyosarcoma with Vertebral and Nodal Metastasis in a Young Woman: A Rare Case Report

Introduction. Primary leiomyosarcoma of bone is rarely described in the literature. In young patients, the clinical and radiological features may mimic relatively common tumours like osteosarcoma. Vertebral and nodal metastasis from osseous leiomyosarcoma is extremely uncommon. Case presentation. A 25-year-old female presented with progressively increasing pain and swelling of the right knee. Clinical and radiological features were suggestive of osteosarcoma. Pre-operative biopsy showed a malignant spindle cell tumour. The surgical resection specimen showed features of leiomyosarcoma of the right proximal tibia. On further evaluation, the patient was found to have an L3-L4 vertebral lesion and histopathological evaluation showed a similar tumour. After 11 months of initial presentation, the patient had axillary lymph node metastasis. Conclusion. Primary osseous leiomyosarcoma should be considered as a differential diagnosis even in young patients presenting with meta-diaphyseal expansile malignant bony lesions. Histology and ancillary studies can confirm the diagnosis.

L1CAM Expression in Microcystic, Elongated, and Fragmented (MELF) Glands Predicts Lymph Node Involvement in Endometrial Carcinoma

In endometrial carcinoma, both L1CAM overexpression and microcystic, elongated and fragmented (MELF) patterns of invasion have been related to epithelial-to-mesenchymal transition and metastatic spread. We aimed to assess the association between L1CAM expression, the MELF pattern, and lymph node status in endometrial carcinoma. Consecutive cases of endometrial carcinoma with MELF pattern were immunohistochemically assessed for L1CAM. Inclusion criteria were endometrioid-type, low-grade, stage T1, and known lymph node status. Uni- and multivariate logistic regression were used to assess the association of L1CAM expression with lymph node status. Fifty-eight cases were included. Most cases showed deep myometrial invasion (n = 42, 72.4%) and substantial lymphovascular space invasion (n = 34, 58.6%). All cases were p53-wild-type; 17 (29.3%) were mismatch repair-deficient. Twenty cases (34.5%) had positive nodes. No cases showed L1CAM positivity in ≥10% of the whole tumor. MELF glands expressed L1CAM at least focally in 38 cases (65.5%). L1CAM positivity in ≥10% of the MELF component was found in 24 cases (41.4%) and was the only significant predictor of lymph node involvement in both univariate (p < 0.001) and multivariate analysis (p < 0.001). In conclusion, L1CAM might be involved in the development of the MELF pattern. In uterine-confined, low-grade endometrioid carcinomas, L1CAM overexpression in MELF glands may predict lymph node involvement.

Fluorescent Tracers for In Vivo Imaging of Lymphatic Targets

The lymphatic system continues to gain importance in a range of conditions, and therefore, imaging of lymphatic vessels is becoming more widespread for research, diagnosis, and treatment. Fluorescent lymphatic imaging offers advantages over other methods in that it is affordable, has higher resolution, and does not require radiation exposure. However, because the lymphatic system is a one-way drainage system, the successful delivery of fluorescent tracers to lymphatic vessels represents a unique challenge. Each fluorescent tracer used for lymphatic imaging has distinct characteristics, including size, shape, charge, weight, conjugates, excitation/emission wavelength, stability, and quantum yield. These characteristics in combination with the properties of the target tissue affect the uptake of the dye into lymphatic vessels and the fluorescence quality. Here, we review the characteristics of visible wavelength and near-infrared fluorescent tracers used for in vivo lymphatic imaging and describe the various techniques used to specifically target them to lymphatic vessels for high-quality lymphatic imaging in both clinical and pre-clinical applications. We also discuss potential areas of future research to improve the lymphatic fluorescent tracer design.