Paracardiac adenopathy: CT evaluation

What are the implications of radiologically abnormal cardiophrenic lymph nodes in advanced ovarian cancer? An analysis of tumour burden, surgical complexity, same-site recurrence and overall survival

INTRODUCTION

Our paper evaluates the relationship between radiologically abnormal cardiophrenic lymph nodes (CPLN) in advanced ovarian cancer and pattern of disease distribution, tumour burden, surgical complexity, rates of cytoreduction and same-site recurrence. Impact of suspicious CPLN and CPLN dissection on overall survival also determined.

MATERIALS AND METHODS

Retrospective review of index CT imaging for 151 consecutive patients treated for stage III/IV ovarian malignancy in a large UK cancer centre to identify radiologically abnormal CPLN. Corresponding surgical, histo-pathological and survival data analysed.

RESULTS

42.6% of patients had radiologically 'positive' CPLN on index CT. Radiological identification of CPLN involvement demonstrated a sensitivity of 82% within our centre. Patients with cardiophrenic lymphadenopathy on pre-operative CT had significantly more co-existing ascites (p = 0.003), omental (p = 0.01) and diaphragmatic disease (p < 0.0001). At primary debulking (PDS), suspicious CPLN were associated with significantly higher surgical complexity scores, without feasibility of complete cytoreduction being impacted. Cardiophrenic involvement at initial diagnosis was associated with same-site relapse at recurrence (p = 0.001). No significant difference in overall survival was demonstrated according to CPLN status following either PDS or delayed debulking (DDS). CPLN dissection did not improve patient outcomes.

CONCLUSION

Radiological identification of abnormal CPLN is reliable. Suspicious CPLN appear to represent a surrogate marker of tumour volume - in particular, heralding upper abdominal disease - and should prompt anticipation of high complexity surgery and referral to an appropriate centre. Patients with prior CPLN involvement are more likely to develop same-site recurrence at relapse. Our survival data suggests cardiophrenic LN disease does not worsen patient prognosis and that the therapeutic benefit of CPLN dissection remains unclear.

Enlarged cardiophrenic lymph nodes predict disease involvement of the upper abdomen and the outcome of primary surgical debulking in advanced ovarian cancer

INTRODUCTION

The outcome of ovarian cancer patients is highly dependent on the success of primary debulking surgery in terms of postoperative residual disease. This study critically evaluates the clinical impact of preoperative radiologic assessment of the cardiophrenic lymph node (CPLN) status in advanced ovarian cancer.

MATERIAL AND METHODS

Baseline CT scans of 178 stage III and IV ovarian cancer patients were retrospectively reviewed by two independent radiologists. CPLN enlargement defined at a short-axis ≥5 mm was evaluated for its prognostic value and predictive power of upper abdominal tumor involvement and the chance of complete intra-abdominal tumor resection at primary debulking surgery. Only patients without surgically removed CPLN were eligible for this study.

RESULTS

Enlarged CPLNs were detected in 50% of patients and correlated with radiologically suspicious (P = .028) and histologically confirmed (P = .001) paraaortic lymph node metastases. CPLNs ≥ 5 mm were associated with high CA-125 levels at baseline and revealed independent prognostic relevance for progression-free survival (hazard ratio [HR] 2.14, 95% confidence interval [CI] 1.33-3.42) and overall survival (HR 2.18, 95% CI 1.16-4.08). Noteworthy, patients with enlarged CPLNs nonetheless benefit from complete intra-abdominal tumor debulking in terms of an improvement in progression-free survival (HR 0.60, 95% CI 0.38-0.94) and overall survival (HR 0.59, 95% CI 0.35-0.82). Enlarged CPLNs correctly predicted carcinomatosis of the upper abdomen in 94.6%. A predictive score of complete tumor debulking, termed CD-score, which integrates, beside a CPLN short axis <5 mm, an ascites volume <500 mL, and CA-125 levels <500 U/mL at baseline, correctly predicted complete intra-abdominal debulking in 100% of patients.

CONCLUSIONS

CPLNs ≥5 mm predict upper abdominal tumor involvement. The application of the CD-score predicted complete macroscopic tumor resection at primary surgery in all of the patients. Although, CPLN pathology suggests extra-abdominal disease, we consistently demonstrated that patients nonetheless benefit from complete intra-abdominal tumor resection.

Omitting cardiophrenic lymph nodes in the treatment of patients with Hodgkin lymphoma via modified involved-site radiation therapy

Cardiophrenic lymph nodes (CPLNs) are occasionally involved in Hodgkin lymphoma (HL). We characterized the incidence of CPLN involvement among 169 HL patients and evaluated outcomes after treatment with omission of the CPLN region from the involved-site radiation therapy (ISRT) field. Three types of RT fields were used: standard (S)-ISRT, reduced-dose (RD)-ISRT (lower dose to CPLNs, standard to other sites), or modified (M)-ISRT (omission of CPLNs). CPLNs were involved at diagnosis in 29 patients (17%). Of the 20 patients who received RT after complete response to chemotherapy, 4(20%) received S-ISRT, 8(40%) RD-ISRT, and 8(40%) M-ISRT. The four-year progression-free survival was 94.7%. One relapse occurred at a non-CPLN site after RD-ISRT. The mean heart dose and volume of the heart that received 25 Gy was higher for S-ISRT patients compared to M-ISRT (p = .043 and p = .025, respectively). Re-planning the M-ISRT cases as S-ISRT resulted in significant increase in cardiac doses.

Detection of Metastatic Disease in Cardiophrenic Lymph Nodes: FDG PET/CT Versus Contrast-Enhanced CT and Implications for Staging and Treatment of Disease

OBJECTIVE

To determine whether FDG PET/CT was more sensitive than CT in detecting metastatic disease in the cardiophrenic space and whether the presence of disease in this location would change the staging and clinical management.

MATERIALS AND METHODS

About 1200 PET/CT scans were retrospectively reviewed over 20 months for the presence of FDG-avid cardiophrenic lymph nodes. The SUVmax was used to quantify the metabolic activity in each of the lymph nodes. The radiographic data was used for correlation. A retrospective review of diagnostic CT reports performed within a 1-month period of time of the PET/CT in the same subset of patients determined whether cardiophrenic lymph nodes were mentioned.

RESULTS

About 9 (0.8%) of the 1200 studies were found to have FDG-avid cardiophrenic lymph nodes (four males and five females with a mean age of 55 years; range 7-69, median 59). The mean SUVmax was 2.4 (range 1.2-7.9; median 1.9). Only three of the patients were found to have suspicious lymph nodes on CT. The presence of cardiophrenic lymph nodes had the potential to change the staging and/or management in three of the patients.

CONCLUSION

PET/CT is more accurate in the detection of pathologic cardiophrenic lymph nodes than CT, especially when they are subcentimeter in size. When present, staging and/or management was potentially affected in 33%. Therefore, these nodes should be included in the TNM staging classification.

Prognostic significance of visible cardiophrenic angle lymph nodes in the presence of peritoneal metastases from colorectal cancers

BACKGROUND

Visible cardiophrenic angle lymph nodes (CPALN) (enlarged or not), detected on CT scan are correlated with the presence of peritoneal metastases (PM), and contribute to the diagnosis of PM in colorectal cancer patients.

OBJECTIVE

To study whether visible CPALN exert a prognostic impact on survival after complete cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CCRS + HIPEC) treating PM.

PATIENTS AND METHODS

From 1999 to 2010, 114 patients with colorectal cancer and PM were treated with CCRS + HIPEC. CPALN were depicted in 64% of cases. The impact of visible CPALN on survival was investigated retrospectively.

RESULTS

The mean peritoneal cancer index (PCI) score was 9.2, 21% of the patients had presented with associated liver metastases, and 71% of the women with ovarian metastases. Median follow-up was 3.9 years. Visible CPALN had no impact on OS nor on DFS, unlike the PCI score which was unequivocably the most potent prognostic factor in the multivariate analysis.

CONCLUSION

Although some arguments might suggest that CPALN are malignant, paradoxically, we found that visible CPALN did not exert a positive nor a negative impact on survival after CCRS + HIPEC.

SYNOPSIS

Visible cardiophrenic angle lymph nodes (CPALN) on CT-scan are strongly associated with the presence of peritoneal metastases. But this study demonstrates that the presence of CPALN has no prognostic impact after optimal cytoreductive surgery plus HIPEC.

Computed tomography and magnetic resonance imaging of the thoracic lymphatic system

Several radiographic diagnostic techniques are currently available to assess the potential involvement of mediastinal lymph nodes in thoracic oncology. In particular, computed tomography and magnetic resonance imaging have been repeatedly validated; these techniques allow adequate imaging with a reasonable accuracy. The morphologic information provided by these techniques is crucial to stage lung cancer and plan treatment. These techniques are also extremely useful to evaluate other disorders and differentiate malignancy from benign disease.

How to differentiate benign versus malignant cardiac and paracardiac 18F FDG uptake at oncologic PET/CT

Patients undergoing 2-[fluorine 18]fluoro-2-deoxy-d-glucose (FDG) whole-body oncologic positron emission tomography (PET)/computed tomography (CT) are studied while fasting. Cardiac FDG uptake in fasted patients has been widely reported as variable. It is important to understand the normal patterns of cardiac FDG activity that can be seen in oncologic FDG PET/CT studies. These include focal and regional patterns of increased FDG myocardial activity. Focal activity can be observed in papillary muscles, the atria, the base, and the distal anteroapical region of the left ventricle. Regional increased cardiac FDG activity may be diffuse or localized in the posterolateral wall or the base of the left ventricle. Abnormal patterns of cardiac FDG activity not related to malignancy include those associated with lipomatous hypertrophy of the interatrial septum, epicardial and pericardial fat, increased atrial activity associated with atrial fibrillation or a prominent crista terminalis, cardiac sarcoidosis, endocarditis, myocarditis, and pericarditis. Knowledge of these patterns of cardiac FDG activity is important to be able to recognize malignant disease involving the paracardiac spaces, myocardium, and pericardium. With a better understanding of the range of normal and abnormal patterns of cardiac FDG activity, important benign and malignant diseases involving the heart and pericardium can be recognized and diagnosed.

Prognostic Significance of Supradiaphragmatic Lymphadenopathy Identified on Preoperative Computed Tomography Scan in Patients Undergoing Primary Cytoreduction for Advanced Epithelial Ovarian Cancer

Introduction:

It has been hypothesized that the supradiaphragmatic lymph nodes serve as the principal nodes for lymphatic drainage of the entire peritoneal cavity. The purpose of this study was to determine the prognostic significance of enlarged supradiaphragmatic nodes noted on preoperative computed tomographic (CT) scan in patients undergoing primary cytoreduction for advanced epithelial ovarian cancer (EOC).

Methods:

We performed a retrospective chart review of all patients with stage III and IV EOC according to the International Federation of Gynecology and Obstetrics who had preoperative CT scans, including the supradiaphragmatic region, and had undergone primary cytoreductive surgery at our institution between January 1997 and June 2004. Scans were retrospectively reviewed by a radiologist. We defined supradiaphragmatic adenopathy as nodes measuring greater than 5 mm on the largest of 2 perpendicular measurements on the CT scan. The Fisher exact test was used to compare proportions. Kaplan-Meier curves and log-rank tests were used for the survival analyses.

Results:

A total of 212 evaluable patients were identified. All underwent attempted primary cytoreduction followed by systemic chemotherapy. None had any supradiaphragmatic nodes removed at primary cytoreduction. With a median follow-up time of 52 months, median overall survival for the entire cohort was 48 months. Of 212 patients, 92 (43%) had supradiaphragmatic adenopathy. Median survival was 50 months for patients without adenopathy and 45 months for patients with adenopathy (P = 0.09). Of the 212 patients, 155 (73%) underwent optimal cytoreduction. In these patients, median survival was 55 months for the 91 without adenopathy and 50 months for the 64 patients with supradiaphragmatic adenopathy (P = 0.09).

Conclusions:

We observed a trend toward worse survival in patients with enlarged supradiaphragmatic nodes. The prognostic impact of supradiaphragmatic adenopathy remains uncertain and deserves further study.

The significance of paracardiac lymph node enlargement in ovarian cancer

The computed tomography (CT) scans of 78 patients with stage II, stage III and relapsed stage I ovarian carcinoma were reviewed in order to identify the incidence of enlarged paracardiac lymph nodes in this disease, recognize their association, if any, with peritoneal metastases and establish whether they had any bearing on progression free interval and survival. Twenty-two patients (28%) were found to have enlarged paracardiac nodes, nine at initial presentation and a further 13 during the course of follow-up. The association between paracardiac node enlargement and peritoneal metastases was found to be highly significant. Thirty per cent of 27 patients with peritoneal metastases at presentation were found to have enlarged paracardiac nodes whereas of the 51 patients without peritoneal dissemination only 2% had enlarged paracardiac nodes (P < 0.001). In order to determine whether paracardiac nodal status had any independent prognostic value, multivariate analysis using Cox's regression was performed. When status at presentation was considered, the presence of enlarged paracardiac lymph nodes was found to be an independent predictor for survival. (Hazard ratio 3.70, 95% confidence interval (1.18-11.6), P < 0.04.) The hazard ratio for paracardiac nodal status with respect to progression free survival was not significant but in the expected direction. (Hazard ratio 1.85 (0.65-5.25).) When time-dependent covariate analysis was applied, paracardiac nodal status and peritoneal metastases status were found to be independent predictors for both progression free survival and overall survival. The presence of peritoneal metastases indicated a poorer prognosis than the presence of paracardiac lymph nodes, the hazards ratios for progression free survival were 12.9 and 2.58, respectively, and those for survival were 20.7 and 3.62, respectively. We have demonstrated that the presence of paracardiac lymph node enlargement is a significant adverse prognostic factor for both progression free interval and survival. The diagnosis of involved paracardiac lymph nodes is important as it can define patients having stage IV as opposed to stage III disease.

The association of paracardial adenopathy with hepatic metastasis found on CT arterial portography

BACKGROUND

The association of paracardial lymphadenopathy with hepatic metastases in patients undergoing computed tomographic arterial portography (CTAP) prior to possible resection of hepatic metastases is documented.

METHODS

CTAP was performed on 45 patients with hepatic metastasis, including 30 with colorectal carcinoma, using 1 cm increments from the dome of the diaphragm through the liver. Two radiologists, blinded to the diagnosis and surgical results, reviewed all portograms and identified all paracardial lymph nodes larger than 8 cm.

RESULTS

Enlarged paracardial lymph nodes were found in three of the 30 colorectal carcinoma patients and two of the remaining 15 patients. All three colorectal patients with paracardial lymphadenopathy demonstrated massive metastatic involvement of the anterior segment of the right hepatic lobe (segment 8: Couinaud nomenclature). Additional metastasis in the superior aspect of the liver was seen in two of these patients as well. Both patients without colorectal carcinoma with paracardial lymphadenopathy had metastasis involving the superior aspect of the liver. Paracardial lymphadenopathy was right-sided in all five patients and bilateral in one. By contrast, 48% (19 of 40) of patients without enlarged paracardial lymph nodes had metastasis in the anterior segment of the right lobe.

CONCLUSIONS

This study suggests that paracardial lymphadenopathy is associated with metastatic disease to specific areas within the liver. This nodal involvement can be attributed to lymphatic drainage from the diaphragmatic surface of the liver.

Cascade of metastatic colorectal carcinoma from the liver to the anterior diaphragmatic lymph nodes

RATIONALE AND OBJECTIVES

Metastases of colon carcinoma from the liver to porta hepatis and celiac axis lymph nodes constitute a contraindication to hepatic metastatic resection. Our objective was to determine the frequency of anterior diaphragmatic lymph node (ADLN) enlargement, another efferent pathway of hepatic lymphatic drainage, in patients with colon carcinoma.

METHODS

Abdominal computed tomography scans from 50 patients with colon carcinoma in whom hepatic metastases were either present (n = 25) or absent (n = 25) were reviewed. ADLNs greater than or equal to 5 mm were considered enlarged.

RESULTS

Thirteen of 25 patients with hepatic metastases had ADLNs greater than or equal to 5 mm; three of 25 patients without hepatic metastases had ADLNs greater than or equal to 5 mm. The difference was statistically significant (p = .002).

CONCLUSION

Metastases of colon carcinoma from the liver to the ADLNs probably are not rare. ADLN involvement would obviate hepatic resection. The ADLNs should be assessed preoperatively in surgical candidates with hepatic metastases of colon carcinoma.