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Koester TM, Chewning RH, Weldon CB, Shaikh R, Weil BR. Lymphatic Embolization for the Management of Post-operative Chyle Leaks Following Solid Tumor Resection in Pediatric Patients. J Pediatr Surg 2023; 58:2141-2148. [PMID: 37336682 DOI: 10.1016/j.jpedsurg.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/16/2023] [Accepted: 05/22/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Chyle leaks are a common post-operative complication following solid-tumor resection in pediatric patients. Current treatments for persistent chyle leaks are limited, leading many patients to experience prolonged hospitalization, nutritional deficits and/or delays in cancer therapies. Lymphatic embolization is an emerging treatment option for chyle leaks, however, limited reports exist of its use in pediatric populations. METHODS We conducted a retrospective review of pediatric patients (<18) who underwent lymphangiogram with intent for lymphatic embolization for the management of chyle leaks following solid-tumor resection between 2017 and 2022. RESULTS Seven patients underwent a total of 11 attempted lymphatic embolization procedures after current standard of care treatments failed to resolve the leak. Lymphangiograms identified a chyle leak in 6 of 7 patients and embolization had a technical success rate of 73%. The complication rate was 9% and complications were limited to one episode of inadvertent gastric wall perforation that did not result in a gastric leak. Lymphatic embolization was ultimately associated with chyle leak resolution in 100% of patients within a median of 24 days, however, repeat embolization was required in 5 of 7 patients (83%). CONCLUSION Lymphatic embolization appears to be a safe and effective treatment for persistent chyle leaks in pediatric patients, leads to a direction reduction in chyle output, and has high rates of technical and clinical success. Complete resolution of the chyle leak may require multiple embolization procedures. Further work is needed to determine whether earlier intervention may offer benefit for the management of pediatric chyle leaks. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - Rush H Chewning
- Harvard Medical School, 25 Shattuck Street, Boston, MA, USA; Division of Interventional Radiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
| | - Christopher B Weldon
- Harvard Medical School, 25 Shattuck Street, Boston, MA, USA; Department of Pediatric Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
| | - Raja Shaikh
- Harvard Medical School, 25 Shattuck Street, Boston, MA, USA; Division of Interventional Radiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
| | - Brent R Weil
- Harvard Medical School, 25 Shattuck Street, Boston, MA, USA; Department of Pediatric Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
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2
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Hoa TQ, Cuong NN, My TTT, Linh LT, Hoan L, Canh PH, Tinh TQ, Chi TNK, Luu DT, Long H. Chylous ascites after donor nephrectomy: MR lymphangiography and lymphatic embolization treatment. Radiol Case Rep 2023; 18:1029-1032. [PMID: 36684632 PMCID: PMC9849999 DOI: 10.1016/j.radcr.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/02/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023] Open
Abstract
Chylous ascites results from the leakage of lipid-rich lymphatic fluid into the peritoneal cavity. Most postsurgical chylous ascites occurs following abdominal aortic surgeries. However, rarely, it is a complication after laparoscopic donor nephrectomy. Postsurgical chylous ascites are often managed with conservative treatment or surgery, but lymphatic embolization may be required. Here, we presented a 45-year-old male patient who was referred for abdominal distension for 1 week after left donor nephrectomy. The drain fluid was milky and fluid analysis revealed high concentrations of triglycerides and chylomicron, confirming diagnosis of chylous ascites. The patient was treated with conservative therapy including a low-fat diet and fluid drainage but continued to have high draining output (up to 1500-2000 mL/24 h). He underwent magnetic resonance lymphangiography and intranodal lymphangiography, revealing extravasation of contrast into the abdomen and the left renal fossa. We embolized the interstitial lymphatic of the left retroperitoneal and lymphatic vessels leak. The patient was discharged from hospital at the fifth day after intervention. In this article, we demonstrate lymphatic lesions, the safety, and success of this technique.
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Affiliation(s)
- Tran Quoc Hoa
- Urology Surgery Department, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Nguyen Ngoc Cuong
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam,Corresponding author.
| | - Thieu Thi Tra My
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Le Tuan Linh
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Le Hoan
- Respiratory Department, Hanoi Medical University, Hanoi, Vietnam
| | - Pham Hong Canh
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Trieu Quoc Tinh
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Tran Nguyen Khanh Chi
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Doan Tien Luu
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Hoang Long
- Urology Surgery Department, Hanoi Medical University Hospital, Hanoi, Vietnam
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3
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Aguado A. Role of Interventional Radiology in Pediatric Cancer Patients. Curr Oncol Rep 2022; 24:1731-1740. [PMID: 36057070 DOI: 10.1007/s11912-022-01320-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Pediatric interventional radiology (IR) is a growing subspecialty. Here, we review the current role of IR in children with cancer, which uses imaging such as ultrasound, fluoroscopy, and computed tomography to perform minimally invasive procedures. These include biopsy, needle localization, central venous access, thermal ablation, transarterial chemoembolization, transarterial radioembolization with yttrium-90, non-tunneled/tunneled drainage catheter placement, and lymphatic interventions. RECENT FINDINGS Although locoregional therapies for the treatment of cancer in adults are common, they are less common in children, perhaps due to the relative rarity of cancer in children, their typically better performance status, and paucity of comorbidities. Preliminary results from small-scale studies for ablation, transarterial chemoembolization, and transarterial radioembolization with yttrium-90 used in the front-line armamentarium of curative therapy are encouraging. Pediatric IR offers an array of minimally invasive procedures intended to diagnose and treat pediatric cancer patients. However, more research is required to determine the efficacy of locoregional therapy in children and to define the clinical scenarios where benefit is likely to be optimized.
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Affiliation(s)
- Allison Aguado
- Division of Interventional Radiology, Nemours Children's Health, 1600 Rockland Rd., Wilmington, DE, 19803, USA.
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4
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Youssef EW, Aly A, Brahmbhatt A, Moussa A, Santos E. Lymphatic Interventions in the Cancer Patient. Curr Oncol Rep 2022. [PMID: 35639331 DOI: 10.1007/s11912-022-01293-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The incidence of lymphatic leakage (iatrogenic and non-iatrogenic) is growing in cancer population due to the increased complexity of the surgical procedures and improved overall survival in cancer patients. The purpose of this article is to review the contemporary approach in the field of percutaneous lymphatic embolization in cancer patients with lymphatic leaks. RECENT FINDINGS Since the advent of intranodal lymphangiography in 2011 alongside with the MR and CT lymphangiography, the accuracy of diagnosis of the lymphatic diseases has significantly improved significantly. These advancements have triggered a revival of minimally invasive lymphatic interventions. Lymphatic embolization is expanding from the classic indication, thoracic duct embolization, to other lymphatic disorders (chylous ascites, lymphoceles, liver lymphorrhea, protein-losing enteropathy). The growth of lymphatic research and the standardization of the lymphatic interventions require a multidisciplinary and collaborative approach between physicians and researchers.
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Nguyen NC, Inoue M, Le TL, Pham HC, Trinh HS, Pham DH, Nguyen H, Tran AT, Vu DL, Delphine N. Intrahepatic lymphatic channel sclerotic embolization for treatment of postoperative lymphatic ascites: a report of 3 cases. Radiol Case Rep 2020; 15:2353-2357. [PMID: 32994840 PMCID: PMC7501473 DOI: 10.1016/j.radcr.2020.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 08/31/2020] [Accepted: 09/08/2020] [Indexed: 12/28/2022] Open
Abstract
Postoperative hepatic lymphorrhea is extremely rare and there is no standard treatment for this condition. We report the cases of 3 men, 32-, 56-, and 37-year-old, with postoperative hepatic lymphorrhea, which was refractory to conservative treatment. Transhepatic lymphangiography allowed locating the lymphatic leak and treating it with hepatic lymphatic vessels injection of foam sclerotic agent. This technique seems efficient and safe.
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Affiliation(s)
- Ngoc Cuong Nguyen
- Radiology Department, Hanoi University Hospital, Hanoi, Vietnam
- Corresponding author.
| | | | - Tuan Linh Le
- Radiology Department, Hanoi University Hospital, Hanoi, Vietnam
| | - Hong Canh Pham
- Radiology Department, Hanoi University Hospital, Hanoi, Vietnam
| | | | - Duc Huan Pham
- Department of Surgery, Hanoi University Hospital, Hanoi, Vietnam
| | - Hoang Nguyen
- Department of Surgery, Hanoi University Hospital, Hanoi, Vietnam
| | - Anh Tuan Tran
- Radiology Department, Bach Mai Hospital, Hanoi, Vietnam
| | - Dang Luu Vu
- Radiology Department, Bach Mai Hospital, Hanoi, Vietnam
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Nakamoto H, Kayama S, Harada M, Honjo T, Kubota K, Sawamura S. Airway emergency during general anesthesia in a child with plastic bronchitis following Fontan surgery: a case report. JA Clin Rep 2020; 6:6. [PMID: 32025939 PMCID: PMC6974346 DOI: 10.1186/s40981-020-0311-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/14/2020] [Indexed: 11/28/2022] Open
Abstract
Background Plastic bronchitis (PB) is a complication of Fontan surgery, results in the formation of mucus plug in the tracheobronchial tree, causing potentially fatal airway obstruction. We report critical airway emergency during general anesthesia in a child with plastic bronchitis. Case presentation A 5-year-old boy was scheduled for intrapulmonary lymphatic embolization through percutaneous catheterization under general anesthesia. He underwent Fontan surgery at the age of 2 and frequently developed respiratory failure due to plastic bronchitis. After induction of general anesthesia and tracheal intubation, mechanical ventilation became difficult even with an inspiratory pressure ≥ 50 mmHg due to airway obstruction. He expectorated a large mucus plug through the tracheal tube after administration of sugammadex, naloxone, and flumazenil, and respiratory condition was stabilized thereafter. Conclusion General anesthesia for a patient with plastic bronchitis should be planned with extracorporeal membrane oxygenation or cardiopulmonary bypass stand by.
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Affiliation(s)
- Hirofumi Nakamoto
- Department of Anesthesiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan.
| | - Satoru Kayama
- Department of Anesthesiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Mae Harada
- Department of Anesthesiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Takahiro Honjo
- Department of Anesthesiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Kinuko Kubota
- Department of Anesthesiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Shigehito Sawamura
- Department of Anesthesiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
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Primo WQSP, Primo GRP, Basilio DB, Machado KK, Carvalho JP, Carvalho FM. Vulvar Paget disease secondary to high-grade urothelial carcinoma with underlying massive vascular embolization and cervical involvement: case report of unusual presentation. Diagn Pathol 2019; 14:125. [PMID: 31699107 PMCID: PMC6836446 DOI: 10.1186/s13000-019-0895-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/25/2019] [Indexed: 12/17/2022] Open
Abstract
Background Vulvar extramammary Paget disease is a rare chronic condition, that presents with non-specific symptoms such as pruritus and eczematous lesions. Because most of these lesions are noninvasive, the distinction between primary and secondary Paget disease is crucial to management. Case presentation We report an unusual case of vulvar Paget disease associated with massive dermal vascular embolization, cervicovaginal involvement and metastasis to inguinal and retroperitoneal lymph nodes. The intraepithelial vulvar lesion had a classical appearance and was accompanied by extensive component of dermal lymphovascular tumor emboli, similar to those observed in inflammatory breast carcinoma. Immunohistochemical analysis revealed that the lesion was secondary to high-grade urothelial cell carcinoma. The patient had a history of superficial low-grade papillary urothelial carcinoma of the bladder, which had appeared 2 years before the onset of vulvar symptoms. Conclusions Eczematoid vulvar lesions merit careful clinical examination and biopsy, including vulva mapping and immunohistochemistry. The information obtained may help to define and classify a particular presentation of Paget disease. Noninvasive primary lesions do not require the same aggressive approaches required for the treatment of invasive and secondary disease.
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Affiliation(s)
| | | | - Dunya Bachour Basilio
- Department of Pathology, Instituto Hospital de Base do Distrito Federal IHBDF, Secretaria de Estado da Saude, Brasilia, DF, Brazil
| | | | - Jesus Paula Carvalho
- Instituto do Cancer do Estado de São Paulo ICESP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Filomena M Carvalho
- Department of Pathology, Faculdade de Medicina FMUSP, Universidade de São Paulo, Av. Dr. Arnaldo, 455 - room 1149, Sao Paulo, SP, 01246-903, Brazil.
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Chu HH, Shin JH, Kim JW, Noh SY, Yang WJ, Park S. Lymphangiography and Lymphatic Embolization for the Management of Pelvic Lymphocele After Radical Prostatectomy in Prostatic Cancer. Cardiovasc Intervent Radiol 2019; 42:873-879. [PMID: 30919025 DOI: 10.1007/s00270-019-02209-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 03/18/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To retrospectively evaluate the short-term outcomes of lymphangiography and lymphatic embolization in the treatment of pelvic lymphocele after radical prostatectomy in patients with prostate cancer. MATERIALS AND METHODS The data of nine, consecutive patients who underwent lymphangiography and lymphatic embolization for pelvic lymphocele after radical prostatectomy with pelvic lymph node dissection (PLND) between January 2016 and May 2018, were retrospectively reviewed. Lymphangiography was performed through inguinal lymph nodes in order to identify the lymphatic leakage. When a leakage was found, lymphatic embolization was performed using a directly punctured fine needle at the closest upstream lymph node or lymphopseudoaneurysm and with N-butyl cyanoacrylate glue. RESULTS Lymphangiography demonstrated extravasation and/or lymphopseudoaneurysm in all of these patients. A total of 13 sessions of lymphangiography and lymphatic embolization were performed. The median number of lymphangiography and lymphatic embolizations required to achieve clinical success was one (range, 1-3). Three patients underwent repeated embolization with successful results. The technical and clinical success rates were 100%, respectively. The median time to resolution was 7 days (range, 2-19 days). There was no recurrence and no procedure-related complications during the follow-up period (mean, 26 weeks; range, 8-77 weeks) in all patients. CONCLUSIONS Lymphangiography and lymphatic embolization are safe and effective for the management of pelvic lymphoceles after radical prostatectomy with PLND.
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Affiliation(s)
- Hee Ho Chu
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Seung Yeon Noh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Woo Jin Yang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Suyoung Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
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9
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Cox M, Hurst R, Vossough A. Ultradense Middle Cerebral Artery: Specific Sign of Cerebral Lipiodol Embolization. World Neurosurg 2018; 112:254-256. [PMID: 29408494 DOI: 10.1016/j.wneu.2018.01.189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/25/2018] [Accepted: 01/27/2018] [Indexed: 11/25/2022]
Abstract
Cerebral lipiodol embolization is a rare but known complication of lymphatic embolization for plastic bronchitis. The classic imaging finding on a noncontrast head computed tomography is multiple small areas of hyperdensity within the cerebral hemispheres, which represent lipiodol deposition in the brain. We report a case of lipiodol deposition in the middle cerebral artery following lymphatic embolization, producing an "ultradense" vessel sign on noncontrast computed tomography.
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Affiliation(s)
- Mougnyan Cox
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Robert Hurst
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arastoo Vossough
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Baiocchi GL, Molfino S, Baronchelli C, Giacopuzzi S, Marrelli D, Morgagni P, Bencivenga M, Saragoni L, Vindigni C, Portolani N, Botticini M, De Manzoni G. Recurrence in node-negative advanced gastric cancer: Novel findings from an in-depth pathological analysis of prognostic factors from a multicentric series. World J Gastroenterol 2017; 23:8000-8007. [PMID: 29259375 PMCID: PMC5725294 DOI: 10.3748/wjg.v23.i45.8000] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 09/19/2017] [Accepted: 10/17/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To analyze the clinicopathological characteristics of patients with both node-negative gastric carcinoma and diagnosis of recurrence during follow-up.
METHODS We enrolled 41 patients treated with curative gastrectomy for pT2-4aN0 gastric carcinoma between 1992 and 2010, who developed recurrence (Group 1). We retrospectively selected this group from the prospectively collected database of 4 centers belonging to the Italian Research Group for Gastric Cancer, and compared them with 437 pT2-4aN0 patients without recurrence (Group 2). We analyzed lymphatic embolization, microvascular infiltration, perineural infiltration, and immunohistochemical determination of p53, Ki67, and HER2 in Group 1 and in a subgroup of Group 2 (Group 2bis) of 41 cases matched with Group 1 according to demographic and pathological characteristics.
RESULTS T4a stage and diffuse histotype were associated with recurrence in the group of pN0 patients. In-depth pathological analysis of two homogenous groups of pN0 patients, with and without recurrence during long-term follow-up (groups 1 and 2bis), revealed two striking patterns: lymphatic embolization and perineural infiltration (two parameters that pathologists can easily report), and p53 and Ki67, represent significant factors for recurrence.
CONCLUSION The reported pathological features should be considered predictive factors for recurrence and could be useful to stratify node-negative gastric cancer patients for adjuvant treatment and tailored follow-up.
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Affiliation(s)
- Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia 25121, Italy
| | - Sarah Molfino
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia 25121, Italy
| | - Carla Baronchelli
- Department of Pathology, Spedali Civili di Brescia, Brescia 25121, Italy
| | - Simone Giacopuzzi
- 1st Department of General Surgery, Borgo Trento Hospital, University of Verona, Verona 37129, Italy
| | - Daniele Marrelli
- Department of Human Pathology and Oncology, Surgical Oncology, University of Siena, Siena 53100, Italy
| | - Paolo Morgagni
- Department of General Surgery, Morgagni-Pierantoni Hospital, Forlì 47121, Italy
| | - Maria Bencivenga
- 1st Department of General Surgery, Borgo Trento Hospital, University of Verona, Verona 37129, Italy
| | - Luca Saragoni
- Department of Pathology, Morgagni-Pierantoni Hospital, Forlì 47121, Italy
| | - Carla Vindigni
- Department of Pathology, Azienda Ospedaliera Universitaria Senese, Siena 53100, Italy
| | - Nazario Portolani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia 25121, Italy
| | | | - Giovanni De Manzoni
- 1st Department of General Surgery, Borgo Trento Hospital, University of Verona, Verona 37129, Italy
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