Mediastinal lymph node evaluation, especially at station 4L, in left upper lobe lung cancer

Background

Mediastinal lymph node (LN) dissection during lung resection is essential for accurate staging. Station 4L dissection is anatomically difficult. Therefore, care should be taken to avoid complications. We investigated the importance of mediastinal LN dissection in left upper lobe lung cancer and evaluated intraoperative videos to identify relevant steps during dissection.

Methods

We retrospectively reviewed 151 consecutive patients with left upper lobe lung cancer. Finally, 139 patients were enrolled to examine the survival effects of clinical factors of metastatic LN stations. The association between risk factors or surgical procedures and recurrent laryngeal nerve palsy was analyzed.

Results

LN dissection of the left upper lobe revealed station 4L LN metastasis in nine patients, three of whom were node-negative on mediastinoscopy. Station 4L LN status was confirmed intraoperatively in 12 of 33 patients. Twenty patients had recurrent laryngeal nerve palsy, four of whom were complicated with aspiration pneumonia. Station 4L LN dissection was an independent risk factor for recurrent laryngeal nerve palsy (P=0.03). The use of an energy device near the recurrent laryngeal nerve was a significant risk factor for recurrent laryngeal nerve palsy. Incidentally, pathological N stage ≥2 was an independent prognostic factor for disease-free survival (DFS) (P=0.005) herein.

Conclusions

In patients with left upper lobe lung cancer, pathological N2 disease is an important predictor of recurrence. Therefore, accurate mediastinal LN dissection, including at station 4L, should be performed. We propose to standardize the dissection procedure at each institution to avoid complications, such as recurrent laryngeal nerve palsy.

Clinical significance of 206 station lymph node in transverse colon cancer

Background

Lymph node (LN) metastasis is crucial in determining the prognosis and treatment options for colon cancer patients. Our work was to study whether the lymph nodes beyond D3 station in transverse colon cancer, especially 206 LN, should be dissected.

Methods

A total of 225 patients within our department were reviewed. The primary and secondary endpoints were overall survival (OS) and disease‐free survival (DFS). We employed Propensity score weighting (PSW) for weighing participants to balance observed confounders between the 206^D+ group and the 206^D− group.

Results

The rate of metastasis in station 206 was 9.3%. Only T stage (OR, 3.009; 95% CI, 1.018–8.892), N stage (OR, 9.818; 95% CI, 1.158–83.227), and M stage (OR, 26.126; 95% CI, 1.274–535.945) were an independent risk factor for 206 station metastasis in multivariate logistic analysis. The 206^D+ group had a similarly survival than the 206^D− group (3‐year DFS, 89.6% v 85.9%; p = 0.389; 3‐year OS, 94.6% v 85.3% p = 0.989). PSW further verified it. Metastasis of 206 station LN is not an independent prognostic factor, but a predictive factor of DFS.

Conclusion

Station 206 LN positive is a predictive factor for DFS. Only the patient with T1‐3, N+ who is at a high risk of 206 station LN metastases should consider dissecting 206 station LN.

The impact of an N1 lymph node examination in patients with early-stage non-small cell lung cancer: a retrospective cohort study

Background

The examination of lymph nodes (LNs) is critical for accurate node staging in patients with non-small cell lung cancer (NSCLC), but a consensus on the examinations of hilar and intrapulmonary (N1 station) LNs has not been reached. This study aimed to evaluate the role of LN dissection and pathological examination of N1 LN stations and their effects on survival in patients with stage IA-IIA NSCLC.

Methods

Data from patients pathologically staged as IA-IIA who underwent radical surgery and confirmed as lacking LN metastases from January 2008 to March 2018 were retrospectively reviewed. The Kaplan-Meier method was used to determine the overall survival (OS) and disease-free survival (DFS). After propensity score matching (PSM), a Cox model was used to determine the prognostic factors.

Results

Of the 1,935 patients investigated, the median number of N1 stations examined was 3. Patients with at least 2 N1 stations examined had apparently better OS (P=0.002) and DFS (P=0.001). All patients were divided into patients with 0–1 N1 station examined and patients with 2–5 N1 stations examined. After PSM, the number of N1 stations examined was an independent prognostic factor for DFS (P=0.004). Patients with 2–5 N1 stations examined experienced prolonged DFS (P=0.010). Patients in group 12 experienced prolonged OS (P=0.021) and DFS (P=0.026). Patients in group 13 or 14 experienced prolonged OS (P=0.028).

Conclusions

A larger extent of N1 station examination was associated with prolonged DFS in patients with stage IA-IIA NSCLC after lobectomy. The dissection and examination of at least 2 N1 stations included LNs from the lobar and segmental drainage fields.

Risk factors for lymph node metastasis of the left recurrent laryngeal nerve in patients with esophageal squamous cell carcinoma

Background

The factors for left recurrent laryngeal nerve (RLN) lymph node (LN) metastasis have important guiding significance for whether the left RLN LNs should be dissected in patients with esophageal squamous cell carcinoma (ESCC), but few studies are currently available. To analyze the risk factors of LN metastasis of the left RLN area and to assess which LNs should be dissected in ESCC.

Methods

This was a retrospective study of patients who underwent McKeown minimally invasive esophagectomy (MIE) (no neoadjuvant therapy) at Tianjin Medical University Cancer Institute and Hospital (from January 2016 to December 2019). The detection of left RLN LNs using enhanced computed tomography (CT) was compared with the pathological examination.

Results

Of the total 94 participants, 43 had LN metastasis. The metastatic LNs were mainly located next to left (18.1%) and right (14.9%) RLN, and the left gastric artery (13.8%). Tumor size, LN size, tumor invasion (T stage), N stage, and tumor node metastasis (TNM) stage were associated with left RLN LNs metastasis, while LN size was the only independently associated factor [odds ratio (OR) =1.569, 95% confidence interval (CI): 0.259–1.956, P=0.0012]. The area under receiver operating characteristic (ROC) curve (AUC) reached 0.877, with 64% sensitivity and 75% specificity using a cutoff of 5.5 mm LN size.

Conclusions

The size of left RLN LN is independently associated with metastasis. Left RLN LNs >5.5 mm at CT examination are more likely to be positive and should probably be dissected.

Role of PET/CT in muscle-invasive bladder cancer

The purpose of this study covered the diagnostic accuracy and usefulness of positron emission tomography/computed tomography (PET/CT) imaging in muscle invasive bladder cancer patients through previously published literature. Through 30 September, 2019, the PubMed database was searched for eligible articles that evaluated PET/CT imaging in bladder cancer patients. In general, FDG PET/CT, the most commonly used PET/CT imaging, does not show good performance for the detection of primary lesions; however, according to the literature it could accurately assess pelvic lymph node (LN) status better than other imaging technologies and it was especially helpful in determining extra-pelvic recurrences. More recently, non-FDG PET/CT imaging, such as C-11 acetate and C-11 choline, has been introduced. Although further research is required, preliminary results show the potential of these techniques to overcome the drawbacks of FDG. This concise study will overview the role of PET/CT when treating muscle-invasive bladder cancer (MIBC).

Tfh Cells in Health and Immunity: Potential Targets for Systems Biology Approaches to Vaccination

T follicular helper (Tfh) cells are a specialised subset of CD4+ T cells that play a significant role in the adaptive immune response, providing critical help to B cells within the germinal centres (GC) of secondary lymphoid organs. The B cell receptors of GC B cells undergo multiple rounds of somatic hypermutation and affinity maturation within the GC response, a process dependent on cognate interactions with Tfh cells. B cells that receive sufficient help from Tfh cells form antibody-producing long-lived plasma and memory B cells that provide the basis of decades of effective and efficient protection and are considered the gold standard in correlates of protection post-vaccination. However, the T cell response to vaccination has been understudied, and over the last 10 years, exponential improvements in the technological underpinnings of sampling techniques, experimental and analytical tools have allowed multidisciplinary characterisation of the role of T cells and the immune system as a whole. Of particular interest to the field of vaccinology are GCs and Tfh cells, representing a unique target for improving immunisation strategies. Here, we discuss recent insights into the unique journey of Tfh cells from thymus to lymph node during differentiation and their role in the production of high-quality antibody responses as well as their journey back to the periphery as a population of memory cells. Further, we explore their function in health and disease and the power of next-generation sequencing techniques to uncover their potential as modulators of vaccine-induced immunity.

Adjuvant chemotherapy for intrahepatic cholangiocarcinoma: approaching clinical practice consensus?

Background

Intrahepatic cholangiocarcinoma (ICC) is rare with limited evidence-based guidelines. This retrospective study evaluates the use of chemotherapy in patients with resected ICC.

Methods

The Surveillance Epidemiology and End Results (SEER) program database was used to identify patients with resected ICC. Patients were stratified by date of diagnosis (2000-2004, 2005-2009, 2010-2014), T, and N stage. Multivariable logistic regression models identified predictors of chemotherapy use. Kaplan-Meier and Cox proportional hazard models were used to identify survival trends.

Results

One thousand and two hundred twenty-three patients met inclusion criteria. Chemotherapy utilization increased over time (33% to 41%, P≤0.05). Chemotherapy use increased in lymph node (LN) positive patients [32% to 60% in 2010-2014; (P≤0.05) and T3/T4 disease (40% to 60% in 2010-2014; P≤0.01], but not in patients with LN negative or T1/T2 disease. LN positivity was associated with utilization of chemotherapy in 2005-2009 and 2010-2014. Overall survival increased from 32 to 41 months (P≤0.05). In LN positive patients, chemotherapy was associated with a decreased hazard ratio of death (P≤0.05) and T3/T4 disease was associated with an increased hazard ratio of death (P≤0.05).

Conclusions

Adjuvant chemotherapy use in ICC has increased. More LN positive or patients with T3/T4 tumors are receiving chemotherapy, which may explain the improvement in overall survival.

Variability in Recommendations for Cervical Lymph Node Pathology for Staging of Canine Oral Neoplasia: A Survey Study

There is no clear guideline regarding the indication for routine lymph node extirpation and pathologic evaluation during staging of canine oral tumors, despite a relatively high reported nodal metastatic rate for select tumor types. It is particularly unclear if clinicians recommend removal of lymph nodes only when there is confirmation of metastasis, defined as the N+ neck, or if elective neck dissection (END) is routinely recommended to confirm the true pathologic metastatic status of lymph nodes in the clinical N0 neck (no evidence of metastasis on clinical staging with diagnostic imaging or cytology). When clinicians are recommending END as a staging tool to confirm nodal status, there is also ambiguity regarding the surgical extent for subsequent histopathologic evaluation. The objective of this cross-sectional survey study was to determine the current recommendations given by practicing specialists regarding lymph node removal for dogs with oral tumors. Overall, 87 responses were obtained from 49 private practices (56%) and 38 academic institutions (44%). Respondents identified as oncologists (44%, N = 38), soft tissue surgeons (40%, N = 35), and dentists (16%, N = 14). Regardless of tumor type and stage, extirpation and histopathology were most commonly recommended in the clinical N+ neck only. The recommendation to routinely perform END in the N0 neck was significantly associated with tumor type. Bilateral removal of the mandibular and retropharyngeal lymph nodes was recommended more often for oral malignant melanoma (OMM) than for oral squamous cell carcinoma (OSCC; p ≤ 0.0039) or for oral fibrosarcoma (OFSA; p ≤ 0.0007). The likelihood of recommending END increased with increasing tumor size. Academic clinicians were significantly (p < 0.01) more likely to recommend END compared to private practitioners for canine T1-T3 OMM, T3 OSCC, T2 OFSA, and MCT. This study highlights the variability in recommendations for lymph node pathology for dogs with oral tumors. While tumor type and size influenced the decision to pursue END, it was not routinely recommended, even for tumor types with a known propensity for metastasis. Prospective studies are warranted to determine the potential diagnostic and therapeutic value of END in the N0 neck in veterinary patients such that a consensus approach can be made.

Should the left gastric artery lymph node be considered as the predictive lymph node for extra-gastric lymph node metastases?

Background

To validate the prognostic impacts of the left gastric artery lymph node (No. 7 LN) metastasis and investigate whether the No. 7 LN metastasis should be considered as the predictive LN for extra-gastric LN metastases.

Methods

Between January 2003 and December 2011, a total of 1,586 patients who underwent R0 gastrectomy were retrospected. Patients with LN metastases were divided into three groups: (I) patients with only peri-gastric LN metastases (peri-gastric group); (II) patients with peri-gastric and only No. 7 LN metastases (No. 7 group); and (III) patients with other extra-gastric LN metastases (extra-gastric group). Propensity score matching (PSM) was adopted to accurately evaluate prognoses of all patients after surgery.

Results

Of 1,586 patients, 235 (14.82%) were pathologically identified to present with the No. 7 LN metastases. Patients with the No. 7 LN metastases presented the significantly lower survival rate both before and after adjustment by pTNM stage, compared to those without the No. 7 LN metastases. Patients in the No. 7 group were identified to present the significant lower survival rate than those in the peri-gastric group, and to present the similar median overall survival (OS) to those in the extra-gastric group. In addition, patients with extra-gastric LN except No. 7 LN metastases failed to show any superiority of survival outcomes, compared with those with extra-gastric LN metastases including the No. 7 LN metastasis.

Conclusions

The No. 7 LN metastases had the crucial survival implications. Nevertheless, the No. 7 LN failed to be considered as the predictive LN for the extra-gastric LN metastases in gastric cancer (GC).

Validation of the prognostic value of various lymph node staging systems for cervical squamous cell carcinoma following radical surgery: a single-center analysis of 3,732 patients

Background

To investigate the prognostic value of six lymph nodes (LNs) staging systems: TNM pN stage, 2018 Federation International of Gynecology and Obstetrics (FIGO) stage, number of positive LNs (PLN), number of negative LNs (NLN), metastatic LN ratio (LNR), and log odds of positive LNs (LODDS) in cervical squamous cell carcinoma (CSCC) patients following radical surgery.

Methods

The records of 3,732 CSCC patients who underwent radical surgery between 2006 and 2014 were retrospectively reviewed. We divided variables into different groups by applying tree-based recursive partitioning. Survival curves were compared by the log-rank test, and prognostic factors were identified through Cox regression analysis. The six staging systems underwent assessment for their relative discriminative abilities by way of Harrell’s concordance index (C-index) and the Akaike’s Information Criterion (AIC).

Results

All of the six staging systems had a significant influence on patients’ progression-free survival (PFS) and overall survival (OS), with univariate analysis showing all of the staging systems to have the significant prognostic ability in relation to PFS and OS (P<0.001 for each). Multivariate analysis demonstrated five of the staging methods to be independent prognostic factors, but that NLN classification was not. PLN was noted to have somewhat the best prognostic performance for both PFS (C-index: 0.634; AIC: 33,343.83) and OS (C-index: 0.675; AIC: 34,223.11).

Conclusions

The pN, 2018 FIGO stage, PLN, LNR, and LODDS appeared to predict better survival than the NLN in CSCC patients. Moreover, PLN appeared to be the most valuable and predictive LN staging system.

Lymph Node Subcapsular Sinus Macrophages as the Frontline of Lymphatic Immune Defense

Lymphatic vessels collect and transport lymph and pathogens to the draining lymph node (LN) to generate proper immune protection. A layer of macrophages that strategically line the LN subcapsular sinus (SCS) is directly exposed to the afferent lymph and are denoted as SCS macrophages. These macrophages are the frontline of immune defense that interact with lymph-borne antigens. The importance of these macrophages in limiting the spread of pathogens has been demonstrated in both viral and bacterial infection. In anti-microbial responses, these macrophages can directly or indirectly activate other LN innate immune cells to fight against pathogens, as well as activate T cells or B cells for adaptive immunity. As the first layer of immune cells embracing the tumor-derived antigens, SCS macrophages also actively participate in cancer immune regulation. Recent studies have shown that the LNs' SCS macrophage layer is interrupted in disease models. Despite their importance in fighting the spread of pathogens and in activating anti-tumor immunity, the mechanism and the immunological functional consequences for their disruption are not well-understood. Understanding the mechanism of these macrophages will enhance their capability for therapeutic targeting.

Ultra-small superparamagnetic iron oxide contrast agents for lymph node staging of high-risk prostate cancer

Ultrasmall superparamagnetic particles of iron oxide (USPIOs) imaged with magnetic resonance imaging (MRI) have been proposed as an experimental method for visualizing lymph node (LN) metastases. The method does not require ionizing radiation, yet can detect small nodes that are involved with metastases. USPIOs are naturally taken up by macrophages that deposit in the normal LN creating a low signal region in normal areas; areas within the node that do not show this loss of signal are likely involved by tumor although there can be other causes (fibrosis or inflammation). However, the lack of approved USPIOs that are clinically available hinders adoption and larger studies. The proposed indications for USPIO MRI, including specific compounds and imaging methods are discussed.

Nodal management and upstaging of disease: initial results from the Italian VATS Lobectomy Registry

BACKGROUND

VATS lobectomy is an established option for the treatment of early-stage NSCLC. Complete lymph node dissection (CD), systematic sampling (SS) or resecting a specific number of lymph nodes (LNs) and stations are possible intra-operative LN management strategies.

METHODS

All VATS lobectomies from the "Italian VATS Group" prospective database were retrospectively reviewed. The type of surgical approach (CD or SS), number of LN resected (RN), the positive/resected LN ratio (LNR) and the number and types of positive LN stations were recorded. The rates of nodal upstaging were assessed based on different LN management strategies.

RESULTS

CD was the most frequent approach (72.3%). Nodal upstaging rates were 6.03% (N0-to-N1), 5.45% (N0-to-N2), and 0.58% (N1-to-N2). There was no difference in N1 or N2 upstaging rates between CD and SS. The number of resected nodes was correlated with both N1 (OR =1.02; CI, 1.01-1.04; P=0.03) and N2 (OR =1.02; CI, 1.01-1.05; P=0.001) upstaging. Resecting 12 nodes had the best ability to predict upstaging (6 N1 LN or 7 N2 LN). The finding of two positive LN stations best predicted N2 upstaging [area under the curve (AUC) of receiver operating characteristic (ROC) =0.98].

CONCLUSIONS

Nodal upstaging (and, indirectly, the effectiveness of intra-operative nodal management) cannot be predicted based on the surgical technique (CD or SS). A quantitative assessment of intra-operative LN management may be a more appropriate and measurable approach to justify the extension of LN resection during VATS lobectomy.

Histomolecular Structural Aspects of High Endothelial Vessels in Lymph Node and Its Significance in Oral Cancer and Metastasis

Molecular cancer research studies focus on identifying diagnostic, screening, and metastatic indicators, and monitoring therapeutic responses. Migration of tumor cells and lymphocytes are important aspects in metastasis. High endothelial vessels are specialized histological structures identified in the blood vessels in lymphoid organs, which allow the migration of lymphocytes. In the recent decades, the role of high endothelial vessels is being addressed in cancer metastatic research. This review article is to highlight the histological and molecular structural aspects of high endothelial venules (HEVs) in the lymph node, and to demonstrate the role of HEVs in oral cancer metastasis, specifically oral and pharyngeal squamous cell carcinoma. The literature for the present paper were searched from the data sources such as Medline/PubMed, CINAHL plus, and gray literature sources from inception to May 2015. Searches were conducted using both free texts and medical subject headings related to the title of the present paper. Only the full text manuscripts of the search results that support the objective(s) of the paper and papers written in English were included. HEVs are unique structures that are identified in the lymphocytes and primarily assist in the lymphocytic migration from the blood stream into the lymph node. Understanding the histomolecular characteristics of HEV will allow researchers to develop novel therapeutic approaches in cancer tissues.