Lymph node excision in thyroid carcinoma

The prognostic value of lymph node metastases in thyroid cancer has been a matter of controversy for many years. However, during the past decade most multivariate analyses have shown a prognostic influence of lymph node metastases in papillary as well as medullary thyroid carcinoma constituting the basis for a standardized concept of lymphadenectomy oriented to the lymph node classification of the UICC (1993). Due to the frequency of lymph node metastases in the ipsilateral cervicocentral compartment (42-86%), in the ipsilateral cervicolateral compartment (32-68%), in the contralateral cervicolateral compartment (12-24%), and in the mediastinal compartment (3-20%), these compartments can be defined as the lymph node regions of the first, second, third and fourth order, respectively. Cervicocentral systematic lymphadenectomy should be part of the en bloc resection of the thyroid gland and the first lymph node region in any thyroid cancer. Cervicolateral as well as mediastinal lymphadenectomy should be performed according to the extent of lymph node involvement, i.e. systematically when multiple lymph node metastases are present, otherwise selectively. One exception is in medullary thyroid carcinoma, where a four-compartment lymphadenectomy is recommended in any patient with positive lymph nodes. Performing a gentle technique using magnifying glasses and bipolar coagulation forceps, systematic lymphadenectomy does not increase the rate of complications, can decrease the recurrence rate and improve survival.     

Conservative surgery for stage I ovarian carcinoma in women of childbearing age

OBJECTIVE: To assess the results of a policy of tailored conservative surgical management for young women with stage I ovarian carcinomas. DESIGN: Retrospective study. PARTICIPANTS: Ninety-nine women aged 40 years or younger who underwent either primary surgery in our department or were referred after primary surgery performed elsewhere. METHODS: Of the 99 women in our study, 56 underwent fertility-sparing surgery and 43 more radical surgery. Minimal requirements for conservative management were adequate staging and complete information about the therapeutic options. Factors important in the choice of the treatment were, age, wish to preserve fertility, histologic type and grade, and the stage of the tumour. RESULTS: Conservative treatment was conducted in 84% of nulliparous and in 33% of parous women; 62% of grade 1 tumours, 48% of grade 2, and 50% of grade 3 were treated conservatively. With a median follow up of seven years, we observed five recurrences (9%) of carcinoma in women treated conservatively and five (12%) in those treated more radically. Two women (one in each treatment arm) were saved after recurrence. Two recurrences after conservative surgery involved the residual ovary (3.6%). Two women developed borderline tumour in the contralateral ovary and both were treated by surgery. CONCLUSION: After adequate staging and accurate information is given to the patient, conservative treatment may be safe in some women with early ovarian cancer. The risk of recurrence in the contralateral ovary is low. Conservative surgery may be also considered in some Stage I grade 3 tumours and in some women with stage JC tumours.     

Distribution pattern and risk factors of pelvic and para-aortic lymph node metastasis in epithelial ovarian carcinoma

The distribution of lymph node metastasis and the clinicopathologic risk factors for nodal involvement in ovarian carcinoma need to be clarified based on systematic lymph node dissection. We studied 115 patients with ovarian carcinoma who underwent systematic pelvic and para-aortic lymph node dissection between 1987 and 1997. The incidence and distribution of lymph node metastasis are described and the clinico-pathologic risk factors for nodal involvement are investigated. Based on the occurrence of lymph node metastasis in the early stages, the incidence of solitary node involvement and the distribution of lymph node metastasis, we conclude that the primary site of nodal involvement in ovarian carcinoma is the para-aortic node (PAN), especially PAN superior to the inferior mesenteric artery (IMA). By univariate analysis, clinical stage, histologic type (mucinous vs. others), grade, multiple peritoneal metastases, peritoneal cytology, volume of ascites and serum CA125 level were correlated with overall incidence of lymph node metastasis. By performing a multivariate analysis with the clinical stage excluded, it was revealed that grade and peritoneal cytology were independent factors for PAN metastasis (p < 0.0025 and < 0.001, respectively) and that multiple peritoneal metastases and PAN metastasis were significant predictors of pelvic node metastasis (p < 0.01 and < 0.005, respectively). In conclusion, the PANs superior and inferior to IMA should be explored in staging of ovarian carcinoma that appears to be confined to the ovaries. To determine accurately the extent of disease, both the para-aortic and pelvic areas may need to be sampled or dissected in the case of ovarian carcinoma involving the peritoneal surfaces.     

Lymph node metastasis in breast cancer: common prognostic markers lack predictive value

Isoflavones are present in soybeans and its products in concentrations up to 300 mg/100 g, have estrogenic and antiestrogenic properties, and may be protective against hormone-related cancers. The purpose of this cross-sectional study was to investigate the association between urinary isoflavone excretion and self-reported soy intake. A total of 102 women of Caucasian, Native Hawaiian, Chinese, Japanese, and Filipino ancestry completed a dietary questionnaire for soy products consumed during the last year and during the 24-h period before urine collection. Overnight urine samples were analyzed for coumestrol and the soy isoflavones genistein, daidzein, and glycitein and their main human metabolites by reverse-phase high-pressure liquid chromatography. Soy protein and isoflavone intake (predominantly from tofu) were estimated using published nutritional databases. Wilcoxon's rank-sum test scores and Spearman rank correlation coefficients were computed. Japanese women excreted more daidzein, genistein, and glycitein than did Caucasian women, whereas Caucasian women excreted slightly more coumestrol. Soy intake differed significantly among ethnic groups. Dietary soy protein and isoflavone intakes during the previous 24 h were positively related to urinary isoflavone excretion [rs = 0.61 (P < 0.0001) and 0.62 (P < 0.0001), respectively]. Urinary excretion of isoflavones was also related to annual dietary soy protein and isoflavone intake [rs = 0.32 (P < 0.0012) and 0.31 (P < 0.0016), respectively]. The strong correlation between urinary isoflavone excretion and self-reported soy intake validates the dietary history questionnaire that is now used in a study exploring dietary risk factors for breast cancer.     

Clear cell odontogenic carcinoma with lymph node metastasis

Clear cell odontogenic tumors are rare. Review of the literature showed 9 cases with a prominent clear cell component. These lesions have exhibited an aggressive behavior characterized by an infiltrative local growth pattern, recurrence, or metastases. We report a case of an odontogenic tumor that exhibited a biphasic pattern and was characterized by lymph node involvement identical histologically to the primary tumor. We conclude that the presence of a clear cell component in an ameloblastomatous tumor should be viewed as a sign of de-differentiation, and that a malignancy with or without metastases should be considered and ruled out in such cases.     

Lymph node size does not correlate with the presence of prostate cancer metastasis

Prostate carcinoma (PC) is the second leading cause of cancer death in men in the western world. Although the role of oncogenes and growth factors in prostate carcinoma is still unclear, overexpression of the epidermal growth factor receptor (erbB-1) and the proto-oncogene erbB-2 have been reported in prostate tumors, and erbB-2 related to poor prognosis and distant metastasis. Recent allelotyping studies in prostate cancer have shown chromosomal gains in 7p and 17q, regions where erbB-1 and erbB-2 are localized respectively, although no direct evidence of an increased gene copy number of either erbB-1 or erbB-2 has been reported. To address this question, we analyzed 20 benign prostatic hyperplasia (BPH) samples and 36 samples of metastatic and non-metastatic PC by means of semiquantitative PCR. Thus, 64% (11/17) and 52% (10/19) of metastatic and non-metastatic tumors respectively showed gains of the relative genomic content of erbB-1 and an association of erbB-1 with prostate cancer but not with metastasis. Additionally, 41% (7/17) of metastatic samples showed gains of erbB-2 genomic content, suggesting an association of erbB-2 with metastasis and poor prognosis (p<0.005). No gains of erbB-1 or erbB-2 genomic content were detected in the BPH samples.     

Regional lymph node metastasis from cutaneous squamous cell carcinoma

The phenotypes of various STAT knockout mice reveal an unexpected specificity in the biological roles of these molecules. The mechanisms involved in generating selectivity and modulating STAT activity have been the focus of intense studies. This work has led to the discovery of novel families of proteins that regulate Jak-STAT signaling. Recently, the structures of a STAT dimer/DNA complex and of the amino-terminal domain have been solved, providing new insights into the function of these versatile proteins.     

Para-aortic lymph node metastasis in carcinoma of the distal bile duct

BACKGROUND/AIMS: Lymph node dissection plays an important role in radical surgery for pancreaticoduodenal carcinomas. The aim of this study was to identify the critical areas of lymph node dissection in carcinoma of the distal bile duct. METHODOLOGY: Between January 1995 and December 1996, 20 consecutive patients with distal bile duct cancer underwent pancreaticoduodenectomy with extended lymph node dissection (including the para-aortic nodes). Histopathologic findings were examined with special reference to lymph node metastasis. RESULTS: Histological evidence of lymph node metastasis was found in 11 patients (55%). The areas with frequent metastases were the posterior pancreaticoduodenal lymph nodes (35%), and the nodes around the hepatoduodenal ligament (35%) and around the common hepatic artery (30%). Para-aortic lymph node involvement was identified in 5 patients (25%). Most of these existed in the inter-aorticocaval space. Pancreatic parenchymal invasion was present in 10 patients. Half of the patients with pancreatic invasion had para-aortic nodal involvement. Para-aortic lymph node metastasis was significantly associated with pancreatic parenchymal invasion (p<0.05). CONCLUSIONS: In carcinoma of the distal bile duct with pancreatic parenchymal invasion, extended lymph node dissection (including para-aortic nodes) should be undertaken because of the relatively high incidence of metastasis.     

Assessment of cervical lymph node metastasis in esophageal carcinoma using ultrasonography

Cadherins are Ca2+-dependent cell-cell adhesion molecules, and are involved in the formation and maintenance of the organocellular architecture. Using a combination of molecular biologic and biochemical methods, we analyzed cadherins expressed on cultured human malignant lymphoma cell lines (adult T cell lymphomas, human T cell leukemia virus type 1-negative T cell lines, and thymus-derived lymphoma cell lines), and obtained evidence that N-cadherin is the major cadherin expressed on these cells. These cells were found to form cell aggregates in a Ca2+-dependent manner, and more importantly to coaggregate and adhere with cells expressing N-cadherin, suggesting that N-cadherin on lymphoma cells is functionally active. Therefore, N-cadherin expressed on lymphoma cells could underlie the frequent invasion of these cells into the mesenchymal tissue in the skin and the central nervous system.     

Surgical intervention for patients with stage IV-A hepatocellular carcinoma without lymph node metastasis: proposal as a standard therapy

OBJECTIVE: The aim of this study was to evaluate the effects of surgical treatments for patients with stage IV-A hepatocellular carcinoma (HCC) without lymph node metastasis. SUMMARY BACKGROUND DATA: Nonsurgical therapy for highly advanced HCC patients has yielded poor long-term survival. Surgical intervention has been initiated in an effort to improve survival. METHODS: The outcome of 150 patients who underwent hepatic resection was studied. Survival analysis was made by stratifying stage IV-A HCC patients into two groups-those with and those without involvement of a major branch of the portal or hepatic veins. Those with involvement were further divided into subgroups according to major vascular invasions. RESULTS: Patients who had multiple tumors in more than one lobe without vascular invasion had a significantly better 5-year survival rate (20%) than those with vascular invasion (8%) (p < 0.01). The survival rate of patients with hepatic vein tumor thrombi (10%) was better than the rate for those with tumor thrombi in the inferior vena cava (0%), in whom no patients survived more than 2 years, although the survival rate for those with portal vein tumor thrombi in the first branch (11%) was no different from the rate for that in the portal trunk (4%). The operative mortality decreased from 14.3% in the first 6 years to 1.4% in the following 5 years. CONCLUSIONS: Surgical intervention for stage IV-A HCC patients brought longer survival rates for some patients. We recommend surgical intervention as an effective therapeutic modality for patients with advanced HCC.     

Papillary thyroid carcinoma: MR diagnosis of lymph node metastasis

We investigated the in vitro antifungal activity of amphotericin B, alone and in combination with rifabutin, an inhibitor of bacterial RNA polymerase, against 26 clinical isolates of Aspergillus and 25 clinical isolates of Fusarium. Synergy or additivism between these drugs was demonstrated against all isolates tested. Amphotericin B MICs were reduced upon combination with rifabutin from a mean of 0.65 microg/ml to a mean of 0.16 microg/ml against Aspergillus, and from a mean of 0.97 microg/ml to a mean of 0.39 microLg/ml against Fusarium (P < 0.000001 for both). Similarly, the MICs of rifabutin were reduced upon combination with amphotericin B from a mean of >32 microg/ml to a mean of 1.1 microg/ml against both fungi (P < 0.000001 for both). These positive interactions were corroborated by a colony count study with two Fusarium isolates, for which treatment with the combination of subinhibitory concentrations of amphotericin B (at concentrations 2- and 4-fold less than the MIC) and rifabutin (at concentrations ranging from 4- to 64-fold less than the MIC) resulted in 3.2-log reductions in colony counts compared to those after treatment with either drug alone. Inhibition of RNA synthesis was shown to be the mechanism of antifungal activity. These results suggest that inhibition of fungal RNA synthesis might be a potential target for antifungal therapy.     

A rational treatment of stage I epithelial ovarian cancer

OBJECTIVE: To evaluate the incidence of lymph node metastasis and the role of lymphadenectomy in stage I epithelial ovarian cancer. METHODS: Forty patients with stage I epithelial ovarian cancer treated from 1985 to 1990, were divided into two groups and retrospectively analyzed. First group of 20 patients were treated by routine surgery and cis-platinum based chemotherapy. Second group of 20 patients were treated by routine surgery and cis-platinum based chemotherapy plus retroperitoneal lymphadenectomy, and on the basis of with normal ovary and uterus preserved in the younger stage I a patients. A comparison was made between the five-year survival rates of the two groups. RESULTS: Four patients in the second group were found to have retroperitoneal lymph node metastasis and should be staged as II c postoperatively. In three of the four patients aortic lymph node metastasis were diagnosed. The chances of metastasis to the pelvic and to the aortic lymph nodes were nearly equal. There is a significant difference in the 5-year survival rates between the two groups (85% vs 100%, P < 0.05). Ten patients with their ovaries and uteri preserved are living and well. CONCLUSION: It is suggested that to obtain accurate FIGO staging and to improve survival and its quality, retroperitoneal lymphadenectomy should be performed in all patients with stage I eipthelial ovarian cancer, and younger patients with stage I a cancer may preserve their gestational functions if desired.     

Factors related to axillary lymph node metastasis in T1 breast carcinoma

PURPOSE: To describe the sonographic features of paraovarian cystadenomas. MATERIALS AND METHODS: We searched the computerized pathology and radiology databases for cases of histopathologically proved paraovarian cystadenomas from January 1993 through December 1996 in which preoperative sonography had also been performed. Fourteen paraovarian cystadenomas or cystadenofibromas were identified in 14 patients aged 20-57 years. Sonographic and pathologic findings were correlated. RESULTS: Three of the masses appeared as simple cysts sonographically. Of the remaining 11 masses, nine had solid nodular areas within the cyst; three had septations; and four had a thick wall, an irregular wall, or both at sonography. At sonography, four masses were thought to arise outside the ovary, four were erroneously thought to arise in the ovary, and the location was uncertain in six. CONCLUSION: Paraovarian cystadenomas are cystic masses that usually contain one or more small solid nodules and occasionally contain septations.     

The accuracy of staging: an important prognostic determinator in stage I ovarian carcinoma. A multivariate analysis

BACKGROUND: Several prognostic factors for stage I ovarian carcinoma have been analyzed. Some of them are biological and clinical in nature, but others such as the thoroughness of the staging procedure, the extent of the surgery and the philosophy of treatment, are defined by the human element. PATIENTS AND METHODS: We reviewed the records of 351 patients with Stage I ovarian cancer who had been treated from 1981 to 1991. For all patients the following information was available: age, size of the tumor, FIGO sub-stage, tumor grade, histologic type, rupture of the tumor, cytology, extent of the staging and of the surgery (hysterectomy and bilateral salpingo-oophorectomy vs. fertility-conserving surgery) and use of adjuvant treatments. The thoroughness of the staging was defined as: optimal staging: total abdominal hysterectomy and bilateral salpingo-oophorectomy or fertility-conserving surgery, peritoneal cytology or washing, omentectomy, multiple peritoneal biopsies, sampling of the retroperitoneal nodes or formal lymphadenectomy, peritoneal staging: all the criteria described above were met with the exception of retroperitoneal sampling, incomplete staging: lack of any of the previously-cited criteria. RESULTS: An optimal staging was performed in 100 patients, a peritoneal staging in 107 and an incomplete staging in 144. Radical surgery was performed in 295 women and fertility-conserving surgery in 56. With a median follow-up of 108 months (range 14-184) 64 patients had recurrence of the tumor. Fifty-three died of the disease, two are currently alive with disease and nine were salvaged by surgery and/or chemotherapy. In a multivariate analysis only the tumor grade and the type of staging were significant independent prognostic factors for both disease-free and overall survival. CONCLUSIONS: As described by other authors, we confirm that tumor grade is the single most important biological prognostic factor in early ovarian carcinoma. The thoroughness of the staging impacts significantly on survival, particularly in poorly differentiated carcinomas. Fertility-sparing surgery is not associated with a worse outcome than standard radical surgery.     

Prognostic factors that predict pelvic lymph node metastasis from endometrial carcinoma

BACKGROUND: Recent reports indicate that certain pre- and intraoperatively determined risk factors are predictive of pelvic lymph node metastases from endometrial cancer, allowing selective pelvic lymph node dissection. The objective of this study was to evaluate the accuracy of pre-, pre-/intra- and postoperatively determined tumor characteristics. METHODS: The study is based on 100 patients treated from 1987-1991 with total abdominal hysterectomy and bilateral salpingo-oophorectomy. In all patients thorough pelvic lymphadenectomies were performed (no sampling). These patients were evaluated according to different macroscopic and histologic tumor characteristics retrospectively in a blind fashion (the lymph node status was later determined separately). Multivariate analysis was applied and the results were compared using receiver operator characteristic curves. In 15 of 100 patients, pelvic lymph node metastases could be histologically demonstrated. RESULTS: Multivariate analysis of 22 tumor characteristics identified the following as being independent in relation to pelvic lymph node metastases: preoperatively determined characteristics: serous papillary tumor type, invasion of myometrium, and histologic grade (Christopherson); pre-/intraoperatively: serous papillary type, histologic grade (Christopherson), and cervical involvement; and postoperatively: lymphangiosis carcinomatosa and hemangiosis carcinomatosa. Receiver operator characteristic curves show that for pelvic node metastases the postoperatively determined histologic findings are more predictive than all other factors that can be evaluated pre- and/or intraoperatively. CONCLUSION: Pre- and intraoperative tumor characteristics can determine the individual risk for pelvic lymph node involvement, but additional studies addressing the therapeutic value of pelvic lymphadenectomy would be necessary to define a probability threshold for lymphadenectomy in a decision analysis.     

Lymph node metastasis in gastric cancer in the upper third of the stomach--surgical treatment on the basis of the anatomical distribution of positive node

BACKGROUND/AIMS: Little is known about the most appropriate surgical procedure for gastric cancer in the upper third of the stomach. The objective of this study was to determine the most appropriate surgical treatment for gastric cancer in the upper third of the stomach. METHODOLOGY: The clinicopathological characteristics of 115 node-positive gastric cancers in the upper third of the stomach were reviewed retrospectively and compared with those of 111 node-negative gastric cancers in the upper third of the stomach. RESULTS: Node-positive gastric cancers showed higher rates of peritoneal metastasis (p < 0.005), larger tumor sizes (p < 0.005), deeper tumor penetration (p < 0.005), higher rates of diffuse type in histology (p < 0.025), and more advanced histological stages (p < 0.005), than node-negative gastric cancers. Patients with node-positive gastric cancer demonstrated a poorer survival rate than those with node-negative gastric cancer (p < 0.005). Lymph node metastasis along the lower stomach was observed in cases of gastric cancer which had invaded beyond the muscularis propria of the stomach but not in those confined within the muscularis propria. No lymph node metastasis in the splenic hilum was found in association with gastric cancer when the depth was limited to the mucosa or the submucosa. CONCLUSION: The appropriate surgical procedures for the treatment of gastric cancer in the upper third of the stomach are as follows: a) proximal gastrectomy without splenectomy for gastric cancer when the depth is limited to the mucosa or the submucosa, b) proximal gastrectomy with splenectomy for gastric cancer when the depth of invasion extends to the muscularis propria, c) total gastrectomy with splenectomy for gastric cancer when the depth of invasion extends beyond the muscularis propria.     

Lymph node Merkel cell carcinoma with no evidence of cutaneous tumor--report of two cases

We report two cases of Merkel cell carcinoma within inguinal and axillary lymph nodes, respectively, showing no clinico-pathologic evidence of a primary (extranodal) tumor; one of our patients was alive with no evidence of disease five years and ten months after the surgical excision of the neoplasm with no postoperative chemotherapy. The diagnosis of nodal Merkel cell carcinoma needs to be supported by a careful immunohistochemical study: in fact, cytokeratin- and neurofilament-positive paranuclear "dots", as well as epithelial antigens and neuroendocrine markers may be variably expressed in tumor cells, thus requiring the application of a complete antibody panel. In the presence of a nodal Merkel cell tumor, an exhaustive clinico-radiologic search for a primary tumor must be carried out. After the exclusion of any reasonable starting point of the neoplasm, a provisional diagnosis of "primary" nodal Merkel cell carcinoma may be acceptable; since a primary extracutaneous tumor is expected to follow a less aggressive course than a metastatic one, follow-up data may provide indications as to the truly extracutaneous origin of Merkel cell carcinoma.