Mediastinal lymph node metastasis from esophageal carcinoma: CT assessment with pathologic correlation

Computed tomographic (CT) scans were performed in 179 patients with esophageal carcinoma to evaluate mediastinal lymph node metastasis. Histopathologic findings were compared with CT findings in a total of 7,218 resected lymph nodes. First, the criterion for lymph node metastasis on CT scans was 10 mm or more in long transverse diameter. The overall sensitivity and positive predictive value (PPV) were 19% (60 of 317 nodes) and 33% (60 of 180 nodes), respectively. Analysis of each of the eight subgroups of mediastinal nodes revealed that the PPV was more than 70% in node Nos. 105, 108, 110, and 112. In other subgroups, however, the PPV was less than 60%. Sensitivity was less than 50% in all eight subgroups. Second, the criterion for metastasis was 10 mm or more in short transverse diameter. The overall sensitivity and PPV were 8% (26 of 317 nodes) and 63% (26 of 41 nodes), respectively. Analysis of subgroups showed that the PPV in No. 106 nodes increased to 92%. In No. 106 nodes, use of a 5 mm criterion in long transverse diameter increased sensitivity to only 55%. Of the 317 histopathologically proven metastatic lymph nodes, 90 nodes (28%) were 10 mm or more in size, 112 (35%) were 5-10 mm, and 115 (36%) were less than 5 mm. Of the 6,901 non-metastatic lymph nodes, 473 nodes (7%) were 10 mm or more in size. Small (less than 5 mm in size) metastatic nodes were present in all eight subgroups. Among No. 107 and 109 nodes, large (10 mm or more in size) nonmetastatic nodes were prominent, resulting in low sensitivity and PPV. We conclude that CT does not provide an accurate assessment of metastatic versus non-metastatic mediastinal lymph nodes in patients with esophageal carcinoma.     

Prognostic factors of cervical lymph node metastasis in head and neck squamous cell carcinoma

AIMS AND BACKGROUND: The metastatic spread of squamous cell carcinoma of the head and neck (SCCHN) to the cervical lymph nodes is a negative prognostic factor in terms of survival. We have used multivariate analysis to identify the possible prognostic significance of a number of clinical and pathological characteristics in relation to possible involvement of the cervical lymph nodes in a series of 396 patients. METHOD: 396 patients with SCCHN were studied. Variables regarding the patient, the carcinoma and histology were analysed by multivariate analysis using BMDP's PLR programme. RESULTS: Some variables appear to represent predisposing factors for tumor spread to the lymph nodes: tumor site (supraglottic larynx: P = 0.005; base of the tongue: P = 0.02; hypopharynx: P = 0.02), grading (P = 0.001), and a number of histological parameters (lower degree of histological differentiation: P = 0.001; vascular permeation: P = 0.04; perineural invasion: P < 0.05; prevalently plasmocytic infiltrate: P < 0.05). CONCLUSION: The identification of cases at risk for metastasis can be improved by the assessment of prognostic factors, with a consequent improvement in treatment strategies.     

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.     

Prediction of cervical lymph node metastasis in squamous cell carcinoma of the tongue/floor of mouth

BACKGROUND: Cervical lymph node metastasis has a major influence on survival in oral cancer. However, the factors influencing its occurrence are uncertain. Our aim was to improve the prognostic efficiency of the histologic assessment of the primary tumor in predicting metastasis in an individual patient. METHODS: The relationship between selected clinical and histologic features of the primary tumor of tongue/floor of the mouth and the actual metastatic status was investigated in 45 patients. Invasive cell grading was supplemented by histologic measurements of tumor size and assessments of vascular and perineural invasion. RESULTS: Ten histologic features showed significant differences in relation to metastasis. A logistic regression model with two predictor variables (total histologic malignancy score and vascular invasion) classified correctly 39 (87%) of the 45 cases. CONCLUSIONS: Histologic assessment of tumor size and malignancy grade are useful in predicting metastasis. Vascular and perineural invasion are important predictors and should be included in multifactorial malignancy grading schemes. Application of the prognostic index to the biopsy specimen would aid in treatment planning.     

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.     

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.     

Two cases of gastric involvement of esophageal cancer: intramural metastasis and intramural lymph node metastasis

Cases of esophageal cancer with intramural metastasis to the stomach and esophageal cancer with metastasis to an intramural lymph node of the stomach are herein reported. The former patient was a 52 year-old male. Squamous cell carcinoma (SCC) of the lower esophagus with an intramural metastasis located at the gastric cardia and a small leiomyoma at the fornix were resected. The latter patient was a 70 year-old female. SCC of the lower esophagus and an intramural lymph node metastasis located at the anterior wall of the gastric cardia were resected. The patient died nevertheless of multiple liver metastases. These gastric involvements were detectable by endoscopy before surgery. The clinicopathological features of these esophageal cancers were characterized; the sites were the lower part of the esophagus, and extreme lymphatic and vascular invasions were shown histologically. The gastric tumors were located in the upper third of the stomach, and the findings revealed submucosal tumors. It is therefore important to discriminate other gastric tumors, and to resect them simultaneously with esophageal cancer when a gastric tube has been used for reconstruction after esophagectomy.     

Prognostic evaluation of lymph node metastasis in thoracic esophageal cancer--an analysis of 212 cases

The presence of immunoreactive neurofilament proteins has previously been reported in Merkel cell carcinomas but not in normal human epidermal and dermal Merkel cells. We have studied the immunoreactivity of epidermal Merkel cells for neurofilament triplet proteins (68 KD, 70 KD, 160 KD, 200 KD), using epidermal sheets prepared from the plantar skin of human adults, which enabled us to survey large numbers of Merkel cells. Neurofilament protein 200 KD-positive cells were readily identified, while neurofilament protein 68 KD-, 70 KD- and 160 KD-positive cells were largely absent. 200 KD-positive cells in the epidermis were confirmed to represent Merkel cells by a sequential immunoenzyme labeling for the simple epithelial type cytokeratin (No. 8). 200 KD-positive cells were 5.9% of the total number of epidermal Merkel cells. Despite a heterogeneous expression of neurofilament protein subspecies between the normal and transformed Merkel cells, the presence of neurofilament proteins in epidermal Merkel cells may link them to Merkel cell carcinomas.     

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.     

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.     

Predicting regional lymph node metastasis in carcinoma of the penis: a comparison between fine-needle aspiration cytology, sentinel lymph node biopsy and medial inguinal lymph node biopsy

OBJECTIVE: To evaluate the accuracy of clinical examination and fine-needle aspiration cytology (FNAC) in detecting groin metastases in patients with carcinoma of the penis, and to assess the positive and negative predictive value (PPV, NPV) of a preliminary sentinel lymph-node biopsy (SNB) and biopsy of the most medial of the horizontal group of inguinal lymph nodes (MIN) in selecting patients for an ilio-inguinal block dissection. PATIENTS AND METHODS: The study comprised 28 patients (56 groins) with Stage I (one), Stage II (11) and Stage III (16) carcinoma of the penis. All patients underwent a detailed clinical examination followed by FNAC of the palpable inguinal nodes, and were subsequently submitted for block dissection. The MIN, the SN and the rest of the inguinal and iliac nodes were histologically examined separately for metastases. RESULTS: The clinical evaluation had a sensitivity of 74%, a specificity of 61%, a PPV of 57% and a NPV of 77%. The corresponding values for FNAC were all 100%, and the specificity and PPV for both MIN and SN were 100%. The sensitivity and NPV of MIN were higher than for SN, although not significantly so. CONCLUSION: Clinical examination alone is inaccurate in selecting patients with carcinoma of the penis for block dissection. FNAC is accurate and specific when nodes are palpable; in those with impalpable nodes a preliminary MIN biopsy followed by SNB if the MIN biopsy is negative will accurately select all patients with metastases in the groin nodes. This can be performed by examining frozen sections of the lymph nodes; if positive, block dissection can be carried out at the same time.     

The role of human papillomavirus DNAs in cervical carcinoma and risk of lymph node metastasis: association with 72-kilodalton metalloproteinase immunostaining

BACKGROUND: The role of human papillomavirus (HPV) as a prognostic factor in cervical carcinoma is not understood completely and little is known regarding the intrinsic mechanisms involved in the metastatic process of HPV positive carcinoma. The authors evaluated HPV status with respect to clinical features in early stage cervical carcinoma, with special emphasis on lymph node spread. The authors also analyzed the relation between HPV, lymph node involvement, and 72-kilodalton (kDa) metalloproteinase immunostaining, an enzyme that cleaves Type IV collagen and may play a role in tumor metastasis. METHODS: Thirty-two patients with International Federation of Gynecology and Obstetrics Stage I and IIA squamous cell cervical carcinoma treated by primary radical surgery were reviewed. Histologic grade of differentiation, tumor size, fractional depth of invasion, and lymph node spread were evaluated with respect to HPV status and 72-kDa metalloproteinase immunostaining. HPV DNA was detected by polymerase chain reaction and the primers potentially recognized at least the following HPV subtypes: 6, 11, 16, 18, 31, 33, 34, 35, 42, 51, 56, and 58. Immunohistochemical staining was performed using the avidin-biotin complex technique. Affinity-purified rabbit anti-72-kDa metalloproteinase antibody was used. RESULTS: HPV DNA was detected in a total of 69% of cases, and HPV-16 was the most frequent type detected. HPV positive carcinomas showed a significantly higher rate of lymph node metastases than HPV negative carcinomas (45% vs. 10%; P = 0.03); similarly, 72-kDa metalloproteinase index was significantly higher (P = 0.001). CONCLUSIONS: These findings suggest a relation between HPV and risk of lymph node metastasis, which may be mediated by an increased production of 72-kDa metalloproteinase.     

Factors affecting prognosis of papillary thyroid carcinoma with bilateral cervical lymph node metastases

One hundred thirty nine cases of papillary thyroid carcinoma with bilateral lymph node metastases were reviewed. They were surgically treated at the Cancer Hospital of Shanghai Medical University in the years from 1956 through 1990. There were 73 men and 66 women with a median age of 35 (range 11-70) years. The median follow-up period was 11 years. Kaplan-Meier survival curves were calculated for the population. The overall survival rate was 94.7% at 5 years, 85.9% at 10 years, and 82.3% at 15 years. In univariate analysis, factors influencing prognosis are age at diagnosis, tumor size, extrathyroidal invasion, residual tumor and thoroughness of excision. When Cox proportional risk model was applied to analyze the survival data, factors of survival significance are the age at diagnosis and thoroughness of excision.     

Relationship between nm23-H1 expression and lymph node metastasis and prognosis in cervical cancer

OBJECTIVE: To investigate the expression of nm23-H1 in cervical carcinoma and its significance. METHODS: Expression of nm23-H1 was examined by immunohistochemical method in 39 cases of adenocarcinoma and 39 cases of squamous cell carcinoma of the uterine cervix. The relationship between expression of nm23-H1 and clinic-pathologic factors and prognosis was analyzed by chi-square test. RESULTS: Positive staining rate of nm23-H1 was 44.6% in adenocarcinoma and 39.2% in squamous cell Carcinoma. The positive staining rate of nm23-H1 in stage I and II adenocarcinoma was 61.1% and 28.6% respectively (P = 0.044); in patients with recurrence nm23-H1 positive rate was lower than that in patients without recurrence (21.5% vs 56%, P = 0.39); in patients with lymph node negative, nm23-H1 positive staining was more than that in patients with lymph node positive (52% vs 28.6%), however, this difference was not statistically significant (P = 0.162). None of 14 cases of lymph node metastasis was strong positive stainig, whereas 7 of 25 without lymph node metastasis were demonstrated to have strong positive staining (P = 0.031). The 5-year survival rate in negative staining group was lower than that in the positive staining group (52.5% vs 82.4%, P = 0.042). In squamous cell carcinoma there was no statistically significant relationship between nm23-H1 expression and clinic-pathologic factors and prognosis. CONCLUSIONS: nm23-H1 expression was associated with biologic behavior in cervical adenocarcinoma.     

The MRI of cervical lymph node metastasis with malignant tumor of the head and neck]

Ketamine has many properties that are advantageous to the practitioner in a rural setting, particularly if solo. The personal experience of the author is recounted, and a technique for using ketamine is outlined.     

Juvenile thyroid carcinoma with metastasis to the bilateral cervical lymph nodes--a case report

A case of juvenile thyroid carcinoma with metastasis to the bilateral cervical lymph nodes in a 9-year-old male is reported. The clinical picture of juvenile thyroid carcinoma is characterized by early metastasis to the lungs and cervical lymph nodes. In Europe, there have been many reports of thyroid carcinoma after radiation. However, our patient had received no radiation. Surgery consisted of subtotal thyroidectomy and right modified neck dissection. The tumor was a papillary adenocarcinoma and metastasis was seen in 24 out of 38 lymph nodes removed. The serum thyroglobulin level, determined by radioimmunoassay, was 184 ng/ml preoperatively, but by 8 months postoperatively the level fell to 48 ng/ml. No signs of recurrence have been found to date (30 months after the operation).     

Endoesophageal ultrasonography in the staging of esophageal carcinoma

Staging of esophageal cancer is fundamental for treatment and prognosis of this tumour. At present, barium swallow and computed tomography (CT) are the most utilized diagnostic modalities. In recent years Endoscopic Ultrasonography (EUS) has been employed for this purpose. We retrospectively compared the results of EUS and CT staging of 33 selected patients with postsurgical stage. EUS allowed a correct diagnosis of parietal invasion in 82% of cases vs 67% obtained by CT. At the same time, EUS diagnosed correctly 85% of metastatic lymph nodes vs 64% reached by CT. We believe that EUS, in combination with CT, is an appropriate modality for the staging of esophageal cancer.     

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.     

Clinicopathological features of lymph node metastasis in early gastric cancer

From 1979 through 1992, 482 cases with solitary early gastric cancer were resected in the Department of Surgery of the National Kyushu Medical Center Hospital. Among the 482 cases, the incidence of lymph node metastasis was 10.0% (48/482). The features of lymph node metastasis were studied while taking into account the combination of clinicopathological findings of the gastric cancer. Lymph node metastasis was rare in both the differentiated type mucosal cancers and submucosal cancers measuring 20 mm or smaller in size without depression. From these results, for early gastric cancer with the above-mentioned characteristics, either endoscopic therapy or local resection without lymph node dissection is considered to be sufficient treatment to obtain a favorable outcome.