Sonography: An underutilized diagnostic tool in the assessment of metastatic groin nodes

Krishna, Ravula Phani; Sistla, Sarath Chandra; Smile, Robinson; Krishnan, Ramya

doi:10.1002/jcu.20420

Cited by 38 publications

(11 citation statements)

References 15 publications

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“…The dimensions of these lymph nodes are consistent with those found in the literature, where the maximum diameter reported is 1-2 cm [12]. However, in contrast to other studies, we report a relatively high percentage of lymph nodes (9.86%) with a maximum diameter that exceeds 2 cm.…”

Section: Discussionsupporting

confidence: 90%

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Ultrasound morphology of inguinal lymph nodes may not herald an associated pathology

Solivetti

Elia

Graceffa

et al. 2012

J Exp Clin Cancer Res

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BackgroundAmong patients undergoing follow-up after surgery for melanoma, ultrasound (US) very often reveals lymph nodes in groin area, that do not show clear characters of a metastatic lesion yet that have atypical US features, which could result in diagnostic uncertainty. We evaluated such lesions among a cohort of patients.MethodsThe study population consisted of patients who presented consecutively to our facility for a control between 1 January 2009 and 30 July 2010 and who had undergone surgery for a melanoma, at least 6 months earlier, in areas draining to lymph nodes of the groin but choosing – for this study - the opposite side to the natural drainage. The following parameters of the US performed on the lymph nodes were evaluated: number and size, aspects of the outline, including any extroflexion of the outline and contours morphology, homogeneity and thickness of the cortex and aspects of the hilus, characteristics of the vascularisation of the lymph node at color-power Doppler. A second US examination was performed on the same area after at least 12 months.Results and conclusionsWe found a very high number of patients (42/124) with lymph nodes that did not appear to be fully normal at US examination, particularly those with structural alterations in the hilus and slight loss of physiologic curvature of the outlines, with moderate thickening of the cortex. Of the 124 patients, who were followed for at least one year, 42 showed these characteristics, and none of these showed any progression to malignancy at follow-up. Based on these results, we can conclude that focusing excessively on such US findings could lead to the inappropriate performance of additional diagnostic tests, with a consequent increase in management costs and a worsening of the quality of life for these patients.

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Section: Discussionsupporting

confidence: 90%

“…Moreover, needle aspirates and excisional biopsies often provide false-negative results in these cases [12]. The size of the lymph nodes does not seem to be indicative of a pathology, although there could be a coexisting low grade lymphoma, which could produce similar US findings.…”

Section: Discussionmentioning

confidence: 99%

Ultrasound morphology of inguinal lymph nodes may not herald an associated pathology

Solivetti

Elia

Graceffa

et al. 2012

J Exp Clin Cancer Res

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“…An additional tool is preoperative ultrasound with fine-needle aspiration cytology. Ultrasound may be able to diminish the risks associated with tumor blockage by detecting sizable metastases that are not yet palpable (16)(17)(18)(19). Another measure for reducing the chances of false-negative results is intraoperative palpation of the wound to identify unstained and nonradioactive lymph nodes that are suspected of containing metastases because of their consistency but that were not found during physical examination and ultrasound (6,20,21).…”

Section: Discussionmentioning

confidence: 99%

Visualization of Tumor Blockage and Rerouting of Lymphatic Drainage in Penile Cancer Patients by Use of SPECT/CT

Leijte¹,

Ploeg²,

Olmos³

et al. 2009

J Nucl Med

111

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The reliability of sentinel node biopsy is dependent on the accurate visualization and identification of the sentinel node(s). It has been suggested that extensive metastatic involvement of a sentinel node can lead to blocked inflow and rerouting of lymph fluid to a ''neo-sentinel node'' that may not yet contain tumor cells, causing a false-negative result. However, there is little evidence to support this hypothesis. Recently introduced hybrid SPECT/ CT scanners provide both tomographic lymphoscintigraphy and anatomic detail. Such a scanner enabled the present study of the concept of tumor blockage and rerouting of lymphatic drainage in patients with palpable groin metastases. Methods: Seventeen patients with unilateral palpable and cytologically proven metastases in the groin underwent bilateral conventional lymphoscintigraphy and SPECT/CT before sentinel node biopsy of the contralateral groin. The pattern of lymphatic drainage in the 17 palpable groin metastases was evaluated for signs of tumor blockage or rerouting. Results: On the CT images, the palpable node metastases could be identified in all 17 groins. Four of the 17 palpable node metastases (24%) showed uptake of radioactivity on the SPECT/CT images. In 10 groins, rerouting of lymphatic drainage to a neo-sentinel node was seen; one neo-sentinel node was located in the contralateral groin. A complete absence of lymphatic drainage was seen in the remaining 3 groins. Conclusion: The concept of tumor blockage and rerouting was visualized in 76% of the groins with palpable metastases. Precise physical examination and preoperative ultrasound with fine-needle aspiration cytology may identify nodes with considerable tumor invasion at an earlier stage and thereby reduce the incidence of false-negative results.

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“…Urethral invasion is represented in the TNM system as a T3, which should also be revised. 38 Patients with an index 4 tumor should be individually evaluated for other risk factors or using image studies 32,43,64 or nodal aspiration biopsy in cases of palpable groin nodes. 51 For some patients, especially those without palpable nodes it may be recommended to follow the actual gold standard for groin management, that is, to perform superficial and modified inguinal dissections according to intraoperative frozen sections for defining the presence of microscopic groin metastasis.…”

Section: Discussionmentioning

confidence: 99%

The Prognostic Index

Chaux

Caballero

Soares

et al. 2009

American Journal of Surgical Pathology

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A concern of surgical oncologists has been to find a method to select patients for groin dissection in penile carcinomas considering the high morbidity of this procedure. A promising methodology, in the identification of early metastatic foci by the sentinel lymph node technique (initiated in Paraguay in the 1970s), was found, using a static anatomic approach, to be associated with a recurrence rate of 30%. Later, a dynamic method using radioactive tracers and peritumoral dye injection was introduced with an improvement in patients' outcome. Recurrences, however, remained high in most studies at a rate of about 15% to 20% except in few highly specialized centers with failure rates of 5%. The technical sophistication, lack of multicenter reproduction, and cost of dynamic sentinel node biopsies preclude their routine implementation in developing countries and other approaches are necessary. Because histologic grade, depth of tumor infiltration, and perineural invasion (PNI) are considered among the most important pathologic prognostic parameters in penile cancer, we devised a Prognostic Index combining these 3 factors. In this study, we are evaluating the incidence of nodal metastasis according to the Prognostic Index score. Pathologic materials from 193 patients with penectomy/circumcision and bilateral groin dissections for invasive squamous cell carcinoma were analyzed. The Prognostic Index (ranging from 2 to 7) consisted in the addition of numerical values given to histologic grade (1 to 3), deepest anatomic level involved by cancer (1 to 3), and presence of PNI (0 or 1). Histologic grades were defined as follows: grade 1, carcinomas with minimal to no atypias; grade 3, tumors showing any proportion of anaplastic cells; and grade 2, the remainder tumors. The anatomic levels and their numerical values were: in glans, lamina propria, 1; corpus spongiosum, 2; and corpus cavernosum, 3. In foreskin they were: lamina propria, 1; dartos, 2; and skin, 3. PNI was evaluated as follows: absence of PNI, 0; presence of PNI, 1. Penile intraepithelial neoplasia (carcinoma in situ), or index 1, was excluded from the study. Mean follow-up obtained in all patients was of 81 months. The distribution of cases and rate of metastasis according to index scores were: 2 (1 case), no metastasis; 3 (17 cases), no metastasis; 4 (35 cases), 20% of metastasis; 5 50 cases), 50% of metastasis; 6 (47 cases), 66% of metastasis; and 7 (43 cases), 79% of metastasis. On logistic regression analysis evaluating various pathologic factors, Prognostic Index scores were found as the best predictors of inguinal node metastasis and patients' survival. Inguinal node dissections might not be necessary for patients with low indices (2 and 3). Nodal dissections might be formally indicated for high-grade indexes (5 to 7). Patients with index 4 should be individually assessed for nodal dissection. If sentinel node biopsy cannot be performed for various reasons the Prognostic Index might represent a useful pathologic guide to the clinicians in the often difficu...

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Sonography: An underutilized diagnostic tool in the assessment of metastatic groin nodes

Abstract: Sonography is useful in the evaluation of groin nodes for metastatic disease. It can help select a suspicious lymph node for cytologic/histologic confirmation.

Cited by 38 publications

References 15 publications

Ultrasound morphology of inguinal lymph nodes may not herald an associated pathology

Ultrasound morphology of inguinal lymph nodes may not herald an associated pathology

Visualization of Tumor Blockage and Rerouting of Lymphatic Drainage in Penile Cancer Patients by Use of SPECT/CT

The Prognostic Index

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