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Phi Phi Island ......... Thailand

Phi Phi Island ......... Thailand. Lymph Node Size in Uterine Cancer: A revisit. Siriwan Tangjitgamol,. S. Manusirivithaya,. S. Jesadapatarakul, S. Leelahakorn, T. Thawaramara. Department of Obstetrics and Gynecology, Department of Pathology.

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Phi Phi Island ......... Thailand

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  1. Phi Phi Island ......... Thailand

  2. Lymph Node Size in Uterine Cancer: A revisit Siriwan Tangjitgamol, S. Manusirivithaya, S. Jesadapatarakul, S. Leelahakorn, T. Thawaramara Department of Obstetrics and Gynecology, Department of Pathology Bangkok Metropolitan Administration Medical College and Vajira Hospital, Bangkok, Thailand

  3. Introduction • - an important step in surgical staging for uterine cancer (FIGO 1988) LN evaluation Diagnostic & therapeutic aims • Stated as “selective or sampling”

  4. “How” to do the sampling? SIZE: LN size > 1 cm • abnormal enlargement • suspicious for pathologic conditions • reactive hyperplasia • tumor metastasis • inflammation etc.

  5. So ...... “Can we truly rely on the size of LN to determine uterine cancer metastases?”

  6. Objectives • To evaluate the association between & LN size uterine cancer metastases • To determine LN size with the best diagnostic values for cancer metastases

  7. Materials • Pathologic sections of pelvic/paraaortic LNs of uterine cancer patients who had surgical staging between 1994 to 2004 Methods • Measuring: • maximal dimension of each LN • metastatic lesion in positive LN

  8. Backgrounds in Department of Pathology

  9. Results Number of LN and anatomic sites 1. 4280 LNs from 178 uterine cancer patients • Pelvic 2941 nodes (68.7%) • Common iliac 592 nodes (13.8%) • Subaortic 86 nodes (2.0%) • Paraaortic 544 nodes (12.7%) • Miscellaneous groups 31 nodes (0.7%)

  10. Results Histology & numbers of LN/patients 2. * Other sarcomas included endometrial stromal sarcoma, leiomyosarcoma, andnot otherwise specified sarcoma

  11. Results regarding number of LN 3.

  12. Results single positive LN 3. 9/28 (32%) had only single positive LN 8/9 (88.9%) LNs - not the largest nodes from that case 5/9 (55.6%) LNs - sized < 1 cm

  13. Results regarding size of LN 4. positive nodes: 9 mm (1-50 mm) (n = 86 nodes) Median size p  0.0001 negative nodes: 5 mm (1-35 mm) (n = 4194 nodes)

  14. Results LN sizes in subgroups 5. Note: No significant differences between positive LNs in tumors of: • grade I VS grade II-III • adenocarcinoma VS sarcoma

  15. Results LN size & pathology 6. 52.3% 47.7% a Percentages of negative nodes at different levels of LN size/ total negative LN b Percentages of positive nodes at different levels of LN size/ total positive LN c Percentages of positive nodes at different levels of LN size/ total nodes

  16. Figure 1. Receiver-Operating curve of LN size to determine LN metastases in uterine cancer

  17. Results 7. Diagnostic performance: Sensitivity 47.7% (46.2%-49.2%) Specificity 76.7% (75.4%-77.9%) Negative predictive value 98.6% (98.3%-99.0%) Positive predictive value 4.0% (3.4%-4.6%) (95% confidence interval) LN at 1 cm (size of interest)

  18. Results size of metastatic lesions 8. Median metastatic lesions: 5.5 mm (1-50 mm) • < 2 mm…….. 31.4% • < 5 mm…….. 50.0% • < 10 mm…….. 70.0%

  19. Discussion

  20. Objectives • To evaluate the association between & LN size uterine cancer metastases • To determine LN size with the best diagnostic values for cancer metastases

  21. Discussion 1. An association between …….. LN size & uterine cancer metastases No appropriate …….. LN size to determine cancer metastases

  22. Discussion 2. • Size of + LN was significantly larger than that of – LN (9 mm VS 5 mm)………. “ The difference is of questionable benefit in clinical practice”

  23. Discussion 3. “We have to perform a complete LND” • If we base on nodal size of 10 mm as pathologic enlargement--- low sensitivity of 47.7% “We would miss >1/2 of positive nodes” • If we set it at 3 mm ---high sensitivity of 97.7%

  24. Discussion Characteristics of LN metastasis in EMC 4. a Microscopic referred to size < 2-3 mm b Study of Chuang et al. presented the result as number of cases (not lymph node)

  25. Facts & Figures ....... • Microscopic metastasis …… 31-37% • Subcentimeter positive LNs ..… 48-57% • Single positive LNs ……….… 25-32% Subcentimeter single positive LNs… 56-100% 89% of these single positive LNs ------- were not the largest node from that case.

  26. LN palpation • < 10% positive LNs --- grossly enlarged • 36% positive LNs being missed by palpation Probably insufficient for process of selection Creasman et al. Cancer 1987;60:2035-41. Eltabbakh GH. Am J Obstet Gynecol 2001;184:1177-81.

  27. Other features of LN Shape consistency adherence to surroundingtissue False-negative rates ~ 19-26% Positive predictive values ~ 56-65% facilitate differentiation between post./ neg. LN Eltabbakh GH. Am J Obstet Gynecol 2001;184:1177-81. Khunnarong et al. J Med Assoc Thai 2004;87 (Suppl3):S80-4.

  28. conclusion from our study So ...... LN size --- not a good predictor of LN metastasis Selective LN resection might miss the target positive LN!!! Complete LN dissection --- for patients undergoing surgical staging, in whom LN assessment is indicated

  29. Thank you for your kind attention Welcome to 2008 IGCS Bangkok, Thailand

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