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PubMed1991

[Study of para-aortic lymph node metastasis for advanced gastric cancer on consecutive lymph node slices].

Para-aortic lymph nodes (No. 16) from 21 patients with advanced gastric cancer who underwent extensive lymph node dissection, were sliced consecutively at intervals of 50 mu to study minute metastasis of No. 16 lymph nodes. Twenty-six of 30 metastatic lymph nodes had minute involvement, in which carcinoma cells were detected in marginal sinus of lymph node, microscopically. The rate of the metastases to No. 16 lymph nodes was 19% among N0-3 cases by conventional method (not consecutive slices). On the contrary, the percentage of metastasis to No. 16 lymph nodes by consecutive slices was 33% among N0-3 cases. Therefore, No. 16 nodes are involved in metastasis at high rate at operation and the extensive lymph node dissection including No. 16 nodes (R4) will be recommended to prevent lymph node recurrence caused by such a minute metastasis.

Aorta↗
PubMed1993

Lymphoscintigraphy in high-risk melanoma of the trunk: predicting draining node groups, defining lymphatic channels and locating the sentinel node.

Lymphoscintigraphy was performed in 209 patients with high-risk melanoma of the trunk referred to the Sydney Melanoma Unit and considered for lymph node dissection. Lymphoscintigraphy accurately defined the draining lymph node groups and was 94% sensitive in detecting draining sites that contained metastases. When combined with the clinical finding of palpable lymph nodes, the sensitivity rose to 98%. Most patients showed lymph drainage to one or two node groups and only 22 patients showed drainage to 3 or more node groups. The major lymph channels could also be marked on the skin prior to incontinuity dissection. Most patients had multiple draining lymph channels and these often diverged significantly from each other in the path to the draining node group. The number and location of interval nodes could be determined and marked on the skin. These and the major lymph channels could thus be excised at the time of surgery. Unusual drainage patterns were sometimes seen; for example, three patients displayed a new lymph pathway with direct drainage from the back anteriorly to the para-aortic nodes. The location of the sentinel nodes in each draining lymph-node group could also be marked on the skin prior to surgery, enabling quick and accurate identification of this node, using the blue-dye technique if biopsy were to be performed. These findings lead us to recommend lymphoscintigraphy prior to wide local excision in patients with truncal melanoma who are candidates for surgery. Lymphoscintigraphy results will help plan surgery and lead to minimum surgical intervention, consistent with effective surgical management.

Female↗
PubMed1996

[An analysis of pelvic and para-aortic lymph node metastasis in ovarian carcinoma by systematic retroperitoneal lymph node dissection].

We performed a systematic retroperitoneal lymph node dissection (RPLND) on 137 patients with primary ovarian carcinoma, of whom 97 had undergone RPLND during the primary surgery before chemotherapy and 40 had undergone RPLND during the secondary cytoreductive surgery after preoperative chemotherapy. The tentative staging of the ovarian carcinoma used in this study was determined according to the FIGO criteria without considering the pathologic findings of retroperitoneal lymph nodes. Nodal metastasis was seen in 21.9% (30/137) of them. Thirteen had positive pelvic lymph nodes (PLN) but no positive para-aortic nodes (PAN). Eleven had both positive PLN and positive PAN. Six had positive PAN but no positive PLN. The PAN was the most frequent site of metastasis (17/137). Next were the common iliac, obturator, and lateral group of deep inguinal nodes. Solitary metastasis in the patients who had undergone RPLND during the primary surgery was seen in a PAN and a common iliac node. Among 24 patients with PLN metastasis, there was a significant (p < 0.05) difference in the number of positive PLN between the patients with PAN metastasis (5.27 +/- 3.00) and the patients without PAN metastasis (2.62 +/- 1.66). These results indicate that the PAN and common iliac nodes are the most important site of nodal metastasis in ovarian carcinoma. The metastasis to PLN such as obturator node and internal iliac node seems to occur independently of the PAN metastasis, and the PAN metastasis occurs not only through the direct route but also as a consequence of extension of PLN metastases. Systematic retroperitoneal lymph node exploration therefore seems to be necessary to clarify the lymph node status.

Aorta↗
PubMed1996

[Distribution of lymph nodes and lymph node metastases in esophageal carcinoma].

BACKGROUND: Lymph node metastases are an independent prognostic factor in esophageal cancer. Accurate pathologic work up depends on detailed knowledges of number and anatomic distribution of lymph nodes and metastases. Factors that may determinate metastatic spread are also important. METHODS: One hundred and fifty-six patients with esophageal cancer were included in this study. Number and localization of nodes and metastases were documented and correlated with localization, infiltration deepness and grade of malignancy of the tumor. The effectivity of the search for nodes and metastases was also studied. RESULTS: We found 3869 lymph nodes containing 338 metastases in the 156 specimens (median 25 and 2). 53.2% of the cases exhibited metastases and 15.4% contained only solitary metastasis. The minimal number of lymph nodes for excluding of metastasis was about six nodes. Most of the nodes were found at lower esophagus and on the oral stomach resection. Tumors of the middle and upper thoracal esophagus spread also frequently to the nodes along the lesser curvature of the stomach. Between infiltration deepness and grade of malignancy of the tumors a positive association was found. CONCLUSIONS: Lymph node metastases are a frequent pathological feature in esophageal cancer which depends on infiltration deepness and grade of malignancy of the tumor. This allows the estimation of metastatic spread. For staging a minimum of six nodes must be found in the specimen. In this context the frequent metastases along the lesser curvature of the stomach must be considered.

Adenocarcinoma↗
PubMed1997

[Rational extent of lymph node dissection for carcinoma of the lower third of the thoracic ESOP-hagus of T2 or T3 stage with abdominal lymph node metastasis].

We discussed the rational extent of the lymph node dissection for carcinoma of the lower third of the esophagus of T2 or T3 stage with abdominal lymph node metastasis. Lymph node metastasis developed in 89.5% of patients. Cervical lymph node metastasis was seen in 35.8%. In the cases with positive abdominal lymph node, 40.9% of the patients had cervical node metastasis. The most frequent site of the positive node in the neck is the area along the right recurrent laryngeal nerve. On the stand point of removal of metastatic lymph node, neck dissection should be required. Three-field dissection yielded better survival rate than two-field dissection but statistical significance was not obtained. When the patients have cervical lymph node metastasis, they have greater possibility of developing blood borne metastasis. However, this observation does not deny the validity of the three-field dissection. Because this dissection may help reducing nodal spread and nodal recurrence. We have to wait for accumulation of the patients to analyze the definite extent of node dissection for T2 or T3 stage of carcinoma of the lower third of the esophagus with positive abdominal lymph node.

Abdomen↗
PubMedDate not supplied

Type-oriented therapy for gastric cancer effective for lymph node metastasis: management of lymph node metastasis using activated carbon particles adsorbing an anticancer agent.

Activated carbon particles are taken selectively up by lymphatics when injected into the tissues and visualize regional lymph nodes colored black. Furthermore, carbon particles adsorb a large amount of the anticancer agent mitomycin C (MMC) on their surface and release the drug reversibly. Using these properties of activated carbon particles, we have applied it for lymph node dissection and chemotherapy of lymph node metastasis. After injection of carbon particles, regional lymph nodes of the stomach were found to be black; blackened lymph nodes extending widely from perigastric to para-aortic nodes were identified from other structures. Four hundred and twenty-four patients with gastric cancer were treated with this method for lymph node metastasis during 1984-1988. Involved nodes were generally colored in high incidence, about 70% of involved ones except for highly positive nodes, which was the same as noninvolved nodes. In highly positive nodes, the colored incidence was decreased to about 48%. The cumulative 5-year survival rate of the patients treated with this series was 74.6%, which was significantly higher than the figures without this method.

Carbon↗
PubMed1997

Prognostic significance of occult lymph node metastases in node-negative breast cancer.

BACKGROUND: Lymph node status, established by a single hematoxylin and eosin (H&E) section from each node, remains an important prognostic indicator in patients with breast cancer, but used alone it is insufficient to identify patients who will develop metastatic disease. This study was conducted to assess the significance of detecting occult metastases in 86 patients with breast cancer originally reported to be histologically node negative. None of the patients received adjuvant systemic therapy. METHODS: Five additional levels from formalin-fixed, paraffin-embedded nodes were examined at 150-microns intervals with H&E staining and a cocktail of antikeratin antibodies (AE1/AE3) recognizing low molecular weight acidic keratins. RESULTS: Nodes from 11 (12.8%) of 86 patients contained occult metastases. All metastases identified by cytokeratin antibody were also detected in H&E-stained sections. With median follow-up of 80 months, distant metastases occurred in five of 11 occult node-positive patients (45%) and 13 of 75 patients whose nodes were negative on review (17%). Median time to recurrence was 89 months for occult node-positive patients and not yet reached for node-negative patients (p = 0.048). The disease-specific 5-year survival rate was 90% for occult node-positive patients and 95% for node-negative patients. CONCLUSIONS: The presence of occult metastases shortened the disease-free interval and suggested that more diligent axillary staging would more accurately identify patients who would benefit from systemic adjuvant treatment.

Biomarkers, Tumor↗
PubMed1997

The impact of lymph node metastases on the survival of breast cancer patients with ten or more positive lymph nodes.

To investigate the impact of the number of involved lymph nodes on survival, we retrospectively reviewed the data for 37 patients with breast cancer and metastases of ten or more lymph nodes who underwent treatment between 1987 and 1995. Based on the number of positive lymph nodes, the patients were allocated to one of three groups. The 5-year disease-free and overall survival rates for all patients were both 53.0%. The 7 patients with 26 or more positive nodes had significantly poorer survival than either the 19 patients with 10-15 nodes, or the 11 with 16-25 nodes, although there were no differences in survival related to the extent of node involvement as defined using the Japanese staging system. Patients with 50%-75% frequency of metastasis, defined as the positive nodes/total resected nodes, had significantly better survival than those with < 50% or > 75% frequency. These results indicate that the number of involved lymph nodes is related to survival and that 25 positive nodes is a cutoff point in breast cancer patients with ten or more positive lymph nodes.

Adult↗
PubMed1997

Occult lymph node metastases detected by cytokeratin immunohistochemistry predict recurrence in "node-negative" colorectal cancer.

There is controversy about the prognostic significance of occult lymph node metastases detected by immunohistochemistry with the anti-cytokeratin antibody CAM 5.2. The aim of this study was to characterize occult lymph node metastases in colorectal carcinomas that might be associated with a higher risk of recurrence. Three hundred fifty-eight lymph nodes from 10 recurrent and 9 nonrecurrent cases of colorectal carcinoma were examined. All these patients had been reported originally as having no lymph node metastases by routine hematoxylin and eosin staining. Three 10-micron sections or ten 3-micron sections (30-micron total thickness) from each lymph node were stained with CAM 5.2 and examined for the presence of occult lymph node metastases. Occult metastases were detected in 67 of 175 lymph nodes from the recurrent cases, and in 23 of 183 lymph nodes from the nonrecurrent cases. The frequency of positive nodes was significantly higher in the recurrent cases. The recurrent cases had metastases in nodes more distant from the main tumor than did the nonrecurrent cases. Detection of occult lymph node metastases with cytokeratin immunohistochemistry may make it possible to identify patients with a higher risk of recurrence after the removal of a primary colorectal tumor.

Adult↗
PubMed2005

Lymph node metastases of prostatic adenocarcinoma in the mesorectum in patients with adenocarcinoma or villous tumor of the rectum with collision phenomenon in a single lymph node: report of five cases.

PURPOSE: Lymph node involvement is the most important prognostic factor when staging patients with rectal cancer. Cancer originating from sites other than rectum rarely may metastasize to the mesorectum. We report five patients with metastatic prostatic carcinoma to mesorectal lymph nodes, with the "collision phenomenon" in one lymph node. The diagnosis of prostate cancer was clinically unsuspected in two cases. METHODS: We examined three cases of primary adenocarcinoma and two villous tumors with high-grade dysplasia (patient age range, 52-74 (mean, 63) years) of the middle or lower third of the rectum. All patients underwent low anterior rectal resection with total mesorectal excision and colorectal or coloanal anastomosis. We used a manual technique for lymph node detection after overnight fixation in 10 percent formalin. All lymph nodes identified (range, 15-32; mean, 21 nodes per patient) were examined histologically. RESULTS: Of 106 lymph nodes examined, 20 contained metastases: 9 from rectal adenocarcinoma, 10 from prostatic adenocarcinoma, and 1 with metastatic foci from both tumors. The diagnosis of prostatic carcinoma was readily confirmed by immunostaining for prostatic-specific antigen, and prostatic acid phosphatase. CONCLUSIONS: Mesorectal lymph node dissection provides prognostic information in rectal cancer, but careful examination may reveal other unsuspected pathology. Immunohistochemical staining is an essential tool in distinguishing the origin of a lymph node metastasis, especially when the histology does not look typical for rectal carcinoma. Moreover, these observations highlight the connection that can exist between mesorectal lymph node drainage, and extra mesorectal lymph nodes drainage.

Adenocarcinoma↗
PubMed1997

Induction of atrioventricular node reentrant tachycardia with adenosine: differential effect of adenosine on fast and slow atrioventricular node pathways.

OBJECTIVES: This study sought to evaluate the sensitivity of fast and slow atrioventricular (AV) node pathways to incremental doses of adenosine in patients with typical AV node reentrant tachycardia. BACKGROUND: Although adenosine is known to depress conduction through the AV node, the relative sensitivity to adenosine of the anterograde fast and slow pathways in patients with dual AV node pathways and typical AV node reentrant tachycardia has not previously been studied. METHODS: Sixteen patients with dual AV node physiology and typical AV node reentrant tachycardia and 10 control patients were given incremental doses of adenosine during atrial pacing. RESULTS: In 14 of 16 patients with dual-AV node physiology, administration of small doses of adenosine during atrial pacing led consistently to transient block of impulse conduction in the fast pathway before block in the slow pathway, resulting in abrupt prolongation of the AH interval with continued 1:1 AV conduction. The mean (+/- SD) doses of adenosine required to cause conduction block in the fast and slow pathways were 2.7 +/- 3.0 and 7.2 +/- 4.7 mg, respectively (p = 0.004). In 9 of 16 patients, administration of low dose adenosine led to initiation of AV node reentrant tachycardia. The control patients showed no abrupt increases in AH interval with administration of adenosine during atrial pacing. CONCLUSIONS: In most patients with dual AV node pathways and typical AV node reentrant tachycardia, the fast pathway is more sensitive than the slow pathway to the effects of adenosine.

Adenosine↗
PubMed2006

Detection of occult lymph node metastases in locally advanced node-negative prostate cancer.

PURPOSE: The purpose of this study was to determine the incidence and clinical significance of occult metastases in the lymph nodes of patients with prostate cancer originally considered node negative by routine histologic evaluation. METHODS: Two hundred seventy four patients with pT3 prostate carcinoma treated by radical prostatectomy and bilateral lymph node dissection were included in this study. One hundred eighty patients were staged node negative (N0), while 94 patients were lymph node positive (N+), based on routine histologic evaluation. All lymph nodes from the 180 N0 patients were evaluated for occult metastases by immunohistochemistry using antibodies to cytokeratins and, if positive, prostate-specific antigen. Recurrence and overall survival were compared among patients with occult tumor cells (OLN+), with patients whose lymph nodes remained negative (OLN-), and with the 94 N+ patients. RESULTS: A total of 3,914 lymph nodes were evaluated from 180 N0 patients (average, 21.7 lymph nodes per patient). Occult tumor cells were found in 24 of 180 patients (13.3%). The presence of OLN+ was significantly associated with increased recurrence and decreased survival compared with OLN- patients (P < .001 and P = .019, respectively; relative risk of recurrence, 2.27; relative risk of death 2.07, respectively). The presence of occult lymph node metastases was an independent predictor of recurrence and death in a multivariable analysis. The outcome for patients with OLN+ disease was similar to that for patients with N+ disease. CONCLUSION: The detection of occult lymph node metastases in patients with pT3N0 prostate cancer identifies those with significantly increased risk of prostate cancer recurrence and death.

Aged↗
PubMed1992

[Experimental study of lymph node metastasis in thoracic esophageal carcinoma--regarding lymph node metastasis and changes in lymphatic flow by ultrafine charcoal in rabbit esophageal carcinoma model].

Esophageal carcinoma models were created by transplanting VX2 cells to rabbit esophagus endoscopically. By injecting finely divided activated charcoal into normal rabbit esophagus and tumor sites of esophageal carcinoma model, lymph flow was observed directly. Existence of lymph node metastasis was studied in detailed pathology. In 30 rabbits with upper esophageal carcinoma, lymph node metastasis was seen in 77%. Metastasis to bilateral intrathoracic paratracheal lymph node was seen in 50%, and also concentration of lymphatic flows from tumor site was seen. However, there were no metastasis and no lymph flow to abdominal lymph nodes. While, metastasis to cervical lymph nodes showed around 13%. Esophageal lymphatic flows were also seen reaching the cervical area along the esophagus. In 40 models with mid lower esophageal carcinoma, lymph node metastasis were seen in 88%. Metastasis to right and left thoracic paratracheal lymph nodes was 75% and 53%, respectively, and 25% of metastasis went to cardia lymph nodes. The lymph flows were going up and down around these lymph nodes, and reaching to lymph nodes at upper highest mediastinum or left gastric artery. The metastatic rate to the cervical lymph nodes was about 5%. There were no significant differences in lymphatic metastasis between right and left mediastinum. These findings suggest the necessity of radical dissection for both sides of the mediastinum.

Animals↗
PubMed1990

[Study of para-aortic lymph node metastasis of gastric cancer subjected to superextensive lymph node dissection].

Para-aortic lymph nodes (n4), were dissected out to the technical extreme (superextensive lymph node dissection) from 129 gastric cancer cases, and were subjected to the histological study for metastasis. Following observations led us to the conclusions in reference to the significance of n4 node dissections on curability of surgery. 1) Among 25 cases with n4(+) metastasis n3 was free [n3(-)] in 11 cases (44.0%). 2) ps(+) cancer presented high rate of n4(+) (31.5%). 3) n4(+) occurred irrespective of the location of the cancer, with particularly high rate of occurrence among CMA and cancers. 4) The rate of the metastasized lymph nodes to the total number of the n4 lymph nodes, was found low (34.9%) in cases with n3(-), and high (90.1%) with n3(+). 5) The cumulative survival rate of the cases with n4(+) was found significantly high with n3(-), as compared to n3(+) cases. The lymphatic drainage from the stomach seems more direct and/or more abundant to the n4 than to the n3 nodes. Such observation coincides with our experience that the n4 nodes are involved in metastasis in earlier timing and in higher incidence than n3 nodes. These results warn the present evaluation of curability in which the n4 node dissection is not performed. It is our opinion that the thorough dissection extended to the n4 nodes (superextensive lymph node dissection) is warranted, particularly in order to improve the curability of n3(-)-n4(+) cases.

Aorta, Abdominal↗
PubMed1985

[Diagnosis of retroperitoneal lymph node swelling by computed tomography in advanced testicular cancer patients, with special reference to retrocrural lymph node swelling].

We tried to divide anatomically the retroperitoneal space into three areas on computed tomography, infrahilar, suprahilar and retrocrural spaces, and investigated the relationship between frequency of lymph node swelling in each space and clinical picture in 15 patients with testicular cancer of stage II or III, particularly focusing on the lymph node swelling in the retrocrural space. Lymph node swelling was found in the infrahilar space in 11 cases (73.3%), in the suprahilar space in 7 cases (46.7%) and in the retrocrural space in 6 cases (40.0%). Retrocrural or suprahilar lymph node swelling was always accompanied by suprahilar or infrahilar lymph node swelling. Most of the patients with retrocrural lymph node swelling had bulky tumors in the infrahilar level and frequently cervical lymph node swelling. Retrocrural lymph node swelling did not necessarily affect the patient's prognosis. The retrocrural lymph node seems to be a sentinel node for retroperitoneal lymph node swelling not only in the case of testicular cancer but also in the cancer of urogenital malignancies.

Adult↗
PubMed1996

Topographic distribution of inguinal lymph nodes metastasis: significance in determination of treatment margin for elective inguinal lymph nodes irradiation of low pelvic tumors.

PURPOSE: To study the distribution of gross inguinal lymph node metastasis and, in particular, its correlation with major pelvic bony structures on a simulation film. METHODS AND MATERIALS: Thirty-seven cases of low pelvic tumors having gross inguinal lymph node metastasis that were treated with radiation therapy between November 1987 and December 1992 were segregated for study. The patient's nodes were palpated and marked with lead wire before the simulation film was assumed to be the origin of the previously uninfested node. A total of 84 such labeled nodes was taken. The geometric center of the usually round or elliptical node on the film was obtained from these 37 cases. These centers were transferred to and mapped collectively on a new simulation film showing major pelvic bony structures of left hemipelvis and upper femur. RESULTS: Distribution of gross inguinal lymph nodes was found confined to the following area, as related to major pelvic bony structure: laterally, just abutting the tangential line that passes through lateral border of the femoral head; medially: 3 cm away from the body's midline axis; superiorly: 1 cm below the line that joins both upper borders of the femoral head; inferiorly: 2.5 cm below the low borders of ischial tuberosity. According to this rectangular boundary, three nodes were out of the field, nine nodes near the border less than 1 cm margin. This area adequately covered 86% (72 of 84) of the studied nodes. CONCLUSION: Distribution study is important in determining the treatment margin. In general, an additional 1-2 cm beyond the area described above is the recommended treatment margin for elective inguinal lymph nodes irradiation with high confidence level of coverage.

Adult↗
PubMed1997

Lymph-node revealing solution: a new method for detecting minute lymph nodes in cystectomy specimens.

OBJECTIVE: To describe the use of a new lymph-node revealing solution (LNRS) for detecting lymph node involvement in total cystectomy specimens from patients with locally confined invasive transitional cell carcinoma (TCC) of the bladder, and to compare the results obtained with those using the conventional method (palpation and sectioning perivesical fat) that may fail to detect very small lymph nodes. MATERIALS AND METHODS: Of 12 cystectomy specimens obtained from patients with TCC, six in which 0-3 metastatic nodes were identified by the conventional method were further investigated using LNRS. The revealing solution comprised 95% ethanol, diethyl ether, glacial acetic acid and buffered formalin (65:20:5:10 v/v) prepared under a fume-hood. After evaluation using the conventional method, the specimens were immersed for 6-12 h in the solution, washed under running tap water and the adipose tissue sectioned at intervals of 2-3 mm. Lymph nodes were identified as white, chalky nodules against the background of yellow fat. The number of the lymph nodes identified by conventional and the LNRS methods was recorded and classified according the TNM system. RESULT: Twenty-two lymph nodes were detected by the conventional method, of which four were positive for tumour metastasis. Using the LNRS, an additional 21 nodes were identified among which 12 were positive. The mean size of the lymph nodes detected by the conventional and LNRS methods was 7.96 mm and 3.81 mm, respectively. The stage of three patients was increased (Nx to N2, N0 to N2 and N1 to N2) and therefore two of these patients received adjuvant chemotherapy. CONCLUSIONS: LNRS significantly enhanced the yield of normal and metastatic nodes of cystectomy specimens and may identify smaller nodes. The LNRS method allows a more accurate staging with better assessment of the prognosis and need for adjuvant therapy.

Carcinoma, Transitional Cell↗
PubMed2004

Predictors of nonsentinel node metastasis in patients with breast cancer after sentinel node metastasis.

HYPOTHESIS: The presence of nonsentinel lymph node (NSLN) metastasis after having a positive sentinel lymph node dissection finding is associated with tumor size and stage, the presence of lymphovascular invasion, micrometastasis, and extranodal extension. DESIGN: Retrospective case series. SETTING: University hospital. PATIENTS: Four hundred seven consecutive patients at a single institution who underwent sentinel lymph node dissection as part of breast conservation or mastectomy with biopsy-proved cancer. INTERVENTION: Completion axillary lymph node dissection and definitive therapy. MAIN OUTCOME MEASURES: Sentinel node metastasis, NSLN metastasis, tumor size and stage, lymphovacular invasion, micrometastasis, extronodal extension, histological tumor characteristics, and number of sentinel nodes removed. RESULTS: In a univariate analysis, size of the primary tumor and extranodal extension were associated with having positive NSLN findings. The presence of micrometastasis was associated with negative NSLN findings. When all factors were included in a logistic regression analysis, the significant predictor of NSLN metastasis was extranodal extension (P =.002). Lymphovascular invasion was not associated with positive NSLN findings (P =.11). The number of sentinel nodes removed also had no bearing on the status of the NSLNs (P =.37). CONCLUSIONS: Although primary tumor size and micrometastases correlate with the status of the NSLNs, extranodal extension is the most important independent predictor of NSLN metastasis. These findings may ultimately spare patients a full axillary lymph node dissection. However, pending results of larger clinical trials, full axillary lymph node dissection is still recommended for patients with sentinel lymph node metastases.

Adult↗