Utility of a Passive Bending Colonoscope for Endoscopic Retrograde Cholangiopancreatography in Patients with Surgically Altered Anatomy.

BACKGROUND AND AIM: The utility of a passive bending colonoscope (PBCS) in ERCP for patients with surgically altered anatomy has not been established. This study compared the outcome of PBCS-ERCP and balloon-assisted enteroscope (BAE)-ERCP. METHODS: This multicenter observational study included 343 patients with surgically altered anatomy who underwent ERCP. Among these, 110 underwent PBCS-ERCP and 233 underwent BAE-ERCP. Propensity score matching was applied, and a final cohort of 210 (105 in each group) with well-balanced backgrounds was analyzed. The primary outcome was the success rate of reaching anastomosis or ampulla of Vater. Secondary endpoints included the cannulation success rate, completion rate, procedure time (to reach, cannulate, complete), and adverse events. RESULTS: The success rate for reaching the target was 91.4% (96/105) with PBCS and 90.5% (95/105) with BAE (odds ratio [95% CI] 1.12, [0.44-2.89], P = 0.809). The mean time required to reach the target was significantly shorter in PBCS: 10.04 min (SD, 9.62) with PBCS versus 18.77 min (SD, 13.21) with BAE (P < 0.001). There were no differences in the success of cannulation or procedure completion, although the required times for cannulation and procedure completion were significantly shorter in PBCS. The incidence of adverse events was significantly higher in BAE (19.0%) than in PBCS (4.8%; P < 0.001). CONCLUSIONS: In patients with surgically altered anatomy, PBCS-ERCP showed promising results with shorter time to reach, cannulate, and a lower incidence of adverse events compared with BAE-ERCP. The success rate of reaching was favorable through PBCS compared with BAE. CLINICAL TRIAL REGISTRATION: UMIN000045546.

The risk of weekend biopsy: Impact of specimen source and fixation status on HER2 assessment in the treatment of advanced gastric cancer (The HER_WEEKEND study).

Accurate evaluation of human epidermal growth factor receptor type 2 (HER2) expression is crucial for determining chemotherapy regimens in gastric cancer. However, formalin fixation status has been identified as an important factor affecting HER2 assessment reliability. This retrospective cohort study aimed to investigate the correlation between sample collection day (weekday vs. weekend) and source (biopsy vs. surgical specimens) in assessing HER2 expression in patients with unresectable advanced/recurrent gastric cancer. Data were collected from gastric cancer patients who received chemotherapy at a single public hospital in Japan from 2008 to 2021. The analysis included 177 patients (109 men, 68 women) with a median age of 68.0 (21-88) years, and the primary outcome was the HER2 positivity rate. The overall HER2 positivity rate was 18.1%, with higher rates on weekdays (20.0%) compared to weekends (12.8%). Biopsies had higher positivity rates on weekdays (23.9%) but lower rates on weekends (11.1%) than surgical specimens. Significant differences were observed in formalin fixation times between weekdays and weekends for both biopsies and surgical samples. The study findings suggest that longer formalin fixation times on weekends may lead to underestimating HER2 expression, particularly in biopsies. Therefore, it is crucial to be cautious of excessive formalin fixation when collecting samples, especially during weekend biopsies.

An Autopsy Case of Rapidly Aggravated Clostridium perfringens Septicemia with Colorectal Cancer.

This report presents a case of a 60-year-old man who was diagnosed with ascending colon cancer with metastases of the lymph nodes and multiple liver metastases. Three days before the introduction of the first chemotherapy, he visited our hospital due to high fever. The blood test revealed an increase in the inflammatory response, hepatobiliary enzyme level, lactate dehydrogenase (LDH) level, and renal function deterioration. Contrast-enhanced computed tomography (CT) showed a rapid progression of primary lesion and liver metastatic lesions. Treatment with 5-fluorouracil, leucovorin, and oxaliplatin and cetuximab (FOLFOX/Cmab) was initiated, and the patient was admitted to our hospital after the first day of chemotherapy. At midnight, he had chills, red urine, and rapid hypoxemia. The second blood test showed progression of anemia; increased total bilirubin, aspartate aminotransferase, and LDH levels; and decreased platelet and fibrinogen levels. The serum was red wine in color, indicating marked hemolysis. The respiratory condition rapidly deteriorated, and tracheal intubation was performed and transferred into the intensive care unit. However, blood oxygenation did not increase, and the patient died the next morning, 19 h after admission, despite intensive care. Postmortem CT showed intraperitoneal free air and gas retention in the liver tumor and portal vein system. Pathological autopsy revealed perforation in ascending colon cancer, many Gram-positive rods in the perforation site, dissemination of bacteria throughout the body, and diffuse pulmonary edema. Subsequently, blood cultures reported Clostridium perfringens (CP), which is a product of alpha-toxin. CP infection can cause rapid aggravation and sudden death. The physicians should be aware of this highly fatal infection, leading to immediate diagnosis and treatment.

Risk Factors of Postoperative Facial Palsy for Benign Parotid Tumors: Outcome of 1,018 Patients.

OBJECTIVE: The aim of this study was to evaluate the rate of postoperative facial palsy in benign parotid tumors, as well as its risk factors, pathology, and clinical results. STUDY DESIGN: Retrospective analysis. METHODS: We performed a retrospective analysis of data from patients whose initial operation for a benign parotid tumor had been performed in our department between 1999 and 2020. RESULTS: We included 1,018 patients in this study. The most common tumor observed was pleomorphic adenoma (614 patients), followed by Warthin tumor (234 patients). Fine-needle aspiration cytology and frozen section biopsy were used to identify the tumor histopathology. The overall rate of postoperative facial nerve palsy was 19.5%; the rate was significantly higher in patients with large-diameter tumors or deep lobe tumors. Postoperative facial palsy improved within 24 months of surgery in all cases. There were no cases with permanent facial palsy. CONCLUSIONS: Postoperative facial nerve palsy developed regularly after surgery to remove benign parotid tumors despite preservation of the nerve. Palsy rate was high in patients with large tumors or deep lobe tumors. Despite the high risk of facial palsy in these patients and the benign nature of the tumor, we recommend surgery rather than follow-up observation, as the risk of postoperative facial palsy may increase as the tumor grows. It is important to provide an accurate explanation on the risks of postoperative complications to all patients to obtain appropriate informed consent for surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2857-E2864, 2021.

Immediate Amelioration of Severe Respiratory Distress in Sjögren's Syndrome with COVID-19 Treated with a Single Dose of Off-label Tocilizumab.

The coronavirus disease 2019 (COVID-19) pandemic has become an urgent global health issue. An older age and underlying conditions, such as diabetes, have been reported as risk factors, but whether or not autoimmune diseases increase the risk remains unknown. An 85-year-old man with Sjögren's syndrome developed a severe COVID-19 infection that required oxygen supplementation. After discussing the goals of care with him and his wife, off-label tocilizumab was given concomitantly, resulting in a rapid improvement in his symptoms and respiratory failure. This patient represents a supplementary case confirming the efficacy and safety of tocilizumab for COVID-19 in elderly patients with autoimmune diseases.

Effectiveness of intraoperative facial nerve monitoring and risk factors related to postoperative facial nerve paralysis in patients with benign parotid tumors: A 20-year study with 902 patients.

OBJECTIVE: We examined the incidence, risk factors, and recovery time for postoperative facial nerve paralysis in patients with benign parotid tumors and also investigated the usefulness of intraoperative facial nerve monitoring (FNM). METHODS: Subjects were 902 patients with benign parotid tumors. Univariate and multivariate analyses were conducted for risk factors of postoperative facial nerve paralysis. We investigated the relationship between intraoperative FNM and postoperative facial nerve paralysis, and the recovery time for postoperative facial nerve paralysis according to tumor site. RESULTS: Postoperative facial nerve paralysis occurred in 179 (19.8%) of 902 patients. Among them, 15.1%, 15.8%, and 37.5% had tumors in the superficial lobe, lower pole, and deep lobe, respectively. Paralysis risk factors were deep tumors, large tumors, long operation times, extensive bleeding, and non-use of FNM. Multivariate analysis determined female patients, deep tumors, and long operation times as significant risk factors, and female patients and deep tumors had an odds ratio of nearly 2. Use of intraoperative FNM resulted in a significantly lower incidence of facial nerve paralysis and was particularly useful in patients with superficial lobe tumors. Time to recovery from facial nerve paralysis was 6 months in 88% of the patients. CONCLUSION: The incidence of paralysis should be kept as low as possible to enhance the postoperative quality of life of patients. The use of intraoperative FNM significantly lowered the incidence of paralysis in female patients with superficial tumors.

Challenges with preoperative diagnosis of low/intermediate-grade carcinoma of the parotid gland: single-center study of 112 patients.

BACKGROUND: The malignancy of parotid carcinoma varies, and accurate preoperative assessment of malignancy is important for selecting the appropriate treatment. However, the preoperative diagnosis of low/intermediate-grade carcinoma is difficult, and surgery may sometimes be performed without any prior knowledge of malignancy. METHODS: The results of fine-needle aspiration cytology (FNA), imaging studies (MRI and US), physical examination, and frozen section biopsy (FSB) were evaluated in 112 patients with low/intermediate-grade parotid carcinoma. RESULTS: The result of FNA was benign/inadequate specimen in 44.6% of the patients. In addition, the tumor was diagnosed as benign by MRI/US in 21.4% of the patients and 37.5% had no symptoms/signs of malignancy on physical examination. The rate of misdiagnosis as benign decreased when FNA was combined with imaging and physical findings. However, malignancy could not be diagnosed by FNA and FSB in 12.5% of the patients who were only found to have malignant tumors by the final pathological examination. CONCLUSION: FNA shows a high misdiagnosis rate of malignancy in patients with low/intermediate-grade cancer. Therefore, it is necessary to carefully evaluate the findings of imaging studies and physical examination, and FSB should be conducted if such findings suggest the possibility of malignancy.

Programmed death ligand-1 expression is associated with stage and histological grade of parotid carcinoma.

Background: The immune checkpoint ligand programmed death ligand-1 (PD-L1) is expressed by various cancers, including those of the head and neck. However, the role of PD-L1 is still unknown.Objectives: To investigate the relationship between PD-L1 expression and survival rate in parotid carcinoma.Methods: PD-L1 expression was investigated by immunohistochemical analysis in 127 patients with parotid carcinoma. The relationship between PD-L1 expression and stage, histological grade, and survival was assessed.Results: PD-L1 expression was found in 28.3% of parotid carcinomas, with the expression being higher in tumors with a higher stage, a higher-grade, and node positive cases. However, the 5-year disease-specific survival rate was 82.2% for the patients with PD-L1 positive and 86.9% for those with PD-L1 negative tumors, showing no significant difference.Conclusions: PD-L1 expression was positive in approximately 50% of high- grade carcinomas, which was similar to the level in head and neck squamous cell carcinoma. In patients with other cancers, it has been reported that an anti-PD-1 monoclonal antibody was more effective against tumors with higher PD-L1 expression. Therefore, it could be a possible new therapeutic option for patients with highly malignant parotid tumors that have a poor prognosis.

Clinical characteristics of acinic cell carcinoma and secretory carcinoma of the parotid gland.

PURPOSE: Mammary analogue secretory carcinoma (SC) of the parotid gland is a relatively uncommon cancer associated with the ETV6-NTRK3 fusion product similar to breast cancer. The clinical characteristics and outcome of treatment were reviewed for patients with this tumor at our hospital. METHODS: In this retrospective case series, 24 patients with a diagnosis of acinic cell carcinoma (AcCC) of the parotid gland were classified as having either SC or AcCC based on analysis of the ETV6-NTRK3 fusion gene. These two groups were compared with respect to their clinical and imaging characteristics (MRI/US), cytologic findings, accuracy of fine-needle aspiration cytology and frozen section, treatment outcomes, and immunohistochemical findings. RESULTS: Based on re-classification by ETV6-NTRK3 fusion gene analysis, the diagnosis was SC in 14 patients and AcCC in 10 patients. The SC group had a significantly higher proportion of male patients and was also significantly younger than the AcCC group. Imaging studies revealed that SC was significantly more likely to show internal heterogeneity. Correct grading of both tumors was comparable by fine needle aspiration, with the rate being 60% for AcCC and 50% for SC. Diagnosis by frozen section biopsy diagnosis obtained the correct grade in 90% of the AcCC group and 93% of the SC group. CONCLUSIONS: In 24 patients previously diagnosed with AcCC, re-analysis of the ETV6-NTRK3 fusion product indicated that 14 patients actually had SC. Although AcCC and SC show similarities of their biological aggressiveness and prognosis, patients with SC were significantly more likely to be male and younger.

Incidence of cancer-associated thromboembolism in Japanese gastric and colorectal cancer patients receiving chemotherapy: a single-institutional retrospective cohort analysis (Sapporo CAT study).

OBJECTIVE: Few data regarding the incidence of cancer-associated thromboembolism (TE) are available for Asian populations. We investigated the incidence of TE (TEi) and its risk factors among gastric and colorectal cancer (GCC) patients received chemotherapy in a daily practice setting. DESIGN: A retrospective cohort study. SETTING: A single-institutional study that used data from Sapporo City General Hospital, Japan, on patients treated between January 2008 and May 2015. PARTICIPANTS: Five hundred Japanese GCC patients who started chemotherapy from January 2008 to May 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: TE was diagnosed by reviewing all the reports of contrast-enhanced CT performed during the follow-up period. All types of thrombosis detected by CT or additional imaging tests, such as venous TE, arterial TE and cerebral infarction, were defined as TE. Medical records of all identified patients were reviewed and potential risk factors for TE, including clinicopathological backgrounds, were collected. We defined the following patients as 'active cancer'; patients with unresectable advanced GCC, cancer recurrence during or after completing adjuvant chemotherapy and/or presence of other malignant tumours. RESULTS: Of the 500 patients, 70 patients (14.0%) developed TE during the follow-up period. TEi was 9.2% and 17.3% in GCC patients, 18.1% and 3.5% in active and non-active cancer patients, and 24.0% and 12.9% in multiple and single primary, respectively. Multivariate logistic regression analysis showed that colorectal cancer (CRC) (OR 2.371; 95% CI 1.328 to 4.233), active cancer (OR 7.593; 95% CI 2.950 to 19.543) and multiple primary (OR 2.527; 95% CI 1.189 to 5.370) were independently associated with TEi. CONCLUSION: TEi was 14.0% among Japanese GCC patients received chemotherapy, and was significantly higher among patients with CRC, active cancer and multiple primary than among those with gastric cancer, non-active cancer and single primary, respectively. TRIAL REGISTRATION NUMBER: UMIN000018912.

Recurrent benign pleomorphic adenoma of the parotid gland: Facial nerve identification and risk factors for facial nerve paralysis at re-operation.

OBJECTIVE: Surgery for recurrent pleomorphic adenoma of the parotid gland is challenging since there is a considerable risk of facial nerve injury and a high re-recurrence rate. We investigated surgery for recurrent pleomorphic adenoma, focusing on management of the facial nerve. METHODS: We reviewed 29 patients who underwent surgery for recurrent benign pleomorphic adenoma of the parotid gland at our department between 1999 and 2018. We examined clinicopathologic features and risk factors for facial nerve injury during reoperation. RESULTS: Factors associated with difficulty in identifying the main trunk of the facial nerve during surgery were bilobar tumors, multiple tumors, and use of an S-shaped skin incision at the previous operation. When the facial nerve was identified intraoperatively, it could be preserved in 2/3 of patients, while the nerve was only preserved in 1/3 of patients when it was not identified. Factors related to permanent postoperative paralysis included recurrence in the deep lobe or both lobes and multiple tumors. CONCLUSION: The probability of successfully preserving the facial nerve is relatively high if the nerve can be identified during surgery for recurrent pleomorphic adenoma, although intentional resection is necessary in some patients. Factors associated with difficulty in identifying the facial nerve are similar to those related to permanent postoperative paralysis, including bilobar tumors and multiple tumors. In patients with recurrent pleomorphic adenoma, preservation of the facial nerve is difficult, when they may have undergone previous extensive resection or have multiple tumors requiring subtotal or more extensive resection.

Patterns of lymph node metastasis and the management of neck dissection for parotid carcinomas: a single-institute experience.

BACKGROUND: There is no consensus about the indications and range of neck dissection in patients who have parotid carcinoma, with elective neck dissection for cN0 disease being particularly controversial. METHODS: This study retrospectively reviewed 185 patients with newly diagnosed parotid carcinoma who were treated at our department between September 1999 and August 2018. RESULTS: 50 of the 185 patients had lymph node metastasis, including 7.7%, 12.2%, 36.0%, and 55.8% of patients with T1, T2, T3, and T4 disease, respectively. When classified by histological grade, 5.7% of patients with low/intermediate-grade disease had lymph node metastasis versus 55.0% of patients with high-grade disease. Multivariate analysis revealed that the histological grade and T classification were independent predictors of lymph node metastasis. Occult metastasis was found in 8 out of 73 clinically node negative patients undergoing neck dissection. The most common site of cervical metastasis was level 2, followed by the periparotid nodes, level 3, and level 4. CONCLUSION: Elective neck dissection may be most appropriate for parotid carcinoma patients with high grade disease and/or an advanced T classification. Because preoperative evaluation of the histological grade of parotid carcinoma has limited reliability, it is important to decide the indications and range of neck dissection from the results of frozen section biopsy.

Values of fine-needle aspiration cytology of parotid gland tumors: A review of 996 cases at a single institution.

BACKGROUND: We evaluated the diagnostic accuracy of fine-needle aspiration cytology (FNAC) in a large series of benign and malignant parotid tumors. METHODS: The FNAC diagnosis of 821 benign and 175 malignant parotid tumors managed at our department between 1999 and 2017 was correlated with the final histology. RESULTS: FNAC made a correct histopathological diagnosis in 72% of the benign parotid tumors; however, FNAC provided a correct grade in only 34% of the malignant tumors. FNAC correctly identified the histology of 94% of pleomorphic adenomas subsequently confirmed by histopathological examination. The sensitivity, specificity, and diagnostic accuracy of FNAC for detecting malignancy were 82.3%, 98.7%, and 95.9%, respectively. CONCLUSION: FNAC generally provided the correct histological diagnosis for benign tumors. However, the histological evaluation and grading of malignant tumors were poor. Although FNAC showed good sensitivity, specificity, and accuracy, its sensitivity decreased when nondiagnostic cases were included in the analysis.

A Prospective Observational Study on Effect of Short-Term Periodic Steroid Premedication on Bone Metabolism in Gastrointestinal Cancer (ESPRESSO-01).

BACKGROUND: A multicenter prospective observational study evaluated the effect of gastrointestinal cancer chemotherapy with short-term periodic steroid premedication on bone metabolism. PATIENTS AND METHODS: Seventy-four patients undergoing chemotherapy for gastrointestinal cancer were studied. The primary endpoints were changes in bone mineral densities (BMDs) and metabolic bone turnover 16 weeks after initiation of chemotherapy. BMDs, measured by dual-energy x-ray absorptiometry, and serum cross-linked N-telopeptides of type I collagen (sNTX), and bone alkaline phosphatase (sBAP) were assessed for evaluation of bone resorption and formation, respectively. RESULTS: In 74.3% (55/74) of the patients, BMDs were significantly reduced at 16 weeks relative to baseline. The percent changes of BMD were -1.89% (95% confidence interval [CI], -2.67% to -1.11%: p < .0001) in the lumbar spine, -2.24% (95% CI, -3.59% to -0.89%: p = .002) in the total hip, and -2.05% (95% CI, -3.11% to -0.99%: p < .0001) in the femoral neck. Although there was no significant difference in sNTX levels during 16 weeks (p = .136), there was a significant increase in sBAP levels (p = .010). Decreased BMD was significantly linked to number of chemotherapy cycles (p = .02). There were no significant correlations between changes in BMDs and the primary site of malignancy, chemotherapy regimens, total cumulative steroid dose, steroid dose intensity, and additive steroid usage. CONCLUSION: Gastrointestinal cancer chemotherapy with periodic glucocorticoid premedication was associated with reduced BMD and increased sBAP levels, which were linked to number of chemotherapy cycles but independent of primary site, chemotherapy regimen, duration, and additive steroid usage. The Oncologist 2017;22:592-600 IMPLICATIONS FOR PRACTICE: Bone health and the management of treatment-related bone loss are important for cancer care. The present study showed that a significant decrease in bone mineral density (BMD) and an increase in serum bone alkaline phosphatase levels occurred in gastrointestinal cancer patients receiving chemotherapy, which were linked to number of chemotherapy cycles but were independent of primary site, chemotherapy regimen, total steroid dose, and steroid dose intensity. Surprisingly, it seems that the decreasing BMD levels after only 16 weeks of chemotherapy for gastrointestinal cancer were comparable to that of 12-month adjuvant aromatase inhibitor therapy for early-stage breast cancer patients.

Assessing the histological type and grade of primary parotid carcinoma by fine-needle aspiration and frozen section.

OBJECTIVE: The aim of this study is to compare preoperative fine needle aspiration cytology (FNAC) and intraoperative frozen section (FS) for the correct identification of malignancy, histological grade, and histological type. METHODS: FNAC was performed on all 105 patients and FS on 71 patients with parotid carcinoma. RESULTS: The rate of correctly determining the histological grade by FNAC and FS was 32% and 73%, respectively. The correct diagnosis rate for both the histological type and grade by FNAC and FS was 20% and 48%, respectively. CONCLUSIONS: The correct grading of both high and low/intermediate grade carcinoma is possible in 70-80% of patients by FS. If the histological grade is identified correctly, the extent of resection can usually be decided appropriately. Therefore, we should put emphasis on determining the histological grade.

Radiotherapy concurrent with S-1 and radiotherapy alone for T2N0 glottic carcinoma: a retrospective comparative study.

OBJECTIVE: We examined the completion rate, safety, and adverse events in patients with T2N0 glottic carcinoma who received chemoradiotherapy with S-1 (tegafur-gimeracil-oteracil potassium). METHODS: In T2N0 glottic carcinoma patients, we retrospectively compared the local control rate and outpatient therapy completion rate between 20 patients who received radiotherapy plus S-1 (S-1 group) and 20 who received radiotherapy alone (RT group). RESULTS: Local recurrence was not detected in any of the 20 subjects from the S-1 group, whereas local recurrence was found in 4 of the 20 subjects (20%) from the RT group (p<0.05). Outpatient treatment was completed by 15 of the 20 subjects from the S-1 group and 17 of the 20 subjects from the RT group (p=0.43). CONCLUSION: We investigated chemoradiotherapy with S-1 in patients who had T2N0 glottic carcinoma and found a higher local control rate when compared with radiotherapy alone as well as comparable safety for outpatient delivery.

Novel differential diagnostic method for superficial/deep tumor of the parotid gland using ultrasonography.

BACKGROUND: The purpose of this study was to prepare the ultrasonographic diagnostic criteria on parotid tumors for preoperative differentiation of superficial and deep tumors. METHODS: We evaluated 154 patients with a benign parotid tumor who underwent surgery. The minimum thickness of normal parotid gland tissue between the parotideomasseteric fascia and tumor (minimum fascia-tumor distance [MFTD]) was measured on preoperative ultrasonography and compared among tumors at different locations, and the optimum cutoff value to differentiate a deep tumor was identified. RESULTS: The MFTD showed significant differences between superficial and deep tumors and between inferior pole and deep tumors. The sensitivity, specificity, and accuracy of an MFTD ≥3 mm for the differentiation of deep tumors were 85%, 91%, and 89%. CONCLUSION: A tumor with an MFTD ≥3 mm on preoperative ultrasonography is very likely to be a deep tumor based on a new differentiation method for deep parotid tumors considering those present at other locations.

Late nodal metastasis of T2 oral cancer can be reduced by a combination of preoperative ultrasonographic examination and frozen section biopsy during supraomohyoid neck dissection.

CONCLUSION: The occult metastasis rate for T2 oral cancer can be reduced by ultrasonography (US). Also, the late metastasis rate is considered to be reduced by combining US with frozen section biopsy (FSB) during supraomohyoid neck dissection (SOHND). OBJECTIVES: Early oral cancer has been reported to show occult metastases in 15-53% of patients, but the criteria or methods for the diagnosis of cervical lymph node metastasis are unclear in many studies, and there is no clear definition of occult metastasis. In patients with T2 oral cancer, the diagnosis of lymph node metastasis by US and its pathological diagnosis (pN) after neck dissection were compared to evaluate the usefulness and limitations of US, occult metastasis rate, significance of SOHND as preventive neck dissection, and use of FSB. METHODS: A total of 73 patients with T2 oral cancer were investigated retrospectively. Modified radical neck dissection (MRND) was performed in N+ patients, and SOHND was carried out in N0 patients. FSB was performed in all patients undergoing SOHND. US and pN diagnoses were compared. RESULTS: The occult metastasis rate was 18% when occult metastases were limited to those detected by SOHND and 22% when late nodal recurrences were also included.