Sentinel Node Navigation Surgery for Early Gastric Cancer: Analysis of Factors Which Affect Direction of Lymphatic Drainage

World Journal of Surgery - We started performing sentinel node navigation surgery (SNNS) for patients with early gastric cancer (EGC) using infrared ray electronic endoscopy (IREE) with indocyanine...     

Clinical Implementations of Preoperative Computed Tomography Lymphography in Gastric Cancer: A Comparison with Dual Tracer Methods in Sentinel Node Navigation Surgery

Background

Current sentinel node (SN) detection techniques require a learning period and tracers have many disadvantages for practical use. The purpose of this study was to evaluate the feasibility of preoperative computed tomography (CT) lymphography using lipiodol for detecting SNs in gastric cancer.

Methods

A total of 24 patients who underwent laparoscopic surgery for early gastric cancer were enrolled in this study. Noncontrast CT images were obtained 1–2 h after endoscopic submucosal peritumoral injection of 1 mL of lipiodol the day before surgery. The final sentinel basins (SBs) were decided by the dual tracer method (indocyanine green plus ^99mTc-antimony sulfur colloid) during laparoscopic gastrectomy. SN detection rate by preoperative CT lymphography using lipiodol and agreement between CT lymphography versus dual tracer method were evaluated. The agreement was confirmed with soft X-ray radiography of detected SBs.

Results

Technical failure of endoscopic lipiodol injection occurred in one patient. SNs were successfully detected in the remaining 23 patients (95.8 %), whereas the intraoperative SB detection rate using the dual method was 100 %. The agreement rate, defined as the concordance between two methods or inclusion of SNs detected by CT lymphography in SBs by the dual tracer method, was 87 %.

Conclusions

Our initial experience of CT lymphography using lipiodol shows good potential in predicting SBs of gastric cancer preoperatively. However, SN detection by CT lymphography and the dual method should be applied complementarily in gastric cancer because discrepancies between these methods occur.     

Laparoscopic Local Resection Based on Sentinel Node Evaluation for Early Gastric Cancer: A Preliminary Report

We previously reported that lymphatic mapping using isosulfan blue can be used to identify sentinel nodes (SNs). This study was undertaken to evaluate the feasibility of using the SN technique in treating early gastric cancer and to explore its usefulness for minimal invasive surgery. Twenty-three patients with early gastric cancer who underwent SN biopsy were retrospectively evaluated. Based on SN evaluation, individualized surgery was performed in five patients with T1N0M0 gastric cancer. When pathological examination of frozen sections revealed metastasis in SNs, we performed a standard D2 gastrectomy. Laparoscopic local resection was applied when the SN biopsy was negative. Our results showed that the success rate with SN biopsy in early gastric cancer was 100%, as were the accuracy, sensitivity, and specificity. All five patients with early gastric cancer had SNs negative for metastases both by frozen section and by postoperative pathology. Thus, all these patients underwent laparoscopic local resection without extended lymphadenectomy. We conclude that SN biopsy is a useful tool to individualize the operative procedure, and laparoscopic local resection can be safely performed using SN guidance in selected patients with early gastric cancer.     

Sentinel Node Navigation Surgery is Acceptable for Clinical T1 and N0 Esophageal Cancer

Background

If the sentinel node (SN) concept is established for esophageal cancer, it will be possible to reduce safely the extent of lymphadenectomy. Our objective was to perform SN mapping in esophageal cancer to assess distribution of lymph node metastases with the goal to reduce the need for extensive lymphadenectomy.

Methods

A total of 134 patients who underwent esophagectomy with lymph node dissection were enrolled. The number of patients with clinical T1, T2, and T3 tumors was 60, 31, and 32, respectively. Eleven patients also received neoadjuvant chemoradiation therapy (CRT). ^99mTc-Tin colloid was injected endoscopically into the esophageal wall around the tumor 1 day before surgery. SNs were identified by using radioisotope (RI) uptake. RI uptake of all dissected lymph nodes was measured during and after surgery. Lymph node metastases, including micrometastases, were confirmed by hematoxylin eosin and immunohistochemical staining.

Results

Detection rates of SNs were 93.3% in cT1, 100% in cT2, 87.5% in cT3, and 45.5% in CRT patients. In the 120 cases where SNs were identified, lymph node metastases were found in 12 patients with cT1, 18 with cT2, 24 with cT3 tumors, and 3 with CRT. Accuracy rate of SN mapping was 98.2% in cT1, 80.6% in cT2, 60.7% in cT3, and 40% in CRT patients. Although one false-negative case had cT1 tumor, the lymph node metastasis was detected preoperatively.

Conclusions

SN mapping can be applied to patients with cT1 and cN0 esophageal cancer. SN concept might enable to perform less invasive surgery with reduction of lymphadenectomy.

     

肺功能与肺癌全肺切除术后近期预后的关系

分析２６５例非小细胞肺癌术前肺功能等因素与全肺切除术后近期预后的关系，证实肺功能越差，术后近期预后越差，尤其当ＶＣ、ＭＶＶ占预计值〈６０％，ＦＥＶ１〈１．５Ｌ或ＦＥＶ１％〈５０％时，全肺切除术后危险性明显增高，有长期吸烟史和慢性支气管炎史，有心血管疾病或术前作过化疗或放疗者，术后并发症也随之增多。     

Intraoperative Imprint Cytologic Assessment of the Sentinel Node for Early Breast Cancer

Abstract An increasing number of patients are undergoing sentinel node biopsy alone for axillary staging of early breast cancer. A reliable method for evaluating the status of the sentinel node intraoperatively would allow patients with sentinel node metastases to undergo immediate rather than delayed axillary clearance. Sentinel nodes in 53 consecutive patients were examined by intraoperative imprint cytology. When compared with subsequent analysis by hematoxylin-eosin staining and immunohistochemistry, the accuracy of imprint cytology for the detecting nodal metastases was 81.1%; the false negative rate was 47.0%, and there were no false positives. Results were made available to the operating surgeon within a mean time of 25 minutes. All but one of the false negatives involved micrometastatic deposits of less than 0.1 mm. Intraoperative imprint cytologic examination of the sentinel node is a useful technique that can be performed efficiently and without loss of nodal tissue for subsequent analysis. With the use of this technique, more than 50% of lymph node-positive patients would potentially be spared a second operation.     

术前艾灸联合术后针刺对胃癌术后患者胃肠功能的影响

目的探讨术前艾灸联合术后针刺对胃癌术后患者胃肠功能的改善效果。方法:选取江苏大学附属澳洋医院2019 年1 月—2021 年7 月行胃癌手术的患者96 例,按随机数字表法分为对照组和观察组,每组各48 例。对照组术后行围手术期常规治疗措施;观察组在对照组基础上术前艾灸中脘、足三里联合术后针刺期门、行间干预。比较两组术后胃肠功能指标改善时间、胃肠功能障碍评分、临床疗效以及胃肠激素指标。结果:观察组术后的首次排气、排便、肠鸣音恢复、经鼻胃空肠营养管进食时间均显著短于对照组(P ＜ 0.01);术后7 d,两组胃肠功能障碍评分显著降低,且观察组降低更显著(P ＜ 0.01);术后7 d,观察组的有效率为97.92%(47/48)高于对照组的83.33%(40/48),差异有统计学意义(P ＜ 0.05);术后7 d,两组血清胃泌素、胃蛋白酶原(PG)Ⅰ、PG Ⅱ水平明显增加,且观察组增加更明显(P ＜ 0.01)。结论:术前艾灸中脘、足三里联合术后针刺期门、行间有助于胃癌术后患者胃肠功能的恢复,提高治疗效果,且能调节胃肠激素分泌。     

Prediction of Metastasis to Non-sentinel Nodes by Sentinel Node Status and Primary Tumor Characteristics in Primary Breast Cancer in Taiwan

We aimed to determine how to approach the axilla after finding a positive sentinel node (SN) for a woman with breast cancer in Taiwan. We used blue dye staining to identify the SN in 824 procedures on 811 patients with breast cancer small than 3 cm by a single surgeon. All patients underwent SN biopsy, followed by at least level II axillary dissection. All SNs were evaluated histologically and immunohistochemically with anti-cytokeratin antibodies. Non-SNs were examined by routine histology. SNs were identified in 814/824 procedures (98.8%). SN metastases were found in 286/814 (35.1%). Subsequent axillary dissections revealed tumors in non-SNs in 188 (65.7%) of these patients. There was a relatively high incidence of non-SN metastases in our population. Tumor exhibiting high nuclear grading, ER-, PR-, Erb-2/neu overexpression, lymphovascular invasion, increasing tumor size, multiple positive SNs, and macrometastatic size in SNs (> 2 mm) were all significantly correlated with non-SN metastases. Multivariate analysis showed that tumor size, the number of positive SNs, and the metastatic size in SNs were independent factors predicting the presence of positive non-SNs. Small (< 2 cm) cancers, having only micrometastatic foci in the SN and having only one SN involved are closely correlated with the tumor-free non-SNs. Our data will assist such patients regarding the need for axillary dissection after finding a positive SN.     

Interim Results of Sentinel Node Biopsy during Laparoscopic Gastrectomy: Possible Role in Function-Preserving Surgery for Early Cancer

Introduction Intraoperative detection of sentinel nodes (SNs) has been used clinically to predict regional lymph node (LN) metastasis in patients with breast cancer and malignant melanoma. Intraoperative lymphatic mapping and SN biopsy can potentially be combined with minimally invasive surgery. However, few reports have demonstrated the validity of SN biopsy during laparoscopic gastrectomy. The aim of this study was to investigate the feasibility and accuracy of laparoscopic lymphatic mapping in predicting LN status in patients with gastric cancer. Methods A total of 35 patients with gastric cancer diagnosed preoperatively as T1, N0 were enrolled. Endoscopic injection of technetium-99m-radiolabeled tin colloid was completed 16 hours before surgery, and radioactive SNs were identified with a gamma probe intraoperatively. Isosulfan blue dye was injected endoscopically during the operation. Laparoscopy-assisted gastrectomy with LN dissection was performed. All resected LNs were evaluated by routine pathology examination. Results SNs were detected in 33 (94.3%) of 35 patients. The mean number of SNs was 3.9, and the diagnostic accuracy according to SN status was 97.0% (32/33), as one patient with a false-negative result was observed. The patient with the false-negative specimen was finally diagnosed as having advanced gastric cancer with invasion into the proper muscular layer and severe lymphatic vessel invasion, causing destruction of normal lymphatic flow by the tumor. Conclusions Radio-guided SN mapping during laparoscopic gastrectomy is an accurate diagnostic tool for detecting lymph node metastasis in patients with early-stage gastric cancer. Validation of this method requires further studies on technical issues, including indications, tracers, methods of lymph node retrieval, and diagnostic modalities of metastasis.     

A Novel Approach for Sentinel Lymph Node Identification Using Fluorescence Imaging and Image Overlay Navigation Surgery in Patients with Breast Cancer

Background  

We reported a novel technique of sentinel lymph node (SLN) identification using fluorescence imaging of indocyanine green injection. Furthermore, to obtain safe and accurate identification of SLN during surgery, we introduce the image overlay navigation surgery and evaluate its efficacy.     

Sentinel Node Biopsy for the Individualization of Surgical Strategy for Cure of Early-Stage Colon Cancer

Introduction  The requirement for nodal analysis currently confounds the oncological propriety of focused purely endoscopic resection for early-stage colon cancer and complicates the evolution of innovative alternatives such as natural orifice transluminal endoscopic surgery (NOTES) and its hybrids. Adjunctive sentinel node biopsy (SNB) deserves consideration as a means of addressing this shortfall. Methods  Data from two prospectively maintained databases established for multicentric studies of SNB in colon cancer that employed similar methodologies were pooled to establish technique potency selectively in T1/T2 disease (both overall and under optimized conditions) and to project potential clinical impact. Results  Of 891 patients with T1–4, M0 intraperitoneal colon cancer, 225 had T1/T2 disease. Sentinel nodes were either not found or were falsely negative in 18 patients with T1/T2 cancers (8%) as compared with 17% (112/646) in those with T3/T4 disease (P = 0.001). Negative predictive value (NPV) in the former exceeded 95%, while sensitivity [including immunohistochemistry (IHC)] was 81%. In the 193 patients with T1/T2 disease recruited from those centers contributing >22 patients, sensitivity was 89% and NPV 97%. Thus, in this cohort, SNB could have correctly prompted localized resection (obviating en bloc mesenteric dissection) in 75% (144) of patients, including 59 with T1 lesions potentially amenable to intraluminal resection alone as their definitive treatment. Forty-four patients (23.4%) would still have conventional resection, leaving three patients (1.6% overall) understaged (11% false-negative rate). Conclusion  These findings support the further investigation of SNB as oncological augment for localized resective techniques. Specific prospective study should pursue this goal. Professor Schlag and Dr. Saha share equally senior co-authorship of this work.     

胃癌不同部位淋巴结转移率及其临床意义的研究

目的探讨胃癌不同部位淋巴结转移的分布特点,旨在为合理的外科治疗提供依据。方法回顾性分析1995年1月至2004年12月期间在中国医科大学附属第一医院胃肠肿瘤外科实施手术的胃癌病例,分析各组淋巴结的转移率及其特点。结果 1 505例胃癌患者中,928例出现淋巴结转移,转移率为61.7%。上部癌(U)中转移率较高的淋巴结依次是No.1(32.9%)、No.3(28.7%)、No.2(20.4%)及No.7(18.6%);中部癌(M)中转移率较高的淋巴结依次是No.3(32.5%)、No.4(24.7%)、No.7(20.6%)及No.1(17.3%);下部癌(L)中转移率较高的淋巴结依次是No.6(33.7%)、No.3(31.3%)、No.4(25.6%)及No.7(21.5%)。结论胃周淋巴结转移根据胃癌的部位、浸润深度等,有着不同的特点。了解胃周淋巴结的转移规律能够获得pN分期无法提供的信息,对于正确评估胃癌的淋巴结转移程度、制订治疗方案及手术范围,具有重要的意义。     

A Comparison of Indocyanine Green Fluorescence Imaging Plus Blue Dye and Blue Dye Alone for Sentinel Node Navigation Surgery in Breast Cancer Patients

Purpose

To evaluate two methods of sentinel node navigation surgery (SNNS) using blue dye with and without indocyanine green (ICG) fluorescence imaging (FI) to determine the usefulness of combined ICG and blue dye.

Methods

Between 2005 and 2010, a total of 501 patients underwent SNNS in our hospital. Detection of sentinel lymph node (SLN) was performed with sulfan blue (SB) alone until 2008 and with a combination of SB and ICG-FI since 2009. ICG 5?mg and SB 15?mg were injected in the subareolar region, and FI was obtained by a fluorescence imaging device.

Results

We attempted to identify SLNs in 393 patients by SB alone and in 108 patients by a combination of SB and FI. The mean number of SLNs detected was 1.6 (0?C5) for SB alone and 2.2 (1?C6) for the combination method. The SLN identification rate was 95.7?% for SB alone and 100?% for the combination method so that the combination was significantly superior to SB in terms of the identification rate (p?=?0.0037). In patients who received the combination method, detection of SLN was made through only SB in 1 patient, only ICG in 8 patients, and both in 99 patients. Lymph node metastasis was found in 56 patients with SB alone and in 16 patients with the combination method. Recurrence of an axillary node was observed in 3 patients (0.8?%) with SB alone and in no patients with the combination method.

Conclusions

ICG-FI is a useful method and is especially recommended in cases where no radiotracers are available.     

Paradigm Shift of Staging and Treatment for Early Breast Cancer in the Sentinel Lymph Node Era

Abstract:   Lymph node status is the most reliable prognostic indicator for the clinical outcome of patients with most solid cancers. Because it is the first node draining the primary cancer, the sentinel lymph node (SLN) is most likely to harbor metastatic cancer cells. The tumor size of primary breast cancer is highly correlated with SLN metastasis. If the SLN is negative, the negative predictive value of the remaining nodal basin exceeds 95%. It appears that even using different techniques from different institutions, the successful rate to harvest the SLN is more than 95%. The false-negative rate is about 5–10% in most series. Breast cancer patients with early detection and a negative SLN have a significantly improved survival rate. The SLN data in breast cancer is so convincing that SLN information has been incorporated into the new American Joint Committee on Cancer (AJCC) classification of breast cancer. The therapeutic value of additional lymph node dissection after a positive SLN for breast cancer is still controversial. Follow-up data from breast cancer patients is somewhat limited, but available information shows that patients with negative SLNs fare much better. In summary, several important patterns of metastasis can be established based on the current SLN experience: 1) The earlier the breast cancer is found, the less the metastatic potential. 2) In most cases, breast cancer follows an orderly progression of metastasis to the SLN. 3) A small subgroup of patients may develop systemic dissemination without SLN involvement. Since metastatic cancer is usually incurable, it is important for oncologists to detect and resect an early breast cancer without delay. The challenge in the future will be to dissect these different patterns of metastasis based on molecular or genetic markers. Such information will be critical to select high-risk patients for adjuvant therapy.      

Patterns of Axillary Surgical Care for Breast Cancer in the Era of Sentinel Lymph Node Biopsy

Background  Population-based overall patterns of surgical management of the axilla in women with operable breast cancer during the era of adoption of sentinel lymph node biopsy (SLNB) were studied. Methods   Women with operable breast carcinoma residing in 14 geographic areas of the Surveillance, Epidemiology, and End Results (SEER) cancer registries (1998–2004, n = 239,661) were assessed for axillary surgical patterns of care. Results  Use of SLNB increased from 11 to 59%. Use of no axillary surgery decreased from 14 to 6.6%. In pathologic node-negative women, use of axillary lymph node dissection (ALND) decreased from 94 to 36%. Independent factors most associated with failure to receive SLNB included diagnosis year (2000: 62%; 2004: 29%), surgery (mastectomy: 64%; breast-conserving surgery: 36%), tumor size (T3: 71%; T2: 56%; T1: 40%), age (≥70 years: 50%; <70 years: 45%), grade (high: 42%; low: 38%), urbanity (non-large metropolitan area: 49%; large metropolitan area: 42%), and, by quartile, poverty (highest: 47%; lowest: 35%), and white-collar employment (lowest: 56%; highest: 47%). In pathologic node-positive women who had SLNB, failure to undergo completion ALND increased from 20% in 1998 to 32% in 2004. Patients with smaller, lower-grade tumors, and those with smaller size of nodal metastasis, lack of extracapsular extension, age ≥70 years, increased linguistic isolation, African-American or Hispanic race/ethnicity, and white-collar employment were less likely to undergo completion ALND. Conclusions  Management of the axilla changed dramatically during the period of rapid adoption of SLNB. Patterns of care suggest both appropriate and inappropriate selection for SLNB and ALND.     

Causes of Death and Recurrence after Surgery for Early Gastric Cancer

n = 2), pneumonia ( n = 3), sepsis ( n = 1), and car accident ( n = 1). Four patients died from gastric stump recurrence, three from liver metastases, two from lymph node metastases, and two from peritoneal dissemination. Using Cox multivariate analysis, histologic type had the most significant effect on recurrence. Although influenced by the tumor nature, the EGC prognosis is relatively good. Based on the results of this study, particularly in Western institutions, histologic examination of resection margins and lymphadenectomy should be improved. Moreover, patients must be carefully followed for late recurrence and metachronous cancer.     

Impact of Splenectomy for Lymph Node Dissection on Long-Term Surgical Outcome in Gastric Cancer

Background:In the treatment of gastric cancer, splenectomy is performed for effective lymph node dissection around the splenic artery and splenic hilum. The purpose of this study was to clarify the long-term outcome of splenectomy in the treatment of gastric cancer.Methods: The effect of splenectomy on recurrence and prognosis was examined in a retrospective analysis of 665 patients who had undergone curative total gastrectomy for gastric carcinoma from 1987 to 1996. The risk factors associated with recurrence and prognosis were investigated by univariate and multivariate analysis.Results: The splenectomy group showed more advanced lesions and a higher recurrence rate than the spleen-preserved group. However, after adjusting for the TNM (tumor, node, metastasis) stage, there was no significant difference in recurrence rate and pattern between the two groups. Logistic regression analysis revealed that gross type, serosal invasion, and nodal metastasis were independent risk factors for recurrence while splenectomy was not. When comparing patients with the same TNM (tumor, node, metastasis) stages, no significant difference in the 5-year survival rates was apparent. Multivariate analysis demonstrated that age, serosal invasion, and nodal metastasis were independent prognostic factors whereas splenectomy was not.Conclusions: These data suggest that splenectomy for lymph node dissection in gastric cancer is not effective regarding long-term patient prognosis.