Evaluation of neck lymph node dissection for thoracic esophageal carcinoma

We studied a series of 150 patients treated for thoracic esophageal carcinoma at our institution. The patients were divided into two matched groups. Group B underwent transthoracic esophagectomy with mediastinal and abdominal lymphadenectomy only; group A also underwent bilateral neck lymph node dissection. The rates of operative mortality and operative complications did not differ significantly between the two groups. The 5-year survival rate was 38.7% overall (48.7% in group A and 33.7% in group B). Group A had a significantly better survival curve than group B. Twenty patients (26.0%) in group A had metastasis in the dissected neck lymph nodes. The 4-year survival rate of these patients was 47.9%. The significantly better survival of group A and the satisfactory prognosis in the patients with positive cervical lymph nodes demonstrates the effectiveness of neck lymph node dissection in radical operation for thoracic esophageal carcinoma.     

Protocol for lymph node dissection in stomach carcinoma. Possibility for quality assurance

Since 1984 we have been using the opportunity to registrate the dissected lymph nodes at different locations of the lymph nodes and the carcinoma in case of D-2 dissection by means of a lymph node dissection protocol. The total rate of lymph nodes by the several patients is an indirect sign for the quality of the lymph node dissection and the preparation work of the pathologist. In about 17% of all cases the number of all found lymph nodes by the pathologist was lower than 15 and so an exactly classification in the N-category was not possible. In case of an exactly lymph node dissection on one hand side the prognosis for the patients life can be improved and on the other hand side an exactly pathological classification is an opportunity to estimate the prognosis better than.     

Study on extensive lymph node dissection: metastatic lymph nodes in papillary carcinoma of the thyroid

Bilateral cervical lymph node dissection was performed in 71 cases of papillary thyroid carcinoma, considered to be relatively early cases because of mobility, irrespective of the size of tumor or presence of node enlargement. Of these, 33 cases received additional node dissection of the anterosuperior mediastinum through longitudinal sternotomy. The number of lymph nodes examined per subject averaged 89.9, the number of metastatic nodes was 13.8, and metastasis was noted in 88.7% of all cases. Lymph node metastasis tended to be more frequent on the affected side, but was simultaneously scattered over the whole cervical area. As to sites, metastasis of paratracheal nodes on the affected side occurred at a frequency of 66.2%, inferior and superior jugular nodes at 62.0% and 59.0% respectively, pretracheal nodes at 50.7%, and tracheoesophageal nodes at 47.9%. The high incidence of para- and pretracheal nodes suggests that the lymph flow in this direction is of great importance in metastasis. In fact, lymph nodes in the mediastinum, which were directly continuous with these nodes, showed as high as 39.4% metastasis in cases of anterosuperior mediastinal extirpation. This extensive node dissection is considered to be very preferable as at least the agony of survival with carcinoma can be lessened.     

Sentinel lymph node dissection for merkel cell carcinoma

Merkel cell carcinoma is an aggressive neuroendocrine skin tumor whose treatment modality is still controversial. It resembles malignant melanoma in its cutaneous presentation, unpredictable biologic behavior, early regional lymph node involvement, early distant metastases, and high recurrence rate. Regarding these common features, we used sentinel node biopsy (a well-described technique for the treatment of malignant melanoma) in a 50-year-old man with Merkel cell carcinoma of the left arm. Only one sentinel lymph node was identified and it was revealed to be disease-free on histology. No further axillary dissection was performed. This case report shows that sentinel node biopsy is applicable to Merkel cell carcinoma.     

Cervico-thoracic-abdominal lymph node dissection for carcinoma of the thoracic esophagus

Over the period from 1982 to 1988, 127 cases with carcinoma in the thoracic esophagus underwent curative resection through a right thoracotomy. Cervicothoracic-abdominal lymph node dissection was performed in twenty-seven cases. No operative death occurred and only one hospital death (4%) was recorded. The only postoperative complication was recurrent laryngeal nerve palsy. Based on the adjusted survival-rate curves using Cox's method, there was significant difference in prognosis in favor of these 27 cases that received cervicothoracic-abdominal lymph node dissection over those that did not. The survival rate of all curatively operated cases was noticeably improved by using this procedure. Of those that underwent dissection only, or dissection with postoperative radiotherapy or chemotherapy, the best prognosis could be reached by a combination of the cervicothoracic-abdominal lymph node dissection and postoperative chemotherapy. From follow-up data regarding recurrence rates, a more extended dissection and complete removal of lymph nodes in the left upper mediastinum and retroperitoneum should further improve the long-term prognosis.     

The lymph node dissection in thyroid carcinoma

Rule and indications of lymph node dissection (LD) in thyroid carcinoma is still under debate because of the biological variety of different histological types and the difficulty to have an accurate preoperative diagnosis of metastatic lymph nodes; moreover prognostic factors of metastatic lymph nodes are still unclear. The AA. have separately analyzed different thyroid carcinomas and different clinical situations requiring thyroid LD. Metastatic lymph nodes from differentiated carcinomas, including papillary and follicular type, range from 12 to 90% and apparently do not worsen the prognosis. Level II-VI LD is indicated in presence of metastatic lymph nodes or macroscopic nodal recurrence after a previous LD. No prognostic advantages have been demonstrated when LD is performed without clinical or instrumental evidence of metastatic disease, including suspected recurrence characterised only by plasma Thyreoglobulin increased values. Lymph node metastases from medullary carcinoma range from 25 to 63%. Level II-VI LD is indicated if node metastases are present, whereas prophylactic LD, confined to level VI, is always recommended. Controversies still remain about: 1) LD extension whether it is prophylactic (level VI vs. II- VI) or in case of nodal involvement (levels II- VI monolateral or bilateral), 2) LD indications in case of an increased plasma Calcitonin levels during the follow-up after total thyroidectomy, without clinical or instrumental evidence of nodes involvement. Anaplastic carcinoma represents 5% of all thyroid carcinomas; it is the most aggressive type with an early tendency to invade surrounding organs and to give metastases; prognosis is very poor. LD is indicated only for a palliation in cases with compression syndromes.     

Cervical lymph node dissection and thyroid carcinoma

After an anatomic recall of the cervical lymph node compartments we describe the surgical technique of the lymph node dissection in patients with differentiated thyroid carcinoma. These lymphadenectomies should be associated with total thyroidectomy. Cervical lymph node dissection always concerns central compartment and is sometimes extended to the cervico lateral compartments. Lymphadenectomy of a compartment should be complete, reoperations leading to an important morbidity. The two main complications of cervical lymph node dissection are inferior laryngeal nerve palsy and hypoparathyroidism.     

Laparoscopic retroperitoneal lymph node dissection for nonseminomatous testicular carcinoma

Retroperitoneal lymph node dissection (RPLND) is still the most sensitive and specific method for the detection of lymph node metastases in stage I nonseminomatous testicular carcinoma. In stage II disease, residual malignant tumor and mature teratoma can be removed. Acceptance of this operation, however, has decreased due to the morbidity caused by the open approach. To reduce this morbidity, and to improve the acceptance of RPLND, laparoscopy has been introduced. Clinical data with long-term follow-up are now available which demonstrate the technical feasibility of laparoscopic RPLND. Studies comparing laparoscopy and open surgery show advantages for the laparoscopic approach in terms of reduced blood loss, intraoperative complications and operative time. Mainly minor complications, such as chylous ascites or lymphocele formation, are observed. The conversion rate to open surgery, mainly due to intraoperative bleeding, is acceptable at less than 10%. As in open surgery, antegrade ejaculation can be preserved successfully. RPLND has also been shown to provide adequate oncological results. In stage I disease, lymph node metastasis is found in 25–41% of cases. Patients with histologically proven retroperitoneal tumor receive adjuvant chemotherapy whereas individuals without evidence of retroperitoneal disease do not require additional treatment. Follow-up controls in both groups, without local recurrence, demonstrate the excellent diagnostic accuracy of this procedure. Meanwhile laparoscopic RPLND has also been introduced successfully in the management of stage II disease. Small volume residual tumors can be removed with an acceptable complication rate. However, this operation is technically demanding and should be performed only at institutions with considerable laparoscopic experience. In conclusion, laparoscopic RPLND is a safe method for low-stage germ cell tumors with minimal invasiveness and excellent clinical results. Thus laparoscopy might contribute to a better acceptance of RPLND.     

Evaluation of extended lymph node dissection for gastric cancer

A total of 587 cases with gastric cancer was reviewed. Particular emphasis was placed on the comparative studies on the stages of stomach cancer and end-results of the R₂ (with a conventional lymph node dissection) and the R₃-resections (with an extended lymph node dissection). R₃-resections were found to be generally associated with higher 5-year survival rates than R₂-resections. Especially for the positive lymph node cases not having a marked serosal invasion, the 5-year survival rate was considerably higher with R₃-resections than with R₂-resections (55.3 percent versus 21.5 percent). Although the differences were not significant statistically, it has been suggested from these results that the end-results might be improved more effectively by performing R₃ resection for cases without a marked serosal invasion.     

Evaluation of rational lymph node dissection for abdominal neuroblastoma

Complete tumor resection has a significant role in the treatment of localized neuroblastoma. Recently we have applied activated carbon particles to lymph node dissection in the surgery of retroperitoneal neuroblastoma with nodal involvement for the complete resection of this tumor. In this study, we have reviewed 22 consecutive patients with retroperitoneal neuroblastoma who received rational lymph node dissection using activated carbon particles from 1985 through 1990, including 16 patients detected through mass screening. Fourteen patients with stages I, II, and IV-S of neuroblastoma have survived for a median duration of 37.6 months, and all patients detected through mass screening survived for a median duration of 36.7 months, with no evidence of disease after operation. Two of the 8 patients with advanced disease (stages III and IV) died of tumor progression. No local recurrence was observed in all patients, and early or late complications were minimal. In conclusion, rational lymph node dissection considering the lymphatics is recommended for the surgery of patients with retroperitoneal neuroblastoma, including the patients detected through mass screening.     

Optimal lymph node dissection for carcinoma of the biliary tract]

To clarify the optimal lymph node dissection for carcinoma of the biliary tract, we analyzed the mode of lymphatic spread in 86 resected cases with carcinoma of the gallbladder and 139 with carcinoma of the extrahepatic bile duct, and investigated long-term results after resection based on the degree of lymph node metastasis. Of the 86 patients with carcinoma of the gallbladder, 62 (72.1%) had lymph node metastasis. Patients with m and mp tumors (n = 9) had no lymph node metastasis, whereas ss tumors (n = 13) had 23.1% lymph node metastasis. Those with se, si tumors (n = 64) had greater lymph node involvement (92.2%). In 4 patients with advanced carcinomas (ss or more) who survived more than 5 years, only one (limited to periportal lymph nodes) of them had lymph node metastasis. Of the 139 patients with carcinoma of the extrahepatic bile duct, 58 (41.7%) had lymph node metastasis. There was no lymph node metastasis in 15 patients with m or fm tumors. The frequency of metastasis in the ss (n = 39) and se, si (n = 85) tumors was 17.9% and 60.0%, respectively. Twenty-four patients with advanced tumors survived more than 5 years. Curative resection was achieved in all 24 and lymph node metastasis was n0 in 19, n1 in 4 and n2 in 1 patients. Satisfactory long-term result can be achieved in carcinoma of the biliary tract after resection when lymph node metastasis is limited to nodes in the hepatoduodenal ligament. In view of our surgical results and the lymphatic drainage system of the biliary tract, systemic dissection of the regional lymph nodes, including periportal, posterior pancreato-duodenal, and celiac nodes, is necessary in patients with N0-N2 (limited to lymph nodes in the hapatoduodenal ligament) tumors in whom it contributes to good prognosis.     

手助腹腔镜胃癌淋巴结清扫规范性的临床研究

目的:应用纳米碳微粒作为淋巴结示踪剂,评价手助腹腔镜胃癌根治术中淋巴结清扫的规范性.方法:回顾性分析8个月内实施手助腹腔镜胃癌根治术患者40例的临床资料.将手术中注射纳米碳混悬液后进行淋巴结清扫的患者15例设为观察组,其余25例为对照组.结果:观察组15例中,小弯侧淋巴结显色12例(80.00％);8a组和6组淋巴结色染各8例(53.33％);脾门和大弯侧淋巴结色染各3例(20.00％).观察组与对照组的主要手术相关指标,包括切口长度[(6.90±0.28) cm vs.(6.82±0.38)cm],术中出血量[(286±168) mL vs.(235±98)mL],手术时间[(182±31)min vs.( 176±21)min],淋巴结检出数[(16.8±6.71)枚vs.( 14.9±3.90)枚],术后住院时间[( 10.1±3.8) d vs.(11.6±6.5)d],差异均无统计学意义(均P＞0.05).结论:淋巴结示踪剂的应用,对完善术中淋巴结清扫有一定的辅助作用;更能体现出手助腹腔镜胃癌根治术淋巴结清扫的规范性.