INDICATIONS FOR LAPAROSCOPIC PELVIC LYMPH NODE DISSECTION IN THE STAGING OF PROSTATE CANCER

Laparoscopic pelvic lymph node dissection is increasing in popularity, in the absence of validated surgical indications. This retrospective study was performed to identify those patients who would benefit from laparoscopic pelvic lyrnphadenectomy. The case notes of 50 patients who underwent bilateral open pelvic lymphadenectorny with frozen section examination were reviewed. The patients were staged clinically as having A2 (16), B1 (20) and B2 (14) prostate cancer. Except for the two patients who had macroscopically involved pelvic lymph nodes at operation, all proceeded to total prostatectorny. Six patients were found to have positive pelvic nodes. Of the six, four patients were clinical stage B2, one was B1 and one was A2. The Gleason score of two of these six patients was greater than seven. The prostate specific antigen (PSA) levels correlated more with high turnour volume (i. e. grade C) rather than with D1 disease. Frozen section at the time of lyrnphadenectomy had a false negative rate of 2 of 6. We conclude that laparoscopic pelvic lymph node dissections (LPLND) should be performed where there is a high likelihood of nodal disease, viz. bulky tunours, poorly differentiated histology and a high PSA reading. We consider that such selective use of LPLND optimizes its diagnostic utility while minimizing its unnecessary application.     

胃癌淋巴结清扫的临床应用解剖

目的 为胃癌的临床、病理描述提供一个通用的语言,有助于提高胃癌的诊治水平。方法采用文献回顾的方法对胃周淋巴结的构成分布解剖、胃癌的分期及相应的手术要求加以综述。结果 胃癌周围淋巴结沿胃周围血管及其邻近器官分布,解剖结构的熟悉,能使胃癌台术做到合理化、科学化。结论 有效的淋巴结清扫可使胃癌患者获得最佳疗效。     

IMPACT OF SEPARATE VERSUS EN BLOC PELVIC LYMPH NODE DISSECTION ON THE NUMBER OF LYMPH NODES RETRIEVED IN CYSTECTOMY SPECIMENS

PURPOSE: Pelvic lymphadenectomy during radical cystectomy yields a various number of lymph nodes depending on the extent of lymph node dissection and pathologist aggressiveness when searching the specimen. How the surgeon submits lymph nodes for pathological evaluation may also affect how many are retrieved. MATERIALS AND METHODS: Bilateral pelvic lymph node dissection and radical cystectomy for transitional cell carcinoma of the bladder was performed in 32 patients. The extent of lymph node dissection involved standard and extended lymphadenectomy in 20 and 12 cases, respectively. In patients who underwent standard dissection unilateral en bloc submission of the lymph nodes was done with the contralateral lymph node dissection sent as an individual discrete packet. In those who underwent extended dissection all lymph nodes from each side were submitted en bloc or as 6 packets. RESULTS: Standard lymphadenectomy en bloc specimens yielded a mean of 2.4 lymph nodes compared with 8.5 retrieved from individual lymph node specimens (p = 0.003). Extended lymphadenectomy en bloc specimens yielded a mean of 22.6 lymph nodes compared with 36.5 retrieved from the individually submitted packets (p = 0.02). CONCLUSIONS: Submitting pelvic lymph nodes as separate specimens optimizes pathological evaluation of the number of lymph nodes that may be involved with metastatic cancer. Such information is important for identifying patients who may benefit from adjuvant chemotherapy.     

COMBINED POST-CHEMOTHERAPY RETROPERITONEAL LYMPH NODE DISSECTION AND RESECTION OF CHEST TUMOR UNDER THE SAME ANESTHETIC IS APPROPRIATE BASED ON MORBIDITY AND TUMOR PATHOLOGY

Purpose

We determine if post-chemotherapy resection of residual retroperitoneal and chest tumor under the same anesthetic is reasonable based on tumor pathology and morbidity, and if the finding of necrosis in the abdomen allows observation of chest tumor.

Materials and Methods

We retrospectively reviewed 143 post-chemotherapy patients who underwent resection of residual retroperitoneal and chest disease under the same anesthetic.

Results

Retroperitoneal pathology was generally predictive of chest pathology. Concordance existed in 77.5% of patients with necrosis, 70% with teratoma and 69% with cancer of the abdomen. However, the correlation was much stronger (86%) in predicting necrosis/fibrosis if cases were categorized as uncomplicated by Indiana University criteria. Although the morbidity of the combined approach is higher than that of standard post-chemotherapy retroperitoneal lymph node dissection, it was acceptable.

Conclusions

The morbidity of post-chemotherapy retroperitoneal lymph node dissection and resection of chest disease under the same anesthetic is acceptable. Retroperitoneal pathology generally predicts chest pathology but this correlation is much stronger if the case is uncomplicated based on our criteria. In an uncomplicated case the discovery of necrosis of the abdomen allows observation of chest tumor.     

PELVIC LYMPH NODE METASTASES FROM BLADDER CANCER: OUTCOME IN 83 PATIENTS AFTER RADICAL CYSTECTOMY AND PELVIC LYMPHADENECTOMY

PURPOSE: We evaluate the outcome in patients with node positive bladder cancer with particular reference to the effect of individual characteristics of positive nodes on survival after meticulous pelvic lymphadenectomy at cystectomy. MATERIALS AND METHODS: This prospective analysis contains 452 cases of bladder cancer staged preoperatively as N0M0, managed with pelvic lymphadenectomy and cystectomy between 1984 and 1997. A total of 83 (18%) patients with histologically confirmed node positive disease are included in our study. RESULTS: The median overall survival of patients with positive nodes was 20 months. Median 5-year survival was 29%. Patients who survived were found with positive nodes at each site in the pelvis. The median survival of 57 patients with less than 5 positive nodes was 27 months, compared with 15 months for 26 with 5 nodes or more (log-rank test p = 0.0027). Median survival of 26 patients with no lymph node capsule perforation was 93 months, compared with 16 months for 57 with capsule perforation (p = 0.0004). The median survival of 18 patients with a maximum diameter of lymph node metastasis up to 0.5 cm. was 64 months, compared with 16 months for 65 with nodal metastasis greater than 0.5 cm. (p = 0.024). Contralateral positive nodes were found in 16 of 39 (41%) patients with unilateral bladder cancer. CONCLUSIONS: Long-term survival is possible with node positive bladder cancer. Those patients with few as well as smaller and, therefore, unsuspected nodal metastases, and those without lymph node capsule perforation have the best results after removal of pelvic metastatic nodal disease. Because patients who survive may be found regardless of the site of pelvic nodal metastases, meticulous bilateral pelvic lymphadenectomy is warranted in all patients at the time of attempted curative cystectomy for bladder cancer, particularly if there is no clinical evidence of nodal involvement.     

THE MODULATION OF TUMOUR-VERSUS-HOST RESPONSE IN LUNG,COLON, AND BREAST,CANCER PATIENTS: IMPLICATIONS FOR ADJUVANT IMMUNOCHEMOTHERAPY1

Major advances in the understanding of clinical tumour biology occurred with the appreciation that tumour-associated substances circulated in the blood of cancer patients. In this study their origin and immunogenic function have been investigated. Whole tumour cells (WTC) and cancer cell membrane fractions (CMF) of 24 patients with lung, colon, and breast cancer were investigated for their antigenic effect upon the patients' own lymphocytes and upon healthy allogeneic ones. The antigenicity of whole lung and breast cancer cells to stimulate lymphocyte DNA synthesis, and the ineffectiveness of colon cells were confirmed. CMF had little stimulating effect upon autologous lymphocytes; however, they were able to augment lymphocyte response to PPD and PHA in high dilution and to sppress it in high concentration. The serum of cancer patients exerted similar biphasic activity upon PPD and PHA stimulated lymphocytes (“lymphosppressive-stimulatory factors”, or LSSF). Sephadex studies confirmed that LSSF activity in cancer serum correlated with circulating CMF. These substances modulate lymphocyte nucleic acid synthesis in vitro; it is likely that they similarly modulate the patient tumour-host cell relationship.     

COMPARISON OF HELICAL COMPUTERIZED TOMOGRAPHY, POSITRON EMISSION TOMOGRAPHY AND MONOCLONAL ANTIBODY SCANS FOR EVALUATION OF LYMPH NODE METASTASES IN PATIENTS WITH PROSTATE SPECIFIC ANTIGEN RELAPSE AFTER TREATMENT FOR LOCALIZED PROSTATE CANCER

PURPOSE: We compare the detection of metastatic disease by helical computerized tomography (CT), positron emission tomography (PET) with F-18 fluorodeoxyglucose and monoclonal antibody scan with 111indium capromab pendetide in patients with an elevated prostate specific antigen (PSA) after treatment for localized prostate cancer. MATERIALS AND METHODS: A total of 45 patients with an elevated PSA (median 3.8 ng./ml.) were studied following definitive local therapy with radical prostatectomy in 33, radiation therapy in 9 and cryosurgery in 3. CT of the abdomen and pelvis, and whole body PET were performed in all patients, of whom 21 also underwent monoclonal antibody scan. Lymph nodes 1 cm. in diameter or greater on CT were considered abnormal and were sampled by fine needle aspiration in 12 patients. RESULTS: PET and CT were positive for distant disease in 50% of 22 patients with PSA greater than 4, and in 4 and 17%, respectively, of 23 with PSA less than 4 ng./ml. The detection rate for metastatic disease was similar for CT and PET, and higher overall than that for monoclonal antibody scan. Monoclonal antibody scan was true positive in only 1 of 6 patients, while PET was true positive in 6 of 9 with CT guided fine needle aspiration proved metastases. CONCLUSIONS: CT and PET each detected evidence of metastatic disease in 50% of all patients with a high PSA or PSA velocity (greater than 4 ng./ml. or greater than 0.2 ng./ml. per month, respectively). Both techniques are limited for detecting metastatic disease in patients with a low PSA or PSA velocity. Our data suggest that monoclonal antibody scan has a lower detection rate than CT or PET.     

A POPULATION‐BASED STUDY OF THE INCIDENCE,MORTALITY AND OUTCOMES IN PATIENTS FOLLOWING SURGERY FOR COLORECTAL CANCER IN WESTERN AUSTRALIA

Background : The literature contains many reports on the management of colorectal cancer from single institutions or groups of specialist surgeons. But there are few data on community‐wide patterns of treatment or the outcomes of colorectal surgery. The aim of the present study was to use a population‐based linked database to assess the trends in colorectal cancer incidence and mortality in Western Australia (WA) in the period 1982–95, and to evaluate the outcomes following surgical care. Methods : A population‐based linked database was used to relate the cancer registry, hospitalization and mortality records of all patients with a diagnosis of colorectal cancer in WA during 1982–95. Data on surgical treatment and postoperative morbidity and mortality in this group of patients were available only in 1988–95. Patient records were selected using the international classification for diagnosis and procedure codes pertaining to colorectal cancer and surgery. Incidence and mortality trends in colon and rectal cancers were estimated by Poisson regression of age‐standardized rates, and relative survival analysis was used to compare patient survival with the general population. Results : During the 14‐year period, 9673 patients presented with a diagnosis of colorectal cancer. The sex distribution of patients with colon cancer was evenly divided, but rectal cancer was more common in men (ratio 1:4). The mean age at diagnosis was 67.8 years (SD: 12.7). During the study period there was a significant increase in the standardized incidence rate of rectal cancer in men, and in the mortality rates from colon cancer in women. The overall crude 5‐year survival was 57%. Large bowel resections were performed on 71% of patients with an in‐hospital postoperative mortality of 4.2%. Conclusion : Colorectal cancer is a continuing major cause of morbidity and mortality in WA. The present study demonstrated increases in the incidence rate of rectal cancer in men and in the mortality rate from colon cancer in women in the period 1982–95.     

HP37PROGNOSTIC FACTORS IN OESOPHAGEAL CANCER: NUMBER OF LYMPH NODES AND EXTRACAPSULAR LYMPH NODE INVASION – AN INTERIM ANALYSIS

Purpose Pre‐operative scanning for hepatic colorectal metastases surgery remains a challenge, especially in the age of neo‐adjuvant chemo, which has marked biochemical & physical effects on the liver. We investigated helical CT and CT portography as pre‐op planning tools. Methodology All patients who had resection of hepatic colorectal metastases between Jan 2004 and June 2006 were included. Patients were divided into those who received neo‐adjuvant chemo and those who did not. The number of malignant hepatic lesions found on each scan was compared with those found on histopathology & intra‐op ultrasound/examination. Accurate scans (scan lesions = true lesions), over‐estimations (scan lesions > true lesions) and under‐estimations (scan lesions < true lesions) were recorded. Results 25 patients had pre‐op CT portography with neo‐adjuvant chemo and 63 without. Accurate scans on a per‐patient basis were 2 (8%) for the chemo group vs. 27 (43%) for the non‐chemo group, p < 0.002. Notably, there were 17 (68%) over‐estimates in the chemo group vs. 25 (40%) in the non‐chemo group. There were 6 (24%) vs. 11 (17%) under‐estimates respectively. 23 patients had pre‐op helical CT with neo‐adjuvant chemo and 64 without. Accurate scans on a per‐patient basis were 7 (30%) for the chemo group vs. 26 (41%) in the non‐chemo group, p = 0.388. There were 8 (35%) over‐estimates in the chemo group vs. 12 (19%) in the non‐chemo group. There were 8 (35%) vs. 26 (41%) under‐estimates respectively. Conclusion While CT portography is useful for detecting occult hepatic metastases, there is evidence that over‐estimation of disease is a problem, particularly when neo‐adjuvant chemo was used. Helical CT also shows this trend although to a lesser extent.     

COMBINED ORCHIECTOMY AND EXTERNAL RADIOTHERAPY VERSUS RADIOTHERAPY ALONE FOR NONMETASTATIC PROSTATE CANCER WITH OR WITHOUT PELVIC LYMPH NODE INVOLVEMENT: A PROSPECTIVE RANDOMIZED STUDY

Purpose

We compare the combination of orchiectomy and radiotherapy to radiotherapy alone as treatment for pelvic confined prostate cancer, that is T1-4, pN0-3, M0 (TNM classification).

Materials and Methods

In this prospective study 91 patients with clinically localized prostate cancer were, after surgical lymph node staging, randomized to receive definitive external beam radiotherapy (46) or combined orchiectomy and radiotherapy (45). Patients treated with radiotherapy alone had androgen ablation at clinical disease progression. The effects on progression-free, disease specific and overall survival rates were calculated.

Results

After a median followup of 9.3 years (range 6.0 to 11.4) clinical progression was seen in 61% of the radiotherapy only patients (group 1) and in 31% of the combined treatment patients (group 2) (p = 0.005). The mortality was 61 and 38% (p = 0.02), and cause specific mortality was 44 and 27%, respectively (p = 0.06), in groups 1 and 2. The differences in favor of combined treatment were mainly caused by lymph node positive tumors. For node negative tumors there was no significant difference in survival rates.

Conclusions

The progression-free, disease specific and overall survival rates for patients with prostate cancer and pelvic lymph node involvement are significantly better after combined androgen ablation and radiotherapy than after radiotherapy alone. These results strongly suggest that early androgen deprivation is better than deferred endocrine treatment for these patients.     

ABDOMINAL SURGERY IN HIV/AIDS PATIENTS: INDICATIONS,OPERATIVE MANAGEMENT,PATHOLOGY AND OUTCOME

Despite the increasing number of patients with the human immunodeficiency virus (HIV) infection. surgical experience with these patients remains limited. A retrospective review over a 9 year period (January 1985 to December 1993) was undertaken to determine the indications, operative management. pathologic findings and outcome of major abdominal surgery in these patients. A total of 51 procedures were performed in 45 patients; 30 patients had acquired immunodeficiency syndrome (AIDS) and IS patients had asymptomatic HIV infection. Indications included gastrointestinal bleeding. complicated pancreatic pseudocysts. cholelithiasis. bowel obstruction, immune disorders, acute abdomens. elective laparotomy. colostomy formation. menorrhagia and Caesarean section. Pathologic findings directly related to the HIV infection were found in 81% of the AIDS patients and 35% of the asymptomatic HIV infected patients (P<0.05). These included opportunistic infections. non-Hodgkin's lymphoma. Kaposi's sarcoma, immune disorders. lymphadenopathy and pancreatic pseudocysts. It was noted that AIDS patients had more complications than asymptomatic HIV infected patients with most complications related to chest problems and sepsis (61 vs 7%; P<0.01). Emergency operations carried a higher complication rate than elective operations though this was not significant. The hospital mortality was 12%. On follow up, 13 of the 25 AIDS patients had died with the median survival of 7 months, while three of the 14 asymptomatic HIV infected patients had died with the median survival of 40 months. Of the remaining patients, the 12 AIDS patients had a median postoperative follow up of 7 months and the 11 asymptomatic HIV infected patients had a median postoperative follow up of 29.5 months. Despite impaired immune function, surgical treatment of HIV infected patients with abdominal pathology can be practised with acceptable mortality and morbidity and be of major benefit to these patients.     

ISOFLURANE SEDATION FOR PATIENTS UNDERGOING MECHANICAL VENTILATION: METABOLISM TO INORGANIC FLUORIDE AND RENAL EFFECTS

The metabolism and renal effects of isoflurane sedation werestudied for 24 h in patients undergoing mechanical ventilation.Forty-six patients admitted to our intensive therapy unit wereallocated randomly to receive either 0.1–0.6% isofluraneor midazolam 0.01–0.2 mg kg^–1 h^–1 for sedation.In 26 patients sedated with isoflurane, plasma inorganic fluorideincreased from a mean concentration of 4.03 µmol litre^–1to 13.57 µmol litre^–1 12 h after stopping sedation.Plasmainorganic fluoride concentrations in 20 patients sedated withmidazolam were unchanged from baseline values (mean 5.32 µmollitre^–). Serum electrolyte, urea and creatinine concentrations,and urine output rates during and after sedation in patientswho receivedisoflurane were similar to those who received midazolam.We conclude that, following isoflurane sedation for up to 24h, metabolism to inorganic fluoride is insufficient to causeclinical renal dysfunction University Department of Anaesthesia, Queen Elizabeth Hospital,Birmingham B15 2TH     

SURGICAL REPAIR OF TYPE-A AORTIC DISSECTION: EARLY AND LATE RESULTS IN 32 CONSECUTIVE PATIENTS

Background : Acute type-A aortic dissection is a surgical emergency. One unit's experience in the surgical repair of type-A aortic dissection is documented. Methods : Surgical treatment was undertaken for type-A aortic dissection in 32 consecutive patients between January 1988 and August 1994 at Royal North Shore Hospital. Retrosternal chest pain was the commonest presenting symptom and in four of these cases it was initially misinterpreted as myocardial ischaemia. Results : A total of 24 patients had signs of aortic incompetence on presentation. Computed tomography (CT) scanning was the commonest modality of definitive diagnosis, but trans-oesophageal echocardiography was used as confirmation wherever possible, and we now consider it the initial, best investigation whenever a diagnosis of dissection is considered. There were 15 supra-coronary ascending aortic replacements, and a further four with aortic valve re-suspension. There were 13 operations of the Bentall's type. The overall 30-day mortality was 19%. The late mortality was 19%. with 62% long-term survival at a mean follow-up of 4.8 years. Conclusion : Early diagnosis and surgical intervention can give excellent palliation and improved life expectancy in acute type-A aortic dissection.