A case of epididymal sarcoidosis

Sarcoidosis is a systemic inflammatory condition that primarily affects the lungs, lymphatic system and skin. Extra thoracic manifestations occur in about 50% of cases; however, it rarely affects the male reproductive tract. The first documented case of epididymal and testicular sarcoid in the Irish literature is of a 25-year-old male who presented with a painful 1-cm extra-testicular scrotal mass. While the involvement of the male reproductive tract is rare, it should be included in the differential of testicular pathology. It can be diagnosed on frozen section and may be managed conservatively.     

Retroperitoneal lymphocele after abdominal aortic surgery

Lymphoceles may occur as a result of lymphatic injury during abdominal aortic surgery. These lymphatic collections may occur as a retroperitoneal mass or as groin lymphoceles. Four cases are presented in which persistent retroperitoneal lymphoceles were discovered 2 to 8 years after surgery. Reexploration of the groin and repeated aspirations of lymphatic fluid failed to control the drainage. Reexploration of the retroperitoneum documented lymphatic injury, which was controlled by ligation of the lymphatics with suture. A review of the literature discloses five similar reported cases of retroperitoneal lymphocele and 12 cases of chylous ascites after abdominal aortic surgery. Clearly, avoiding lymphatic injury or immediate repair of any lymphatic injuries will prevent this problem. Once a persistent lymphocele has developed, aspiration will establish the diagnosis. Our experience would suggest that reexploration of the retroperitoneum is required to control the drainage and to prevent possible graft infection.     

Intraoperative limphonodal mapping in gastric, pulmonary and large bowel tumors. The sentinel limphonode technique

The concept of the sentinel lymphatic node was introduced by Cabanas in 1977, but it has proved to be successful for the treatment of the melanoma and breast cancer only since the 90s. Many studies have recently extended this technique to other neoplasias. This study deals with 36 patients who were to undergo surgery for 14 gastric adenocarcinomas, 11 of the colon and 11 pulmonary. Once the neoplastic mass was detected, 2 to 5 ml of a vital dye (Blu Patent) were injected in the serosa along the perimeter of the tumor by means of several 0.5 ml injections. A lymphatic node was diagnosed in 22 patients, respectively 10 gastric neoplasias, 6 pulmonary, 6 of the colon. In 14 cases the lymphatic node was found to be negative, in 8 cases positive. In the remaining 14 patients the lymphatic node was not detected. Although data do not always agree, the sentinel lymphatic node technique seems to have been successful for this kind of tumors. For this reason we have carried out this study and published our first data.     

Experimental study for lymphatic routes of the cardia and diaphragm]

We report discovery of the lymphatic routes in the gastric cardia and adjacent diaphragm after producing a blockage in the descending lymphatic route in dogs. CH40 black carbon hydrate was injected into the cardia portion during operation followed by total gastric and diaphragm combined resection to investigate lymphatic routes. In the 12 dogs with a blockage, and an ascending route to the lower mediastinum was recognized in 4 cases, and lateral routes from the hiatus of the esophagus to the diaphragm in a further 3 of the 12 cases. The lateral route was considered to be a collateral lymphatic route of neo-lymphatic vessel. Further, we found that phrenic lymphatic flows went in multiple directions, whereas the lymphatic flow at the phrenic lumbar vertebrae went mainly in the direction of the esophageal opening or aortic opening, although there was some expansion to the mediastinal side or celiac side. Consequently, it was assumed that metastasis to the lateral direction besides the ascending route might occur in cases with cancer in the cardiac portion infiltrating to the hiatus of the esophagus.     

Infralevator Lymphatic Drainage of Low-Rectal Cancers: Preliminary Results

Background  Some low-rectal cancers may spread into or recur in the inguinal lymph nodes despite optimal resection of the primary tumor. Hence, we hypothesized that lymphatic drainage of low-rectal malignancies may be inhomogeneous and that an extramesorectal route may be involved in at least some cases. The idea of our preliminary study was to analyze the potential lymphatic drainages in low-rectal cancer patients. Methods  The first stage of the experiment included two consecutive low-rectal adenocarcinoma patients (free from inguinal lymph node metastases), in whom the lymphatics of the primary tumor were traced with Patentbalu dye. During the second stage the records of 206 consecutive low-rectal cancer patients were analyzed for presence of inguinal lymph node metastases. Results  An evaluation of specimens from two rectal cancer patients revealed extramesorectal lymphatic drainage of the primary tumor besides the mesorectal route. An analysis of 206 patients revealed six cases of inguinal node metastases. Median age of patients was 55 years. They were all diagnosed with rectal adenocarcinoma, T3 or T4 tumors with G2 or G3 grade. Conclusion  The demonstration of an alternative route of lymphatic drainage suggests that more radical surgical procedures are necessary for successful treatment of low-rectal cancers.     

Implementation of New Surgical Technology: Outcome Measures for Lymphatic Mapping of Breast Carcinoma

Background: Recent advances in technology and the subsequent development of minimally invasive surgical techniques have heralded a new era in the surgical treatment of breast cancer. The dilemma of how to train surgeons in new technologies requires teaching, certification, and outcomes reporting in a non-threatening and non–economically damaging manner. This study examines 700 cases of lymphatic mapping and sentinel lymph node (SLN) biopsy for breast cancer and documents surgeon-specific and institution-specific learning curves.Methods: Seven hundred cases of lymphatic mapping and SLN biopsy were examined. All procedures were performed using a combination of vital blue dye and radiolabeled sulfur colloid. Learning curves were generated for each surgeon as a plot of failure rate versus number of cases.Results: Examination of the learning curves in this study demonstrates similar characteristics. Following a high initial failure rate, there is a rapid decrease after the first twenty cases. The learning curve, representing the mean of the five surgeons experience, indicates that 23 cases and 53 cases are required to achieve success rates of 90% and 95%, respectively.Conclusions: The initial reports regarding lymphatic mapping combined with this experience of 700 cases confirm the presence of a significant learning curve. Although this procedure may have an inherent failure rate, it is important to identify those factors that are under the control of the surgeon and, therefore, subject to improvement. We believe that these data provide surgeons performing lymphatic mapping and SLN biopsy with a new paradigm for assessing their skill and adequacy of training.Presented at the 52nd Annual Meeting of the Society of Surgical Oncology, Orlando, Florida March 4–7, 1999.     

淋巴化疗与区域缓释化疗治疗直肠癌淋巴结转移的疗效比较

目的 比较淋巴化疗和区域缓释化疗(regional extended release chemotherapy, RERC)治疗直肠癌淋巴结转移的疗效.方法 分别取对照组(20例)、淋巴化疗组(20例)和RERC组(20例)直肠癌患者第1、2、3站淋巴结,比较淋巴结内癌细胞增殖指数(proliferation index, PI)、凋亡指数(apoptotic index, AI)及AI/PI.结果 各组淋巴结内肿瘤细胞PI、AI、AI/PI比较,淋巴化疗组与其余两组对应站比较差异有统计学意义(F=4.973～7.394,5.372～8.694,4.527～5.436,P<0.05;t=3.128～7.688,3.388～9.615,6.518～13.180,P<0.05);RERC组前两站与对照组比较差异有统计学意义(t=5.103、4.927,6.938、6.450,8.839、9.021,P<0.05),与组内第3站比较差异有统计学意义(F=6.572,8.964,5.845,P<0.05;t=3.505、3.353,5.397、4.701,9.039、8.629,P<0.05).对淋巴结肿瘤细胞疗效,淋巴化疗组各站最好,RERC组第1站较好,第2站稍低,第3站最低几乎等同于对照组各站.结论 淋巴化疗在防治直肠癌淋巴结转移的作用范围和强度优于RERC.     

New development in Crohn's disease: ++unravelling the mystery and its reinstatement as a surgically treatable condition. Part 2. Potential etiopathogenesis of "terminal ileitis" and extension of the disease to mesenteric small intestine and the colon

INTRODUCTION: The aetiopathogenesis of terminal ileitis is still unknown, as is the cause of its spread to the small and large bowel. The aim of this study was to shed light on these unknown aspects of Crohn's disease. CONCLUSIONS: The lack of patency of the ileal branch of the ileocolic lymphatic collector which causes terminal ileitis, usually in the earlier part of life, is likely to occur in the foetus around the 10th week of pregnancy as a result of a minor abnormality of the physiological regression of the vitelline duct. Excessive atrophy of the lymphatic network seems to occur, also affecting the rudimentary lymphatic vessels in the midgut destined to become the terminal ileum. The terminal ileitis spreads to the large bowel in an increasing percentage of cases and is directly related to duration of the disease, causing first ileitis plus right colitis, and then ileitis plus total colitis (which, however, does not include the rectum). It may also include the jejunum, causing skip lesions. This spread of lesions is not due to any genetic predisposition (that is to say, it is not predetermined in empirical terms), but rather to the extent of the lymphatic obstruction caused by the spread of immunocomplexes via the lymphatic network. This is shown by the fact that secondary lesions of the jejunum and large bowel are also typical of lymphoedema and that their spread is segmentary. In the light of these pathogenetic mechanisms, it is reasonable to assume that the spread of the process from the ileum to the colon might be prevented by prompt surgery during the initial phase of the ileitis. If these views are correct, the traditional subdivision of Crohn's disease forms into ileitis, ileocolitis and solitary colitis should be replaced by a very simple scheme showing the spread of the primary ileitis very often to ileocolitis, first confined to the right colon and then total. We cannot include either solitary colitis (not clearly defined in the literature) or anorectal Crohn's disease (whose forms have yet to be fully acknowledged) in this scheme.     

A rectal carcinoid tumor of less than 1 cm in diameter with lymph node metastasis: a case report and a review of the literature

We report herein, a patient with a rectal carcinoid tumor of less than 1 cm in diameter with lymph node metastasis, and discuss a surgical policy for these lesions with reference to other such cases reported in the literature. A 40 year old female was admitted with a rectal mass and colonoscopy revealed a subpedunculated lesion, 1 cm in diameter, with a depression in its tip. A diagnosis of carcinoid was made by biopsy and transsacral excision performed. The excised specimen revealed a subpedunculated lesion measuring 7 X 6 X 6 mm with a central depression. The tumor was histologically confined to the submucosa but lymphatic invasion with pararectal lymph node involvement was observed. A radical proctectomy was thus performed. The incidence of metastasis from rectal carcinoids with a diameter of 1 cm or less is very low ranging from 1.5 to 3.4 per cent, and it therefore seems that most lesions of 1 cm or less in diameter can be treated by local excision alone. Thus, although it is recommended that local excision be performed first to determine the extent of spread, lymphatic vessel invasion and lymph node metastasis, radical surgery is indicated if lymphatic invasion or nodal involvement is present, even when muscle invasion is absent.     

A rectal carcinoid tumor of less than 1 cm in diameter with lymph node metastasis: A case report and a review of the literature

We report herein, a patient with a rectal carcinoid tumor of less than 1 cm in diameter with lymph node metastasis, and discuss a surgical policy for these lesions with reference to other such cases reported in the literature. A 40 year old female was admitted with a rectal mass and colonoscopy revealed a subpedunculated lesion, 1 cm in diameter, with a depression in its tip. A diagnosis of carcinoid was made by biopsy and transsacral excision performed. The excised specimen revealed a subpedunculated lesion measuring 7×6×6 mm with a central depression. The tumor was histologically confined to the submucosa but lymphatic invasion with pararectal lymph node involvement was observed. A radical proctectomy was thus performed. The incidence of metastasis from rectal carcinoids with a diameter of 1 cm or less is very low ranging from 1.5 to 3.4 per cent, and it therefore seems that most lesions of 1 cm or less in diameter can be treated by local excision alone. Thus, although it is recommended that local excision be performed first to determine the extent of spread, lymphatic vessel invasion and lymph node metastasis, radical surgery is indicated if lymphatic invasion or nodal involvement is present, even when muscle invasion is absent.     

Chylous reflux in the lungs and pleurae

Lymphangiectasis of varying extent may be present in some cases of chronic pulmonary disease. Often the dilated lymphatic channels are not identified because pulmonary fibrosis and emphysema together with secondary inflammatory changes obscure the lymph vessel pathology. When chylothorax is associated with such chronic pulmonary pathology, attention may be drawn to the lymphatic system. The presence of a chylothorax is usually attributed to obstruction or injury of the thoracic duct, whereas in some cases chylous reflux into the lungs and pleurae via abnormal lymph channels in the lungs and pleurae as well as in the mediastinum may cause the chylothorax. In rare instances a patient may actually expectorate chylous fluid which seeps into the bronchi from the abnormal peribronchial lymphatics. A detailed analysis of reported cases together with some personal experience has demonstrated that pathological changes in the pulmonary and pleural lymphatic vessels are more common than is usually appreciated. The normal remarkable regenerative potential which is usually evident after experimental interruption of the lymphatics apparently is lacking in some humans due to genetic and other factors. Thus pathological changes, difficult to simulate experimentally, may be encountered. Lymphangiectasis is often found not to be limited to a single organ if complete studies of the lymphatic system are made.     

Chevron—Typ切口肾癌根治术

采用Ｃｈｅｖｒｏｎ－Ｔｙｐ切口施行肾癌根治术治疗肾癌６例，其中Ｔ２Ｎ１Ｍ０期肿瘤２例，Ｔ２Ｎ０Ｍ０期肿瘤３例，Ｔ４Ｎ２Ｍ０期肿瘤１例。结果手术历时２ｈ３０ｍｉｎ￣３ｈ１５ｍｉｎ，均顺利完成手术，无一例发生术中意外，认为Ｃｈｅｖｅｒｏｎ－Ｔｙｐ切口显露良好，扩大了肾癌手术适应证，手术效果良好，适用于肾肿瘤较大，肾蒂有淋巴结转移或隔下型下腔静脉癌栓或肾静脉癌栓形成者。     

Impact of the sentinel lymph node in the staging of colorectal carcinoma

In view of the very good results obtained by lymphatic mapping and sentinel node biopsy in the staging of patients with melanoma or breast cancer, we investigated the feasibility of intraoperative regional lymphatic mapping in patients with primary colorectal carcinoma. The aim of this study was to determine whether lymphatic mapping and sentinel node assessment can identify aberrant drainage patterns or make for better staging of the neoplasm in those cases with no or only minimal lymphatic neoplastic involvement. Sixteen consecutive patients with primary colorectal cancer (stage T2-T3) but without macroscopic involvement of the lymphatic system underwent intraoperative lymphatic mapping by injecting 1-1.5 ml of isosulfan blue dye. The identified and resected sentinel nodes were examined using conventional haematoxylin-eosin staining and cytokeratin immunohistochemistry. Sentinel node identification was successful in 15 out of 16 cases (93.8%). In 11 cases (73.3%) sentinel node status correctly predicted the final staging. The false-negative rate was 26.7%. Immunohistochemical analysis revealed the presence of micrometastasis in one case (6.7%), which was consequently upstaged. In cases of colorectal cancer lymphatic mapping is an easy, perfectly feasible technique. However, in our experience, it would not appear to significantly improve the accuracy of the histopathological staging of colorectal carcinoma.     

D2—40／CKpan免疫组织化学双标记染色检测胃癌淋巴管癌栓及其临床意义

目的对比应用D2．40／CKpan免疫组织化学双标记染色（双标记）和苏木精一伊红染色检测胃癌淋巴管癌栓及其预后的临床意义。方法收集2001年1—12月间于解放军总医院病理科行胃癌根治术的108例进展期胃癌的组织蜡块，以苏木精．伊红染色为对照．评估D2．40／CKpan双标记对淋巴管癌栓的检出情况，并分析其与淋巴结转移及患者总体生存的关系。结果苏木精．伊红染色检出淋巴管癌栓57例（52．8％），D2—40／CKpan双标记检出淋巴管癌栓73例（67．6％），后者检出率明显高于前者（P=0．007）；苏木精．伊红染色中8例为假阳性，24例为假阴性。经苏木精-伊红染色评估的淋巴管癌栓不仅与淋巴结转移有关（P=0．024），还与患者的总体生存有关（P=0．043）；但经D2．40／CKpan双标记评估的淋巴管癌栓则与淋巴结转移及预后均无关（辟0．422和P=-0．402）。结论D2．40／CKpan双标记提高了淋巴管癌栓的检出率，但基于其评估的淋巴管癌栓与患者淋巴结转移及预后均无关。     

超声引导下注射平阳霉素治疗淋巴管畸形

目的：探讨超声引导下注射平阳霉素治疗淋巴管畸形的疗效及优点。方法：38例淋巴管畸形患者,在超声引导下抽尽囊内液体,注入平阳霉素进行治疗。结果：随访本组患者3～6年,治愈29例,有效4例,好转4例,无效1例,无明显瘢痕,无并发症发生。结论：该疗法定位准确、简便、安全、损伤小、疗效好、费用低,易为多数医生和患者所接受。     

Lymphatic Vessels in Pancreatic Islets Implanted Under the Renal Capsule of Rats

Transplantation of pancreatic islets necessitates an engraftment process, including revascularization of the graft. Studies of graft vasculature have demonstrated that islets become revascularized during the first post-transplant week through an angiogenic process. If this also involves lymphatic vessels is unknown. The aim of the present study was to functionally evaluate if lymphatic vessels, which are absent in endogenous islets, form after islet transplantation. To achieve this, inbred Wistar-Furth rats were transplanted with 250 syngeneic islets under the renal capsule. Intra-vital microscopy of the graft in combination with interstitial injection of Evans Blue was performed 1 week, 1 month or 9-12 months later. In all animals studied, there was drainage through intra-graft lymphatic capillaries emptying into larger lymphatic vessels associated with the renal capsule. The number was slightly lower 1 week post-transplantation. Most of the lymphatic capillaries were present in the graft stroma, rather than interspersed among the endocrine cells. In some animals, we were able to demonstrate dye in regional lymph nodes. We conclude that unlike endogenous islets, islet grafts develop a lymphatic drainage. Its functional importance and characteristics remain to be established. However, it can be speculated that immune reactions may be facilitated by the presence of lymphatic vessels.     

Peripheral lymphedema: new advances in microsurgical treatment and long-term outcome

We report on the modern surgical management of peripheral lymphedema. An adequate diagnostic route is essential: it has to include patient history and clinical examination, an isotopic lymphography, an accurate study of the venous circulation, and in cases of angiodysplasia, an accurate study of the artery circulation. Based on over 25 years of clinical experience (more than 1,000 patients), the role of derivative and (in those cases where a venous disease is associated with lymphostatic pathology) reconstructive lymphatic microsurgery is particularly underlined, in comparison with conservative medico-physical treatment, to which it is complementary. "Debulking" surgery can be used just in properly selected patients for minor operations with only cosmethic-reductive purposes. With a follow-up even over 15 years after surgery, positive results from lymphatic microsurgery can be achieved in more than 80% of cases, especially in patients at precocious stages.     

Re-sentinel node biopsy after previous breast and axillary surgery

There is no consensus regarding the strategy for managing the regional lymph nodes in patients with local breast cancer recurrence. This paper reviews the updated data on re-sentinel lymph node biopsy (re-SLNB) after previous surgery. The identification rate of re-SLNB varied from 29 to 100 % (mean 67 %). The success rate of re-SLNB depends on the method used for the previous axillary surgery and the number of lymph nodes harvested. Re-SLNB may be feasible even after mastectomy. A relationship between post-operative radiotherapy and identification of re-SLNB was not seen. A longer disease-free interval may correlate with a lower identification rate, but this finding is not definitive. Based on data regarding back-up dissection after re-SLNB, the accuracy of re-SLNB may be as good as SLNB in primary cases. Altered lymphatic drainage was reported in 2–89 % (mean 32 %) of cases. Because the altered lymphatic drainage can be detected only by lymphoscintigraphy, the radioisotope method, followed by lymphoscintigraphy, should be used. There are not many reported cases of axillary recurrence after re-SLNB, and the follow-up periods have been short. Because re-SLNB cases have a wide variety of backgrounds, it is necessary to accumulate a larger number of cases and to obtain data from longer follow-up period in order to make clear recommendations.     

胃癌脉管转移与细胞增殖活性关系的探讨

目的探讨胃癌脉管转移与细胞增殖活性的关系。方法用溴化脱氧脲嘧啶核苷(BrdUrd)/DNA双参数流式细胞术对60例胃癌新鲜标本进行检测,研究胃癌细胞BrdUrd标记指数(BrdUrdLI)、胃癌G2/M期细胞比率(G2/M-fraction,G2/MPF)和DNA含量与胃癌静脉浸润、淋巴管浸润及淋巴结转移的关系。结果静脉癌栓阳性较阴性者G2/MPF明显增高(P<0.01),淋巴管癌栓阳性较阴性者BrdUrdLI、G2/MPF均明显增高(P<0.01)。淋巴结阳性较阴性者BrdUrdLI、G2/MPF均明显增高(P<0.01)。异倍体癌淋巴结阳性者明显增多(P<0.05)。淋巴结转移第Ⅱ站以远(N2↑)者,BrdUrdLI、G2/MPF均较无转移者明显增高(P<0.01);淋巴结转移第Ⅰ站者,G2/MPF较无转移者明显增高(P<0.01)。异倍体癌淋巴结转移N2↑者明显增多(P<0.01)。结论胃癌细胞BrdUrdLI、G2/MPF和DNA含量与脉管浸润有关。     

Blue-dye sentinel node mapping in thyroid carcinoma: debatable results of feasibility

The present study aims to investigate the feasibility and influence of the lymphatic mapping and sentinel node biopsy on determination of the nodal status in thyroid carcinoma using blue-dye method. Nine consecutive patients with cytological diagnosis of papillary carcinoma were included in this study. To detect the sentinel lymphnode, intra- or perinodular injection of an average quantity of 0.5 ml (range : 0.1-1.2) of Ble Patenté V was performed intraoperatively in 8 cases only, as in one case a solitary cystic nodule occupied the entire lobe and thus any injection was impossible. After an average time of 16 minutes (range : 5-25) before dissection of the thyroid , no lymphnodes and no lymphatic afferent thereto visibly coloured were evidenced, except for spread of the vital dye into adjacent tissue and disrupted blood and lymphatic vessels at the injection site. Our results evidence that : intranodular injection, does not allow proper diffusion of the dye in the adjacent parenchyma, and in nodules smaller than 1 cm it may be difficult ; and that it is hazardous in cystic nodule because of the rupture risk; perinodular injection, at the four cardinal points, is impossible when the nodule occupies the entire lobe or the isthmus; multinodular goiter complicates the identification by palpation of the neoplastic nodule in which the dye should be injected or, if perinodular injection is given, to detect the parenchyma surrounding the nodule.