Better grading systems for evaluating the degree of lymph node invasion in cancer of the thoracic esophagus

To evaluate the quality of various grading systems for lymph node invasion in cancer of the thoracic esophagus, the surgical results of 142 patients who underwent systematic lymph node dissection with curative intent were analyzed. The survival probability of patients in the same grade was modeled using a Weibull distribution and the parameters were estimated by the maximum likelihood principle. The quality of each grading system was measured by the Akaike Information Criterion (AIC) of the estimated statistical model, by which the smaller the AIC of a grading system, the smaller the loss of information for predicting outcomes. The AIC of the TNM grading of the International Union Against Cancer, the grading of the Japanese Society for Esophageal Diseases, and the grading designed according to the total number of positive lymph nodes became substantially smaller in that order. The AIC of grading systems variously designed on rather simple criteria were examined with the aim of creating a better grading system. It was concluded that a grading system based on the total number of positive nodes and the state of the paratracheal and/or middle mediastinal node groups was better than the other systems examined.     

Endoscopic evaluation of the tracheobronchial tree and mediastinal lymph nodes

Assessment of the airways and surrounding structures, including the mediastinum and pulmonary parenchyma, has been greatly facilitated by advancements in bronchoscopic techniques, both rigid and flexible. Recent years have seen an explosion in technologies that have revolutionized the ability to visualize, biopsy, or otherwise assess regions of potential pathology within the upper aerodigestive tract and adjacent structures. This article concisely and comprehensively reviews the endoscopic evaluation of the tracheobronchial tree and mediastinum with a focus on emerging technologies and their role in treatment of thoracic disease.     

Incidental malignancy in internal thoracic artery lymph nodes

The incidental finding of malignant internal thoracic lymph nodes while mobilizing the internal thoracic artery (ITA) for coronary bypass grafting has not to our knowledge been previously reported. The cases of 3 male patients who underwent surgery between January 1990 and January 1993 and in whom malignant lymph nodes were found in the ITA pedicle are reviewed. One individual was found to have metastatic carcinoma of the breast, whereas the other 2 were discovered to have previously undiagnosed lymphomas. After undergoing further relevant investigation and treatment, all 3 patients remain free of recurrent disease 6.8 to 9.8 years after their original cardiac surgery. Primary or metastatic malignancy may be encountered in the course of ITA mobilization for grafting. Abnormally enlarged internal thoracic lymph nodes should be sent for pathologic examination.     

PET staging of mediastinal lymph nodes in thoracic oncology

There is an extensive and growing body of literature about the role of positron emission tomography (PET) in the management of non-small cell lung cancer and esophageal cancer. This article focuses on the use of PET in mediastinal staging of these common thoracic malignancies. PET is the most accurate noninvasive approach to staging mediastinal lymph nodes in non-small cell lung cancer. The role of PET in mediastinal lymph node staging in esophageal cancer is less clear, since it has been largely supplanted by endoscopic ultrasonography. A review of the evidence for and against the use of PET in mediastinal staging is provided and the use of PET in practice is discussed.     

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.     

Metastatic involvement of regional lymph nodes and long-term results of the treatment of patients with cancer of the thoracic part of the esophagus

The patients who underwent the radical operations for cancer of the thoracic esophagus were subdivided into three groups: group 1--patients with no metastatic involvement of the regional lymph nodes (N0); group 2--with enlarged regional lymph nodes because of their hyperplasia, but without metastatic involvement (NX); group 3--with metastatic involvement of the regional lymph nodes (N1). The best results of 5-year survival after radical operation (50.2%) were noted in patients with a tumor size less than 3 cm, infiltration of only muscular layer, high degree of cancer differentiation, without metastatic involvement of regional lymph nodes. In presence of metastases, the 5-year survival was 6.01%. Discovering at operation the enlarged lymph nodes is a poor prognostic sign, 5-year survival of these patients do not exceed 9%.     

Radical lymph node dissection for cancer of the thoracic esophagus.

OBJECTIVE: The authors documented the localization and frequency of lymphatic spread in squamous cell carcinoma of the thoracic esophagus and evaluated the influence of radical systematic lymph node dissection on patient survival. SUMMARY BACKGROUND DATA: From accumulated surgical experience, it was suggested that some of the patients with lymph nodal involvement from cancer could be cured by its clearance. However, it is only recently that cancer of the esophagus has been evaluated in terms of analyzing lymphatic spread and results of lymphadenectomy. METHODS: Among 1298 patients admitted to the Toranomon Hospital between 1973 and 1993, 913 (70.3%) had resections, including curative and palliative procedures. For this study, 717 patients with TNM RO (resection with no residual tumor at operation in TNM classification) were analyzed. Survival was compared between groups of patients with less extensive thoracoabdominal (two-field) dissections and extensive collothoracoabdominal (three-field) dissections. RESULTS: Comparative study revealed that 5-year survival rate for TNM RO patients after free-field dissection (55.0%) was significantly better (log rank test, p = 0.0013) than the rate after two-field dissection (38.3%). The results were particularly significant in subgroups with stage III and IV (because of nodal factor). Overall 5-year survival rate after all resections was 42.4%. CONCLUSIONS: The role of radical lymph node dissection in cancer of the thoracic esophagus evaluated. Long-term survival was compared between two groups with two- and three-field dissection. It was concluded that survival rate was significantly better in patients with extensive three-field dissection.     

Prognosis of patients with carcinoma of the thoracic esophagus, with special reference to the number of metastatic lymph nodes and their metastatic portions

One hundred and sixty two patients (69 patients without lymph node metastases and 93 patients with positive node metastases) out of patients with thoracic esophageal carcinoma resected within the past 12 years were studied regarding prognostic factors, with special reference to the number of positive nodes and their metastatic portions. Among patients with positive nodes, 5 years survival rates were 14.5% in patients with one or two positive nodes, 16.3% in patients with positive nodes only in the abdomen, 14.3% in patients with positive nodes only in the thorax, and 17.8% in patients with regional lymph node metastases (n1(+) and n2(+)). While among patients with distant lymph node metastases (n3(+) and n4(+)), with more than three positive nodes, or with positive nodes both in the thorax and abdomen, almost all of them expired due to recurrence within three years. Patients with one or two positive nodes and with positive nodes only in the abdomen who underwent postoperative irradiation combined with chemotherapy had a better prognosis than patients treated with postoperative irradiation alone or patients receiving no combined therapy.     

Predictors of carcinomatous invasion of the mandible

The preoperative assessment of mandibular invasion by oral or oropharyngeal squamous cell carcinoma poses a challenge for the head and neck surgeon. A study of 64 composite resection patients was performed to determine which variables in the patient's history, physical exam, and diagnostic workup had a predictive association with carcinomatous mandibular invasion. Four postoperative variables were included in this analysis. Thirty-nine percent of the mandibular specimens demonstrated cancerous involvement. A multivariate recursive partitioning statistical analysis was performed to create a decision tree. Branching was based on the two statistically predictive variables: computed tomographic (CT) scan results and primary tumor location. The guide provides improved predictive accuracy with a 100% negative predictive value (NPV) and a 46% positive predictive value (PPV). This decision guide should help the surgeon provide accurate patient counseling, anticipate reconstructive needs, and maximize surgical oncologic effectiveness. © 1994 John Wiley & Sons, Inc.     

Origin of the thoracic duct and pancreaticoduodenal lymphatic pathways to the para-aortic lymph nodes

We investigated the afferent and efferent connections of the para-aortic lymph nodes (group 16 nodes) relative to the origin of the thoracic duct in 85 postmortem cadavers. The origin was usually restricted to groups 16b1-inter and -latero nodes (type I; 90.6%), regardless of whether the union of their efferents occurred at the abdominal or thoracic level. We also occasionally observed thick collecting vessels originating from the dorsal aspect of the pancreaticoduodenal region, running along the right side of and superficial to the celiac plexus and emptying into group 16b1 nodes. The thoracic duct originated occasionally not only from group 16b1 nodes but also from group 16a2 nodes (type II; 9.4%). Moreover, in all 85 specimens, the group 16a2-inter node often received afferents from the celiac plexus itself or the tight connective tissue between the plexus and diaphragmatic crus, or both. The results support the reliability of the extended D2 lymphadenectomy (D2 + group 16b1 nodes + group 16a2-inter node) for curative cancer surgery in the pancreaticoduodenal region. Received: October 12, 2000 / Accepted: December 5, 2000     

Clearance technique for the detection of lymph nodes in colorectal cancer

Lymph node metastases are an important determinant of prognosis following surgery for colorectal cancer. A xylene alcohol clearance technique has been employed in Guildford to facilitate the identification of lymph nodes in the mesorectum of rectal cancer specimens. The numbers of lymph nodes and lymph node metastases were compared with seven other centres and St. Mark's Hospital, where clearance techniques were not employed in patients undergoing a randomized trial of pre-operative radiotherapy for rectal cancer. The total number of lymph nodes identified per patient in the mesorectum of patients at Guildford (mean = 23.1 +/- 1.18) was significantly higher when compared with patients at St. Mark's Hospital alone (mean = 13.1 +/- 0.86) and the seven combined "non-cleared' centres (mean = 10.5 +/- 0.6) (P less than 0.001). The number of lymph node metastases per patient was significantly higher in the Guildford series (mean = 3.21 +/- 0.58) when compared with the seven combined centres (mean = 1.9 +/- 0.3) (P less than 0.05). The numbers of lymph node metastases found in the lowest part of the specimen close to the levator ani were significantly higher in the Guildford patients (mean = 1.2 +/- 0.4) compared with St. Mark's Hospital (mean = 0.13 +/- 0.1) and the seven combined 'non-cleared' centres (mean = 0.56 +/- 0.1). This clearance technique identified not only a greater number of lymph nodes but also more metastases within those nodes, particularly in the supralevator area of the mesorectum.     

Problems in therapy of thoracic esophageal cancer in view of recurrence in the lymph nodes

The forms of recurrence from the first onset were confirmed in 171 out of 776 patients with thoracic esophageal cancer excised at our Department from 1959 to 1987; 87 patients (50.9%) had recurrence in the lymph nodes. Postoperative radiation in order to prevent recurrence in the lymph nodes was useful for the prevention of recurrence in the cervical lymph nodes, but radiation myelopathy/radiation pneumonitis might be of therapeutic difficulty in patients with recurrence in the areas of radiation. Moreover, patients treated by irradiation were apt to be involved in visceral recurrence. Incidence of recurrence in the lymph nodes was less in patients who had dissection in three areas than that in patients who received dissection in one or two. However, recurrence was observed in the border region between the cervix and the thorax, on the left side of the trachea, in the anterior portion and on the left side of the hilum in the areas of dissection. Useful postoperative chemotherapy is desirable in consideration of the fact that recurrence in the lymph nodes was observed at the posterior region of the pharynx, at the temporal region and in the pelvis and that dissemination and visceral recurrence were increased.     

Guidelines for the detection of sentinel lymph nodes using radionuclides

For the detection of sentinel lymph nodes, the technetium-99m (99mTc) method is the most accurate and widely used. 99mTc has many advantages, such as a short half-life of 6 h, emission of 140 KeV gamma-rays, etc. Radiation to medical personnel is minimal and this technique can be safely performed under the guidelines issued by the Japanese Society of Nuclear Medicine.     

Ultrasonographic detection of metastatic axillary lymph nodes in breast cancer

Metastatic involvement of the axillary lymph nodes is the most important prognostic factor in breast cancer. Preoperative knowledge of lymph node status would be useful in planning the therapy for breast cancer. The aim of our study was to find how accurately metastatic lymph nodes can be detected with ultrasonography (US). Our study consisted of 63 breast cancer patients having 65 breast cancers. Their axillae were examined preoperatively with US (with a 7.5 Mhz linear-array transducer). 27.7% of these patients had metastatic axillary lymph nodes. With US we could detect 12 of these 18 axillary metastases. In 2 of our 6 false negative results only micrometastases were found on histological examination. In our study the sensitivity of US was 66.6%. There was only one axilla, in which nodes were detected with US, but on histological examination no metastases were found, thus giving a specificity of 97.9%. Our study indicates that in the axilla normal nodes are not visible with US.     

Patterns of lymph node metastasis in 3-field dissection for carcinoma in the thoracic esophagus

Lymph node metastasis is well-known as the most important prognostic indicator for esophageal carcinomas, and an accurate assessment of positive metastasis can only be made after total lymphadenectomy around the esophagus. However, prior to the development of 3-field lymph node dissection in Japan, no such operation existed for ascertaining the full positivity distribution. We report herein the results of a restrospective study conducted on 70 patients who underwent subtotal esophagectomy with 3-field dissection to discover the patterns of lymph node metastasis from carcinoma in the thoracic esophagus. Lymph node metastases tended to have an orderly spreading pattern in relation to the tumor location, even though the lymph node metastasis varied widely from the lower neck to the upper abdomen. The nodes along the right recurrent nerve and the paracardiac nodes were most frequently found to be positive for metastasis. In contrast, no metastasis was found in the internal jugular nodes, the pretracheal nodes, the common hepatic nodes, or the splenic nodes. Patients with carcinoma in the upper thoracic esophagus rarely had metastasis in the abdominal nodes, while those with carcinoma in the lower thoracic esophagus rarely had metastasis in the cervical nodes. Thus, surgical extirpation of the lymph nodes during 3-field dissection is effective not only to determine the correct tumor staging for the planning of adequate adjuvant therapies postoperatively, but also to produce a guideline for prospective lymphadenectomy for esophageal carcinomas.