Curettage and aspiration in splenic hilar lymph node dissection for spleen-preserving radical D2 gastrectomy

D2 radical gastrectomy is the standard procedure for gastric cancer in the middle or upper part of the stomach. According to the latest Japanese treatment guidelines for gastric cancer, dissection of the splenic hilar lymph nodes is required during the radical treatment for this condition. This study reports a D2 radical total gastrectomy employing the curettage and dissection techniques, in which the resection of the anterior lobe of transverse mesocolon, vascular denudation and splenic hilar lymph node dissection were successfully completed.Key Words: Gastric cancer, gastrectomy, lymph node dissection, curettage and dissection     

Impact on survival of the number of lymph nodes removed in patients with node-negative gastric cancer submitted to extended lymph node dissection

Purpose

This study was designed to establish whether the number of lymph nodes removed has an effect on prognosis in patients with node-negative gastric cancer.

Patients and Methods

We retrospectively analysed data of 114 consecutive patients who underwent gastrectomy and extended lymph node dissection for node-negative adenocarcinoma of the stomach between 2000 and 2005. Standard survival methods and restricted cubic spline multivariable Cox regression models were applied.

Results

Median age was 63 years and 67 patients out of 114 (59%) were males. Median number of dissected LNs was 22 (range 2-73). Median follow-up was 76 months. Patients who had ≤15 nodes removed had significantly worse distant disease-free survival, disease-free survival and overall survival at multivariable analysis than other patients. The results did not change when pT1 and pT2-3 cancer patients were analysed separately. The risk of distant metastases decreased as the number of dissected lymph nodes increased (>15).

Conclusions

More extended lymph node resection offered survival benefit even in the subgroup of patients with early stage disease. Lymphadenectomy involving more than 15 lymph nodes should be performed for the treatment of node-negative gastric cancer.

Synopsis

The impact on survival of the number of lymph nodes removed in patients with node-negative gastric cancer has not been established. This study suggests that more extended lymph node resection offers protection, as patients who had ≤15 nodes removed had significantly worse disease-free survival and overall survival at multivariate analysis than patients in whom >15 nodes were removed.     

On the road to standardization of D2 lymph node dissection in a European population of patients with gastric cancer

The amount of lymph node dissection (LD) required during surgical treatment of gastric cancer surgery has been quite controversial. In the 1970s and 1980s, Japanese surgeons developed a doctrine of aggressive preventive gastric cancer surgery that was based on extended (D2) LD volumes. The West has relatively lower incidence rates of gastric cancer, and in Europe and the United States the most common LD volume was D0-1. This eventually caused a scientific conflict between the Eastern and Western schools of surgical thought: Japanese surgeons determinedly used D2 LD in surgical practice, whereas European surgeons insisted on repetitive clinical trials in the European patient population. Today, however, one can observe the results of this complex evolution of views. The D2 LD is regarded as an unambiguous standard of gastric cancer surgical treatment in specialized European centers. Such a consensus of the Eastern and Western surgical schools became possible due to the longstanding scientific and practical search for methods that would help improve the results of gastric cancer surgeries using evidence-based medicine. Today, we can claim that D2 LD could improve the prognosis in European populations of patients with gastric cancer, but only when the surgical quality of LD execution is adequate.     

Quality control of lymph node dissection in the Dutch randomized trial of D1 and D2 lymph node dissection for gastric cancer

Background. Variability among surgeons and reduced protocol adherence threaten the conduct and outcome of surgical multicenter trials. We introduced, in the Dutch Gastric Cancer Trial of D1 and D2 (extended) lymph node dissection for gastric cancer, a novel way of managing instruction, quality control, and evaluation of protocol adherence. Methods. Of 1078 patients entered in the Dutch trial, 711 patients with potentially curative resections were evaluated. Numbers and locations of lymph nodes detected at pathological investigation were compared according to the guidelines of the Japanese Research Society for the Study of Gastric Carcer. Non-compliance indicated inadequate removal of lymph node stations, whereas contamination indicated that lymph nodes were detected outside the intended level of dissection. Protocol adherence during the course of the trial, and the impact on complications, hospital mortality, and survival were evaluated. Results. Major non-compliance was noted in 15.3% of D1 and 25.9% of D2 patients. Contamination was present in 22.9% of D1 and 23.5% of D2 patients, and was limited to one or two lymph node stations only. Intensification of quality control resulted in only a marginal improvement in protocol adherence and in the number of lymph nodes detected. There was no association between protocol adherence and the occurrence of complications or long term survival. Conclusions. Contamination proved an important parameter to substantiate protocol adherence by the surgeon, whereas non-compliance had a multifactorial cause. Non-adherence to the protocol did not lead to increased hospital morbidity and mortality, but also had no impact on long term survival. Received for publication on Aug. 17, 1998; accepted on Nov. 12, 1998     

Neoadjuvant chemotherapy followed by surgery in gastric cancer patients with extensive lymph node metastasis

Gastric cancer with extensive lymph node metastasis (ELM) is usually considered unresectable and is associated with poor outcomes. Cases with clinical enlargement of the para-aortic lymph nodes and/or bulky lymph node enlargement around the celiac artery and its branches are generally dealt with as ELM. A standard treatment for gastric cancer with ELM has yet to be determined. Two phase II studies of neoadjuvant chemotherapy followed by surgery showed that neoadjuvant chemotherapy with S-1 plus cisplatin followed by surgical resection with extended lymph node dissection could represent a treatment option for gastric cancer with ELM. However, many clinical questions remain unresolved, including the criteria for diagnosing ELM, optimal regime, number of courses and extent of lymph node dissection.     

治疗性腹腔镜胃癌腹主动脉旁淋巴结清扫术的操作技巧及临床意义

目的探讨治疗性腹腔镜胃癌腹主动脉旁淋巴结清扫术的安全性和有效性。方法回顾性分析2017年1月至2018年12月就诊广东省中医院胃肠外科实施治疗性腹腔镜胃癌腹主动脉旁淋巴结术的6例病人基线资料、术中及术后短期结果。结果6例病人术前经影像学评估均存在第16组淋巴结转移,无其他远处转移,经转化治疗后,均达到部分缓解并顺利完成腹腔镜胃癌D2根治并腹主动脉旁淋巴结清扫术,术中1例因合并胰腺侵犯而联合行胰体尾+脾切除术,无中转开腹、腹腔出血、脏器损伤等并发症发生;中位手术时长482.5(445,510)min;中位淋巴结清扫总数、腹主动脉旁淋巴结(para-aortic lymph nodes,PALN)清扫总数及PALN阳性数目分别为50(16,80)枚、18(3,31)枚、3.5(0,15)枚,其中5例PALN病理阳性,1例阴性;术后1例出现胰瘘,1例胸腔积液,1例腹泻,Clavien-Dindo分级均为2级,经对症治疗后均好转出院;术后中位住院时间17(6,30)天,术后30天内无二次手术及死亡发生;中位随访时间13.25(10~18)月,3例病人因肿瘤复发死亡,术后存活时间10~18月,余3例均未见肿瘤复发转移。结论治疗性腹腔镜腹主动脉旁淋巴结清扫术在技术上是可行的,对于胃癌合并PALN转移的患者。     

Current status of lymph node dissection in gastric cancer

Gastrectomy with lymph node (LN) dissection has been regarded as the standard surgery for gastric cancer (GC), however, the rational extent of lymphadenectomy remains controversial. Though gastrectomy with extended lymphadenectomy beyond D2 is classified as a non-standard gastrectomy, its clinical significance has been evaluated in many studies. Although hard evidence is lacking, D2 plus superior mesenteric vein (No. 14v) LN dissection is recommended when harbor metastasis to No. 6 nodes is suspected in the lower stomach, and dissection of splenic hilar (No. 10) LN can be performed for advanced GC invading the greater curvature of the upper stomach, and D2 plus posterior surface of the pancreatic head (No. 13) LN dissection may be an option in a potentially curative gastrectomy for cancer invading the duodenum. Prophylactic D2+ para-aortic nodal dissection (PAND) was not routinely recommended for advanced GC patients, but therapeutic D2 plus PAND may offer a chance of cure in selected patients, preoperative chemotherapy was considered as the standard treatment for GC with para-aortic node metastasis. There has been no consensus on the extent of lymphadenectomy for the adenocarcinoma of the esophagogastric junction (AEG) so far. The length of esophageal invasion can be used as a reference point for mediastinal LN metastases, and the distance from the esophagogastric junction to the distal end of the tumor is essential for determining the optimal extent of resection. The quality of lymphadenectomy may influence prognosis in GC patients. Both hospital volume and surgeon volume were important factors for the quality of radical gastrectomy. Centralization of GC surgery may be needed to improve prognosis.     

Benefit of mediastinal and para-aortic lymph-node dissection for advanced gastric cancer with esophageal invasion

BACKGROUND AND OBJECTIVES: Lymph-node dissection in gastric cancers with esophageal invasion (AGCE) is of current interest. This study examined the significance of inferior mediastinal lymph-node (IM) and para-aortic lymph-node (PA) dissection for this type of cancer. METHOD: Two hundred and seventy cases of AGCE were clinicopathologically reviewed. An index of estimated benefit from lymph-node dissection (IEBLD) was calculated from the frequency of lymph node metastasis in IM and PA, and from 5-year survival rates for metastatic cases. RESULTS: Among the cases of AGCE, IM and PA metastasis rates were 18.1% and 22.2%, respectively. The IEBLD for IM and PA was similar to that for dissection of the second-tier lymph nodes around the celiac axis. The IM metastasis rate was 0.0% for esophageal invasion of 0-9 mm, 2.2% for 10-19 mm, 17.8% for 20-29 mm, and 21.7% for 30-39 mm of esophageal invasion. CONCLUSION: AGCE is associated with a high rate of PA metastasis, and with a high rate of IM metastasis when esophageal invasion exceeds 2 cm. Since dissection of IM and PA achieved the same benefit as dissection of second-tier lymph nodes, we recommend thorough dissection of these lymph nodes.     

Single-port robotic inguinal lymph node dissection: A safe and feasible option for penile cancer

IntroductionInguinal lymph node dissection (ILND) is essential to the accurate staging of advanced penile cancer and in determining prognosis. Open ILND is associated with significant morbidity. The robotic-assisted approach has been described with comparable nodal yield with the advantage of decreased postoperative complications when studied with the multiport robotic platform. This video shows our approach for an ILND with the Intuitive single port (SP) robotic platform.MethodA 54-year-old man underwent a partial penectomy for a penile mass that revealed squamous cell carcinoma invading the corpus spongiosum (pT2). Patient had non-palpable lymph nodes on physical examination. We proceeded with the bilateral inguinal lymph node dissection using the Intuitive da Vinci Single-Port Robot.ResultsA standard template dissection was performed on both sides. Due to nodal enlargement noted on the pre-operative CT scan on the right side, superficial and deep ILND were performed on that side. Intra-operative frozen section pathologies of superficial lymph nodes were negative on the left side. Bilateral saphenous veins were preserved. Total procedure time was 4 hours and 51 minutes in duration with minimal blood loss noted (<30 mL). Pathology revealed one 4.5cm superficial positive node on the right with no extra-nodal extension and no other positive nodes. No complications were noted. He was discharged on post-operative day 1 with minimal pain or leg swelling.ConclusionsWe describe the technique and feasibility of ILND using the SP robotic platform. This approach has the potential to reduce morbidity with comparable nodal dissection as the open approach.     

Lateral lymph node dissection in rectal cancer: State of the art review

Half of the local regional recurrences from rectal cancer are nowadays located in the lateral compartments, most likely due to lateral lymph node (LLN) metastases. There is evidence that a lateral lymph node dissection (LLND) can lower the lateral local recurrence rate. An LLND without neoadjuvant (chemo)radiotherapy in patients with or without suspected LLN metastases has been the standard of care in the East, while Western surgeons believed LLN metastases to be cured by neoadjuvant treatment and total mesorectal excision (TME) only. An LLND in patients without enlarged LLNs might result in overtreatment with low rates of pathological LLNs, but in patients with enlarged LLNs who are treated with (C)RT and TME only, the risk of a lateral local recurrence significantly increases to 20%. Certain Eastern and Western centers are increasingly performing a selective LLND after neoadjuvant treatment in the presence of suspicious LLNs due to new scientific insights, but (inter)national consensus on the indication and surgical approach of LLND is lacking. An LLND is an anatomically challenging procedure with intraoperative risks such as bleeding and postoperative morbidity. It is therefore essential to carefully select the patients who will benefit from this procedure and where possible to perform the LLND in a minimally invasive manner to limit these risks. This review gives an overview of the current evidence of the assessment of LLNs, the indications for LLND, the surgical technique, pitfalls in performing this procedure and the future studies are discussed, aiming to contribute to more (inter)national consensus.     

Effect of fat volume on postoperative complications and survival rate after D2 dissection for gastric cancer

Background. D2 lymph node dissection in gastric cancer is controversial in Western countries because of the relatively high complication and mortality rates. The purpose of this study was to clarify the effects of fat volume on operation factors, postoperative complications, and survival in gastric cancer surgery. Methods. We studied 293 consecutive patients who had undergone distal gastrectomy with D2 dissection for gastric cancer at our hospital between 1990 and 1997. The patients were classified into three groups according to their body mass index (BMI; kg/m²). We analyzed differences in the operation time, the amount of blood loss, the postoperative complications and the survival rate among the three groups. Results. Group A patients had a BMI of less than 20 (n = 61), group B had a BMI of 20–25 (n = 178), and group C had a BMI of more than 25 (n = 54). There were significant differences in operation time (group A, 206 ± 66 min; group B, 226 ± 61 min; group C, 252 ± 61 min; P < 0.05), blood loss (group A, 417 ± 282 ml; group B, 501 ± 295 ml; group C, 605 ± 333 ml; P < 0.05), and postoperative complications (group A, 3.3%; group B, 5.6%; group C, 22.0%). There were significant differences in postoperative complications between groups A and C, and between groups B and C. However, the difference between groups A and B was not significant, and no significant difference in survival rate was seen among the three groups. Conclusion. Fat volume definitely increases the postoperative complications. Accordingly, the high rate of postoperative complications of D2 surgery in Western countries may be related to the patients' relative obesity. Received: September 1, 2000 / Accepted: October 23, 2000     

强负压吸引治疗8例颈淋巴结清扫术后乳糜瘘

背景与目的颈部乳糜瘘是颈部手术后的并发症之一,其产生机制与其特定的解剖位置及变异密切相关,有关其治疗的意见仍有分歧。本文总结8例颈清扫术后并发乳糜瘘患者采用强负压吸引和饮食处理的临床经验,以评价其疗效。方法全部病例在确诊为乳糜瘘后立即采用强负压(-50～-30kPa)吸引,嘱禁食并给予合理的静脉营养。结果7例患者经此保守治疗痊愈,未出现其他严重并发症;1例无效,采用胸大肌肌瓣填塞。结论强负压吸引和合理的饮食处理有可能是颈清扫术后并发乳糜瘘早期处理较为理想且安全的保守疗法之一。     

Positive impact of adding No.14v lymph node to D2 dissection on survival for distal gastric cancer patients after surgery with curative intent

Background

D2 lymphadenectomy has been increasingly regarded as standard surgical procedure for advanced gastric cancer (GC), while the necessity of No.14v lymph node (14v) dissection for distal GC is still controversial.

Methods

A total of 920 distal GC patients receiving at least a D2 lymph node dissection in Department of Gastric Cancer, Tianjin Medical University Cancer Institute and Hospital were enrolled in this study, of whom, 243 patients also had the 14v dissected. Other 677 patients without 14v dissection were used for comparison.

Results

Forty-five (18.5%) patients had 14v metastasis. There was no significant difference in 3-year overall survival (OS) rate between patients with and without 14v dissection. Following stratified analysis, in TNM stages I, II, IIIa and IV, 14v dissection did not affect 3-year OS; in contrast, patients with 14v dissection had a significant higher 3-year OS than those without in TNM stages IIIb and IIIc. In multivariate analysis, 14v dissection was found to be an independent prognostic factor for GC patients with TNM stage IIIb/IIIc disease [hazard ratio (HR), 1.568; 95% confidence interval (CI): 1.186-2.072; P=0.002]. GC patients with 14v dissection had a significant lower locoregional, especially lymph node, recurrence rate than those without 14v dissection (11.7% vs. 21.1%, P=0.035).

Conclusions

Adding 14v to D2 lymphadenectomy may be associated with improved 3-year OS for distal GC staged TNM IIIb/IIIc.     

200 Sentinel lymph node biopsies without axillary lymph node dissection -- no axillary recurrences after a 3-year follow-up

The aim of this study is to evaluate the rate of axillary recurrences in sentinel lymph node (SLN)-negative breast cancer patients after sentinel lymph node biopsy (SLNB) alone without further axillary lymph node dissection (ALND). Between May 1999 and February 2002, 333 consecutive patients with primary invasive breast cancer up to 4 cm and clinically negative axillae were entered into this prospective study. Sentinel lymph nodes were identified using the combined method with blue dye (Patent blue V) and technetium 99m-labelled albumin (Nanocoll). Sentinel lymph nodes were examined by frozen sections, standard haematoxylin and eosin staining and immunohistochemistry staining. In SLN-positive patients, ALND was performed. Sentinel lymph node-negative patients had no further ALND. The SLN identification rate was 98.5% (328 out of 333). In all, 128 out of 328 (39.0%) patients had positive SLNs and complete ALND. A total of 200 out of 328 (61.0%) patients were SLN negative and had no further ALND. The mean tumour size of SLN-negative patients was 16.5 mm. The mean number of SLNs removed was 2.1 per patient. There were no local or axillary recurrences at a median follow-up of 36 months. The absence of axillary recurrences after SLNB without ALND in SLN-negative breast cancer patients supports the hypothesis that SLNB is accurate and safe while providing less surgical morbidity than ALND. Short-term results are very promising that SLNB without ALND in SLN-negative patients is an excellent procedure for axillary staging in a cohort of breast cancer patients with small tumours.     

Completely laparoscopic extraperigastric lymph node dissection for gastric malignancies located in the middle or lower third of the stomach

Dissection of the extraperigastric lymph nodes is necessary in most submucosal gastric cancers. Laparoscopy-assisted gastrectomy with extraperigastric lymph node dissection via minilaparotomy has been performed, but, to our knowledge, completely laparoscopic extraperigastric lymph node dissection has never been reported. We successfully performed completely laparoscopic distal gastrectomy with extraperigastric lymph node dissection in 12 patients, of whom 11 had early gastric cancer and 1 had malignant lymphoma. This surgery is technically feasible, has an acceptable complication rate, and a curability similar to that with open surgery. Received for publication on June 15, 1999; accepted on Aug. 18, 1999     

Indications,Extent, and Benefits of Pelvic Lymph Node Dissection for Patients with Bladder and Prostate Cancer

The role of pelvic lymph node dissection (PLND) in both bladder and prostate cancer has recently been generating renewed interest. In an attempt to avoid PLND, both nomograms and imaging studies have been evaluated; however, so far they have shown limited success because of inadequate accuracy in staging patients. The three primary objectives of this review are: to define patients in whom PLND should be performed, to define the extent and consequences of the template for PLND, and to identify the staging and prognostic benefits seen with PLND in bladder and prostate cancer. Based on the findings from this review, we conclude that PLND for bladder cancer patients is undoubtedly beneficial, whereas it is less so for prostate cancer patients, in whom a selection strategy should be employed. PLND, in particular with an extended template, seems to provide superior accuracy for postoperative staging than the presently available imaging studies and may be pivotal when considering adjuvant therapies. Furthermore, it has an impact on survival in high‐risk patients, and potentially more so in low‐risk cancer patients with occult metastases.     

甲状腺癌颈淋巴结清除术的“平衡”与思考

甲状腺癌近年来发病激增,已成为最常见的恶性肿瘤之一。颈淋巴结清除术作为甲状腺癌根治术的重要组成,存在诸多不规范问题及争论焦点,备受关注。现就颈淋巴结清除术中的几个“平衡”问题予以浅谈分析,以期提高临床医生对于甲状腺癌颈淋巴结清除术精准诊疗的全面认识。     

Avoidance of axillary lymph node dissection in selected patients with node-positive breast cancer

Aims

Currently, it is standard practice to avoid ALND in patients with negative SLN, whereas this procedure is mandated for those with positive SLN. However, there has been some debate regarding the necessity of complete ALND in all patients with positive SLN. This review article discusses the issues related to eliminating the need for ALND in selected patients with positive nodes.

Methods

A review of the English language medical literature was performed using the MEDLINE database and cross-referencing major articles on the subject, focusing on the last 10 years.

Results

Currently, complete ALND is mandated in patients with SLN macrometastases as well as those with clinically positive nodes. It is not clear whether SLN biopsy is appropriate for axillary staging in patients with initially clinically positive nodes (N1) that become clinically node-negative (N0) after neoadjuvant chemotherapy. Although there is debate regarding whether ALND should be performed in patients with micrometastases in the SLN, it seems premature to abandon ALND in clinical practice. Moreover, it remains unclear whether it is appropriate to avoid complete ALND in patients with ITC-positive SLN alone.

Conclusions

In the absence of data from randomised trials, the long-term impact of SLN biopsy alone on axillary recurrence and survival rate in patients with SLN micrometastases as well as those with ITC-positive SLN remains uncertain. These important issues must be determined by careful analysis of the results of ongoing clinical trials.