The role of lymphadenectomy in the surgical treatment of intrahepatic cholangiocarcinoma: A review

Cholangiocarcinoma is the second most common primary tumor of the liver. The incidence and mortality of its intrahepatic form has been increasing over the past 2 decades. Currently, the only available curative treatment for intrahepatic cholangiocarcinoma is surgical resection. There is still no prospective evidence to support neoadjuvant systemic treatments in resectable disease, while adjuvant chemotherapy with Capecitabine is currently the only recommended systemic treatment after liver resection based on the results of randomised trial. Despite the implementation of perioperative treatments and improvements in resective surgery, intrahepatic cholangiocarcinoma remains a disease characterized by high incidence of recurrence and poor long-term survival. Lymph node metastases can be found in 45–65% of patients and are one of the most impacting prognostic factors after surgical resection. Preoperative imaging is not always sufficient in assessing lymph node status, thus hepatic pedicle lymphadenectomy can be important to ensure precise staging in surgical patients. An increasing trend in performing lymph node dissection during liver resection for intrahepatic cholangiocarcinoma has been observed in the last 20 years, although its actual efficacy compared to the potential complications remains debated. The current evidence on the prognostic role of the lymph node status, its preoperative predictability, the basis for a correct hepatic pedicle lymphadenectomy and its prognostic role in the surgical treatment of intrahepatic cholangiocarcinoma are presented.     

Lymph node dissection for gastric cancer.

Complete tumor removal with margins of clearance at the resection lines must be the aim of today's surgical treatment of gastric cancer, and this must be applied even in lymph node dissection. But, over the last few decades, the extent and impact of lymphadenectomy remains controversial. Whereas Japanese centers advocate extensive lymph node dissection as the base of their excellent results, many Western surgeons, supported by actual randomized trials, believe that the potential benefit of such procedures cannot outweigh the risk of increased postoperative morbidity and mortality. However, if lymphadenectomy is restricted to the removal of nodes only, it does not influence the operative risk. Further, the lymph node ratio and number of lymph nodes involved are relevant prognostic parameters. Survival improvement can be achieved in a moderate degree of metastatic involvement of the nodes (pN0,1). Therefore, systematic lymph node dissection should be an integral part of the curative resection sought. Limited or no lymphadenectomy might be indicated in noncurative surgery or in special types of mucosal early gastric cancer, respectively.     

Principles of surgical resection in hilar cholangiocarcinoma

The aim of this article is to describe the surgical techniques for the treatment of hilar cholangiocarcinoma(HC).Resection with microscopically negative margin(R0) is the only way to cure patients with HC.Today,resection of the caudate lobe and part of segment Ⅳ,combined with a right or left hepatectomy,bile duct resection,lymphadenectomy of the hepatic hilum and sometimes vascular resection,is the standard surgical procedure for HC.Intraoperative frozen-section examination of proximal and distal biliary margins is necessary to confirm the suitability of resection.Although lymphadenectomy probably has little direct effect on survival,inaccurate staging information may influence post resection treatment recommendations.Aggressive venous and arterial resections should be undertaken in selected cases to achieve a R0 resection.The concept of "no-touch proposed" in 1999 by Neuhaus et al combine an extended right hepatectomy with systematic portal vein resection and caudate lobectomy avoiding hilar dissection and possible intraoperative microscopic dissemination of cancer cells.More recently minor liver resections have been proposed for treatment of HC.As the hilar bifurcation of the bile ducts is near to liver segments Ⅳ,Ⅴ and Ⅰ,adequate liver resection of these segments together with the bile ducts can result in cure.     

Radical lymph node dissection for gallbladder cancer: indications and limitations

Radical lymph node dissection provides survival benefit for patients with pT2 or more advanced gallbladder carcinoma tumors only if potentially curative resection is feasible; it must always be considered when planning a resection or re-resection for robust patients with pT2 or more advanced gallbladder carcinoma tumors. The degree of radical lymphadenectomy depends on clinically assessed nodal status: portal lymph node dissection is limited to cN0 disease; extended portal nodal dissection is indicated for cN0 and a modest degree of cN1 disease; peripancreatic lymph node dissection with pancreaticoduodenectomy is indicated for selected cases of evident peripancreatic nodal disease and/or direct organ involvement. Extended resection with extensive lymphadenectomy should be limited to expert surgeons because it may cause serious morbidity and mortality.     

Extended resection for pancreatic adenocarcinoma

Adenocarcinoma of the pancreas presents a number of therapeutic challenges. Given the poor long-term outcomes after pancreaticoduodenectomy (PD), many surgeons have sought to improve survival via a radical or "extended" pancreatectomy which may include (a) total pancreatectomy (TP), (b) extended lymph node dissection (ELND), and (c) portal/mesenteric vascular resections. These themes of "extended" resection are addressed in this review. TP should not be performed for most cases of adenocarcinoma of the pancreatic head because of the nominal incidence of lymph node involvement along the body and tail of the pancreas, the scarcity of multicentric disease, and the better management of pancreatic leaks after PD. Most studies show no difference in long-term survival and demonstrate greater postoperative morbidity after TP than after PD. Performing ELND in addition to PD is not worthwhile because most studies do not demonstrate any long-term benefits from ELND and the circumferential dissection around the mesenteric vessels required to harvest distant lymph nodes increases postoperative morbidity. Major arterial resection increases postoperative morbidity after PD and worsens long-term survival as the need for arterial resection to achieve negative resection margins indicates more aggressive disease. In contrast, portal and/or mesenteric venous resection does not increase the morbidity after PD or impact long-term survival as venous resection is often performed because of tumor location and not extent of disease. The disappointing experience with extended resections underscores the need for better adjuvant systemic strategies and the interdisciplinary care of patients with pancreatic adenocarcinoma.     

进展期远端胃癌行扩大淋巴结清扫术的研究进展

淋巴结清扫范围一直是胃癌外科的热点问题。D2根治术作为进展期胃癌标准手术已达成共识,然而扩大淋巴结清扫的价值依然存在争议。进展期远端胃癌第14v组淋巴结转移率较高,D2+14v组淋巴结清扫有可能改善第6组淋巴结明显转移患者预后;尽管胃癌腹主动脉旁淋巴结转移视为M1,但D2+16a2/b1淋巴结清扫对局限性第16组淋巴结转移患者可能获益;而D2+13组淋巴结清扫有可能提高伴有十二指肠浸润胃癌患者生存率。本文旨在探讨扩大淋巴结清扫在胃癌中的价值,以期为临床提供依据,现就进展期远端胃癌扩大淋巴结清扫的研究进展进行综述。      

Chirurgie des Kolonkarzinoms

Radical resection with central ligation of the vessels and radical lymphadenectomy remains the surgical standard for treating colon cancer. It has been shown that laparoscopic surgery for colon cancer can be an alternative treatment option, although there are still limitations for the use of this technique. A multivisceral resection with resection of the involved organs is the treatment of choice for locally advanced colon cancer. The prognosis for these patients is very good if a curative (R0) resection can be achieved. Recent data suggest that the quality of surgery with an adequate dissection plane is important not only for rectal cancer but also for colon cancer. It has also been shown that the prognosis for colon cancer patients depends significantly on the surgeon’s experience and the patient volume of the treating institution. The postoperative management has now changed to a fast-track concept with immediate enteral nutrition and early recovery of the patients.     

Papillary thyroid cancer: Surgical management of lymph node metastases

Opinion statement Papillary thyroid cancer (PTC), the most common thyroid malignancy, is associated with cervical lymph node metastases in 30% to 90% of patients. While surgery is the primary treatment modality for PTC, radioactive iodine and thyroid hormone suppression often complement the treatment plan. Although thyroid hormone suppression may decrease the incidence of recurrent disease and radioactive iodine may diagnose and treat metastases, lymph node dissection (LND) is the mainstay treatment for clinically evident cervical lymph node metastases. The surgical treatment options published in the literature include the traditional radical LND, the modified radical LND, the selective LND (compartment-based resection based on documented lymph node metastases), and a ‘berry picking’ resection (in which only the grossly abnormal lymph nodes are excised). At the University of California, San Francisco, we prefer the modified radical LND with preservation of the cervical sensory nerves for the first lymph node dissection with the ‘berry picking’ procedure limited to surgical treatment of recurrent nodal metastases in previously resected lymph node basins. Some centers are evaluating the potential role of sentinel lymph node biopsies for PTC. While the extent of lymphadenectomy is debated, most physicians treating patients with PTC agree that clinical evidence of lymphatic metastases should be surgically exercised and there is no role for prophylactic LND.     

腹膜后淋巴结切除术在卵巢癌中的应用

上皮性卵巢癌是否需做系统性腹膜后淋巴结清扫一直存在争议。对于早期上皮性卵巢癌,尚无证据表明系统性淋巴结清扫可以改善患者的生存,但为了准确分期及指导术后辅助治疗,应做腹膜后淋巴结取样切除术。对于晚期上皮性卵巢癌,切除肿大的转移淋巴结是肿瘤细胞减灭术的一个组成部分,尽管有随机对照研究证实,系统性腹膜后淋巴结清扫术可以改善患者的肿瘤无进展生存期,但是否能真正改善患者的总生存期,仍需进一步研究证实。     

Principles of surgical radicality in the treatment of gastric cancer

The aim of curative surgery is to perform an RO resection, that is, the volume of resection should encompass the tumor volume in toto and fall in healthy margins. This means maintaining a transection margin 6 cm from the tumor and removing neighboring organs altogether if involved by the tumor. With regard to lymphadenectomy, the adequate number to be retrieved which allows a proper staging, and probably the optimal results, is about 25 lymph nodes.     

Current trends in the surgical treatment of esophageal and cardia adenocarcinoma

Since adenocarcinoma of the esophagus and cardia is increasing at an alarming rate, major efforts are currently oriented to identify patients who may benefit from extensive resection. Between November 1992 and May 1998, 218 patients with histologically proven adenocarcinoma of the distal esophagus or cardia were referred to our Department. In six patients (10.2%) with Barrett's adenocarcinoma, cancer was discovered during endoscopic surveillance program for Barrett's metaplasia. Overall, one hundred-forty-seven patients (67%) underwent resection. Fifty-one underwent an extended mediastinal lymphadenectomy. Median cumulative survival was 25.9+/-3.1 months in patients undergoing resection, and 7+/-1.3 months in patients having palliation (p<0.01). Survival was significantly longer in patients with negative nodes than in those with lymph node metastases (54+/-12.9 versus 17+/-2.8 months, p<0.01). Six of the 51 patients (11.8%) undergoing extended lymphadenectomy had metastatic upper mediastinal nodes. Additional serial sections and immunohistochemistry were performed in 46 patients. In 6 of 18 patients (33.3%) with negative nodes at conventional hematoxylin-eosin examination, immunohistochemistry demonstrated micrometastases in the lesser curve, paracardial, peripancreatic, or lower mediastinal nodes. Early diagnosis remains the prerequisite for curative treatment of adenocarcinoma of the esophagus and cardia. When a curative resection is attempted, extended lymphadenectomy improves tumor staging and may prevent local recurrences. Serial sections and immunohistochemistry provide additional accuracy in the staging of the disease and may prove useful to select patients for adjuvant therapy.     

Completeness of lymph node dissection in patients undergoing minimally invasive- or open surgery for non-small cell lung cancer: A nationwide study

ObjectiveIn patients with NSCLC, lymph node metastases are an important prognostic factor. Despite an accurate pre-operative work up, for optimal staging an intrapulmonary- and mediastinal lymph node dissection (LND) as part of the operation is mandatory. The aim of this study is to assess the completeness of LND in patients undergoing an intended curative resection for NSCLC in the Netherlands and to compare performance between open surgery and minimally invasive surgery (MIS).Materials and methodsThe intraoperative LND was evaluated in 7460 patients who had undergone a lobectomy for clinically staged N0-1 NSCLC (2013–2018). The LND was considered complete, when three mediastinal (N2) lymph node stations, including station 7, were sampled or dissected, in addition to the lymph nodes from station 10 and 11. A comparison was made between open surgery and MIS.ResultsOf 5154 patients, who had MIS, a sufficient intrapulmonary LND was performed in 47.9% and a sufficient mediastinal LND in 58.6%. A complete LND was performed in 31.6%. For 2306 patients who had an open resection, these numbers were 45.0%, 59.0%, and 30.6%, respectively. The overall between-hospital variation in a complete LND ranged between 0 and 72.5%.ConclusionIn the Netherlands, a complete LND of both intrapulmonary- and mediastinal lymph nodes is performed only in a minority of patients with clinically staged N0-1 NSCLC, with substantial between-hospital variation. No differences were seen between open surgery and MIS. Because of poor performance, completeness of lymph node dissection will be recorded as a mandatory performance indicator in our national audit, to improve the quality of resection.     

食管胃交界腺癌的外科治疗

食管胃交界腺癌（ＡＥＧ）指发生于食管远端和胃贲门区域的腺癌,其发生率明显上升。由于两种腺癌发生部位接近、生物学行为相似、预后均较差,多数学者认为ＡＥＧ是一独特的临床病理类型。目前对ＡＥＧ分型采用最广泛的是Ｓｉｅｗｅｒｔ分型方法;在分期方面尚无单独的分期研究,一般根据病灶主体所在部位,按现行ＴＮＭ分期系统,Ⅰ型和Ⅱ、Ⅲ型分别按食管癌和胃癌分期。手术切除是ＡＥＧ最主要的治疗手段,在保证手术安全的前提下应力争达到Ｒ０切除,切缘应距肿瘤边缘５ｃｍ。常规手术径路有经胸、经腹、胸腹联合３种,一般Ⅰ型者多采用经胸途径,Ⅱ、Ⅲ型者多采用经腹途径。对于Ｔ２期以上者应按Ｄ２标准进行淋巴结清扫,扩大切除（联合脾或胰腺体尾切除）仅限于特定的较晚期病例。早期病例（Ｔ１ｂ）可行Ｄ１手术。有关ＡＥＧ综合治疗的研究很少,对病期较晚（Ｔ２分期以上）者可以选择ＥＣＦ为主的新辅助化疗或辅助化疗、化放疗。     

The Role of Surgical Staging for Cervical Cancer

Recent trends in gynecologic oncology have favored surgical staging of disease not only to define local extent, but more importantly nodal involvement. For cervical cancer, surgical staging includes intraperitoneal exploration, cytological washings, direct tumor palpation, and para-aortic with or without pelvic lymph node (LN) dissection. In the Gynecologic Oncology Group (GOG) experience, extraperitoneal selective para-aortic lymphadenectomy was associated with a lower risk of enteric complications following radiation for advanced cervical cancer and was, therefore, judged to be the preferred surgical procedure. In the GOG data base, para-aortic LN involvement was the most significant prognostic factor in multivariate analysis. If para-aortic LN were negative, pelvic LN metastases and tumor size were the most significant independent prognostic factors. Progression-free interval at 5 years decreased from 57% for patients with negative nodes to 34% and 12% for patients with pelvic or para-aortic LN metastases, respectively. As such, surgical staging must retain an integral role in protocol development to assure equal stratification of prognostic variables and, thereby, assess the benefit of innovative treatments for locally advanced cervical cancer in randomized prospective trials. The potential for lymphanglography and laparoscopy as alternatives to laparotomy are reviewed.     

经胸食管全切除术

In patients with esophageal carcinoma surgical resection remains the standard of curative treatment. For locally advanced tumors (pTlsm-pT3) transthoracic esophagectomy with extended lymphadenectomy is the standard surgical procedure since it offers a complete removal of the primary tumor and possible lymph node metastases. This surgical resection is appropriate for squamous cell but also adenocarcinoma of the esophagus because both histological entities demonstrate a lymphatic spread to the abdominal compartment and the upper mediastinum. In-hospital mortality rates are between 6% and 9%; anastomotic leakage and pulmonary complications mainly contribute to postoperative morbidity. In terms of 5-year survival the transthoracic procedure offers a better prognosis compared to the transhiatal resection.     

Lymphadenectomy for papillary thyroid cancer: changes in practice over four decades.

AIMS: Lymphadenectomy in the management of papillary thyroid cancer (PTC) has evolved. The aim of this study was to examine the changing role of neck dissection as reflected in the practice of a large thyroid unit over four decades. METHODS: A retrospective cohort study of patients that underwent primary thyroid surgery for papillary cancer in a single unit in the period 1958-2002. Nine 5-year periods were considered and the data relevant to the treatment of the regional lymph nodes reviewed. RESULTS: Nine hundred patients with PTC underwent surgery between 1958 and 2002 of whom 32.7% underwent lymph node dissection (LND). The use of lymphadenectomy increased from 21.4% in 1958-1962 to 48.1% in 1998-2002 of which 84% underwent a selective lymph node dissection (SLND)-a dissection where the LND is determined by the extent of the disease encountered. The mean number of nodes removed during SLND was 12.6 (range 1-56) of which a mean of 3.1 (24.8%) (0-19) were involved by the disease. Cervical levels 6 and level 4 were those most frequently dissected. There was no statistically significant difference in the complication rates in patients undergoing neck dissection and those not. CONCLUSION: The four decade experience reflects a move away from modified radical neck dissection and cherry picking towards SLND. Growing evidence suggests that lymphadenopathy in adult PTC is an adverse prognostic factor. SLND, a lymphadenectomy tailored to the extent of the disease process, is the coherent treatment for PTC since it serves the dual purpose of staging as well as control of local disease. This can be achieved with little morbidity when performed in a specialist centre.     

The role of lymphadenectomy in patients undergoing radical cystectomy for bladder cancer

The role of regional lymph node dissection (LND) in surgical management of high-grade, invasive transitional cell carcinoma of the bladder has evolved over the past several decades. The current concepts and rationale for LND in patients undergoing radical cystectomy for bladder cancer are reviewed and discussed. Evidence suggests that a more extended LND (with cephalad extent to include at least the common iliac vessels) for lymph node-positive and-negative patients undergoing radical cystectomy for bladder cancer may provide therapeutic benefits in addition to prognostic information. Lymph node density also provides risk stratification for lymph node-positive patients and may reduce the surgical bias and extent of the LND, both of which are currently not standardized. Although the absolute limits of the LND remain to be determined, an evolving body of data supports a more extended LND at the time of cystectomy in appropriate surgical candidates.     

Surgical management of vulvar cancer.

Vulvar cancer is an uncommon disease, marked by typical long delays in diagnosis due to lack of awareness by doctors and patients. The most common histology is squamous, although melanoma, sarcoma and adenocarcinoma occur less frequently. The predictable spread pattern of vulvar cancer to regional then distant lymphatics has allowed for improvements in survival largely due to radical surgical intervention. However, the significant morbidity from radical surgery has led to the search for better prognostic indicators and complementary therapeutic modalities to modify the extent of surgery in both early and advanced disease. En bloc radical vulvectomy and bilateral inguinal-femoral lymphadenectomy are rarely performed today: an early invasive stage has been defined where only limited excision is required. The extent of and the indications for inguinal lymphadenectomy for various clinical tumors and role of separate incisions have been clarified. When disease has spread to more than one inguinal node, adjuvant radiotherapy has replaced pelvic lymphadenectomy as the standard. Inguinal radiotherapy without groin dissection does not appear to be adequate therapy for most patients. The use of chemotherapy and radiation to shrink large tumors to allow surgical resection continues to be evaluated but has demonstrated excellent results to date. The utility of newer techniques of sentinel node mapping is also being evaluated in squamous cancers and melanoma to limit the extent of lymphadenectomy in patients with clinically normally lymph nodes.     

Randomized clinical trials in pancreatic cancer

The authors reviewed 59 prospective, randomized, controlled trials for pancreatic carcinoma that were published between 1977 and 2000. Of the 11 surgical trials, two each studied extent of resection (standard versus pylorus-preserving pancreaticoduodenectomy) and lymphadenectomy (standard versus extended lymph node dissection), five trials compared different types of pancreaticenteric reconstruction, and one each evaluated the role of prophylactic gastrojejunostomy and chemical splanchnicectomy in the setting of advanced disease.     

Surgical exploration of the mediastinum: mediastinoscopy and intraoperative staging

Lung resection remains the therapy of choice offering the greatest potential for cure in non-spread lung cancer. Prognostic importance of lymph-node involvement has been underlined by several studies. So, exploration of the mediastinum is of major importance for defining the therapeutic strategy in a possibly curative setting. Pre-resectional exploration of the mediastinal lymph-nodal status is mandatory to define tumour stage exactly and establish specific therapy. Cervical mediastinoscopy is the primary diagnostic procedure and remains the gold standard in invasive surgical staging. Complementary, parasternal mediastinoscopy, extended mediastinoscopy, and video-assisted thoracoscopy may be performed. These techniques allow accurate assessment of mediastinal lymph-node involvement, resulting in an appropriate judgement as to resectability and possible treatment options. Different techniques are established for intraoperative exploration and staging. In terms of curative surgery of lung cancer we demand accurate staging which is achieved by systematic and complete Lymph-node dissection. So, individually and dependent on primary tumour site, accurate mediastinal staging of Lung cancer should be performed in combination with definitive lung resection.