The role of lymphadenectomy in curative surgery for gastric cancer

A total of 530 cases of gastric cancer treated by curative surgery was analyzed with regard to lymph node metastases and survival rate. During this period, curative resections made up 75.9% of all resections (530/698) for gastric cancer, and the 5-year survival rate was 50.6% (268/530). A total of 15,739 regional lymph nodes (an average of 30 per specimen) removed at surgery were examined histologically for metastases, and 16.0% were found to be positive. Of 339 patients with advanced, transmural cancers, 74.9% had lymph node métastases; those with negative nodes had a 5-year survival rate of 63.5%, while those with positive nodes had a 5-year survival rate of 29.9%. The 5-year survivors with positive nodes made up 58.5% of all 5-year survivors. The almost complete removal of at least the primary and secondary lymph node groups draining a gastric neoplasm is an essential part of the curative surgical treatment of gastric cancer. For lesions in the upper and middle portions of the stomach that invade the serosa of the posterior wall, total gastrectomy with a caudal hemipancreatectomy and splenectomy should be aggressively performed, so as to accomplish complete en bloc removal of the lymph nodes in these regions.

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Résumé Nous avons analysé, aux points de vue métastases ganglionnaires et survie, 530 cas de cancers gastriques traités par chirurgie curative. Pendant cette période, les résections à visée curative ont représenté 75.9% de toutes les résections pour cancer gastrique (530/698) et la survie à 5 ans a été de 50.6% (268/530). Au total, 15,739 ganglions régionaux enlevés en cours d'opération (en moyenne 30 par pièce opératoire) ont été examinés: 16.0% renfermaient des métastases. Sur 339 malades avec cancer avancé ayant effracté les limites de l'organe, 74.9% avaient des métastases ganglionnaires; les survies à 5 ans ont été de 63.5% dans les cas sans métastase ganglionnaire et de 29.9% dans les cas avec métastase. Sur l'ensemble des survivants à 5 ans, 58.5% avaient des ganglions envahis. La résection presque totale d'au moins les premier et deuxième relais ganglionnaires drainant le cancer gastrique est un élément essentiel du traitement à visée curatrice. Pour les lésions des tiers supérieur et moyen de l'estomac qui envahissent la séreuse de la paroi gastrique postérieure, il faut réaliser une gastrectomie totale avec splénectomie et hémipancréatectomie gauche pour enlever en bloc les ganglions régionaux.

     

The role of superextended lymphadenectomy (D4) in gastric cancer

AIM: The outcome of surgery in gastric cancer differs in Japan and Western countries and the extension of lymphadenectomy may play a crucial role in survival. In Japan the choice of performing extended (D2) and superextended (D4) lymphadenectomies is based on retrospective studies, and a prospective randomized study comparing D2 and D4 is still in course. In Western countries the randomized trials comparing D1 and D2 could not provide definite indications, D2 is not yet performed as a routine procedure and D4 is accepted only by few surgeons. We report our experience and discuss indications and results. METHODS: Since January 2000 through December 2002 we performed 27 superextended lymphadenectomies for the radical treatment of advanced gastric cancer. Early gastric cancers and patients over 80 years of age received conventional D2 gastrectomies. Selection of patients for D4 was made after laparotomy, when intraoperative peritoneal lavage cytology could rule out the presence of malignant cells, while D2 was done in case of peritoneal micrometastases. RESULTS: Every patients had 39.5 nodes removed on average (range 17-94), and micrometastases in tier 16 were found in 7 cases (26%). Early post-operative surgical morbidity was 18% (5 patients) and mortality was 3.7% (1 patient). As much as 30% of patients complained of diarrhea as a late complication. The follow up could demonstrate a 3 year overall actuarial survival of 76%. Actuarial survival was 100% for N- and 70% for N+. A remarkable data was that 4 out of 5 patients who died from recurrence in the follow-up, were N4+. Actuarial survival at 3 years for N4+ patients was 34%, and the difference in survival between N4+ and other N+ was statistically significant (p<0.05). CONCLUSIONS: Superextended lymphadenectomy in gastric cancer is feasible with postoperative morbidity and mortality rates not exceeding the rates of other lymphadenectomies. Actuarial survival at 3 years with D4 was better than in previous personal experience with D2, although the patients who underwent D4 were selected by intraperitoneal lavage cytology, while D2 patients had not been selected. The prognosis for N4- patients was better than for N4+ with micrometastases in tier 16. The presence of N4 micrometastases worsens the prognosis, but it is still uncertain whether D4 does improve survival: it is undoubtedly a new means of more accurate staging in gastric cancer surgery. The newer TNM classification regards the number of nodes removed as an indicator of radicality. Every surgeon should consider that superextended lymphadenectomies could comply with R0 radicality, and perform it within the ranges of low morbidity and mortality, until randomized trials with definitive results are available.     

The role of lymphadenectomy in prostate cancer

It has been shown that an adequate lymphadenectomy for exact staging of prostate cancer consists of removal of all the tissue along the external iliac vein, in the obturator fossa and along the internal iliac artery. Morbidity associated with this procedure is low, if certain technical details are respected. This review discusses in detail the indications for lymphadenectomy and the extent of dissection, based on the localization of the positive nodes. The potential therapeutic impact of extended lymph node dissection in men with prostate cancer is also addressed.     

The role of lymphadenectomy in penile cancer

In patients with squamous carcinoma of the penis, the presence and extent of metastases involving the inguinal nodes are the most important factors predictive of survival. Favorable prognostic indicators of cure in surgically treated patients in whom metastases develop include: (1) minimal nodal disease, (2) unilateral involvement, (3) no evidence of extranodal extension of cancer, and (4) absence of pelvic nodal metastases. Prophylactic lymphadenectomy in select patients at high risk for metastasis seems reasonable in lieu of prospective randomized trials because novel procedures have significantly decreased the morbidity of surgical staging. Patients with poor prognostic indicators either before or after surgery should be considered for multimodal therapy.     

The role of central lymphadenectomy in treatment of patients with thyroid cancer

Direct and long-term results of surgical interventions for differentiated cancer of the thyroid gland supplemented with lymphadenectomy on the tumor side were studied on the material of 1136 patients. As a group of comparison there was a group of 303 patients with similar histological diagnoses, gender and age and distribution of carcinomas by stages in which the ablation of para- and pretracheal lymph nodes was not fulfilled by any reasons. The investigation gives proofs of the necessity to perform central lymphadenectomy simultaneously in all primary operations for differentiated cancer of the thyroid gland.     

The role of lymphadenectomy in lung cancer surgery

Adequate lymphadenectomy represents a fundamental procedure in lung cancer surgery for accurate staging and potential survival benefit. Various techniques are used in current surgical practice for the intraoperative lymph node removal associated with pulmonary resection, without definitive indications concerning the preferable option. Different studies in the last decades have compared complete mediastinal lymph node dissection with lymph node sampling regarding their effect on long-term survival, recurrence rate, accuracy of pathologic staging, and surgical morbidity. Literature data and technical aspects of lymph node dissection are reported and discussed in this article.     

胃癌第2站淋巴结清扫方法的研究

目的总结胃癌第2站淋巴结清扫的手术体会。方法对57例胃癌D2淋巴结清扫手术方法及结果进行回顾性研究,统计淋巴结清扫数目、手术失血量、术后并发症,总结安全彻底的胃癌第2站淋巴结清扫经验及术中注意事项。结果 57例胃癌患者D2手术均取得成功,共清扫淋巴结1543枚,平均27.07枚;淋巴结癌转移共486枚,转移率31.5%。手术失血量平均244.7ml。术后并发症发生率22.8%,未出现淋巴结清扫相关的并发症。结论在熟悉胃周局部解剖,掌握淋巴结清扫技术,遵循解剖层次分离的基础上,是可以安全彻底地进行胃癌第2站淋巴结清扫的。     

Axillary lymphadenectomy for breast cancer in elderly patients and fibrin glue

Background

Axillary lymphadenectomy or sentinel biopsy is integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies with controversial results.

Methods

Thirty patients over 60 years underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray were applied to the axillary fossa in 15 patients; the other 15 patients were treated with harmonic scalpel.

Results

Suction drainage was removed between post-operative Days 3 and 4. Seroma magnitude and duration were not significant in patients receiving fibrin glue compared with the harmonic scalpel group.

Conclusions

Use of fibrin glue does not always prevent seroma formation, but can reduce seroma magnitude, duration and necessary evacuative punctures.

     

The role of lymphadenectomy in high-grade invasive bladder cancer

Radical cystectomy with bilateral pelvic iliac lymphadenectomy is a standard treatment for high-grade, invasive bladder cancer. Cystectomy arguably provides the best survival outcomes and the lowest local recurrence rates. Although the extent or absolute limits of the lymph node dissection are unknown and remain to be better defined, an ever-growing body of data supports a more extended lymphadenectomy at the time of cystectomy in all patients who are appropriate surgical candidates. An extended lymph node dissection should include the distal para-aortic and paracaval lymph nodes as well as the pre-sacral nodes, known anatomic sites of lymph node drainage from the bladder and potential sites of lymph node metastases in patients with bladder cancer. An extended dissection may provide a survival advantage in patients with node-positive and node-negative tumors without significantly increasing the morbidity or mortality of the surgery. The extent of the primary bladder tumor (p stage), the number of lymph nodes removed, and the lymph node tumor burden are important prognostic variables in patients undergoing cystectomy with pathologic evidence of lymph node metastases. Lymph node density may become an even more useful prognostic variable in these high-risk, node-positive patients with bladder cancer. This concept simultaneously incorporates the lymph node tumor burden (number of lymph nodes involved) and the number of lymph nodes removed (extent of the lymphadenectomy), improving the stratification of lymph node-positive patients following radical cystectomy. This notion may also be useful in future staging systems. Adjuvant therapies and clinical trials should consider applying these concepts, because they may help reduce bias and incorporate the extent of the lymphadenectomy, which currently is not standardized.     

Strategy for lymphadenectomy of gastric cancer

To determine the extent of lymphadenectomy necessary to cure early gastric cancer, the relationship between the frequency of nodal involvements and the extent of the primary invasion was examined in 274 patients with primary cancer of the stomach. We also evaluated the relationship between the number of metastatic lymph nodes, the pattern of metastases to the nodes, and the histologic type of the primary tumor. In early gastric cancer, lymph node metastasis was more frequent in protruded-type cancer with invasion into the submucosa more than 3 cm in diameter and located in the lower third of the stomach, but was limited to the group 1 lymph nodes, which were defined as being anatomically located nearest to the cancer. In cancer invading into the muscularis propria, metastasis to the group 2 or 3 lymph nodes, which were defined as being anatomically located farther from the cancer than group 1, was found. The number of lymph nodes involved and extent of cancer metastasis in these lymph nodes metastasis, differentiated early gastric cancer had more lymph node involvement and wider extent of metastases than undifferentiated cancers. The cancer cells sometimes replaced most of the node and invaded the perinodal fatty tissue, even in early gastric cancer. In addition, it is occasionally difficult to distinguish macroscopically early gastric cancer with submucosal invasion from cancer invaded into the muscle layer. In conclusion, group 1 and 2 lymph nodes, including perinodal fatty tissue, should be removed completely, even in early gastric cancer, except for carcinoma in situ, particularly when the cancer is of the differentiated type.     

The role of lymphadenectomy in high risk prostate cancer

Historically, patients with high risk prostate cancer were considered poor candidates for radical prostatectomy (RP) due to the likelihood of positive pelvic lymph nodes and decreased long term survival. Although there is still no consensus on the optimal therapy for this group of patients, there is increasing evidence that surgery could play a role. Cancer specific survival (CSS) rates after RP for locally advanced disease at 10 year follow up range from 29 to 72%, depending on tumor differentiation. The role of pelvic lymph node dissection (PLND) in prostate cancer remains a controversial topic. Nonetheless, in conjunction with RRP extended PLND (ePLND) should be performed as extended lymph node dissection in lieu of standard PLND may increase staging accuracy, influence decision making with respect to adjuvant therapy and possibly impact outcome. High risk patients with organ confined prostate cancer and low volume (micro)metastatic disease may be the ones to profit most from this approach.     

217例早期胃癌扩大胃切除与淋巴结清除术的回顾分析

目的评价早期胃癌不同扩大手术的实际意义，以选择合理的胃切除和淋巴结清除范围。方法以临床病理资料完整、施行规范D2及扩大手术的217例早期胃癌患者为研究对象。分析施行不同扩大手术的原因、淋巴结清除的必要性及第Ⅱ站淋巴结转移与临床病理因素的相关性。结果胃上部癌行全胃切除术6例，No．5、6淋巴结均未见转移；联合脾、脾动脉切除2例，No．10、11p、11d淋巴结均未见转移；胃下部癌联合横结肠系膜切除3例，No．15淋巴结未见转移。以上病例术中多数误认为进展期胃癌而扩大了胃切除或淋巴结清除范围，手术时间长，术中失血较多。胃下部癌清除的第Ⅱ站淋巴结中No．11p、12a、14v均未见转移；黏膜下癌（sm癌）中，No．7、8a淋巴结转移率明显高于黏膜内癌（m癌）（P〈0．05）；淋巴管癌栓阳性者No．7淋巴结转移较阴性者明显增多（P〈0．001），No．1、13淋巴结转移仅出现在淋巴结转移高危病例（sm、癌灶大于3．0cm、凹陷型，淋巴管癌栓阳性）。结论早期胃癌不需施行淋巴结扩大清除术和联合脏器切除。早期胃上部癌不需施行全胃切除术。早期胃下部癌中No．11p、12a、14v淋巴结不需清除．但对胃下部癌淋巴结转移高危病例，应行标准D2淋巴结清除术。     

腹腔脂肪量与胃癌病人术中淋巴结清扫的关系

目的:探讨腹腔脂肪分布的CT测量与胃癌病人术中淋巴结清扫的关系。方法:回顾性收集2008年5月至2009年9月在我院外科胃切除加D2淋巴结清扫术的226例胃癌病人。手术前通过CT扫描及重建分别测量了腹腔脂肪面积(IFA)及腹腔脂肪体积(IFV)。将IFA分为高IFA组(IFA≥85 cm2)和低IFA组(IFA<0.001)。结论:病人腹腔脂肪面积影响胃癌的术中淋巴结清扫个数。     

胃癌规范化淋巴结清扫治疗的价值

目前世界范围内，胃癌的总体死亡率仅次于肺癌居第二位。外科手术是唯一有希望治愈胃癌的方法。随着外科手术技术的发展和围手术期监护、治疗水平的提高，胃癌的手术切除率和生存率在不断提高。东西方对胃癌根治性手术时进行淋巴结清扫的必要性目前已基本达成共识。规范开展淋巴结清扫术已成为目前讨论的焦点。本文回顾胃癌外科治疗研究进展，结合自身研究经验，对胃癌规范化淋巴结清扫的价值进行探讨。     

老年胃肠道肿瘤患者的围手术期处理

<正>世界范围内,胃肠道肿瘤的发病率在所有恶性肿瘤中始终排名前5位,GLOBOCAN统计数据显示,2012年全球胃癌和结直肠癌新发病例数分别为95.2万和136.1万例,死亡病例数分别为72.3万和69.4万例~([1])。在我国,胃癌和结直肠癌同样是最常见的恶性肿瘤,其死亡率分别位居所有癌症的第2和第5位~([2])。随着我国社会经济的发展,居民平均寿命逐年延长,人口老龄化趋势日益显现,因此老年患者甚至是高龄患者在胃肠道肿瘤病患中的比例越来越高。世界卫生组织将65岁以上人群定义为老年人,但随着这部分人群的不断扩大,