Regional pancreatectomy: en bloc pancreatic, portal vein and lymph node resection.

Eighteen patients are reported who have had a regional pancreatectomy. The pancreatic segment of portal vein was excised with en bloc total pancreatectomy and regional lymph node dissection in all 18. Venous repair was by end-to-end anastomosis without a graft. Five of the 18 also had various arterial resections and reconstructions. Sixteen of the 18 had been explored and deemed nonresectable elsewhere. This operation has doubled the resectability rate in this institution. The 30-day operative mortality rate was 16.6%. Acurarial survival is 62% at one year compared with 36% one year survival rate for patients undergoing pancreaticoduodenectomy for less advanced cancer in previous years. A more valid comparison would be between those who had a palliative procedure since most patients in the present series were initially considered unresectable. One year survival for these patients was 22%. The quality of life was good for most patients.     

Risk factors for patients with pelvic lymph node metastases following radical cystectomy with en bloc pelvic lymphadenectomy: concept of lymph node density

PURPOSE: We evaluated the clinical outcomes and risk factors for progression in a large cohort of patients with lymph node metastases following en bloc radical cystectomy and bilateral pelvic lymphadenectomy. MATERIALS AND METHODS: From July 1971 through December 1997, 1,054 patients underwent radical cystectomy and bilateral pelvic-iliac lymphadenectomy for high grade, invasive transitional cell carcinoma of the bladder. Of these patients 244 (23%) with a median age of 66 years (range 36 to 90) had pathological lymph node metastases. Overall 139 of the 244 patients (57%) received some form of chemotherapy. At a median followup of greater than 10 years (range 0 to 28) outcomes data were analyzed in univariate analysis according to tumor grade, carcinoma in situ, primary bladder tumor stage, pathological subgroups, total number of lymph nodes removed and involved with tumor, and lymph node density (total number of positive lymph nodes/total number removed). In addition, the form of urinary diversion and the administration of chemotherapy were also evaluated. Multivariate analysis was then performed to analyze these variables independently. RESULTS: The incidence of positive lymph nodes increased with higher p stage and pathological subgroups. Of 669 patients 75 (11%) with organ confined primary tumors and 169 of 385 (44%) with extravesical tumor extension had involved lymph nodes. The median number of lymph nodes removed in the 244 lymph node positive cases was 30 (range 1 to 96), while the median number of positive lymph nodes was 2 (range 1 to 63). Overall recurrence-free survival at 5 and 10 years for the 244 patients with lymph node positive disease was 35% and 34%, respectively. Patients with lymph node positive disease and an organ confined primary bladder tumor had significantly improved 10-year recurrence-free survival compared with those with extravesical tumor extension (44% vs 30%, p = 0.003). The total number of lymph nodes removed at surgery was also prognostic. Patients with 15 or less lymph nodes removed had 25% 10-year recurrence-free survival compared with 36% when greater than 15 lymph nodes were removed. Recurrence-free survival at 10 years for patients with 8 or less positive lymph nodes was significantly higher than in those with greater than 8 positive lymph nodes (40% vs 10%, p <0.001). The novel concept of lymph node density was also a significant prognostic factor. Patients with a lymph node density of 20% or less had 43% 10-year recurrence-free survival compared with only 17% survival at 10 years when lymph node density was greater than 20% (p <0.001). On multivariate analysis the total number of lymph nodes involved, pathological subgroups of the primary bladder tumor, lymph node density and adjuvant chemotherapy remained significant and independent risk factors for recurrence-free and overall survival. CONCLUSIONS: Patients with lymph node tumor involvement following radical cystectomy may be stratified into high risk groups based on the primary bladder tumor, pathological subgroup, number of lymph nodes removed and total number of lymph nodes involved. Lymph node density, which is a novel prognostic indicator, may better stratify lymph node positive cases because this concept collectively accounts for the total number of positive lymph nodes (tumor burden) and the total number of lymph nodes removed (extent of lymphadenectomy). Future staging systems and the application of adjuvant therapies in clinical trials should consider applying lymph node density to help standardize this high risk group of patients following radical cystectomy.     

Lymph node metastasis in an animal model: effect of piecemeal laser surgical resection

BACKGROUND AND OBJECTIVES: Endoscopic laser surgical resection of advanced squamous cell carcinoma (SCC) often requires division of the tumor into several pieces. It is unknown if this approach influences the incidence of regional and distant metastases. STUDY DESIGN/MATERIALS AND METHODS: In 143 rabbits VX2 SCC was induced. Eight days later the tumor was resected by two different methods. In the first group en bloc cold steel resection was performed. In the second group piecemeal laser resection was performed. On the 51th day the animals were sacrificed and examined for lymph node and distant metastases. RESULTS: After piecemeal laser resection 47.7% of the animals had lymph node metastases compared to 24.6% after en bloc resection (P = 0.01). The incidence of distant metastases did not differ for the two groups. CONCLUSIONS: In our model narrow margin piecemeal laser resection was associated with a higher incidence of metastases compared to wide en bloc surgical resection. The exact mechanism responsible for this increase is unclear.     

Factors affecting postoperative course and survival after en bloc resection for esophageal carcinoma

Background

To identify factors affecting postoperative course and survival after esophagectomy for cancer and reasons for improved survival over time.

Methods

Complete esophageal resection was attempted for middle and lower third esophageal carcinomas in 386 consecutive patients between January 1982 and January 2002. Two study periods were analyzed: 1982 to 1993 and 1994 to 2002. Prognostic factors were identified by multivariate analysis and the two periods compared.

Results

Hospital mortality rate decreased from 5.4% to 2.9% (p = 0.245). Both anastomotic leakage and pulmonary complications rates decreased from 9.8% to 2.2% (p = 0.001) and 24.1% to 19.3% (p = 0.295), respectively. An increased proportion of patients had R0 resection in the latter period, 78.5% versus 67.0%, (p = 0.028). Five-year survival rate after R0 resection increased from 29% to 46% (p = 0.001), with a decreased recurrence rate from 65.8% to 44.3% (p = 0.002). Three favorable prognostic factors were identified: low pT stage, pN0 stage, and operation during the 1994 to 2002 study period.

Conclusions

Short-term outcome and survival of patients with resected esophageal cancer have improved over time. Advances in perioperative technique, staging methods, and surgical management combined with higher patient selection and use of neoadjuvant chemoradiation may be responsible for this progress.     

Patients with penile carcinoma benefit from immediate resection of clinically occult lymph node metastases

PURPOSE: In this retrospective study we compared the clinical outcome of early vs delayed excision of lymph node metastases in patients with penile squamous cell carcinoma. MATERIALS AND METHODS: A total of 40 patients with a T2-3 penile carcinoma with lymph node metastases were included in this study. All patients initially presented with bilateral impalpable lymph nodes. In 20 patients (50%) metastases were removed when they became clinically apparent during meticulous followup (median interval 6 months, range 1 to 24). There were 20 patients (50%) who underwent resection of inguinal metastases detected on dynamic sentinel node biopsy before they became palpable. The histopathological characteristics of the tumors and lymph nodes were reevaluated. RESULTS: The 2 populations were similar in terms of patient age, T-stage, pathological tumor grade, vascular invasion and infiltration depth. Disease specific 3-year survival of patients with positive lymph nodes detected during surveillance was 35% and in those who underwent early resection, 84% (log rank p = 0.0017). In multivariate analysis early resection of occult inguinal metastases detected on dynamic sentinel node biopsy was an independent prognostic factor for disease specific survival (p = 0.006). CONCLUSIONS: Early resection of lymph node metastases in patients with penile carcinoma improves survival.     

Results of resection for bronchogenic carcinoma with mediastinal lymph node metastases in selected patients.

Between 1982 and 1988, 254 consecutive patients underwent resection for bronchogenic carcinoma with mediastinal lymph node metastases at Marie Lannelongue Hospital. Selection of cases for surgery was carried out using CT and mediastinoscopy. The surgical procedure performed were pneumonectomy (169), lobectomy (65), or bilobectomy (20) associated with resection of ipsilateral mediastinal lymph nodes. Almost all diseased nodes appeared grossly enlarged at surgery and only a few were of normal size. Postoperative mortality was 5.6%. Resection was potentially curative in 191 cases (75%) and palliative in 63 cases (25%). Almost all patients received adjuvant treatment (mainly radiotherapy). Actuarial 5-year survival was 18% for the entire group, and 23% for those who underwent curative resection. No patient with palliative resection survived 5 years. The following factors proved to be significantly associated with a better prognosis: complete resection, independent lymph node metastases, involvement of only one level, lower paratracheal involvement. On the other hand, there was no difference between pathological types (squamous cell carcinomas, adenocarcinomas, oat cell carcinomas) with regard to prognosis. We advocate an aggressive approach in selected cases of N2 bronchogenic carcinoma. Neoadjuvant chemotherapy should be tested in these specific patients with a view to the possibility of improving results.     

Long-term survival after surgical resection of metachronous inguinal lymph node and contralateral lung metastases from lung cancer; report of a case

The majority of patients with metastatic diseases are not indicated for radical surgery because of another metastatic lesions. We herein describe a case of long-term survival after surgical resections of metachronous inguinal lymph nodal and contralateral pulmonary metastases from lung cancer. In August 1999, a 71-year-old man presented with hemosputa. Chest computed tomography (CT) showed a tumor of the right lung. In January 2000, the right upper lobectomy was performed, and thereafter the lesion was diagnosed as a large cell carcinoma. Two months later, a groin tumor was detected, diagnosed as a metastatic lesion with aspiration cytology, and resected. In October 2001, a newly developing lung tumor in the left upper lobe was detected by routine chest CT. In December 2001, a partial resection of the left upper lobe was performed, and the tumor was diagnosed as a large cell carcinoma. The patient is alive without recurrence for 5 years.     

Results of resection in non-oat cell carcinoma of the lung with mediastinal lymph node metastases.

From 1974 to 1981, 1598 patients with non-oat cell carcinoma of the lung were seen and treated. All were staged according to the AJC staging system. Of these, 706 patients had evidence of mediastinal lymph node metastases (N2). There were 151 patients (21%) who had complete, potentially curative resection of their primary tumor and all accessible mediastinal lymph nodes. The histologic type of tumor was adenocarcinoma in 94 patients, epidermoid carcinoma in 46 patients, and large-cell carcinoma in 11 patients. The extent of pulmonary resection consisted of a lobectomy in 119 patients, pneumonectomy in 26 patients, and wedge resection or segmentectomy in six patients. Almost all patients also received radiation therapy to the mediastinum. Clinical staging of the primary tumor and the mediastinum was based on the radiographic presentation of the chest and on bronchoscopy. Before treatment, 104 of 151 patients (69%) were believed to have had stage I (90 patients) or II (14 patients) disease, and 47 patients had stage III disease, of whom only 33 had evidence of mediastinal lymph node involvement. Excluding deaths from unrelated causes, the overall survival rate was 74% at 1 year, 43% at 3 years and 29% at 5 years. Survival in patients with clinical stage I or II disease treated by resection was favorable despite the presence of N2 nodes (50% at 3 years). Survival in obvious clinical N2 disease was poor (8% at 3 years). There was no difference in survival between patients with adenocarcinoma and those with epidermoid carcinoma. However, survival was poorer in patients with N2 nodes in the inferior mediastinum compared to those without lymph node involvement at that level.     

胃癌淋巴结转移灶中COX-2和Bcl-2的表达及其与体外化疗敏感性的关系

目的 探讨胃癌淋巴结转移灶中环氧合酶-2(COX-2)和Bcl-2的表达及其与体外化疗敏感性的关系. 方法对40例胃癌新鲜肿瘤组织及转移淋巴结进行肿瘤细胞体外培养化疗药敏性实验,并对原发灶和转移灶行COX-2和Bcl-2免疫组化染色. 结果原发灶中COX-2和Bcl-2强表达率分别为52%和45%,转移灶中分别为72%和60%.COX-2在转移灶中的表达明显高于原发灶(χ~2=4,P<0.05),而Bcl-2在转移灶与原发灶中表达强度相比差异无统计学意义(χ~2=3,P>0.05).在原发灶与转移淋巴结之间COX-2和Bcl-2表达均具有明显相关性(r=0.3403,0.4560,均P<0.05);在原发灶及转移灶中,COX-2与Bcl-2之间表达强度均具有正相关性(r=0.6014,0.5330,均P<0.01).在原发灶中COX-2强表达组的5氟尿嘧啶、长春新碱、表阿霉素对肿瘤细胞的抑制率明显低于弱表达组(t=2.29、2.18、2.41,均P<0.05);Bcl-2强表达时,5氟尿嘧啶、紫杉醇、表阿霉素对肿瘤细胞的抑制率均明显低于弱表达组(t=2.46、2.23、2.22,均P<0.05).在转移淋巴结中,COX-2强表达时长春新碱和甲氨蝶呤对肿瘤细胞的抑制率明显下降(t=2.17、2.35,均P<0.05);Bcl-2强表达组的5氟尿嘧啶、足叶乙甙、紫杉醇和甲氨蝶呤4种药物的抑制率均低于弱表达组(t=2.32、2.29、2.50、2.25,均P<0.05).结论 COX-2和Bcl-2参与了胃癌多药耐药,且在淋巴结转移灶中的表达及化疗药敏性均呈现与原发灶不同的异质性,术后辅助化疗应针对淋巴结转移灶进行.     

食管癌淋巴结转移特点及其危险因素

目的 探讨食管癌淋巴结转移情况及其危险因素,为外科手术行淋巴结清扫提供参考。方法回顾总结2006年1月至2010年12月在复旦大学附属肿瘤医院胸外科行三野淋巴结清扫食管癌根治术308例患者的临床资料．分析淋巴结的转移规律及特点。结果308例患者平均清扫淋巴结（35．6±14．5）枚,197例（64％）患者出现淋巴结转移。Logistic单因素分析结果显示,脉管（淋巴管及血管）侵犯（P=0．019）及肿瘤浸润深度（P〈0．001）是发生淋巴结转移的危险因素。各站淋巴结中,胸部气管旁淋巴结转移率最高（25．0％）。上段食管癌腹部淋巴结转移率显著低于中段或下段食管癌（P=0．001）,而各段食管癌颈胸部淋巴结转移率比较,差异无统计学意义（P〉0．05）。颈胸部和颈胸腹部淋巴结转移率分别为14．6％和11．0％,而颈腹部和胸腹部则分别为3．6％和4．9％。脉管侵犯（P〈0．001）和胸部气管旁淋巴结转移（P=0．014）是食管癌发生颈部淋巴结转移的危险因素。结论食管癌淋巴结转移具有上、下双向和跳跃性的特点．胸部气管旁淋巴结转移可作为行颈部淋巴结清扫的指征。     

联合血管切除术在胰头癌治疗中的临床意义(附34例报告)

目的　探讨联合血管、胰十二指肠切除术的临床意义。方法　回顾性分析近 10年来34例联合血管、胰十二指肠切除术病例的临床资料。血管切除包括 ,门静脉 (SMV)或肠系膜上静脉(PV)楔形切除 ,SMV或PV切除 ,肠系膜上动脉 (SMA)切除 ,SMV或PV +SMA切除 ,SMV或PV +肝动脉切除。结果　本组病人术后并发症发生率 17 6 5 % (6 / 34) ,主要并发症有胃潴留、上消化道出血、切口裂开等 ,围手术期 (术后 1个月内 )死亡率 8 82 % (3/ 34)。 11例随访病人生存期为 5～ 2 6个月 ,平均 (15 4 4± 7 89)个月。结论　行血管切除有助于提高局部较晚期肿瘤的切除率 ,能明显改善病人的生存质量 ,在一定程度上延长病人的生存期。     

Relationship of cell type and lymph node metastasis to survival after resection of bronchial carcinoma.

In the completed adjuvant chemotherapy lung trials conducted by the Veterans Administration Surgical Group, the cell type was recorded in 2,341 of 2,349 curative resections; extent of lymph node involvement was known in all cases. Nodes were normal in 1,231 patients. Five- and ten-year survival computed by the life-table method was 33.7% and 20.4%, respectively. These rates were significantly greater than the 16.2% and 8.8% recorded in 1,118 patients whose nodes showed metastases. Among patients whose cell type was known, five-year survival in 484 with hilar node involvement was 17.4% and was not significantly different from 20.1% in 364 patients in whom only lobar nodes were involved. The survival was 8.9% in 268 patients with cancer in the mediastinal nodes; this was significantly worse than either of the aforementioned groups. A five-year survival of 26.8% in 1,482 patients with squamous cell carcinoma was greater than the 24.3% in 359 with adenocarcinoma and 22.4% in 500 with undifferentiated cell types, but the differences were not significant. Variations between these groups remained nonsignificant when nodes were normal and were of only borderline significance, at the 5% level, when they showed metastasis. When a curative resection has been accomplished, cell-type as classified in this study has little bearing on long-term survival, whereas the presence of node metastasis as well as its location is of the utmost importance.     

Curative resection of carcinoma of the ampulla of Vater with lymph node metastases around the abdominal aorta after chemotherapy: A case report

IntroductionFor carcinoma of the ampulla of Vater, lymph node metastasis around the abdominal aorta is an inoperable factor equivalent to distant metastasis, such as hepatic metastasis or peritoneal carcinomatosis, making the cancer unresectable.Presentation of caseA 53-year-old man was referred to our hospital and was diagnosed as having carcinoma of the ampulla of Vater with lymph node metastases around the abdominal aorta. Although only chemotherapy was initially scheduled, the chemotherapy was effective, and the metastases were dramatically reduced after 4 cycles of chemotherapy. Curative surgical resection was performed.DiscussionThere were only eight case reports describing curative resections of initially unresectable biliary tract carcinomas excluding intrahepatic cholangiocellular carcinoma after chemotherapy.ConclusionCurative surgical resection after chemotherapy may be a feasible treatment plan in patients with unresectable biliary tract cancer.     

Cervical lymph node metastases and squamous cell carcinoma of the lip.

BACKGROUND: Squamous cell carcinoma of the lip generally has a favorable outcome. The chance of long-term survival is significantly reduced if lymph node metastases develop. Any features that could identify patients having increased risks of occult lymph node metastases would allow more aggressive treatment and, possibly, a better outcome. METHODS: A chart review of lip cancer from this institution identified 1001 patients with squamous cell carcinoma of the lip. This database was used to identify the characteristics that are associated with occult lymph node metastases. RESULTS: Delayed cervical lymph node metastases developed in 40 patients. No significant differences were noted in the frequency of delayed lymph node metastases according to gender, lip subsite, or age less than 40 years. Significant differences were noted in association with the tumor size, tumor differentiation, and local recurrence. CONCLUSIONS: Elective cervical lymphadenectomy is justifiable for higher grade tumors and for locally recurrent tumors. An increase in delayed metastases was observed in patients with tumors greater than 3 cm, but the proportion is not great enough to justify elective neck dissections.     

Metastases to the regional lymph nodes,lymph node recurrence,and distant metastases in nonadvanced papillary thyroid carcinoma

To investigate the biological characteristics of papillary thyroid carcinoma from the perspectives of lymph node metastasis, lymph node recurrence, and distant metastasis, 746 patients with nonadvanced papillary thyroid carcinoma were retrospectively studied. There were 76 men and 670 women with a mean age of 42.7 years. The rate of lymph node metastasis was significantly higher in young patients (aged less than 30 years). Lymph node recurrence was observed in 80 patients and distant metastasis in 13, being seen with significant frequency in the young and elderly (aged over 50 years) patients and in the men. The frequency of distant metastasis was significantly greater in the elderly patients and in those with lymph node recurrence. These findings indicate that the role of regional lymph nodes and the clinical meaning of lymph node recurrence differ between young and elderly patients.     

Mode of lymph node metastases in esophageal cancer induced in rabbits with Vx2 carcinoma

We carried out experimental studies in which Vx2 carcinoma was inoculated submucosally into the esophagi of 57 rabbits. The purpose was to clarify the mode of tumor growth and lymph node metastasis of esophageal cancer. The inoculation was given into five different segments of the esophagus and the cardia in six different groups of rabbits: the cervical (Ce), the cervicothoracic junction (Ce=Iu), the upper thoracic (Iu), the middle and lower thoracic (ImEi) and the abdominal (Ea) segments and the cardia (C). The lymph node metastatic pattern of the Vx2 carcinoma was then observed. The Ce and Ce=Iu located carcinomas metastasized mainly above the tracheal bifurcation; the ImEi located carcinomas metastasized equally above and below the tracheal bifurcation. In cases of the Ea and C located carcinomas, the lymph node metastasis was restricted to the abdomen when serosal invasion was excluded but it spread widely from the abdomen to the neck when serosal invasion was positive. Thus, in experimentally-induced carcinoma, tracheal lymph node metastasis occurred with a high frequency. As intraoperative assessment is closely related to anatomical factors and operative risk, care should be taken that such assessments are thoroughly carried out.     

病理科医师细致取材对直肠癌根治术后淋巴结检出数量的影响

目的分析病理科医师细致取材对直肠癌根治手术患者淋巴结检出数量的影响。方法对第二军医大学附属长海医院肛肠外科2008年1。12月和2009年1。5月收治的原发性直肠癌患者（Ⅰ～Ⅲ期）临床资料进行回顾性分析,比较2008年间（2008年组）和2009年间（自2009年1月起,病理科建议每例直肠癌患者手术检出淋巴结数量不少于15枚;2009年组）患者的淋巴结检出数量。结果232例直肠癌患者入组．其中2008年组156例,2009年组76例。两组患者性别（P=0．436）、年龄（P=0．527）、肿瘤距肛缘距离（P=0．761）、肿瘤分化程度（P=0．074）和TNM分期（P=0．167）及手术方式（P=0．715）的比较,差异均无统计学意义。2009年组检出淋巴结数量[（16．0±0．3）枚／例]显著高于2008年组[（11．4±0．3）枚／例]（P〈0．01）;2009年组检出淋巴结达12枚／例者的比例94．7％（72／76例）,显著高于2008年组的45．5％（71／156例）,差异有统计学意义（P〈0．01）。结论对未行术前新辅助治疗、且无远处转移的直肠癌根治术患者．病理科医师细致取材可以获得理想的淋巴结检出数量。