腹腔镜改良性腹膜后淋巴清除术治疗临床Ⅰ期睾丸非精原细胞瘤

目的:探讨腹腔镜改良性腹膜后淋巴清除术初步经验,评估其手术可行性和近期临床疗效。方法:2004年10月~2006年7月,对7例临床诊断为Ⅰ期睾丸非精原细胞瘤患者,施行了经腹腔途径腹腔镜改良性腹膜后淋巴清除术,年龄26~36岁,平均年龄为30岁,睾丸肿瘤大小为3.0 cm×2.5 cm×2.0 cm~6.5 cm×4.5 cm×3.0 cm,左侧3例,右侧4例,均通过B超、腹膜后CT、胸片检查,并施行了根治性睾丸切除和病理证实。术后淋巴结阳性患者施行了3个疗程的化疗。结果:7例均获得成功,无1例改开放手术。手术时间为120~210 min,平均160 min,手术失血量50~200 ml,平均150 ml,均未输血。术后1~3 d肛门排气,于1~2 d拔除引流管;术后平均住院时间5.5 d。病理报告6例均无转移性淋巴结,其中1例为1/18淋巴结转移,术后无明显并发症。随访6~32个月,平均14个月,阴茎勃起功能良好,射精功能正常。定期复查血hCG、AFP均阴性,B超复查均未发现腹膜后淋巴结,胸片表现均正常。其中淋巴结阳性1例患者术后接受3个疗程的辅助化疗,随访6个月,无瘤存活。结论:腹腔镜改良性腹膜后淋巴清除术具有损伤小、并发症少、术后恢复快等特点,可以代替传统开放手术。     

Risk Factors for Non-Sentinel Lymph Node Metastases in Patients with Breast Cancer. The Outcome of a Multi-institutional Study

Background In this multi-institutional prospective study, we evaluated whether we could identify risk factors predictive for non-sentinel lymph node (non-SN) metastases in breast cancer patients with a positive sentinel lymph node (SN). Methods In this multi-institutional study, 541 eligible breast cancer patients were included prospectively. Results The occurrence of non-SN metastases was related to the size of the SN metastasis (P = .02), primary tumor size (P = .001), and lymphovascular invasion (P = .07). The adjusted odds ratio was 3.1 for SN micro-metastasis compared with SN isolated tumor cells, 4.0 for SN macro-metastasis versus SN isolated tumor cells, 3.1 for tumor size (>3.0 cm compared with ≤3.0 cm), and 2.0 for lymphovascular invasion (yes versus no). There were no positive non-SNs when the primary tumor size was ≤1.0 cm (n = 24) [95% confidence interval (95% CI) 0%–14.0%]. The proportion of positive non-SNs ranged in a prognostic logistic regression model from 9.7% (95% CI 4.0%–23.0%) for patients with SN isolated tumor cells, tumor size of 1.1–3.0 cm, and without vessel invasion, to 72.6% (95% CI 47.0%–89.0%) for patients with SN macro-metastasis, tumor size >3.0 cm, and with vessel invasion. Conclusion We identified three predictive factors for non-SN metastases in breast cancer patients with a positive SN: size of the SN metastasis; primary tumor size; and vessel invasion. We were not able to identify a specific group of patients with a positive SN in whom the risk for non-SN metastases was less than 5%.     

Postoperative UFT Adjuvant and the Risk Factors for Recurrence in Renal Cell Carcinoma: A Long-Term Follow-Up Study

Background Radical nephrectomy is the standard therapy for low-stage renal cell carcinoma. However, recurrence sometimes develops even in patients who are considered to have undergone a curative resection of the primary tumor. The purpose of this study was to evaluate the usefulness of UFT (a 1: 4 mixture of tegafur and uracil) adjuvant and the risk factors for recurrence in renal cell carcinoma.
Methods A prospective randomized trial was conducted to compare the use of long-term oral UFT adjuvant with nonadjuvant therapy after a radical nephrectomy for Robson stage I or II renal cell carcinoma. A multivariate analysis was also performed to estimate the risk factors for recurrence.
Results A total of 71 patients were entered into this study, and 66 were evaluable (33 for each group). There was no significant difference in patient characteristics between the 2 groups. The nonrecurrence rate at 5 years after a radical nephrectomy was 80.5% and 77.1% in the UFT adjuvant group and the nonadjuvant group, respectively, with a median follow-up of 112.9 months; the difference was not significant. The toxicity of UFT was generally mild and tolerable. The tumor grade was found to be an important factor influencing recurrence.
Conclusion UFT cannot be universally recommended as an adjuvant therapy for radical nephrectomy in all patients with low-stage renal cell carcinoma.     

Dynamic Sentinel Lymph Node Biopsy in Patients with Invasive Squamous Cell Carcinoma of the Penis: A Prospective Study of the Long-Term Outcome of 500 Inguinal Basins Assessed at a Single Institution

Background

Dynamic sentinel node biopsy (DSNB) in combination with ultrasound scan (USS) has been the technique of choice at our centre since 2004 for the assessment of nonpalpable inguinal lymph nodes (cN0) in patients with squamous cell carcinoma of the penis (SCCp). Sensitivity and false-negative rates may vary depending on whether results are reported per patient or per node basin, and with or without USS.

Objective

To determine the long-term outcome of patients undergoing DSNB and USS-guided fine-needle aspiration cytology (FNAC) in our cohort of newly diagnosed cN0 SCCp patients, as well as to analyse any variation in sensitivity of the procedure.

Design, setting, and participants

A series of consecutive patients with newly diagnosed SCCp, over a 6-yr period (2004–2010), were analysed prospectively with a minimum follow-up period of 21 mo. All patients had definitive histology of ≥T1G2 and nonpalpable nodes in one or both inguinal basins. Patients with persistent or untreated local disease were excluded from the study.

Intervention

All eligible patients had DSNB and USS with or without FNAC of cN0 groins.

Outcome measurements and statistical analysis

The primary end point was no nodal disease recurrence on follow-up. The secondary end point was complications after DSNB. Sensitivity of the procedure was calculated per node basin, per patient, with DSNB alone, and with USS with DSNB combined.

Results and limitations

Five hundred inguinal basins in 264 patients underwent USS with or without FNAC and DSNB. Seventy-three positive inguinal basins (14.6%) in 59 patients (22.3%) were identified. Four inguinal basins in four patients were confirmed false negative at 5, 8, 12, and 18 mo. Two inguinal basins had positive USS and FNAC and negative DSNB results. Sensitivity of DSNB with USS, with and without FNAC, per inguinal basin was 95% and per patient was 94%. Sensitivity of DSNB alone per inguinal basin and per patient was 92% and 91%, respectively. The DSNB morbidity rate was 7.6%.

Conclusions

DSNB in combination with USS has excellent performance characteristics to stage patients with cN0 SCCp, with a 5% false-negative rate per node basin and a 6% false-negative rate per patient.     

The 111 Study: A Single-arm,Phase 3 Trial Evaluating One Cycle of Bleomycin,Etoposide, and Cisplatin as Adjuvant Chemotherapy in High-risk,Stage 1 Nonseminomatous or Combined Germ Cell Tumours of the Testis

BackgroundStandard management in the UK for high-risk stage 1 nonseminoma germ cell tumours of the testis (NSGCTT) is two cycles of adjuvant bleomycin, etoposide (360 mg/m²), and cisplatin (BE₃₆₀P) chemotherapy, or surveillance.ObjectiveTo test whether one cycle of BE₅₀₀P achieves similar recurrence rates to two cycles of BE₃₆₀P.Design, setting, and participantsA total of 246 patients with vascular invasion–positive stage 1 NSGCTT or combined seminoma + NSGCTT were centrally registered in a single-arm prospective study.InterventionOne cycle comprising bleomycin 30000 IU on days 1, 8, and 15, etoposide 165 mg/m² on days 1–3, and cisplatin 50 mg/m² on days 1–2, plus antibacterial and granulocyte colony stimulating factor prophylaxis.Outcome measurements and statistical analysisThe primary endpoint was 2-yr malignant recurrence (MR); the aim was to exclude a rate of ≥5%. Participants had regular imaging and tumour marker (TM) assessment for 5 yr.Results and limitationsThe median follow-up was 49 mo (interquartile range 37–60). Ten patients with rising TMs at baseline were excluded. Four patients had MR at 6, 7, 13, and 27 mo; all received second-line chemotherapy and surgery and three remained recurrence-free at 5 yr. The 2-yr MR rate was 1.3% (95% confidence interval 0.3–3.7%). Three patients developed nonmalignant recurrences with localised teratoma differentiated, rendered disease-free after surgery. Grade 3–4 febrile neutropenia occurred in 6.8% of participants.ConclusionsBE₅₀₀P is safe and the 2-yr MR rate is consistent with that seen following two BE₃₆₀P cycles. The 111 study is the largest prospective trial investigating one cycle of adjuvant BE₅₀₀P in high-risk stage 1 NSGCTT. Adoption of one cycle of BE₅₀₀P as standard would reduce overall exposure to chemotherapy in this young population.Patient summaryRemoving the testicle fails to cure many patients with high-risk primary testicular cancer since undetectable cancers are often present elsewhere. A standard additional treatment in Europe is two cycles of chemotherapy to eradicate these. This trial shows one cycle has few adverse effects and comparable outcomes to those seen with two cycles.