Lymphatic spread of T2 gallbladder carcinoma: Regional lymphadenectomy is required independent of tumor location

BackgroundThis study aimed to investigate the incidence and distribution of regional lymph node metastasis according to tumor location, and to clarify whether tumor location could determine the extent of regional lymphadenectomy in patients with pathological T2 (pT2) gallbladder carcinoma.MethodsIn total, 81 patients with pT2 gallbladder carcinoma (25 with pT2a tumors and 56 with pT2b tumors) who underwent radical resection were enrolled. Tumor location was determined histologically in each gallbladder specimen.ResultsSurvival after resection was significantly worse in patients with pT2b tumors than those with pT2a tumors (5-year survival, 72% vs. 96%; p = 0.027). Tumor location was an independent prognostic factor on multivariate analysis (hazard ratio, 14.162; p = 0.018). The incidence of regional lymph node metastasis was significantly higher in patients with pT2b tumors than in those with pT2a tumors (46% vs. 20%; p = 0.028). However, the number of positive nodes was similar between the two groups (median, 2 vs. 2; p = 0.910). For node-positive patients with pT2b tumors, metastasis was found in every regional node group (12%–63%), whereas even for node-positive patients with pT2a tumors, metastasis was observed in regional node groups outside the hepatoduodenal ligament.ConclusionsTumor location in patients with pT2 gallbladder carcinoma can predict the presence or absence of regional lymph node metastasis but not the number and anatomical distribution of positive regional lymph nodes. The extent of regional lymphadenectomy should not be changed even in patients with pT2a tumors, provided that they are fit enough for surgery.     

肺癌纵隔淋巴结合理廓清范围的临床探讨

目的：探讨非小细胞肺癌(NSCLC)纵隔淋巴结转移方式。方法：回顾性研究1989年1月—1999年1月，淋巴结廓清术后病理证实的纵隔淋巴结转移(pN2)137例。分析临床病理因素与pN2的关系．应用Logistic回归分析判定纵隔淋巴结CT扫描阴性时(cN0-1)pN2有意义的预测指标；总结不同位置肺癌纵隔淋巴结转移的方式。结果：NSCLC无论病理类型和临床状态如何，均有纵隔淋巴结转移发生。纵隔淋巴结增大(cN2)和cT2或cT3腺癌患者转移的发生率较高(65．0％，75．0％)。纵隔淋巴结转移多为区域性(80．9％)，跨区域纵隔淋巴结转移多数伴有隆凸下淋巴结受累。结论：对NSCLC应行纵隔淋巴结廓清，尤其对cN2和cT3、cT3腺癌。多数患者单独廓清区域纵隔淋巴结即可达到目的。建议手术中对肺门和隆凸下淋巴结冰冻病理检查，无转移时可不必廓清非区域纵隔淋巴结。     

Radical surgery for gallbladder cancer: a worthwhile operation?

AIMS: Extended operations are the only chance of a cure for patients with advanced gallbladder carcinoma, but there is no consensus about which subset of patients can benefit. The aim of this retrospective study is to evaluate the results of surgical resection with special reference to the prognostic factors and to long-term survival. METHODS: A retrospective review of 70 patients with a diagnosis of gallbladder cancer treated from 1985-1998 was performed: 33 patients had a curative resection and were included in this study. For stage I disease, simple cholecystectomy was considered curative; in most of the other cases, cholecystectomy was associated with lymph node dissection and liver resection. RESULTS: Hospital mortality and morbidity were 6% and 33%, respectively. Curative resection was associated with an actuarial 5-year survival of 27.4%. Survival of pT1-2 patients was significantly better than that of pT3 (P=0.04) or pT4 patients (P=0.002). Patients with lymph node spread had a poorer prognosis (P=0.06) but four were alive and disease-free with a median survival of 22 months. CONCLUSIONS: Depth of the tumour and lymph node metastases are important prognostic factors. Patients with pT3-4 tumours or regional lymph node spread should be considered for curative resection because long-term survival is possible.     

The role of lymph node dissection in renal cell carcinoma: the pendulum swings back

The incidence of regional lymph node metastases in patients with renal cell carcinoma ranges from 13% to over 30%, and portends a poor prognosis in both locally advanced and metastatic settings. Patients with small, organ confined tumors are at low risk for regional lymph node metastases and lymph node dissection can be omitted in these patients. In contrast, patients with clinical evidence of regional lymph node metastases may derive therapeutic benefit from aggressive removal of all affected lymph nodes within the retroperitoneum. Patients with locally advanced primary tumors but no clinical evidence of lymphadenopathy can be selectively targeted for aggressive lymph node dissection as an adjunct to radical nephrectomy, based on their individual risk of harboring micrometastatic lymph node disease. Several predictive tools have been developed for prediction of occult retroperitoneal nodal metastases. Although early identification of micrometastatic nodal disease in this group of patients has not conclusively been shown to improve survival, accurate pathologic nodal staging allows for early implementation of adjuvant systemic therapies in these high-risk patients. No formal guidelines exist regarding the extent and boundaries of lymph node dissection at the time of radical nephrectomy; however, overwhelming evidence suggests that the staging accuracy of lymph node dissection can be markedly improved if extended template dissections, rather than limited node sampling, is implemented.     

Radical surgery for gallbladder cancer: current options.

Gallbladder carcinoma is the most common malignancy of the biliary tract. There are still many controversies regarding the type of curative surgical treatment for each stage of the disease. The staging system used is the TNM classification of the International Union Against Cancer. Different patterns of spread characterize gallbladder cancer but the two main types are direct invasion and lymph node metastases; since only the depth of invasion can be easily recognized by imaging techniques, it becomes the main variable in choosing the appropriate surgical treatment. Most Tis and T1 tumours are incidentally discovered after cholecystectomy for cholelithiasis and no further therapy is requested; for pT1b tumours, relaparotomy with hepatic resection and N1 dissection is associated with a better survival. For T2 tumours, cholecystectomy with hepatic resection and dissection of N1-2 lymph nodes is the standard treatment, with a 5-year survival of 60-80%. The only chance of long-term survival for patients with a T3-T4 tumour is an extended operation combining an hepatic resection with an N1-2 dissection with or without excision of the common bile duct. A subset of patients with peripancreatic positive nodes or invasion of adjacent organs seems to benefit from a synchronous pancreaticoduodenectomy.     

Radical cystectomy for bladder cancer today--a homogeneous series without neoadjuvant therapy.

PURPOSE: To investigate the effect of pelvic lymph node dissection and radical cystectomy for transitional cell cancer of the bladder on recurrence-free and overall survival, pelvic recurrences, and metastatic patterns in a homogeneous group. PATIENTS AND METHODS: A consecutive series of patients undergoing pelvic lymphadenectomy and radical cystectomy between 1985 and 2000 was analyzed. All patients were staged N0, M0 preoperatively, and no patient received neoadjuvant radio/chemotherapy. Pathologic characteristics based on the 1997 tumor-node-metastasis system, recurrence-free/overall survival, and metastatic patterns were determined. RESULTS: Five hundred seven patients (age 66 +/- 12 years) with a mean follow-up time of 45 months (range, 0.1 to 176 months) were analyzed. Five-year recurrence-free and overall survival were, respectively, 73% and 62% for patients with organ-confined, lymph node-negative tumors (n = 217; < or = pT2, pN0) and 56% and 49% for non-organ-confined, lymph node-negative tumors (n = 166; > pT2, pN0). Positive lymph nodes were found in 124 (24%) patients who had a 5-year recurrence-free (33%) or overall (26%) survival. Isolated local recurrences were observed in 3% of patients with organ-confined tumors (< or = pT2, pN0), 11% with non-organ-confined tumors (> pT2, pN0), and 13% with positive lymph nodes (any pT, pN+). Distant metastases developed in 25% of patients with organ-confined tumors, 37% with non-organ-confined tumors, and 51% with positive lymph nodes. CONCLUSION: Despite negative preoperative staging, pelvic lymphadenectomy and cystectomy for bladder cancer reveal a high percentage of unsuspected nodal metastases (24%) that have a 25% chance for long-term survival. This procedure also ensures a low pelvic recurrence rate even in lymph node-positive patients, and patients with locally advanced cancer have a 56% probability of 5-year recurrence-free survival.     

Factors influencing outcome in gastric cancer involving muscularis and subserosal layer.

AIMS: The prognostic factors for advanced gastric carcinoma without serosal invasion (pT2 AGC) are not clear. In terms of prognosis, pT2 AGC is considered intermediate between early gastric cancer (EGC) and gastric carcinoma with serosal invasion. METHODS: From January 1985 to December 2000, 182 patients with pT2 AGC underwent curative gastric resection in our Department. Prognostic factors were evaluated by univariate and multivariate analyses. RESULTS: Univariate analysis demonstrated that gender, tumour location, lymph node involvement, Borrmann type, number of lymph nodes involved, venous infiltration and extent of lymphadenectomy were significantly related to the prognosis. Multivariate analysis revealed that extent of lymph node metastasis (N1 vs N0 relative risk (RR) of recurrences=3.96, p<0.05; N2 vs N0 RR=6.55, p<0.05), and extent of lymphadenectomy (D1 vs D2 RR=3.2, p<0.01) were independent prognostic factors. In a subset of patients in which venous infiltration was analysed, this factor was also significant (RR=3.9, p<0.05). CONCLUSIONS: Our study shows that lymph node involvement and venous infiltration are important prognostic factors for pT2 AGC and, as such, adjuvant chemotherapy could be useful in this group of patients. An extensive lymph node dissection, minimum D2, should always be performed in order to reduce the risk of recurrence.     

肠系膜下动脉根部结扎及淋巴廓清对直肠癌根治术的临床评价

研究进展期直肠癌肠系膜下动脉（ＩＭＡ）根总结中扎和区域性淋巴廓清对患者生存率的影响。方法：分析行肠系膜下动脉根部结扎的Ｄ３式淋子清术６９例和同期行非根总结中扎根治上肠癌５６例。结果：肠系膜下动脉根部及腹主动脉周围淋巴结转移率为１１．６％，肿瘤浸润深度ＰＴ３和ＰＴ４期发生转移明显增多。     

Level IIb lymph node metastasis in elective neck dissection of oropharyngeal squamous cell carcinoma

This study investigated the oncologic safety of preserving level IIb lymph nodes in ipsilateral and/or contralateral elective neck dissection (END) in patients with oropharyngeal squamous cell carcinoma (SCC). Fifty-one oropharyngeal SCC patients who underwent surgery as an initial treatment were reviewed. Twenty-one patients had clinically node negative necks (cN0) while 30 patients had ipsilateral clinically node positive necks (cN+). Of the cN0 patients, bilateral or ipsilateral END was performed in 15 and six patients, respectively. For the cN+ cases, ipsilateral therapeutic neck dissection with contralateral END was performed in 24 of 30 patients. In the cN0 patients, nodal metastasis to level IIb lymph nodes was not observed in any ipsilateral (21) or contralateral necks (15). Of the 24 cN+ patients who underwent contralateral END, two cases (8.3%) showed contralateral occult level IIb lymph node metastasis. Our data suggest that in cN0 oropharyngeal cancer patients, level IIb lymph nodes may be preserved in ipsilateral and contralateral neck dissection. However, caution is advised when preserving contralateral level IIb nodes in ipsilateral cN+ cases.     

Disparity in pathologic and clinical lymph node staging in oral tongue carcinoma. Implication for therapeutic decision making

BACKGROUND: Regional lymph node metastasis is the most reliable predictor of treatment outcomes for patients with squamous cell carcinoma of the oral tongue (SCCOT). A recent American Joint Committee on Cancer staging update of malignant melanoma has incorporated pathologic lymph node staging. The authors hypothesized that pathologic lymph node staging (pN) would be a more reliable predictor of treatment outcomes than clinical lymph node staging (cN). METHODS: The authors retrospectively reviewed 266 patients who received primary surgical treatment for SCCOT, including a neck dissection, from January 1980 to December 1995. Overall and disease-specific survival and disease-free interval were compared with respect to clinical and pathologic lymph node stages. RESULTS: Statistically significant survival differences were identified for both clinical (cN0-cN2) and pathologic lymph node stages (pN0-pN2). However, survival and disease-free interval differences for pathologic lymph node staging reached higher statistical significance (P < 0.0001) than for clinical lymph node staging (P < 0.002). This disparity can be explained by stage migration (i.e., patients with cN0-1 disease have a more advanced lymph node stage at the time of pathologic review compared with patients without cN0-1 disease). The authors found a 34% rate of occult lymph node disease in the cN0 group (19% of occult lymph nodes had extracapsular spread [ECS]). Similarly, 43% of cN1 patients had a higher stage than pN2b disease and 50% had ECS. CONCLUSIONS: Pathologic lymph node staging, based on a staging or therapeutic neck dissection, should be considered for patients treated for SCCOT to identify high-risk patients who may benefit from additional adjuvant therapy. Prospective studies are essential to validate these findings before pathologic lymph node staging is included in standard staging criteria.     

Rate of detection of lymph node metastasis is correlated with the depth of submucosal invasion in early stage gastric carcinoma.

BACKGROUND: Gastric carcinoma invading the submucosa is often accompanied by lymph node metastasis. However, the relation between the depth of submucosal invasion and the status of metastasis has not been investigated. The objective of this study was to clarify the relation between lymph node status and the histologic features of gastric carcinoma invading the submucosa. METHODS: The histopathology of 118 patients who underwent gastrectomy and lymph node dissection for gastric carcinoma invading the submucosa was examined. These pT1 tumors with invasion of the submucosa were confirmed by histologic examination of the resected specimens. Tumor size, depth of submucosal invasion, histologic type, and macroscopic type were investigated in association with presence or absence of and anatomic level of lymph node metastasis. RESULTS: Among the 118 patients, 16 (14%) had lymph node metastasis, and the status of metastasis significantly correlated with tumor size and depth of submucosal invasion. The frequency of metastasis to perigastric lymph nodes and extragastric lymph nodes was 0% and 0% for < or =1-cm tumors, 5% and 1% for 1- to 4-cm tumors, and 46% and 15% for >4-cm tumors, respectively. There was no lymph from a node metastasis in tumors with less than 300 microm of submucosal invasion. The frequency of lymph node metastasis for tumors with 300-1000 microm and >1000 microm of submucosal invasion were 19% and 14%, respectively. CONCLUSIONS: Tumor size and depth of submucosal invasion serve as simple and useful indicators of lymph node metastasis in early stage gastric carcinoma. Optimal lymph node dissection levels are as follows: 1) local resection (D0) for lesions < or =1 cm, 2) limited lymph node dissection (D1) for 1- to 4-cm lesions, and 3) radical lymph node dissection (D2) for lesions >4 cm. When submucosal invasion of a locally resected tumor is more than 300 microm, additional gastrectomy and lymph node dissection are necessary.     

Nodal abdominal spread in adenocarcinoma of the cardia. Results of a multicenter prospective study

Background. Precise knowledge of the abdominal nodal spread of cardia adenocarcinoma in relation to the depth of invasion of the tumor and its longitudinal extension may be very important for the surgeon as a guide in choosing the type of resection and lymphadenectomy. Methods. The frequency of node metastases in each abdominal station of the first and second tier was prospectively studied in 101 patients with type II and III cardia cancer (defined as approved by the consensus conference held during the second International Gastric Cancer Conference in Munich in April, 1997) who underwent total gastrectomy with D2 lymphadenectomy during the period January 1994 to April 1998. Lymph nodes were retrieved immediately after operation by the surgeon and assigned to the appropriate station according to the classification of the Japanese Research Society for Gastric Cancer. Results. In early gastric cancer, of both type II and type III, lymph node involvement was limited to the perigastric nodes of the upper half of the stomach and to the lymph node station of the celiac trunk. In advanced cancers, whether of type II or type III, there was a fairly high frequency of metastases to the perigastric nodes of the lower half of the stomach; there was also high frequency of metastases at N2 stations, without differences in frequency between pT2 and pT3 tumors (staged according to the classification of the Japanese Research Society for Gastric Cancer). Conclusions. The results of our study provide evidence for the need to perform a total gastrectomy with D2 lymphadenectomy in all patients with advanced cardia cancer type II or type III. In early cancers, a less extensive resection (proximal gastrectomy) with D2 lymphadenectomy may be indicated. Received for publication on Jul. 15, 1998; accepted on Oct. 22, 1998     

Clinicopathological study of depth of subserosal invasion in patients with pT2 gallbladder carcinoma

BACKGROUND: We examined whether depth of subserosal cancer invasion predicts lymph node involvement and survival in gallbladder carcinoma (GBC) patients with pathologicial subserosal invasion (pT2), to explore which patients benefit from radical second resection among patients with inapparent pT2 tumor. METHODS: Subjects comprised 31 patients with pT2 GBC. Thickness of the subserosal layer and vertical length of carcinoma invasion into the subserosa were measured under microscopy. Depth of subserosal invasion was divided subjectively into three categories: ss1, ss2, and ss3 (invasion of upper, middle, and lower thirds of the subserosal layer, respectively). Relationships between subserosal subclassification, histopathological factors, and prognosis were examined. RESULTS: Subserosal layers were significantly thicker (P < 0.001) in portions with cancer invasion (5.46 +/- 0.68 mm; range 1.0 approximately 13.75 mm) than those without cancer invasion (1.89 +/- 0.16 mm, range, 0.88 approximately 4.50 mm). Depth of carcinoma invasion into subserosa was 4.20 +/- 0.65 mm (range, 0.25 approximately 12.5 mm). Rate of lymphatic permeation, venous permeation, and lymph node involvement significantly increased with deeper subserosal invasion (P = 0.014, P = 0.027, P = 0.018, respectively). Among histopathological factors examined, only subserosal subclassification had a significant correlation with presence or absence of lymph node metastasis. Further, there was a significant correlation (P = 0.043) between the degree of subserosal invasion (ss1, ss2, and ss3) and involved nodal disease (pN0, pN1, and pM1 [lymph]). Although 5-year survival rates, according to the degree of subserosal invasion, tended to decrease with deeper invasion into the subserosal layer (ss1, 83.3%; ss2, 62.5%; ss3, 50.0%), no significant differences were noted. CONCLUSIONS: Pathological characteristics tend to become more aggressive with increasing depth of subserous carcinoma invasion in pT2 GBC. Depth of subserosal invasion is a predictor of presence and degree of lymph node metastasis in pT2 GBC. A sampling biopsy of the para-aortic nodes is recommended for inapparent pT2 GBC patients with subserosal invasion beyond one-thirds of the subserosal layer when they undergo radical second resection.     

Site-dependent resection techniques for gastric cancer

In addition to tumor stage and growth pattern, the tumor site is a major factor in determining the extent of resection and lymphadenectomy necessary in patients with gastric carcinoma. Total gastrectomy with D2-lymphadenectomy is the procedure of choice for tumors of the gastric corpus. Extended total gastrectomy with trans-hiatal resection of the distal esophagus is required for tumors of the proximal region; in these patients lymphadenectomy may also include splenic hilum and left retroperitoneal nodes. In patients with distal gastric carcinoma, a subtotal gastrectomy often achieves a complete tumor resection. Extended lymphadenectomy in these patients includes the retroduodenal and right para-aortic nodes in addition to a D2-dissection. In patients with early tumor stages, anatomically oriented limited resection techniques are increasingly important. The concept of the sentinel lymph node may result in more selective lymphadenectomy strategies in the near future [15]. For patients with a locally advanced disease, these surgical concepts must be evaluated within multimodal treatment protocols [16].     

Lymph node dissection around the splenic artery and hilum in advanced middle third gastric carcinoma

Aim

To evaluate the clinicopathological factors influencing lymph node metastasis around the splenic artery and hilum and the effect of spleen-preserved lymphadenectomy in advanced middle third gastric carcinoma.

Methods

We retrospectively studied 131 patients with advanced middle third gastric carcinoma who had received D2 lymphadenectomy and lymph node dissection around the splenic artery and hilum, from 2000 to 2004. Of these patients, 62 simultaneously underwent splenectomy and 69 underwent spleen-preserved lymphadenectomy.

Results

The incidences of Nos. 10 and 11 lymph node metastases were 21% and 15%, respectively, in advanced middle third gastric carcinoma. A tumor size larger than 5 cm, metastases of Nos. 1 and 7–9 lymph node were independent risk factors for metastasis of No. 10 and/or No. 11 lymph node. The spleen-preserved group had a slightly better survival rate and a relatively lower rate of postoperative complications than the splenectomy group. No. 10 and/or No. 11 lymph node metastasis was an independent prognostic factor, while splenectomy was not.

Conclusions

It is necessary to remove the lymph nodes around the splenic artery and hilum to achieve radical resection in advanced middle third gastric carcinoma patients with risk factors. Our results demonstrate that spleen-preserved lymphadenectomy is a good option for those patients.     

A case of long-term survival after resection of advanced undifferentiated rectal cancer treated by short-term preoperative chemoradiotherapy and postoperative adjuvant chemotherapy

A 75-year-old man with advanced undifferentiated rectal cancer, diagnosed by endoscopic biopsy, underwent preoperative short-term chemoradiotherapy (whole pelvis, 4 Gy × 5 day with UFT 400 mg/day × 7 day). Tumor size and lymph node swellings were reduced after radiation therapy. Down-staging was achieved from cT3, cN2, cStage III b to cT3, cN1, cStage III a. A curative low anterior resection with D3 lymphadenectomy including lateral lymph node dissection, was performed 4 weeks after the completion of chemoradiotherapy. Pathological findings of resected specimen showed undifferentiated carcinoma with regional lymph node involvement (pT2, pN1, pStage III a). The histological change in response to chemoradiation was evaluated as Grade 2. The postoperative course was uneventful and postoperative adjuvant chemotherapy (UFT+Uzel) was performed for six months (5 courses). No sign of recurrence has been found until 51 months after the operation. Undifferentiated rectal cancer is a rare condition with extremely poor prognosis according to the Japanese literature. Nine cases have been reported so far with only one long-term survivor. This combination of preoperative short-term chemoradiotherapy and adjuvant chemotherapy, which is one of the standard strategies for advanced rectal cancer in Western countries, but not common in Japan, may be a promising option for treatment of undifferentiated rectal cancer.     

Rationale for extensive lymphadenectomy in early gastric carcinoma.

The incidence of nodal metastasis in early gastric carcinoma (EGC) is 10-20%. However, the optimal nodal dissection for early gastric carcinoma has not been established. A retrospective study was conducted in 392 consecutive patients who underwent potentially curative distal gastrectomy for EGC between 1962 and 1990. Of these 295 patients treated after September 1972 were prospectively entered into an extensive lymphadenectomy protocol. These patients were compared with 97 patients with simple gastrectomy in respect of the causes of death after surgery and the 10 year disease-specific survival rate. The incidence of nodal metastasis in early gastric carcinoma patients was 13.0%. Operative mortality from extensive lymphadenectomy was almost the same as from simple gastrectomy (2.0% and 2.1% respectively). Extensive lymphadenectomy provided a significantly higher 10 year survival rate than limited lymph node dissection (97.9% vs 88.1% respectively; P < 0.005). Among patients with nodal metastasis, the survival rate following extensive lymphadenectomy was significantly higher than that after simple gastrectomy (87.5% vs 55.6%; P = 0.018). Among patients without nodal metastasis, there was no difference between the two groups in the survival rate (99.4% and 96.7% respectively; P = 0.12). Multivariate analysis using the Cox proportional hazards model disclosed two significant independent prognostic factors on disease-specific survival, the nodal involvement (risk ratio: 8.4; P < 0.0001) and the extent of lymph node dissection (risk ratio: 5.8; P < 0.005). Extensive nodel dissection appears to prevent recurrence and to improve the cancer-specific survival in EGC patients with nodal metastasis.     

Surgical approaches and outcomes in the treatment of gastric cancer

Resection with extended lymphadenectomy in obtaining local-regional control with negative margins remains the only potentially curative modality in the treatment of gastric cancer. Complete (R0) resections, along with depth of invasion and adequate nodal staging, remain the most important prognostic factors. Because current chemotherapy regimens have limited benefit in advanced disease, the effectiveness of local-regional modalities takes on greater significance. The extent of surgical resection varies with the size, depth, location of the primary tumor, and the stage of disease. Studying patterns of recurrent disease and elucidating the impact of positive margins have led to insights into the biology of the disease and the limitations of local-regional therapies. Considerable controversy surrounds the notion of what defines an adequate lymph node dissection (LND). The recommendation of routine extended (D2) lymphadenectomy (ELND) is difficult to justify based on available randomized studies, but ELND may benefit selected patients when performed by surgeons who can accomplish the dissection with acceptable morbidity/mortality rates. An extended LND results in improved staging, allowing standardization of prognostic factors and survival data worldwide. Patient selection remains critical, limiting the role of surgery in advanced disease and reserving aggressive surgical resection for patients with high curative potential.     

Caught in the middle: case study of a brachial (sentry) lymph node recurrence after resection and locoregional breast radiotherapy

To reduce local recurrence, adjuvant locoregional radiotherapy is given routinely for post-mastectomy breast patients with 4 or more positive lymph nodes. Most institutions adopt a 3- or 4-field radiotherapy technique, in which the field and shielding placements are informed by bony anatomic landmarks viewed on digitally reconstructed radiographs.Here, we report on a 40-year-old woman who underwent a lumpectomy with axillary node dissection, followed by chemotherapy, completion mastectomy, and adjuvant locoregional radiotherapy (50 Gy in 25 fractions) for a multicentric pT1cN2aM0 invasive ductal carcinoma of the right breast. At 9 months after radiotherapy, she presented with a palpable brachial lymph node, a major draining node of the upper extremity, in the axilla, abutting the previous anterior supraclavicular and axillary radiation fields. This occurrence highlights the potential superolateral border of the level i axillary nodal chain and its relationship to the upper extremity lymphatics via the brachial ("sentry") node. Adapting the delineated nodal target volume in locoregional radiotherapy of the breast for disease with extensive nodal involvement or other high-risk pathologic indications may be warranted in certain situations. Careful imaging and an informed discussion with the patient is needed before deciding to treat the sentry node and including the acromial-clavicular joints, balanced with the potential increased risk of lymphedema.     

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。