Clinicopathologic characteristics and survival of patients with clinical Stage I squamous cell carcinomas of the thoracic esophagus treated with three-field lymph node dissection

Objective: Clinicopathologic characteristics and survival rates of patients with clinical Stage I tumors treated with three-field lymph node dissection have not been well investigated. This report documents the results of a series of cases of clinical Stage I squamous cell carcinomas treated with this surgical procedure in our institute. Methods: From January 1988 to March 1997, 326 patients with carcinomas of the thoracic esophagus underwent transthoracic esophagectomy with three-field lymph node dissection. Two hundred and ninety-seven (91%) of these had squamous cell carcinomas. Fifty-seven (18%) patients with clinical Stage I squamous cell carcinomas of the thoracic esophagus were retrospectively reviewed here. Results: Among 57 clinical Stage I squamous cell carcinomas, ten (18%) were diagnosed as T1-mucosal and 47 (83%) as T1-submucosal. Seventy percent of the patients with clinical T1-mucosal tumors had additional primary esophageal lesions. The operative morbidity and in-hospital mortality rates were 63 and 0%, and the overall 1-, 3-, 5-, and 10-year survival rates were 95, 86, 78, and 70%, respectively. Of the 57 tumors assessed pathologically, 12 (21%) were T1-mucosal, 42 (74%) were T1-submucosal, and three (5%) were T2. Nineteen (33%) exhibited lymph node metastasis. The 1-, 3-, 5-, and 10-year survival rates for patients with lymph node metastasis were 90, 79, 73, and 58%, respectively, as compared with 97, 90, 80, and 76, respectively for patients without lymph node metastasis (P=0.24). The accuracy of preoperative staging, based on both wall penetration and the status regarding lymph node metastasis, was 63%. With reference to the 1997 UICC-TNM staging system, 36 (63%) were pStage I, two (4%) were pStage IIA, 18 (28%) were pStage IIB, and three (6%) were pStage IVB. The 1-, 3-, 5-, and 10-year survival rates for patients with pStage I disease were 97, 92, 85, and 81%, respectively. In those with pStage II or IV disease, the values were 91, 76, 65, and 52%, respectively. Conclusions: Three-field lymph node dissection may be indicated even for patients with clinical Stage I squamous cell carcinoma requiring surgical intervention because this surgical procedure provides for possible cure by removing unsuspected lymph node metastasis.     

Lymph node classification of esophageal squamous cell carcinoma and adenocarcinoma

The lymphatic channels of the esophagus run vertically along the axis of the esophagus and some of them drain into the cervical lymph glands upwards and into the abdominal glands downwards, and the pattern of lymph node metastasis of esophageal carcinoma is widespread. In various classifications of pattern of lymphatic spread, four classifications were proposed; location, number, ratio, and size. No definite survival advantage of aggressive lymph node dissection during esophagectomy has been proved compared with less dissection. Stage migration, micrometastasis, and sentinel lymph node concept all make it possible to individualize surgical management of esophageal carcinoma as a part of various multimodal treatments. Early diagnosis, standardization of surgery including routine lymph node dissection, and perioperative management of patients have all led to better survival rates of esophageal carcinoma.     

Esophagectomy with three-field lymph node dissection for esophageal carcinoma with a nonrecurrent inferior laryngeal nerve

In rare cases, the inferior laryngeal nerve branches directly from the vagus trunk. A 58-year-old man with carcinoma of the thoracic esophagus was referred to our hospital. A nonrecurrent anomaly of the right recurrent laryngeal nerve associated with an aberrant right subclavian artery was detected preoperatively by computed tomography and magnetic resonance imaging. This artery ran on the right side between the esophagus and the vertebral column. Recognition of this nerve before upper mediastinal lymph node dissection was thought to be important for avoiding unexpected neural injuries. For a successful esophagectomy with three-field lymph node dissection in patients associated with this anomaly, a cervico-abdominal procedure followed by a thoracic procedure, which is the reverse of the usual process, could be useful for a safe operation. However, this anomaly made it difficult to dissect lymph node along the left recurrent laryngeal nerve.     

Impact of surgical volume on the rate of lymph node metastases in patients undergoing radical prostatectomy and extended pelvic lymph node dissection for clinically localized prostate cancer

BACKGROUND: Previous trials have shown that the number of procedures done by a single surgeon, that is, surgical volume (SV), is associated with several outcomes after radical prostatectomy (RP). OBJECTIVE: To test the association between SV and the detection of lymph node metastases during extended pelvic lymph node dissection (ePLND). DESIGN, SETTING, AND PARTICIPANTS: The study cohort consisted of 1020 men surgically treated for clinically localized prostate cancer. INTERVENTION: All patients underwent RP and ePLND by a group of six surgeons who were trained by the surgeon with the highest SV. All surgeons performed an anatomically extended PLND, including removal of obturator, external iliac, and hypogastric nodes. MEASUREMENTS: Univariable and multivariable logistic regression models tested the association between SV (either continuously coded or dichotomized according to the most informative cut-off, namely >144 vs /=0.06). Conversely, the surgeon with the highest SV removed more nodes and found more nodal metastases compared with the other surgeons (21.1 vs 17.9 mean number of nodes removed; p<0.001, and 15 vs 9.8% of LNI; p=0.01, respectively). At univariable logistic regression analysis, either continuously coded or dichotomized SV was a significant predictor of LNI (p=0.007 and p<0.001, respectively). In multivariable models, continuously coded as well as dichotomized SV maintained a significant association with the rate of LNI, after accounting for preoperative (p=0.04 and p=0.009, respectively) as well as for postoperative variables (p=0.03 and p=0.002, respectively). CONCLUSIONS: After adjusting for clinical and pathologic case-mix differences, patients treated by the highest-volume surgeons (>144 ePLNDs) were more likely to have LNI than those treated by low-volume surgeons, even though all surgeons used a similar extended template for node removal.     

En-bloc esophagectomy for esophageal cancer

BACKGROUND: The operative approach for esophageal cancer varies from simple palliative resection to extended esophagectomy with 3-field lymph-node dissection or en-bloc esophagectomy (EBE) depending on tumor and patient status and surgical strategy of the surgeon. The merits and demerits of such EBE are yet to be determined. METHODS: A literature review was done regarding EBE for esophageal cancer. RESULTS: Twenty articles describing EBE were reported from experienced institutions during the last 20 years and were selected for this study. The conclusions drawn from those articles showed that EBE would be a safe procedure with acceptable morbidity and low mortality rates when performed by an experienced surgeon. When strict patient selection criteria were maintained, this procedure decreased locoregional recurrence and improved long-term survival rates. CONCLUSIONS: EBE would be the treatment of choice in selected patients presenting with esophageal cancer. Development of meticulous preoperative risk assessment and optimum postoperative care may further improve the acceptability of this procedure with minimum morbidity and acceptable mortality rates.     

Prognostic evaluation for squamous cell carcinomas of the lower thoracic esophagus treated with three-field lymph node dissection

Objective: The efficacy of esophagectomy with three-field lymph node dissection in surgical treatment for patients with squamous cell carcinomas of the lower thoracic esophagus remains controversial. This report documents the outcomes of this surgical procedure for a large series. Methods: From February 1986 to November 1998, 437 patients with squamous cell carcinomas of the thoracic esophagus underwent transthoracic esophagectomy with three-field lymph node dissection. One hundred and sixteen of these had cancer of the lower thoracic esophagus. To avoid the influence of adjuvant therapy on survival, 20 who also received radiation and/or chemotherapy were excluded, leaving 96 patients who were retrospectively analyzed. Results: The operative morbidity, and 30-day and in-hospital mortality rates were 62, 0, and 3%, respectively. The overall 1-, 3-, and 5-year survival rates were 89, 65, and 59%, with a median survival of 76 months. In those with lymph node metastases (66% of cases), the values were 87, 56, and 48%, as compared with 94, 84, and 79%, respectively (P=0.005) for patients without lymph node metastasis. Factors significantly influencing the overall survival rates were patient age (≥65 vs. <65), clinical N status (cN1 vs. cN0), clinical M status (cM1 vs. cM0), longitudinal tumor length of resected specimen (≥5 vs. <5 cm), pathologic T status (pT3 vs. pT1, 2), pathologic N status (pN1 vs. pN0), lymphatic invasion (positive vs. negative), vascular invasion (positive vs. negative) and intramural metastasis (present vs. absent). Independent prognostic factors for survival determined by multivariate analysis were pathologic T status (P=0.02), pathologic N status (P=0.03), and presence of intramural metastasis (P=0.04). Additional pathologic M1 status, cervical or celiac lymph node metastasis, was without significant influence. Conclusions: Patients with pathologic T3 tumors with both pathologic N1 status and the presence of intramural metastasis in the lower thoracic esophagus had a poor prognosis. Cervical or celiac lymph node metastasis in patients with carcinomas of the lower thoracic esophagus should be distinguished from pathologic M1 status in the UICC-TNM staging system.     

选择性三野淋巴结清扫术治疗胸段食管鳞癌的临床研究

目的分析行选择性三野淋巴结清扫术对胸段食管鳞癌患者的预后影响。 方法2009年6月至2012年9月,四川省肿瘤医院对127例胸段食管癌患者根据肿瘤的位置、外侵程度、术前颈部超声检查结果,进行选择性三野淋巴结清扫。全组共127例患者,其中上段49例;中段67例;下段11例;Ⅰ期2例,Ⅱ期26例,Ⅲ期99例。 结果127例患者共清扫淋巴结4963枚,平均每例清扫淋巴结39.3枚;手术时间(325.6±9.3)min,出血量(316.0±18.7)ml。术后76例患者发生并发症,发生率为59.8%(76/127)病死率为1.6%(2/127)。选择性三野淋巴结清扫术后喉返神经旁淋巴结转移率40.2%(51/127);颈部淋巴结转移率55.9%(71/127),其中,胸中下段食管鳞癌颈部淋巴结转移与喉返神经转移显著相关(χ²＝0.005,P＝0.006)。全组中位生存时间(35.0±1.9)个月,3年生存率51.8%。其中Ⅱ期中位生存时间(42.1±3.4)个月,3年生存率74.5%;Ⅲ期生存时间(32.3±2.0)个月,3年生存率44.8%,两组间比较差异有统计学意义(χ²＝3.940,P＝0.047)。颈部淋巴结阳性患者的中位生存时间(26.2±2.1)个月,3年生存率34.9%;阴性患者中位生存时间(41.5±2.3)个月,3年生存率67.6%,差异有统计学意义(χ²＝15.283,P<0.001)。 结论选择性三野淋巴结清扫术是一种安全可行、可提高颈部淋巴结清扫率,同时又能筛选出潜在获益患者、延长生存的手术方式。     

Evaluation of extended lymph node dissection for gastric cancer

A total of 587 cases with gastric cancer was reviewed. Particular emphasis was placed on the comparative studies on the stages of stomach cancer and end-results of the R₂ (with a conventional lymph node dissection) and the R₃-resections (with an extended lymph node dissection). R₃-resections were found to be generally associated with higher 5-year survival rates than R₂-resections. Especially for the positive lymph node cases not having a marked serosal invasion, the 5-year survival rate was considerably higher with R₃-resections than with R₂-resections (55.3 percent versus 21.5 percent). Although the differences were not significant statistically, it has been suggested from these results that the end-results might be improved more effectively by performing R₃ resection for cases without a marked serosal invasion.     

Mediastinoscope-assisted transhiatal esophagectomy for esophageal cancer

Background: Transthoracic esophagectomy (TTE) is a radical strategy for treatment of esophageal cancer, and the morbidity and mortality are high. Transhiatal esophagectomy (THE) is advantageous because it avoids thoracotomy and has a shorter surgical time, but risk of intraoperative morbidity stresses the surgeon and lymph node sampling is not possible. Methods: Mediastinoscope-assited transhiatal esophagectomy (MATHE) was performed in 42 patients with esophageal cancer. Patients with superficial esophageal cancer and medical risk were included. Feasibility and efficacy of this procedure are discussed by examining short- and long-term morbidity, mortality, and survival. Results: With the mediastinoscope, esophagectomy was performed safely under direct vision. There was only a small amount of bleeding, and surgical time was short. Little morbidity and no deaths were recorded. Conclusion: MATHE is a safe and minimally invasive technique that allows direct visualization of mediastinal structures Lymph node sampling was feasible because of clear visualization of the mediastinum.     

The role of inguinal lymph node dissection in men with urethral squamous cell carcinoma

Introduction

Urethral squamous cell cancer is a rare disease with limited clinical recommendations regarding management of the inguinal lymph nodes. Despite the similarities to penile cancer in terms of squamous cell carcinoma (SCC) histology and lymphatic drainage, there is not enough evidence to recommend for or against a prophylactic inguinal lymph node dissection (ILND) in patients with clinically negative groins and a primary tumor stage of T1b or higher. The objective of the study was to identify the rate of prophylactic inguinal lymph node dissection, node positive rate, and overall survival in patients with clinical T1 to T4 stage. The patients were separated into clinical N stage and the rates of node positivity were compared. We hypothesize that the node positivity rate would be similar to that observed in penile cancer of similar clinical T and N stage and provide evidence for prophylactic inguinal lymph node dissection in urethral squamous cancer. We also sought to determine the value of ILND in clinically node positive (cN+) and clinically node negative (cN?) patients.

Laparoscopic retroperitoneal lymph node dissection for nonseminomatous testicular carcinoma

Retroperitoneal lymph node dissection (RPLND) is still the most sensitive and specific method for the detection of lymph node metastases in stage I nonseminomatous testicular carcinoma. In stage II disease, residual malignant tumor and mature teratoma can be removed. Acceptance of this operation, however, has decreased due to the morbidity caused by the open approach. To reduce this morbidity, and to improve the acceptance of RPLND, laparoscopy has been introduced. Clinical data with long-term follow-up are now available which demonstrate the technical feasibility of laparoscopic RPLND. Studies comparing laparoscopy and open surgery show advantages for the laparoscopic approach in terms of reduced blood loss, intraoperative complications and operative time. Mainly minor complications, such as chylous ascites or lymphocele formation, are observed. The conversion rate to open surgery, mainly due to intraoperative bleeding, is acceptable at less than 10%. As in open surgery, antegrade ejaculation can be preserved successfully. RPLND has also been shown to provide adequate oncological results. In stage I disease, lymph node metastasis is found in 25–41% of cases. Patients with histologically proven retroperitoneal tumor receive adjuvant chemotherapy whereas individuals without evidence of retroperitoneal disease do not require additional treatment. Follow-up controls in both groups, without local recurrence, demonstrate the excellent diagnostic accuracy of this procedure. Meanwhile laparoscopic RPLND has also been introduced successfully in the management of stage II disease. Small volume residual tumors can be removed with an acceptable complication rate. However, this operation is technically demanding and should be performed only at institutions with considerable laparoscopic experience. In conclusion, laparoscopic RPLND is a safe method for low-stage germ cell tumors with minimal invasiveness and excellent clinical results. Thus laparoscopy might contribute to a better acceptance of RPLND.     

胸段食管癌淋巴结转移特点的临床研究

目的 探讨胸段食管癌淋巴结转移的规律和特点,从而为其手术入路和淋巴结清扫范围提供参考.方法 回顾性分析2009年1月至2012年12月间中南大学湘雅医学院附属肿瘤医院胸外科收治的72例胸段食管癌患者的临床资料,所有病例均行右胸入路手术. 记录各组淋巴结的清扫及转移情况,并分析淋巴结转移的影响因素.结果 72例患者中,有48例出现淋巴结转移,淋巴结转移率为66.7％;清扫淋巴结总数为1495枚,转移181枚,淋巴结转移度为12.1％,平均每例清扫淋巴结20.8枚.在各组淋巴结中,右喉返神经旁（1R组）淋巴结转移率最高,达30.6％（22/72）.左喉返神经旁淋巴结（2L组、4L组和5组） 转移率为12.5％（9/72）.淋巴结转移率与肿瘤大小和浸润深度有关（均P＜0.05）,而与病变部位和分化程度无关（P＞0.05）.结论 胸段食管癌淋巴结转移以右喉返神经旁淋巴结转移为主,故其手术最佳入路应是右胸入路,淋巴结清扫则应以右、左喉返神经旁淋巴结为重点的系统纵隔、腹野淋巴结清扫.     

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目的：探讨胃癌No16淋巴结清扫术式的可行性和意义，提出合适的No 16淋巴结清扫术指征。方法：对1998年9月至2001年9月所行的48例No16淋巴结清扫术病例资料进行分析。结果：在48例No16淋巴结清扫术中发现有第16淋巴结转移者9例，转移率为18．6％，浸润型胃癌、肿瘤直径大于5cm、肿瘤侵及浆膜以及第2、3站淋巴结受累时，No16淋巴结转移率明显增高（P＜0．05）。全组病例无手术死亡，手术并发症也未见明显增高。结论：只要严格掌握手术适应证，No16淋巴结清扫术是安全、可行、有效的。     

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。     

The effectiveness of extended lymph node dissection for gastric cancer performed in Costa Rica under the supervision of a Japanese surgeon: a comparison with surgical results in Japan

OBJECTIVE: In 1996, the Gastric Cancer Detection Center in Costa Rica (CR) initiated extended lymph node (D2) dissection for gastric cancer patients. We present an analysis of the surgical results compared with those in Japan. BACKGROUND: D2 dissection for gastric cancer is a standard surgical procedure in Japan, whereas it is still controversial in the West because of its poor survival benefit and high morbidity and mortality. METHODS: Between January 1996 and March 2000, 199 gastric cancer patients in Costa Rica underwent gastrectomy with D2 dissection (CR group). A Japanese surgeon performed or assisted on every gastrectomy with Costa Rican surgeons. During the same period, 497 gastric cancer patients underwent D2 dissection at Tokyo Women's Medical University (TWMU), Tokyo, Japan (TWMU group). RESULTS: The operative morbidity was 39.0% in the CR group and 27.0% in the TWMU group (P < .05). The 30-day postoperative mortality in the CR group and the TWMU group was 5% and 0.2%, respectively (P < .05). The 5-year survival rate in the CR group and the TWMU group was 98.0% and 99.3% in stage IA, 88.6% and 94.4% in stage IB, 77.8% and 76.9% in stage II, 60.1% and 66.4% in stage IIIA, 27.2% and 47.2% in stage IIIB, and 39.7% and 27.6% in stage VI, respectively (not significant in any stage). The overall 5-year survival rate in the CR group and the TWMU group was 72.5% and 69.7%, respectively (not significant). CONCLUSIONS: D2 dissection performed at the same level of quality as in Japan consequently produced the same long-term survival in Costa Rica as in Japan.     

根治性膀胱切除术中扩大淋巴结清扫术不可滥用

根治性膀胱全切+尿流改道术是目前肌层浸润性膀胱肿瘤的首选治疗,盆腔淋巴结清扫术是其中的必要步骤,其对进行肿瘤准确分期、判断患者预后、提高患者的生存率至关重要,而是否所有膀胱癌患者都应该行扩大淋巴结清扫术学界尚无定论。在此,作者结合文献报道和临床诊治体会,就根治性膀胱切除术中扩大淋巴结清扫术的意义与适应征作一简要探讨。     

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目的 分析进展期胃癌胃周淋巴结转移及淋巴结清除与病人预后的关系。方法 对1982－1992年间收治并行手术治疗的进展期胃癌299例进行统计分析。结果 肿瘤进展与淋巴结转移的程度显著相关（P＜0.05）。淋巴结转移有无、淋巴结清扫与术后生存直接相关，对于侵及浆膜下或侵出浆膜并伴有远处淋巴结转移的病例，淋巴结清扫仍能提高术后生存率（P＜0.05）。结论 严格的淋巴结清扫可以提高胃癌病人术后生存率。     

Robotic and laparoscopic high extended pelvic lymph node dissection during radical cystectomy: technique and outcomes

Background

With the increasing use of laparoscopic and robotic radical cystectomy (RC), there are perceived concerns about the adequacy of lymph node dissection (LND).

Objective

Describe the robotic and laparoscopic technique and the short-term outcomes of high extended pelvic LND (PLND) up to the inferior mesenteric artery (IMA) during RC.

Design, setting, and participants

From January 2007 through September 2009, we performed high extended PLND with proximal extent up to the IMA (n = 10) or aortic bifurcation (n = 5) in 15 patients undergoing robotic RC (n = 4) or laparoscopic RC (n = 11) at two institutions.

Surgical procedure

We performed robotic extended PLND with the proximal extent up to the IMA or aortic bifurcation. The LND was performed starting from the right external iliac, obturator, internal iliac, common iliac, preaortic and para-aortic, precaval, and presacral and then proceeding to the left side. The accompanying video highlights our detailed technique.

Measurements

Median age was 69 yr, body mass index was 26, and American Society of Anesthesiologists class ≥3 was present in 40% of patients. All urinary diversions, including orthotopic neobladder (n = 5) and ileal conduit (n = 10), were performed extracorporeally.

Results and limitations

All 15 procedures were technically successful without need for conversion to open surgery. Median operative time was 6.7 h, estimated blood loss was 500 ml, and three patients (21%) required blood transfusion. Median nodal yield in the entire cohort was 31 (range: 15-78). The IMA group had more nodes retrieved (median: 42.5) compared with the aortic bifurcation group (median: 20.5). Histopathology confirmed nodal metastases in four patients (27%), including three patients in the IMA group and one patient in the aortic bifurcation group. Perioperative complications were recorded in six cases (40%). During a median follow-up of 13 mo, no patient developed local or systemic recurrence. Limitations of the study include its retrospective design and small cohort of patients.

Conclusions

High extended PLND during laparoscopic or robotic RC is technically feasible. Longer survival data in a larger cohort of patients are necessary to determine the proper place for robotic and laparoscopic surgery in patients undergoing RC for high-risk bladder cancer.     

Laparoscopic-assisted colectomy with lymph node dissection for invasive carcinoma of the colon

The results of performing laparoscopic-assisted colectomy in 20 patients with invasive carcinoma of the colon were analyzed in this study. The site of the lesion was the right colon in 5 patients, the transverse colon in 1, the left colon in 13, and the rectosigmoid in 1. In 2 patients, the laparoscopic procedure needed to be converted to an open laparotomy. Limited lymph node dissection (R1+, R2) was carried out in 10 patients and extensive node dissection (R3) was carried out in 9 patients. The histological depth of invasion in the 18 patients who underwent laparoscopic-assisted colectomy was the submucosa in 9, the muscularis propria in 2, and the extramuscular layer in 7. There were 3 patients who developed postoperative complications, 1 of whom underwent reoperation due to perforation of the colon. The postoperative course of the patients who underwent laparoscopic surgery was compared with that of a retrospectively selected control group of patients who had undergone open laparotomy. The postoperative recovery of the patients who underwent laparoscopic surgery was significantly faster than that of those who had undergone open laparotomy. Thus, we consider that laparoscopic-assisted colectomy with lymph node dissection is technically feasible provided that patients are properly selected. This procedure may be indicated not only for colonic carcinoma in the early stage, but also for that with invasion of the muscularis propria or the extramuscular layer.