Sentinel Lymph Node Procedure in Patients With Epidermoid Carcinoma of the Anal Canal

PURPOSE: This study was conducted to assess the feasibility of the sentinel lymph node procedure in patients with epidermoid carcinoma of the anal canal. METHODS: Between February 2001 and November 2002, 14 patients with epidermoid carcinoma of the anal canal and no clinical evidence of inguinal involvement were prospectively enrolled in the study. The sentinel lymph node procedure consisted of a combination of preoperative lymphoscintigraphy with technetium 99m dextran 500 injected around the tumor and intraoperative detection of the sentinel node with a gamma probe. Patent blue V dye was also injected at the periphery of the tumor to facilitate direct identification of the blue-stained lymph node. After removal, the sentinel node was studied by hematoxylin and eosin staining and immunohistochemistry for pancytokeratins (antigen A1 and A3). RESULTS: Detection and removal of sentinel lymph nodes was possible in all patients. There was no correlation between tumor size and pattern of lymphatic drainage to the groin. Tumors located in the midline of the anal canal gave rise to bilateral sentinel nodes in eight of nine cases. In total, 23 sentinel lymph nodes were removed. One patient (7.1 percent) had a node identified as positive for metastatic carcinoma on immunohistochemical staining. Surgical complications were minimal. CONCLUSIONS: The standardized technique was safe and highly effective in sampling inguinal sentinel lymph nodes in carcinoma of the anal canal. It also proved to be useful as an instrument to detect micrometastatic deposits in clinically normal nodes. Our early results suggest the sentinel lymph node procedure may have a role in guiding a more selective approach for patients with anal cancer. Additional studies in a larger patient population to determine the sensitivity and specificity of this method are warranted.     

Total Mesorectal Excision Results in Low Local Recurrence Rates in Lymph Node-Positive Rectal Cancer

PURPOSE: Most series report lymph node involvement as the main predictor for local recurrence. The principal lymphatic drainage of the rectum is to nodes in the mesorectum and then nodes along the superior rectal and inferior mesenteric arteries. If total mesorectal excision provides adequate block dissection of the lymphatics of the rectum, good local control with low rates of local recurrence should be achieved even in node-positive disease.METHODS: Prospective data on all rectal cancers have been collected since 1978; 170 patients with Dukes C rectal cancer have undergone anterior resection and total mesorectal excision. We did not perform any internal iliac node dissections. Follow-up data were analyzed for local recurrence and distant recurrence.RESULTS: The local recurrence rate was 2 percent for Dukes A cases, 4 percent for Dukes B, and 7.5 percent for Dukes C (P = 0.0127). The systemic recurrence rate was 8 percent for Dukes A, 18 percent for Dukes B, and 37 percent for Dukes C (P = 0.0001).CONCLUSIONS: If surgical priority is given to the difficult task of excision of the whole mesorectum, anterior resection with total mesorectal excision in node-positive rectal cancer, local recurrence rates of < 10 percent can be achieved.Presented at the Association of Colorectal Surgeons of Great Britain and Ireland, Harrogate, United Kingdom, June 25 to 27, 2001.     

Mesorectal Lymph Nodes: Their Location and Distribution Within the Mesorectum

PURPOSE: Total mesorectal excision is an alternative surgical approach for resectable rectal cancer and is associated with favorable results and a low rate of local recurrence. Despite the popularity of this technique, few data exist regarding the location and distribution of lymph nodes within the rectal mesentery. The purpose of this study was to define the distribution, size, and location of lymph nodes within the mesorectum and on the pelvic side wall. METHODS: Seven fresh cadavers at our institution's Fresh Tissue Dissection Laboratory were studied. The rectum, its mesentery, and all fatty tissue from both pelvic side walls were removed and placed in a lymph node clearing solution for 24 hours. After appropriate dissection, the distribution, size, and location of lymph nodes within the rectal mesentery and pelvic side wall tissue were documented. RESULTS: A total of 174 lymph nodes were identified (approximately 25 per patient). The majority (>80 percent) of lymph nodes were smaller than 3 mm in diameter. Fifty-six percent of the nodes within the rectal mesentery were located in the posterior mesentery, and most were located in the upper two-thirds of the posterior rectal mesentery. CONCLUSIONS: The majority of perirectal lymph nodes are small. There are few lymph nodes within the mesentery of the lower third of the rectum and relatively few in the right and left lateral portions of the mesorectum. We confirm that the majority of nodes are located in the proximal two-thirds of the posterior rectal mesentery. It is possible that removal of these nodes is responsible for the superior oncologic results found with total mesorectal excision in contrast to more traditional surgical techniques.     

Tumor Invasion of Lymph Node Capsules in Patients with Dukes C Colorectal Adenocarcinoma

Purpose The objective of this study was to investigate the correlation between the microscopic findings of positive lymph nodes, especially focusing on capsular invasion, and the outcome after curative surgical resection of colorectal cancer. Methods We analyzed 480 positive lymph nodes from 155 consecutive patients with Stage III colorectal cancer to determine the frequency and significance of lymph node capsular invasion. Recurrence-free and cancer-specific survival rates were assessed in the patients with and without lymph node capsular invasion. Results Between April 1995 and December 2000, 406 consecutive patients with primary colorectal cancer underwent curative resection. Regional lymph node metastases were present in 155 cases (38.2 percent). During the median follow-up period of 4.8 years, 41 patients (26.5 percent) developed recurrent disease and 28 patients died of cancer. Lymph node capsular invasion was detected in one or more lymph nodes from 75 cases (48.3 percent). The five-year recurrence-free rate was 56.1 percent in this group, whereas in the 80 patients without lymph node capsular invasion the rate was 88 percent (P<0.01). Features that were associated with recurrent disease were greater number of positive lymph nodes, venous invasion in primary tumor, infiltrative growth pattern of intranodal tumor, and presence of lymph node capsular invasion. Multivariate analysis identified lymph node capsular invasion as the only significant prognostic factor for recurrence. In multivariate analysis with regard to survival, lymph node capsular invasion, venous invasion, and number of positive nodes remained as significant prognostic factors. Conclusions Lymph node capsular invasion, determined by routine hematoxylin-eosin staining, is a potent prognostic factor in Stage III colorectal cancer. Read in part at the meeting of The International Society of University Colon and Rectal Surgeons, Budapest, Hungary, June 9, 2004. Reprints are not available.     

Lymph node evaluation in colorectal cancer

BACKGROUND: In Brazil, colorectal carcinoma is the third cause of death by malignant tumors among women, and the fifth among men. Lymph node involvement is one of the most relevant prognostic maker in these tumors. AIM: To study lymph node involvement in colorectal carcinoma in relationship to biological behavior and tumor location. PATIENTS AND METHODS: One hundred and eight five colorectal carcinoma cases were studied. Lymph node involvement was analyzed according to tumor location, diameter, vessel invasion, and TNM staging. RESULTS: Three thousand nine hundred and six lymph nodes were harvested in 185 patients (21.1 lymph nodes/patient). Metastasis were detected in 399/2,573 peritumoral lymph nodes (15.5%) and in 72/1,333 non-peritumoral lymph nodes (5.4%). Eighty-six patients presented metastasis; in these patients 471/1942 lymph nodes were compromised. In 26 patients peritumoral and non-peritumoral lymph nodes were involved; in 57 cases metastasis were detected only in peritumoral lymph nodes and in 3, only non-peritumoral lymph nodes were involved. The number of lymph node was higher among cecal tumors and smaller in the rectum and sigmoid. There was a positive correlation between the number of metastatic lymph node and pT, tumor diameter and lymphatic and venous invasion; there was a negative correlation between lymph node involvement and lymphocytic response; pN was significantly associated with pT. CONCLUSIONS: Colorectal carcinoma involves preferentially peritumoral lymph node, but in 29 patients (15,7%) non-peritumoral lymph nodes were affected, which is important for tumor staging and prognosis. pN and the number of metastatic lymph nodes were associated with other behaviour markers.     

Comparative Analysis of Nodal Upstaging Between Colon and Rectal Cancers by Sentinel Lymph Node Mapping: A Prospective Trial

PURPOSE Sentinel lymph node mapping accurately predicts nodal status in >90 percent of melanoma and breast and colorectal cancers. However, because of anatomic differences, sentinel lymph node mapping of rectal cancers has been considered inaccurate and difficult relative to colon. A prospective study was undertaken to identify differences in sentinel lymph node mapping between patients with colon cancer and those with rectal cancer.METHODS At operation 1 to 3 ml of 1 percent isosulfan blue dye was injected subserosally around colon cancers. The first to fourth blue-staining nodes seen within ten minutes of injection were marked as sentinel lymph nodes. For cancer of the mid-rectum to low rectum, the dye was injected submucosally via rigid scope and spinal needle. The mesorectum was dissected ex vivo to identify blue nodes nearest the tumor as sentinel lymph nodes. Multilevel microsections of sentinel lymph nodes were stained with hematoxylin and eosin and immunostained for cytokeratin, and standard examination of the entire specimen was performed.RESULTS There were 407 consecutive patients (336 with colon and 71 rectum). The sentinel lymph nodes were identified in 99.1 percent of colon and 91.5 percent of rectal patients (P < 0.0001). Skip metastases were found in 3.6 percent of colon vs. 2.8 percent of rectal patients (P = 0.16). Occult micrometastases were found in 13.4 percent of colon vs. 7.0 percent of rectal patients (P = 0.24). Except for success rates, no other parameters were statistically different between colon and rectum. Lower success in sentinel lymph node identification in rectal cancer may have been related to neoadjuvant chemoradiation received in all six of the patients with sentinel lymph node mapping failures.CONCLUSION Despite higher success rates in sentinel lymph node identification for colon patients, sentinel lymph node mapping was highly successful (91.5 percent) in rectal patients. Nodal upstaging, skip metastases, and occult metastases were similar.Read at the meeting of the American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

Incidence of metastases from rectal adenocarcinoma in small lymph nodes detected by a clearing technique

The incidence of metastases from primary adenocarcinoma of the rectum in lymph nodes smaller than 5 mm is not known. Lymph nodes measuring 5 mm usually are not detected by manual techniques of examination of the surgical specimen. This retrospective analysis describes the results when a lymph node clearing technique that identifies lymph nodes as small as 1 mm was used to treat surgical specimens from 27 consecutive patients with rectal adenocarcinoma who underwent abdominoperineal resection with a curative intent and for whom all pathologic data were retrievable. Nine hundred thirty lymph nodes were found, with an average of 34 lymph nodes per specimen (range 0–88). Seventy-two of the 345 lymph nodes found in patients with Dukes C tumors were found to have metastases. Fifty-six (78 percent) of these 72 lymph node metastases occurred in lymph nodes measuring 5 mm. Three lymph node metastases were found in the perianal zone, 53 in the perirectal zone, and 16 in the pericolonic zone. Lymph node metastases from rectal adenocarcinomas often will occur in lymph nodes smaller than 5 mm. We concluded that the use of lymph node clearing techniques discovers these metastases, thereby offering the potential for enhanced staging of primary rectal adenocarcinomas.Read at the XIIIth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Graz, Austria, June 24 to 28, 1990.     

Coexpression of VEGF-C and Cox-2 in Human Colorectal Cancer and its Association With Lymph Node Metastasis

Purpose Several lines of experimental evidence indicated that over-expression of vascular endothelial growth factor-C and cyclooxygenase-2 genes promotes angiogenesis and lymphangiogenesis, both of which are essential for the growth and spreading of tumor cells. This study was designed to evaluate the coexpression of vascular endothelial growth factor-C and cyclooxygenase-2 in human colorectal carcinoma to determine their relationships and correlations with lymph node metastasis and prognosis. Methods Tissue samples of primary tumors and metastatic lymph nodes from 150 patients undergoing intentionally curative surgical resections for colorectal adenocarcinoma were immunohistochemically examined for vascular endothelial growth factor-C, cyclooxygenase-2, and CD34 expressions. Then, we analyzed their relationships and correlations with clinicopathologic findings and patients' survival time. Results The positivity rate of vascular endothelial growth factor-C and cyclooxygenase-2 in the primary tumor was 68 and 72.7 percent, respectively, and in the metastatic lymph nodes was 93.3 and 80 percent, respectively. A significant correlation was found between the expression scores of vascular endothelial growth factor-C and cyclooxygenase-2 (P < 0.0001), and both also were correlated to microvessels density and several clinicopathologic parameters, including primary tumor size, lymph node metastasis, lymphatic invasion, and TNM stage. Patients with vascular endothelial growth factor-C-positive and/or cyclooxygenase-2-positive tumors had a significant shorter survival time than those with negative tumors did. However, in a multivariate analysis, only cyclooxygenase-2 expression was recognized as an independent prognostic factor (P = 0.0412; relative risk ratio, 3.067; 95 percent confidence interval, 1.046–8.994). Conclusions These data show that in human colorectal carcinoma, vascular endothelial growth factor-C and cyclooxygenase-2 are coexpressed and significantly associated with lymph node metastasis and prognosis. Supported in part by a Grant-in-Aid for Scientific Research from the Ministry of Education, Science, Sports and Culture of Japan. Presented at the meeting of the Japan Society of Clinical Oncology, Kyoto, Japan, October 27 to 29, 2004.     

Role of Intraoperative Sentinel Lymph Node Mapping in the Management of Carcinoma of the Esophagus

Background/Aim:

Precise evaluation of lymph node status is one of the most important factors in determining clinical outcome in treating gastro-intestinal (GI) cancer. Sentinel lymph node (SLN) mapping clearly has become highly feasible and accurate in staging GI cancer. This study aims to investigate the feasibility and accuracy of detection of SLN using methylene blue dye in patients with carcinoma of the esophagus and assess its potential role in determining the rational extent of lymphadenectomy in esophageal cancer surgery.

Materials and Methods:

Thirty-two patients of esophageal cancer diagnosed on endoscopic biopsy were enrolled in this prospective study. After laparotomy, patent methylene blue was injected into the subserosal layer adjacent to the tumor. SLNs were defined as blue stained nodes within a period of 5 min. Standard radical esophagogastrectomy with lymphadenectomy was performed in all the patients. All the resected nodes were examined postoperatively by routine hematoxylin and eosin stain for elucidating the presence of metastasis, and the negative SLNs were examined further with cytokeratin immunohistochemical staining.

Results:

SLNs were detected in 26 (81.25%) patients out of 32 patients who were studied. The number of SLNs ranged from 1 to 4 with a mean value of 1.7 per case. The SLNs of esophageal cancer were only found in N1 area in 21 (80.77%) cases, and in N2 or N3 area in only 19.33%. The overall accuracy of the procedure was 75% in predicting nodal metastasis. SLN had a sensitivity of 85.71% in mid esophageal tumors and 93.33% in lower esophageal tumors. The SLN biopsy had sensitivity of 87.5% in the case of squamous cell carcinoma and 92.86% in the cases of adenocarcinoma of the esophagus. The accuracy of the procedure for squamous cell carcinoma and adenocarcinoma was 60% and 76.47%, respectively.

Conclusion:

SLN mapping is an accurate diagnostic procedure for detecting lymph node metastasis in patients with esophageal cancer and may indicate rational extent of lymphadenectomy in these patients. SLN mapping provides “right nodes” to the pathologists for detailed analysis and appropriate staging, thereby helping in individualizing the multi-modal treatment for esophageal cancer.     

Lymph node micrometastasis in stage II distal rectal cancer following neoadjuvant chemoradiation therapy

Objective The objective was to determine the presence and frequency of micrometastasis in lymph nodes of patients with rectal cancer treated by preoperative chemoradiation followed by curative resection.Patients and methods All 56 patients included were treated with 5-FU and leucovorin plus 5,040 cGy, followed by radical surgery and were diagnosed with stage II distal rectal adenocarcinoma after complete pathological examination (ypT3-4N0M0). Immunohistochemistry was assessed with cytokeratin monoclonal antibody AE1/AE3. Three 4-m paraffin sections were obtained from each lymph node, cut at 50 m apart from each other. The results were reviewed by two independent pathologists.Results Mean number of lymph nodes was 9.6 per patient. Four patients (7%) and seven lymph nodes (1.35%) were positive for micrometastasis. Three patients had pT3 and one a pT4 tumor. One of the patients had positive micrometastasis and the presence of mucinous deposits. One other patient had mucinous deposits without any micrometastasis. All four patients are alive with no evidence of recurrent disease. Fourteen patients negative for micrometastasis had recurrent disease (25%), eight systemic (14.7%) and six locoregional (10.3%). There were two cancer-related deaths. The mean follow-up period was 39 months.Conclusion Patients with rectal cancer treated by preoperative chemoradiation showed a surprisingly low rate of micrometastasis detection (7%), even in high-risk patients (T3 and T4 tumors). Lymph node micrometastasis was not associated with decreased overall or disease-free survival. The identification of mucinous deposits on lymph nodes with no viable tumor cells may be direct evidence of lymph node downstaging. The downstaging effect of preoperative chemoradiation therapy may be significant in reducing even micrometastasis detection in low rectal cancer managed by this treatment strategy.     

In vivo lymph node mapping and pattern of metastasis spread in locally advanced mid/low rectal cancer after neoadjuvant chemoradiotherapy

Purpose

The lymph node status is one of the strongest prognostic determinants in rectal cancers. After chemoradiotherapy (CRT), lymph nodes are difficult to detect. This study aims to evaluate the feasibility of lymph node mapping in the mesorectum after CRT to analyze the pattern of metastasis spread and to assess the reliability of blue dye injection in sentinel lymph node detection.

Method

Ten patients with cN+ mid/low RCs after CRT were prospectively enrolled. The protocol scheduled intraoperative blue dye injection, surgery, and specimen examination with fat clearance technique. The mesorectum was divided into three equal “levels” (upper, middle, and lower); each level was divided into three equal “sectors” (right anterolateral, posterior, and left anterolateral). Lymph nodes were defined “small” if ≤5 mm.

Results

Two hundred seventy-six lymph nodes were retrieved in ten patients; 76.5 % were small lymph nodes. Six patients were pN+ (33 metastatic lymph nodes, 76 % small); small lymph node analysis upstaged one patient from N0 to N1 and four patients from N1 to N2. Metastasis distribution across sectors was continuous, without “skip sectors.” The blue dye detected the sentinel lymph node in all patients; in half of the cases, it was out of the tumor sector. Blue dye identified 69.7 % of metastatic lymph nodes; its sensitivity decreased together with the metastatic deposit size (84 % macrometastases, 28.6 % micrometastases, 0 % occult tumor cells; p?=?0.004).

Conclusion

The fat clearance technique should be the standard pathological examination in patients with RCs after CRT; N staging was improved by small lymph node identification. Lymph node metastases have a continuous spread through mesorectal sectors. Blue dye injection is effective in sentinel lymph node detection.     

A Case Report of Male Occult Breast Cancer First Manifesting as Axillary Lymph Node Metastasis With Part of Metastatic Mucinous Carcinoma

Occult breast cancer (OBC) is a type of breast cancer without any symptoms in the breast (no primary cancer lesion is found in either breast on a physical examination or imaging examination such as ultrasound and mammography). The incidence of OBC is rare in females, whereas in males, there are few cases of breast cancer, and the rate of OBC is very low. This is the first time report a case of male OBC first manifested as axillary metastasis, of which the pathological results showed moderately differentiated adenocarcinoma with part of metastatic mucinous carcinoma.A 40-year-old male patient presenting palpable masses in his left axillary on physical and imaging examination revealed unremarkable despite of multiple swollen lymph nodes in the left axillary, and the resected sample showed metastatic adenocarcinoma with part of metastatic mucinous carcinoma. Based on immunohistochemical analysis, positive of estrogen receptor (ER), progesterone receptor (PR), and human epidermal receptor 2 (Her-2), it was identified as an OBC.This is the fourth case report of male OBC in the literature; 1 case was reported in China in 2008, and it was metastatic infiltrating ductal carcinoma, and 2 cases were reported in Korea in 2012, one of which was reported as metastatic carcinoma and the other was metastatic adenocarcinoma; however, our case was a moderately differentiated adenocarcinoma with part of mucinous carcinoma. Our case of male OBC could metastasize to supraclavicular region and lung in addition to axillary lymph nodes, and the prognosis was relatively poor compared to the 3 cases reported before.The aim of this case report is to introduce the imaging, pathological features, and management of a rare male OBC.     

Tumor micrometastases in mesorectal lymph nodes and their clinical significance in patients with rectal caner

AIM: To investigate the number, size, and status of lymph nodes within the mesorectum and to explore the prognostic significance of lymph node micrometastases in patients with rectal cancer. METHODS: Thirty-one patients with rectal cancer undergone total mesorectal excision between October 2001 and October 2002 were included. Mesorectal nodes retrieved from the resected specimens were detected with a combination of haematoxylin and eosin (HE) staining and immunohistochemistry (IHC). The relations between lymph node metastases, micrometastases and postoperative recurrence were analyzed. RESULTS: A total of 548 lymph nodes were harvested, with 17.7+/-8.2 nodes per case. The average number of metastatic nodes in HE-positive patients and micrometastatic nodes in IHC-positive patients was 5.2+/-5.1 per case and 2.2+/-1.3 per case, respectively. The mean size of all nodes and metastatic nodes was 4.1+/-1.8 mm and 5.2+/-1.7 mm in diameter, respectively. The mean size of micrometastatic nodes was 3.9+/-1.4 mm in diameter. The size of the majority of mesorectal nodes (66.8%), metastatic nodes (52.6%), and micrometastatic nodes (79.5%) was less than 5 mm in diameter. During a median follow-up period of 24.6+/-4.7 mo, 5 patients (16.7%) had recurrence, of them 2 died and 3 survived. Another case died of tumor unrelated cause and was excluded. All 5 recurrent cases had 3 or more nodes involved, and one of them developed only lymph node micrometastases. The mean number of both metastatic and micrometastatic nodes per case differed significantly between the recurrent and non-recurrent groups (P<0.01 and P = 0.01, respectively). CONCLUSION: The majority of lymph nodes, metastatic, and micrometastatic lymph nodes within the mesorectum are smaller than 5 mm in diameter. The nodal status and the number of lymph nodes involved with tumor metastases and micrometastases are related to the rapid postoperative recurrence.     

Injection of methylene blue solution into the inferior mesenteric artery of resected rectal specimens for rectal cancer as a method for increasing the lymph node harvest

Background

The aim of the present study was to determine whether the injection of methylene blue solution into the inferior mesenteric artery could improve the lymph node harvest in rectal specimens of rectal cancer patients treated with rectal resection with total mesorectal excision.

Methods

The study group consisted of 20 randomly selected fresh rectal specimens from patients with stages I-III rectal cancer treated at the Surgery Clinic at the Institute of Oncology of Vilnius University during the period from February 2008 to December 2010, and 20 specimens were selected under the same conditions to serve as the control group. The patients underwent conventional rectal resection with total mesorectal excision and coloanal anastomosis for low rectal cancer performed by the same surgeon, did not receive preoperative radiotherapy and had no distant metastases. After the removal of the specimen, 30?ml of 0.5% methylene blue solution was injected into the inferior mesenteric artery of the specimens in the study group (methylene blue group). The specimens from both the methylene blue and control groups were examined using the standards established by the Lithuanian National Centre of Pathology. The pathologist was not required to make any special macroscopic preparations. A retrospective analysis of clinical and histopathological records was performed.

Results

Comparison of the mean lymph node harvest showed a significant difference between methylene blue and control groups with average lymph node numbers per specimen of 18?±?5 and 14?±?6, respectively (p?=?0.025). The specimens from 12 of the 20 patients in the methylene blue group and the specimens from 7 of the 20 patients from the control group had positive nodes.

Conclusions

Injecting methylene blue solution into the inferior mesenteric artery is an efficient and simple method for improving the lymph node harvest in the histopathological examination of rectal specimens of rectal cancer patients treated with rectal resection with total mesorectal excision.     

Lymphoscintigraphy in patients with primary rectal cancer: the role of total mesorectal excision for primary rectal cancer--a lymphoscintigraphic study

BACKGROUND AND AIMS: Total mesorectal excision based operations is the gold standard of care in patients with middle and lower rectal cancer, but the extent of resection varies widely. In our view, extended lymphadenectomy is unnecessary with precise total mesorectal excision, i.e., anatomically correct and sharp surgery. PATIENTS AND METHODS: Sixteen patients with primary rectal cancer underwent rectal lymphoscintigraphy 1 day prior continence-preserving anterior resection with total mesorectal excision. The specimens were examined for integrity by postoperative angiography of the superior rectal artery in anteroposterior and lateral views. RESULTS: Twelve patients had only mesorectal lymph nodes, and four had additional extramesorectal iliac lymph nodes. The labeled lymph nodes were identified and removed perioperatively using a gamma probe. Activity was measured again in the preparations outside the situs. Histological examination showed tumor-free lymph nodes only. CONCLUSION: Lymph vessels can be divided anatomically into visceral and somatic, and detection of extramesorectal lymph nodes does not call for lateral lymphadenectomy. Primary rectal cancer confined to the organ metastasizes within the mesorectum and does not invade extraregional lymph nodes. The mesorectum is the major visceral route for caudocranial metastatic spread.     

直肠癌周围黏膜下注射微粒子碳在TME术中的应用

目的:探讨微粒子碳在直肠癌全直肠系膜切除术(TME)中的应用价值.方法:对45例直肠癌患者术前3d在直肠镜癌周黏膜下注射微粒子碳,行全直肠系膜切除术.并与常规TME手术组进行比较.所有切除淋巴结行RT-PCR法检测MMP-7mRNA的表达以确定此淋巴结有无转移.结果:实验组共清除淋巴结1056枚,平均23.5枚.对照组清除淋巴结723枚,平均16.1枚,两组比较有统计学意义(t=7.3733,P<0.05).实验组清除转移淋巴结403枚,平均9.0枚.对照组281枚,平均6.2枚,差别具有统计学意义(t=5.4235,P<0.05).实验组黑染淋巴结共680枚,其中转移淋巴结322枚,两者具有线性相关关系(r=0.3468,P<0.05).结论:黏膜下注射微粒子碳应用于直肠癌TME术可增加术中转移淋巴结的清除.直肠癌淋巴结墨染与转移有关.     

Prognostic Value of the Metastatic Lymph Node Ratio in Patients With Resectable Carcinoma of Ampulla of Vater

Patients with carcinoma of the ampulla of Vater (CAV) have better outcomes among periampullary malignancies. However, little is known about the metastatic lymph node ratio (LNR) as a prognostic factor for resectable CAV. We retrospectively reviewed our CAV patients undergoing curative surgery and analyzed their prognostic factors.A total of 212 CAV patients who received radical surgery at Chang Gung Memorial Hospital, Linkou, between 2000 and 2010 were admitted in this study. The lymph node ratio was defined as the number of metastatic lymph nodes (LNs) divided by the total number of LNs removed. The patients’ demographic data, comorbidities, operation type, and tumor features were analyzed retrospectively for survival prediction of patients.The median age of the patients was 62 years, and 57% of the patients were men. The surgical procedure was standard pancreaticoduodenectomy and pylorus-preserving pancreaticoduodenectomy in 53% and 47% of the patients, respectively. The median follow-up duration was 32.6 months, and 50% of the patients had died by the end of the study. The median overall survival time (OS) and disease-free survival time (DFS) were 65.8 and 33.7 months, respectively. In multivariate analysis, patients with a metastatic LNR >0.056 had a significantly poor prognosis in both OS and DFS.A metastatic LNR >0.056 predicted a poor DFS and OS in CAV patients after radical surgery. Greater awareness on the impact of metastatic LNR may help clinicians provide appropriate adjuvant treatment for high-risk CAV patients.     

Expression of ADAMTS1 and Its Correlation with Angiogenesis in Primary Gastric Cancer and Lymph Node Metastasis

Background

A disintegrin and metallopeptidase with thrombospondin motif type 1 (ADAMTS1) is a recently discovered metalloproteinase with antiangiogenic activity. The function of ADAMTS1 in gastric cancer remains unknown. Therefore, we were interested in examining ADAMTS1 expression in human gastric cancer, as well as its possible correlation with angiogenesis.

Methods

The mRNA and protein expression of ADAMTS1, thrombospondin type I (TSP1), and vascular endothelial growth factor (VEGF) was evaluated by RT-PCR and immunohistochemistry, respectively, in 56 paired tumor and normal tissue samples, and corresponding metastatic lymph nodes (n = 42). Microvessel density (MVD) was also evaluated by immunohistochemistry.

Results

ADAMTS1 mRNA and protein levels were significantly lower in primary tumors than in corresponding normal tissues, and were significantly higher in metastatic lymph nodes compared to their matched primary tumors. High ADAMTS1 mRNA and protein expression was found to be significantly associated with lymph node metastasis in primary tumors. There was a negative correlation between ADAMTS1 and VEGF mRNA and protein expression in primary gastric tumors and normal tissues. A negative correlation was also found between ADAMTS1 protein expression and MVD in primary gastric tumors. In contrast, no correlation was detected between ADAMTS1 and TSP1 mRNA and protein expression in primary gastric tumors, normal tissues, and metastatic lymph nodes.

Conclusions

These findings suggest that ADAMTS1 expression is altered in primary gastric cancer and paired lymph node metastasis. In addition, ADAMTS1 has angioinhibitory effects in primary gastric cancer due to its low expression and negative correlation with VEGF and MVD. However, it appears to lose its anti-angiogenic activity in metastatic lymph nodes in gastric cancer.     

Successful resection of metachronous para-aortic,Virchow lymph node and liver metastatic recurrence of rectal cancer

A 66-year-old female presented with the main complaint of defecation trouble and abdominal distention. With diagnosis of rectal cancer, c SS, c N0, c H0, c P0, c M0 c Stage Ⅱ, Hartmann's operation with D3 lymph node dissection was performed and a para-aortic lymph node and a disseminated node near the primary tumor were resected. Histological examination showed moderately differentiated adenocarcinoma, p SS, p N3, p H0, p P1, p M1(para-aortic lymph node, dissemination) f Stage Ⅳ. After the operation, the patient received chemotherapy with FOLFIRI regimen. After 12 cycles of FOLFIRI regimen, computed tomography(CT) detected an 11 mm of liver metastasis in the posteroinferior segment of right hepatic lobe. With diagnosis of liver metastatic recurrence, we performed partial hepatectomy. Histological examination revealed moderately differentiated adenocarcinoma as a metastatic rectal cancer with cut end microscopically positive. After the second operation, the patient received chemotherapy with TS1 alone for 2 years. Ten months after the break, CT detected a 20 mm of paraaortic lymph node metastasis and a 10 mm of lymph node metastasis at the hepato-duodenal ligament. With diagnosis of lymph node metastatic recurrences, we performed lymph node dissection. Histological examination revealed moderately differentiated adenocarcinoma as metastatic rectal cancer in paraaortic and hepato-duodenal ligament areas. After the third operation, we started chemotherapy with modified FOLFOX6 regimen. After 2 cycles of modified FOLFOX6 regimen, due to the onset of neutropenia and liver dysfunction, we switched to capecitabine aloneand continued it for 6 mo and then stopped. Eleven months after the break, CT detected two swelling 12 mm of lymph nodes at the left supraclavicular region. With diagnosis of Virchow lymph node metastatic recurrence, we started chemotherapy with capecitabine plus bevacizumab regimen. Due to the onset of neutropenia and hand foot syndrome(Grade 3), we managed to continue capecitabine administration with extension of interval period and dose reduction. After 2 years and 2 mo from starting capecitabine plus bevacizumab regimen, Virchow lymph nodes had slowly grown up to 17 mm. Because no recurrence had been detected besides Virchow lymph nodes for this follow up period, considering the side effects and quality of life, surgical resection was selected. We performed left supraclavicular lymph node dissection. Histological examination revealed moderately differentiated adenocarcinoma as a metastatic rectal cancer. After the fourth operation, the patient selected follow up without chemotherapy. Now we follow up her without recurrence and keep her quality of life high.     

Anatomic study of the lymph nodes of the mesorectum

PURPOSE: Lymph node involvement is the most important prognostic factor when staging patients with colorectal cancer. The probability of detecting metastasis grows with the number of nodes examined. However, the number of nodes found in surgical specimens varies substantially. We have therefore determined the number and distribution of lymph nodes in the mesorectum by cadaveric dissection. METHODS: Twenty formalin-fixed cadaveric pelvises were dissected (13 males). The search for lymph nodes was performed in a systematic way, from the division of the superior rectal artery following the smallest visible branches to the level of the anorectal ring. RESULTS: A total of 168 lymph nodes were found in 20 mesorectal blocks, with a mean (standard deviation) number per specimen of 8.4 (4.45). Lymph node size ranged from 2 to 10 mm. Distribution of lymph nodes in mesorectum was as follows: 120 nodes (71.4 percent) were found around the branches of the superior rectal artery proximal to the peritoneal reflection, and 48 nodes (28.6 percent) were found distal to the peritoneal reflection. Fourteen specimens (70 percent) had lymph nodes at the division of the superior rectal artery. CONCLUSIONS: The mean number of lymph nodes found in the mesorectum distal to the superior rectal artery division was 8.4. Most of these lymph nodes were proximal to the peritoneal reflection. The range found in the number of lymph nodes per case should be considered for use in the formulation of guidelines in anatomicopathologic studies of surgical specimens obtained after mesorectal excision.Poster presentation at the XVI Congreso Latinoamericano de Coloproctología, Santiago, Chile, October 28 to 30, 1999.