The role of lymphadenectomy for liver tumors: further considerations on the appropriateness of treatment strategy

OBJECTIVE: To evaluate the role of regional lymphadenectomy in patients with liver tumors. BACKGROUND: Lymph node status is 1 of the most important prognostic factors in oncologic surgery; however, the role of lymph node dissection remains unclear for hepatic tumors. METHODS: A total of 120 consecutive patients undergoing liver resections for primary and secondary hepatic tumors were prospectively enrolled in the study. "Regional" lymphadenectomy was carried out routinely after specimen removal. Incidence, site, and influence on survival of node metastases were analyzed. RESULTS: Only 1 postoperative complication (intra-abdominal bleeding) was related to lymph node excision. Median number of dissected nodes was 6.8 +/- 3.6. Periportal, pericholedochal, and common hepatic artery stations were always removed. Lymph node metastases were found in 17 (16.5%) patients. The percentage rises to 20.3% when considering only noncirrhotic patients. The incidence of lymph node metastases was 7.5% for hepatocellular carcinoma, 14% for colorectal metastases, 40% for noncolorectal metastases, and 40% for intrahepatic cholangiocarcinoma (P < 0.002). Median survival time was 486 +/- 93.2 days among all patients with node metastases and 725 +/- 29.7 among patients without node metastases. The 2-year survival was 37.1% and 86.7%, in the 2 groups (P < 0.05). The 2-year recurrence rate was 77.6% and 45.3%, respectively (P < 0.05). CONCLUSIONS: Regional lymphadenectomy is a safe procedure after liver resection, and it should be routinely applied in patients with primary and secondary hepatic tumors, particularly in those without chronic disease. A careful evaluation of node status is nevertheless advisable also in patients with hepatocellular carcinoma on cirrhosis.     

Impact of microscopic hepatic lymph node involvement on survival after resection of colorectal liver metastasis

BACKGROUND: Macroscopic hepatic lymph node involvement is usually a contraindication to hepatic resection. Only a few studies have investigated the impact of hepatic lymph node involvement on survival. The aim of this retrospective study was to assess microscopic hepatic lymph node involvement in resectable colorectal liver metastasis and outcomes in patients with such involvement. STUDY DESIGN: From January 1985 to December 2000, 156 patients underwent curative liver resection in association with systematic hepatic lymph node dissection for colorectal liver metastasis. A first analysis was performed to assess the association between hepatic lymph node metastasis and patients' characteristics. A second analysis assessed survival after resection of liver colorectal metastasis by using the Kaplan-Meier method. RESULTS: Twenty-three of the 156 patients (15%) had microscopically involved hepatic lymph nodes. No predictive factor of lymph node metastasis was identified. Multivariate analysis showed that lymph node metastasis, preoperative carcinoembryonic antigen level, number of metastases, and morbidity were factors influencing survival. The 3- and 5-year survival rates of patients with lymph node metastasis were 27% and 5%, respectively, compared with 56% and 43% without lymph node metastasis (p = 0.0001). CONCLUSIONS: During resection of liver colorectal metastasis, microscopic lymph node involvement occurred in 15% of the patients and was associated with a poor 5-year survival. Hepatic lymph node dissection should be performed systematically to select high-risk patients.     

Results of extensive surgery for liver metastases in colorectal carcinoma.

Hepatic resections were performed during the past 13 years on 31 patients with hepatic metastases from colorectal carcinoma. Of the 31 patients, 22 underwent lymph node dissection of the hepatic hilus. Ten patients underwent removal of recurrent lesions in the liver, lung, adrenal gland and brain after initial hepatic resection. The overall 5-year survival rate was 45 per cent. The outcome for six patients who underwent repeat hepatectomy after an initial hepatectomy was significantly better than for nine patients with unresectable recurrence (P less than 0.01). Six of the 22 patients who underwent lymph node dissection had nodes positive for tumour. Two of the six patients underwent repeat hepatectomy and are alive after 49 and 66 months. Three- and 4-year survival rates of patients with positive lymph nodes were both 40 per cent. Repeat hepatectomy and dissection of hilar lymph nodes improves prognosis in selected patients with hepatic metastases of colorectal cancer.     

影响结直肠癌肝转移手术切除患者预后的多因素分析

目的 探讨影响结直肠癌肝转移患者手术切除的预后因素。方法 收集1995-2001年间收治的结直肠癌肝转移手术切除患者103例的资料，用Kaplan-Meier法计算术后生存率，以Cox模型进行多变量分析。结果 患者术后1、3年无瘤生存率分别为73．8％和43．7％，术后1、3年累积生存率分别为7g．6％和49．5％。单因素分析显示：术前血清CEA水平、转移灶与原发灶的治疗间隔时间、术中切缘情况、肝门淋巴结转移、肝内卫星灶的存在与否、肝转移灶的最大直径、数目及有无包膜影响患者的术后肝内复发和术后累积生存率，而术后化疗可以提高患者的累积生存率。多因素分析显示：转移灶与原发灶的治疗间隔时间、切缘情况、肝内卫星灶的存在与否和肝转移灶的最大直径是影响肝内复发和累积生存率的独立因素，而肝门淋巴结转移是影响累积生存率的独立因素，有无包膜是影响肝内复发的独立因素。结论 手术切除是结直肠癌肝转移有效的治疗手段。转移灶与原发灶的治疗间隔时间、切缘情况、肝内卫星灶、肝转移灶的大小和包膜、肝门淋巴结转移等是患者预后的独立影响因素。     

Anatomical major resection versus nonanatomical limited resection for liver metastases from colorectal carcinoma.

BACKGROUND: Although systematic anatomical hepatic resection has been reported to improve patient survival in hepatocellular carcinoma, principles of hepatectomy procedure have not been clearly demonstrated in secondary hepatic malignancy. The purpose of the present study was to determine whether selection of surgical procedures for liver resection is associated with the pattern of tumor recurrence or patient survival. METHODS: During the period of 1980 through 1999, 174 cases underwent liver resection for hepatic metastasis from colorectal cancer. Of these, 96 underwent systematic anatomical major hepatic resection (anatomical group) and 78 cases underwent nonanatomical limited resection (nonanatomical group). Subset analysis of 115 patients with unilobar single or double tumors was also conducted. RESULTS: The overall 5-year survival rate of 174 patients was 43.2%. Univariate analysis did not show a significant difference in patient survival according to surgical procedure (anatomical group versus nonanatomical group). Operative morbidity and mortality rates were slightly higher in anatomical group. From the subset analysis in unilobar single or double tumors, anatomical major hepatectomy was unnecessary in 80.4% of the cases if the tumors were resectable by nonanatomical limited resection. Ninety percent of the ipsilateral recurrence, which could have been avoided if the first operation was anatomical hemihepatectomy, could undergo second hepatectomy with 5-year survival rate of 58.3%. CONCLUSIONS: There was not a significant difference in patient survival according to surgical procedure. To minimize surgical stress and operative risk, nonanatomical limited liver resection should be a basic surgical procedure for colorectal metastases.     

Surgery for colorectal liver metastases with hepatic lymph node involvement: a systematic review

BACKGROUND: Liver resection for colorectal metastases is the only known treatment associated with long-term survival; extrahepatic disease is usually considered a contraindication to such treatment. However, some surgeons do not regard spread to the hepatic lymph nodes as a contraindication provided that these nodes can be excised adequately. A systematic review of the literature was undertaken to address this issue. METHODS: An electronic search using Medline, Cancerlit and Embase databases was performed for studies reporting liver resection for colorectal metastases from 1964 to 1999. Data were extracted from papers reporting outcome for patients with positive hepatic nodes and analysed according to predetermined criteria. RESULTS: Fifteen studies were identified that gave survival data on 145 node-positive patients. Five patients were reported to have survived 5 years after liver resection; one was disease free, two had recurrent disease and the disease status was not described in the remaining two. Five studies containing 83 patients specified a formal lymph node dissection as part of the surgical procedure and four of the five node-positive 5-year survivors were from these studies. CONCLUSION: There are few 5-year survivors after liver resection, with or without lymph node dissection, for colorectal hepatic metastases involving the hepatic lymph nodes.     

Value of lymph node dissection during resection of intrahepatic cholangiocarcinoma.

BACKGROUND: Hepatectomy with extensive lymph node dissection is the standard operation for intrahepatic cholangiocarcinoma (IHCC). However, lymph node dissection may not always be effective at reducing tumour recurrence. METHODS: Forty-nine patients with IHCC who underwent hepatectomy were investigated to determine patterns of tumour recurrence and to estimate the value of lymph node dissection during resection. RESULTS: At hepatectomy most metastatic lymph nodes were identified at least to the level of group 2 lymph nodes. Among 23 patients who developed recurrence, 17 had liver metastases and the other six had recurrence at other sites, mainly in the peritoneum. Poorly differentiated histology was related to the development of liver metastases. No patient with the intraductal growth type of IHCC had tumour recurrence. Lymph node dissection did not appear to improve patient survival. Histological findings of lymph node metastases and intrahepatic metastases were independent indicators of poor prognosis. CONCLUSION: Lymph node metastases were seldom limited to the regional lymph nodes; most tumour recurrence occurred in the liver. Lymph node dissection did not appear to improve patient survival. Lymph node dissection alone is not likely to improve the prognosis without further control of liver metastases.     

The Significance of Hepatic Pedicle Lymph Nodes Metastases in Surgical Management of Colorectal Liver Metastases and of Other Liver Malignancies

Background: Surgical resection of colorectal liver metastases (CLM) is the only hope for cure, with a 5-year survival rate ranging from 20% to 54%. However, the resectability rate of CLM is reported to be <20%. This limitation is mainly due to insufficient remnant liver and to extrahepatic disease. Among extrahepatic locations, lymph node metastases are often considered indications of a very poor prognosis and a contra-indication to resection.Methods and Results: Our studies showed that the prevalence of hepatic pedicle lymph node metastases ranges from 10% to 20%. When located near the hilum and along the hepatic pedicle (area 1) they should not be considered an absolute contra-indication to resection of CLM, and an extended lymphadenectomy should be performed. However, when they reach the celiac trunk (area 2), there is no survival benefit after resection of CLM. For other cases of liver malignancies, lymph node dissection seems justified only in cases of fibrolamellar hepatocellular carcinoma and in case of hilar cholangiocarcinoma. However, few data are available, and they are controversial.Conclusions: There is a need for more evaluation of lymph node involvement, at least in patients with high risk of such an extension, i.e., patients with more than three metastases, located in segment 4 or 5. There is also a need for prospective trials in order to evaluate the survival benefit of liver resection in such circumstances and the impact of extensive lymphadenectomy.     

Number of Lymph Node Metastases Is a Significant Prognostic Factor in Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma (IHCC) is a rare primary hepatic tumor. Outcomes after resection and the use of lymph node dissection have not been well described. From a prospective database, we identified 53 patients with IHCC who underwent exploration between April 1983 and March 2004. Hepatic resection was performed in 44 patients, 30 of whom underwent lymph node dissection. Clinicopathological features and outcomes were analyzed. The actuarial 1-year survival was 66.2% in resected patients, compared to 0% in unresectable patients (p < 0.0001), with a 50% overall survival of 21.5 months and 3.1 months, respectively. The actuarial 3-year and 5-year overall survival rates in resected patients were 38.3% and 26.3%, respectively. Univariate analysis revealed that factors associated with poor overall survival included multiple tumors, extrahepatic bile duct involvement, noncurative resection, and involvement of lymph nodes. Multivariate analysis in resected patients revealed that multiple tumors (p < 0.0074) and non-curative resection (p = 0.0068) were significant risk factors for poor overall survival. The survival rate in patients with three or more positive nodes was significantly lower than in those with fewer than three (p < 0.0001). Three patients with solitary tumors and one or two involved lymph nodes have survived beyond 4 years after extended lobectomy with systemic lymphadenectomy. Curative resection, single tumor, and fewer than two lymph node metastases were prognostic factors for good outcome. Curative resection with lymph node dissection improved survival in patients with no more than two positive lymph nodes.     

Effects of systemic and regional chemotherapy after hepatic resection for colorectal metastases

Background: Although the survival benefit of hepatic resection for colorectal metastasis has been established, some controversy remains regarding the significance of adjuvant chemotherapy after hepatic resection. Methods: One hundred thirty-two consecutive patients who had liver resection for colorectal metastasis at our hospital between 1980 and 1997 were studied. After curative hepatic resection, 37 patients underwent systemic chemotherapy, administered orally or intraportally. Forty patients had no adjuvant chemotherapy. The chemotherapeutic agents used for oral administration were uracil and Tegafur or Tegafur alone. Mitomycin C (MMC) or 5-FU was used for IV chemotherapy. Combinations of 5-FU/leucovorin or MMC/5-FU (doxorubicin) were used for regional chemotherapy. Univariate and multivariate analyses were applied to test the significance of adjuvant chemotherapy for patient survival or disease-free survival. Results: Overall 5-year survival was 42.2% (95% CL: 31.2%, 53.2%). Among the possible prognostic factors studied, univariate analysis showed a significant difference in survival based on the number of tumors and lymph node metastases in the hepatic hilum. There was a significant difference in disease-free survival based on adjuvant chemotherapy and lymph node metastasis. The multivariate analysis for patient survival selected four prognostic factors (P<.05), including adjuvant chemotherapy, lymph node metastasis, disease-free interval, and tumor size. The multivariate analysis for disease-free survival selected adjuvant chemotherapy, lymph node metastasis, and disease-free interval as significant factors. The most common recurrence site was remnant liver, regardless of adjuvant chemotherapy. Conclusions: Adjuvant chemotherapy significantly improved survival and disease-free survival after hepatic resection for colorectal metastases. It did not decrease recurrence rate in the remnant liver.Presented at the 51st Annual Cancer Symposium of The Society of Surgical Oncology, San Diego, California, March 26–28, 1998.     

肾癌区域淋巴结转移的临床分析

目的 了解肾癌区域淋巴结转移的临床特点及发生发展规律,提高对本病的诊治效果.方法 回顾性分析2004年1月至2008年12月19例肾癌伴有区域淋巴结转移患者的资料.男15例,女4例.年龄29～77岁,中位年龄57岁.肿瘤位于左肾12例,右肾7例.腹膜后肿大淋巴结最大径1.5～5.0 cm,中位数2.8 cm,其中4例影像学检查未发现肿大淋巴结,术中探查证实.行腹膜后肿大淋巴结切除11例,区域淋巴结清扫8例.结果 肾癌发生区域淋巴结转移占同期收治肾癌的1.6%(19/1213).术后19例均获随访,随访时间8～78个月,中位数34个月.无瘤生存6例,带瘤生存7例,死亡6例,5年生存率68.4%.腹膜后区域淋巴结清扫组与肿大淋巴结切除组生存期及术后复发转移率比较差异均无统计学意义(P=0.644;P=0.319).结论 肾癌发生单纯区域淋巴结转移少见,术前影像学可能漏诊,部分患者通过区域淋巴结清扫或肿大淋巴结切除可获得无瘤生存.

Abstract：

Objective To discuss the characteristics of renal cell carcinoma with regional lymph node metastasis at diagnosis. Methods The data of 19 patients diagnosed with renal cell carcinoma with regional lymph node metastases at diagnosis from January 2004 to December 2008 were reviewed.The median age was 57 years (29-77).The study group included 15 males and four females.The primary tumor was located in the left kidney in 12 patients and fight in seven patients.The median maximam diameter of retroperitoneal lymph nodes was 2.8 cm(1.5-5.0).The lymph nodes in four patients were not detected by the preoperative image examination,but were confirmed by intraoperative exploration.Eleven cases had enlarged retroperitoneal lymph nodes resected and eight had regional lymph nodes dissected. Results The patients with regional lymph node metastases at diagnosis of renal celI carcinoma accounted for 1.6% (19/1213) of the total renal cell carcinoma cases.With a median follow-up of 34 months,six patients were survival without progression,and seven were survival with progression.giving a 5-year survival rate of 68.4%.The survival and recurrence rates after surgery were not significantly different by Fisher test(P=0.644 and 0.319 respectively) between the patients who underwent retroperitoneal regional lymph node dissection and those who underwent enlarged lymph node resection. Condmiom Renal cell carcinoma with regional lymph node metastasis at diagnosis is uncommon.Some patients may achieve long-term tumor-free survival through regional lymph node dissection or enlarged Iymph nodes resection.     

Incidence and prognostic significance of lateral lymph node metastasis in patients with advanced low rectal cancer

BACKGROUND: Lateral lymph node metastases occur in some patients with low rectal cancer and may cause local recurrence after total mesorectal excision. The aims of this study were to identify risk factors for lateral node metastases in patients with pathological tumour (pT) stage 3 or pT4 low rectal adenocarcinoma, and to evaluate the prognostic significance of lateral node metastases. METHODS: A retrospective analysis was performed of the outcome of 237 patients with pT3 or pT4 low rectal adenocarcinoma who underwent R0 resection with systematic lateral node dissection. RESULTS: Lateral lymph node metastases were found in 41 patients (17.3 per cent). Increased risk of lateral lymph node metastases was associated with a distal tumour margin close to the anal margin, histological type other than well or moderately differentiated adenocarcinoma, and the presence of mesenteric lymph node metastases. Patients with lateral node metastases had a significantly shorter postoperative survival (5-year survival rate 42 versus 71.6 per cent; P < 0.001) and an increased risk of local recurrence (44 versus 11.7 per cent; P < 0.001) compared with those without lateral node metastases. CONCLUSION: Tumour site, histological type and the presence of mesenteric lymph node metastasis are factors predicting the risk of lateral node metastasis. The poor prognosis of patients with lateral lymph node metastases after systematic lateral dissection suggests the need for adjuvant therapy.     

Hepatic Resection for Metastatic Breast Cancer: Prognostic Analysis of 34 Patients

Liver metastasis of breast cancer is considered a generalized disease, and surgical treatment is rarely discussed. Thirty-four patients who underwent 35 hepatectomies for liver metastases of breast cancer between 1985 and 2003 were analyzed. The median interval between the breast surgery and relapse in the liver was 1.9 years (0–20 years). The liver was the first site of recurrence in 25 patients. Fifteen clinicopathologic factors were evaluated using univariate and multivariate analyses to predict survival after hepatic resection. No patients died because of the surgery. The median survival was 36 months (1 month to 20 years). The overall and disease-free 5-year survival rates after hepatectomy for breast metastases were 21% and 16%, respectively. Four patients survived more than 5 years. The presence of extrahepatic recurrence prior to hepatectomy was the only significant prognostic factor according to the analyses, and the 5-year survival rate of patients without extrahepatic disease was 31%. No patient who had hilar lymph node metastasis survived more than 5 years. In the absence of extrahepatic recurrence, surgical resection of liver metastasis from breast cancer can offer an acceptable prognosis and should not be avoided in selected patients.     

Intrahepatic cholangiocarcinoma: prognostic factors after liver resection

Liver resection may represent the only hope of cure for patients with intrahepatic cholangiocarcinoma (IHC) but long-term results are still far from satisfactory and the impact of prognostic factors is still controversial. Fifty-five patients underwent hepatectomy for IHC between 1997 and 2008 in our unit. Features of the patients and the tumors, operations, postoperative and long-term results were retrospectively assessed. Twenty-one patients had HBV/HCV infection, four had congenital biliary dilatation. Thirty-two patients had increased CA 19-9; 12 had multiple (≥4) tumors. Operations included 43 major resections, with 9 resections of biliary confluence, 40 regional lymphadenectomies. Operative mortality and morbidity were 0 and 27.3%, respectively. There were 44 R0-resections (80.0%). Lymphadenectomy yielded lymph node metastases in 14 cases (14/40; 35.0%). Five-year overall and disease-free survival rates were 30.2 and 27.5%, respectively. At multivariate analysis the strongest poor prognostic factor for overall survival was tumor stage. This factor, with multiplicity of lesions (≥4) and tumor grading > 2, was significant predictor of recurrence. CA19-9 > 100 IU/mL and tumor grading > 2 were found to be significantly related with early multinodular hepatic recurrence. Patients with lymph node metastases had significantly lower overall and disease-free survival but patients who underwent lymph node dissection with negative lymph nodes at final pathology showed significantly higher 5-year disease-free survival than patients who did not underwent lymphadenectomy. In conclusion, these results support the role of hepatectomy with regional lymphadenectomy as the best available treatment for IHC. Prognosis after liver resection correlates with clinical stage and multiplicity of lesions.     

Prognostic factors for survival after pulmonary resection of metastatic renal cell carcinoma

BACKGROUND: Pulmonary resection in metastatic renal cell carcinoma is an accepted method of treatment. The purpose of this study was to determine the clinical course, outcome, and prognostic factors after surgery. METHODS: Between 1985 and 1999, 191 patients (145 men, 46 women) with pulmonary metastases from a renal cell carcinoma underwent surgical resection. Inclusion criteria for the study were the absence of primary tumor recurrence and other extrapulmonary metastases. Complete resection (CR) was achieved in 149 patients. RESULTS: The overall 5-year survival rate was 36.9%. The 5-year survival rate after complete metastasectomy and incomplete resection was 41.5% and 22.1%, respectively. In patients with pulmonary or mediastinal lymph node metastases, we observed after complete resection a 5-year survival rate of 24.4%, whereas the rate was 42.1% in patients without lymph node involvement. A significantly longer survival was observed for patients with fewer than seven pulmonary metastases compared with patients with more than seven metastases (46.8% vs 14.5%). For surgically rendered complete resection (CR) patients with a disease-free interval of 0 to 23 months, the 5-year survival rate was 24.7% compared with 47% for those with more than a 23-month disease-free interval. By multivariate analyses, we showed that the number of pulmonary metastases, the involvement of lymph node metastases, and the length of the disease-free interval were all predictors of survival after complete resection. CONCLUSIONS: We conclude that pulmonary resection in metastatic renal cell carcinoma is a safe and effective treatment that offers improved survival benefit. Prognosis-related criteria are identified that support patient selection for surgery.     

Treatment strategy for hepatic metastases of colorectal cancer

Over the past 25 years, 125 patients with colorectal liver metastases underwent 167 hepatectomies in our department. The 1-, 3-, and 5-year survival rates after the initial hepatectomy were 90%, 58%, and 51%, respectively, and those after repeated hepatectomy were 88%, 60%, and 42%, respectively. The predictive factors significantly associated with poor prognosis after initial hepatectomy were maximal diameter of metastasis (> or = 5 cm), distribution pattern in the liver (multiple bilobar), number of nodules (> or = four), and presence of extrahepatic metastases. A disease-free interval of > 6 months after initial hepatectomy was a significant factor for prolongation of survival after repeat hepatectomy. Patients with hilar node metastases at the initial hepatectomy did not receive a survival benefit from hepatectomy, while 5 patients underwent repeat hepatectomy with lymphadenectomy for remnant liver and hilar node metastases with a disease-free interval of > 8 months and 4 of them survived for > 5 years. Our treatment strategies for colorectal hepatic metastases are as follows: 1) hepatectomy is the first choice for < 4 liver metastases without extrahepatic disease; 2) a careful evaluation for liver resection is performed for patients with > or = 4 liver metastases receiving hepatic arterial infusion chemotherapy because of the high frequency of hepatic and/or extrahepatic recurrence after initial hepatectomy; 3) the presence of hilar node metastases at the initial hepatectomy should be excluded from surgical indications; 4) simultaneous single metastasis limited to the lung is an indication for lung resection; and 5) a suitable indication for repeat hepatectomy for hepatic recurrence is patients with a longer disease-free interval. Aggressive surgery based on the optimum patient selection can contribute to clinical benefit, including long-term survival in patients with colorectal liver metastases.     

Indications for pancreatoduodenectomy in patients undergoing lymphadenectomy for advanced gallbladder carcinoma

Background/Purpose Carcinoma of the gallbladder shows diverse patterns of spread. The most appropriate surgical procedures according to the depth and extent of the spread of the tumor are still controversial.Methods We investigated this surgical problem clinicopathologically, especially regarding the indications for pancreatoduodenectomy (PD), by retrospectively reviewing the clinical records of 216 patients who were surgically treated for advanced gallbladder carcinoma. Detailed studies of resected specimens, in our department, showed that preservation of the pancreas head carried an increased risk of residual microscopic metastases in small peripancreatic lymphatic nodes and ducts. Some patients with curative operations had shown recurrence in lymph nodes around the head of the pancreas within a few years after PD. Therefore, we performed hepatopancreatoduodenectomy (HPD) in 93 patients, some of whom underwent the HPD as a prophylactic dissection of peripancreatic lymph nodes and some of whom underwent the HPD as a curative resection due to invasion to the peripancreatic lymph nodes, duodenum, and pancreas, observed macroscopically. The surgical outcome after PD was compared with that obtained after other curative resections (non-HPD).Results In patients with microscopically negative lymph node metastasis without hepatoduodenal ligament invasion, PD was not necessary for a complete resection of lymphatic metastases around the pancreas head. The 5-year survival rate of these patients who had HPD was not significantly higher than that for non-HPD resections with curative intent (73% vs 63%), and lymphatic recurrence was not marked. On the other hand, in patients with positive lymph node metastases without hepatoduodenal ligament invasion, PD was necessary for a complete resection. The 5-year survival rate after HPD in these patients was significantly improved compared to that after non-HPD resections with curative intent (87% vs 17%), because lymphatic recurrence was reduced (0% vs 80%).Conclusions In advanced carcinomas with positive hepatoduodenal ligament invasion, although the basic operative strategy, which inevitably includes right lobectomy, should be curative, PD should not be performed for prophylactic lymphatic resection, because local recurrence in the hepatoduodenal ligament cannot be controlled by PD, and the 5-year survival rate of curative HPD was only 4% (non-HPD resection with curative intent, 18%); moreover, frequent, lethal, major postoperative complications (hepatic failure) occurred after combined right lobectomy.     

Effect of Surgery on the Outcome of Midgut Carcinoid Disease with Lymph Node and Liver Metastases

We have evaluated survival and tumor-related symptoms in the presence of mesenteric lymph node and liver metastases in relation to surgical procedures in 314 patients (148 women, mean age at diagnosis 61 years; 249 with liver metastases) treated for midgut carcinoid tumors. Of the operated patients, 46% presented with severe abdominal pain and intestinal obstruction and were operated on before the diagnosis. Medical treatment (somatostatin analogs, interferon-a) was initiated in 67% and 86%, respectively. Surgical attempts included small intestine or ileocecal/right-sided colon resection with excision of mesenteric lymph node metastases. Most of the patients (n = 286) had mesenteric lymph node metastases; 33% of them had unresectable mesenteric lymph node metastases and underwent surgery without mesenteric dissection. Patients who underwent resection for the primary tumor had a longer survival than those with no resection (median survival 7.4 vs. 4.0 years; p <0.01). Patients who underwent successful excision of mesenteric metastases had a significantly longer survival than those with remaining lymph node metastases. Patients operated on for a primary tumor but with remaining lymph nodes but no liver metastases and who subsequently received interferon and somatostatin analog treatment had a median survival of 7.4 years. Resection of the primary tumor and the mesenteric lymph node metastases led to a significant reduction in tumor-related symptoms. Surgery to remove the primary intestinal tumor including mesenteric lymph node metastases is supported by the present results, even in the presence of liver metastases. Liver metastases and significant preoperative weight loss are identified as major negative prognostic factors for survival.     

胃癌肝转移的肝切除治疗及预后分析

目的 探讨胃癌肝转移肝切除治疗的疗效以及不同临床病理因素与预后的关系.方法 回顾性总结24例胃癌肝转移行肝转移灶手术切除患者的临床资料并对预后进行单因素和多因素分析.结果 全组病例均获得随访,胃癌肝转移外科治疗后1年生存率为67%,3年生存率为21%,5年生存率为13%.单因素分析显示淋巴结转移、脉管瘤栓、R0切除、转移灶大小为重要预后因素;多因素分析显示转移灶大小、脉管瘤栓为独立预后因素.结论 严格适应证的胃癌肝转移手术切除可以改善预后.综合治疗有望进一步提高疗效.     

Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study.

OBJECTIVE: In 1986 a prospective multicenter observation trial in patients with resected gastric cancer was initiated in Germany. An analysis of prognostic factors based on the 10-year survival data is now presented. PATIENTS AND METHODS: A total of 1654 patients treated for gastric cancer between 1986 and 1989 at 19 centers in Germany and Austria were included. The resected specimen were evaluated histopathologically according to a standardized protocol. The extent of lymphadenectomy was classified after surgery based on the number of removed lymph nodes on histopathologic assessment (25 or fewer removed nodes, D1 or standard lymphadenectomy; >25 removed nodes, D2 or extended lymphadenectomy). Endpoint of the study was death. Follow-up is complete for 97% of the included patients (median follow-up of the surviving patients is 8.4 years). Prognostic factors were assessed by multivariate analysis. RESULTS: A complete macroscopic and microscopic tumor resection (R0 resection according to the UICC 1997) could be achieved in 1182 of the 1654 patients (71.5%). The calculated 10-year survival rate in the entire patient population was 26.3% +/- 4.7%; it was 36.1% +/- 1.6% after an R0 resection. In the total patient population there was an independent prognostic effect of the ratio between invaded and removed lymph nodes, the residual tumor (R) category, the pT category, the presence of postsurgical complications, and the presence of distant metastases. Multivariate analysis in the subgroup of patients who had a UICC R0 resection confirmed the nodal status, the pT category, and the presence of postsurgical complications as the major independent prognostic factors. The extent of lymph node dissection had a significant and independent effect on the 10-year survival rate in patients with stage II tumors. This effect was present in the subgroups with (pT2N1) and without (pT3N0) lymph node metastases on standard histopathologic assessment. The beneficial effect of extended lymph node dissection for stage II tumors persisted when patients with insufficient lymph node dissection (<15 nodes) were excluded from the analysis. There was no difference in the postsurgical morbidity and mortality rates between patients with standard and extended lymph node dissection. CONCLUSIONS: Lymph node ratio and lymph node status are the most important prognostic factors in patients with resected gastric cancer. In experienced centers, extended lymph node dissection does not increase the mortality or morbidity rate of resection for gastric cancer but markedly improves long-term survival in patients with stage II tumors. This effect appears to be independent of the phenomenon of stage migration.