Absence Of Palpable Nodes Research Articles

Occult metastases in cancer of the larynx and their relationship to clinical and histological aspects of the primary tumor: a four-year multicentric research.

The authors have tried to verify whether some clinical or pathological features of laryngeal cancer may favor the occurrence of occult metastases in the lymph nodes of the neck in N0 cases. The purpose of the investigation was to define the possible existence of tumors, where elective neck dissection, in the absence of palpable nodes, could be done without, thus contributing to settlement of a long debated problem. Different parameters, both clinical and pathological, have been considered. The result of a cross comparison of such parameters in 237 cases of cancer of the larynx without palpable nodes, submitted to surgery on the primary and elective neck dissection, indicates that, although the frequency of occult metastases is significantly related to the site and size of the tumor, its grading, and the degree and type of stromal reaction, the favorable concurrence of all said parameters occurs in 2% of cases only. However, if only clinical parameters, viz. site and size of tumor, are taken into account, a favorable concurrence occurs in 18% of cases with an incidence of occult metastases lower than 2%. These cases are almost exclusively represented by T1N0 supraglottic and T2N0 glottic tumors. We can conclude by saying that clinical and pathological preoperative findings may offer a useful clue in evaluating the risk of occult metastases, and hence advising, or not, an elective neck dissection in N0 cases. Nevertheless, in the vast majority of cases, an elective functional neck dissection still offers the best guarantee of oncologic safety while avoiding unnecessary mutilation.

Diagnostic Accuracy of Exfoliative Pulmonary Cytology

he increased incidence of bronchogenic carcinoma has brought with it diagnostic problems, especially in the evaluation of abT normal chest roentgenograms. In primary carcinoma of the lung, bronchial biopsy will reveal the diagnosis in about one-third of cases. Biopsy of scalene lymph nodes in the absence of palpable nodes will demonstrate the presence of metastatic carcinoma in about 10 to 20% of cases. An outcome of the development of exfoliative cytology during the last two decades has been the growing dependence of thoracic surgeons on cytological examination of respiratory secretions to diagnose lung cancer. It is not generally realized, however, that not only can cytological examination of sputum or bronchial aspirate be used to diagnose the presence of bronchogenic carcinoma; it also can be applied to the histological typing of the neoplasms. In our medical center the presence of malignant cells in sputum or bronchial aspirate is regarded as reliable evidence that a malignant neoplasm exists in the respiratory tract. A question has been raised, however, concerning the reliability of cytological examination in the typing of bronchogenic carcinomas. T o answer this question, we have reviewed our experience with 104 cases of bronchogenic carcinoma. In these cases a definite statement as to the type of carcinoma was arrived at by cytological examination, and there was histopathological material to confirm or refute the cytological typing.

Long-term results in the treatment of carcinoma of the thyroid

This report consists of a review of the surgical procedures and long-term follow-up results in 122 patients with documented carcinoma of the thyroid who were seen at Duke Hospital from 1930 to 1962. Thyroid lobectomy or subtotal thyroidectomy was performed in the majority of patients with papillary adenocarcinoma with only 6 per cent of these patients dying with thyroid cancer. Although six patients had proved tumor recurrences in the residual thyroid tissue, all are now living after more extensive thyroid resection and now have no further evidence of tumor spread. In addition, several interesting cases of prolonged survival of more than ten years with widespread metastases are noted. Total thyroidectomy was reserved primarily for more malignant follicular or undifferentiated tumors which rarely remain confined to the neck, being disseminated by the hematogenous route in many instances. The variation in biologic response of the more invasive undifferentiated tumors was also evident in three long-term survivors after thyroid resection. Regional lymph node dissections were limited to patients with gross evidence of nodal involvement with tumor. Ten patients with follicular or papillary tumors who did not have palpable nodes initially later required neck dissection for spread of tumor. Only one death occurred in a patient in whom carcinoma of the breast later developed and who was found to have widespread tumor originating in either the thyroid or the breast. Thirty-five remaining patients never underwent node dissection with no apparent adverse effect on the long-term survival. These observations emphasize the relatively benign clinical course associated with papillary carcinoma and suggest a conservative surgical approach limited to lobectomy with subtotal resection of the contralateral lobe. Total thyroidectomy should be reserved for patients with follicular and undifferentiated tumors. Regional lymph node dissection offers no benefit in the absence of palpable nodes. Finally, the variation in host response of these tumors should promote caution when one attempts to offer prognosis, even in the presence of wide-spread tumor.

Cancer of the tongue—comments on surgical treatment

Abstract In this report ninety-six consecutive en bloc resections (Commando) are analyzed. Comparison is made using thirty consecutive staged excisions of the primary lesion followed by neck dissection when lymphadenopathy developed. 1.1. The nodal palpability is of prognostic significance: the five year cure rate was 50 per cent in the patients with nonpalpable nodes and 27 per cent in those with palpable nodes. (Table II.) The histologic presence of metastasis is more prognostically meaningful than nodal palpability: the five year cure rate was 68 per cent in the group histologically negative for metastasis. (Table III.) Combined palpability and pathologic findings are prognostically most significant: the five year cure rate was 76 per cent in the patients with nonpalpable nodes which were histologically negative and 11 per cent in the patients with palpable nodes which were histologically positive. (Table IV.) Of the characteristics of the primary lesion, only involvement of the floor of the mouth had prognostic significance. (Table VI.) The size and location of the lesion and the histologic differentiation did not affect cure rates. 2.2. Local recurrence of the primary lesion was the most frequent cause of treatment failures. (Table VII.) The high incidence of treatment failures due to local recurrence emphasizes the need for more adequate excision of the primary lesion. 3.3. Palpability of neck nodes is an unreliable index for determining the presence of metastasis. (Table VIII.) When the nodes were not palpable, metastasis was present (false-negative) in 52 per cent of the cases; when the nodes were palpable, it was absent (false-positive) in 33 per cent. It appears that neck dissection was unnecessary in 48 per cent of the patients with nonpalpable nodes and in 33 per cent of those with palpable nodes. 4.4. The high incidence of unnecessary neck dissections suggests the need for reducing their number, if possible. Since neither the nodal palpability nor the characteristics of the primary lesion allows predicting the presence of metastasis with acceptable accuracy, the question arises as to whether stricter criteria and staging the excision of the primary lesion and neck dissection would reduce the number of unnecessary neck dissections without adversely affecting the cure rates. The data (Table X) suggest that staging is an acceptable therapeutic alternative in selected lesions, that is, in those of limited size and easy accessibility and in the absence of palpable nodes.

Cancer of the tongue: Comments on surgical treatment

In this report ninety-six consecutive en bloc resections (Commando) are analyzed. Comparison is made using thirty consecutive staged excisions of the primary lesion followed by neck dissection when lymphadenopathy developed. 1. 1. The nodal palpability is of prognostic significance: the five year cure rate was 50 per cent in the patients with nonpalpable nodes and 27 per cent in those with palpable nodes. (Table II.) The histologic presence of metastasis is more prognostically meaningful than nodal palpability: the five year cure rate was 68 per cent in the group histologically negative for metastasis. (Table III.) Combined palpability and pathologic findings are prognostically most significant: the five year cure rate was 76 per cent in the patients with nonpalpable nodes which were histologically negative and 11 per cent in the patients with palpable nodes which were histologically positive. (Table IV.) Of the characteristics of the primary lesion, only involvement of the floor of the mouth had prognostic significance. (Table VI.) The size and location of the lesion and the histologic differentiation did not affect cure rates. 2. 2. Local recurrence of the primary lesion was the most frequent cause of treatment failures. (Table VII.) The high incidence of treatment failures due to local recurrence emphasizes the need for more adequate excision of the primary lesion. 3. 3. Palpability of neck nodes is an unreliable index for determining the presence of metastasis. (Table VIII.) When the nodes were not palpable, metastasis was present (false-negative) in 52 per cent of the cases; when the nodes were palpable, it was absent (false-positive) in 33 per cent. It appears that neck dissection was unnecessary in 48 per cent of the patients with nonpalpable nodes and in 33 per cent of those with palpable nodes. 4. 4. The high incidence of unnecessary neck dissections suggests the need for reducing their number, if possible. Since neither the nodal palpability nor the characteristics of the primary lesion allows predicting the presence of metastasis with acceptable accuracy, the question arises as to whether stricter criteria and staging the excision of the primary lesion and neck dissection would reduce the number of unnecessary neck dissections without adversely affecting the cure rates. The data (Table X) suggest that staging is an acceptable therapeutic alternative in selected lesions, that is, in those of limited size and easy accessibility and in the absence of palpable nodes.

Prescalene lymph node biopsy.

In the presence of an undiagnosed intrathoracic lesion it is obvious that palpable supraclavicular lymph nodes should be submitted to biopsy. It is less clear whether prescalene node biopsy is indicated in the absence of palpable nodes. It is the purpose of this study to review a series of simple prescalene node biopsies to determine the value of this procedure as a routine, particularly with respect to carcinoma of the lung. Daniels, 1 in 1949, and, later, Weiss et al., 2 Johnson and MacCurdy, 3 and Storey and Reynolds 4 first described prescalene node biopsy as a means of diagnosing intrathoracic disease. Several subsequent series have been reported that have not distinguished between patients with palpable and those with nonpalpable supraclavicular nodes. Among these, 5-9 positive diagnoses were obtained in 25% to 40%. Sarcoidosis (Boeck's Sarcoid) was the most frequent diagnosis in the three series of over 100 cases. 5,6,9

A Technic for Intensive Roentgen Irradiation of the Neck

The radiation treatment of intra-oral cancer involves technics combining intra-oral radium applications directly to the primary seat of the disease and external radiation to the glandular regions of the neck. The problem of the primary lesion has been successfully met by electrosurgical methods, radium seed implantations directly into and about the site of the disease, and by heavily filtered radium applicators immediately in contact with the diseased tissues (1). External radiation to the glandular region of the neck is generally considered essential even in the absence of palpable nodes. Heavily filtered radium packs applied over long periods of time—200 to 300 hours (1)—and short wavelength roentgen rays in massive and divided doses have been widely used with a moderate degree of success. Isolated nodes have been treated successfully with gold seed radon implantations and also with platinum needles (0.5 mm. wall thickness), using weak intensities (1 mgm. per 15 mm. length of needle) over continuous periods of six to seven days.