Extensive Lymphadenectomy Research Articles

Sentinel-Lymphadenektomie beim Prostatakarzinom

There is no consensus on which prostate cancer patients should undergo lymph node removal and which lymph nodes should be included. Therefore, most clinicians rely on nomograms and dispense with lymph node dissection in patients with low-risk disease. Meanwhile, there are some studies which prove that there are also lymph node metastases in patients with low-risk prostate cancer and that lymph node metastases are predominantly localized outside the region of standard lymphadenectomy. In more than 800 men we could show that lymph node metastases were found more often than shown in the Partin tables. These lymph node metastases were detected by sentinel lymph node dissection outside the region of standard and extended lymphadenectomy. Because of insufficient preoperative diagnostics it is unclear which patients have positive lymph nodes. Therefore, it is useful to perform lymph node dissection in every patient. Men with positive nodes could have a better prognosis, when sentinel and extended lymph node dissection are performed.

965: Extended Lymphadenectomy Should be Performed in Patients with PSA≥6, Biopsy Gleason Score 7-10 and Stage T2 or Higher Prostate Cancer

You have accessJournal of UrologyModerated Poster, Monday, May 22, 2006, 3:30 - 5:30 pm1 Apr 2006965: Extended Lymphadenectomy Should be Performed in Patients with PSA≥6, Biopsy Gleason Score 7-10 and Stage T2 or Higher Prostate Cancer Alberto Briganti, K.-H. Felix Chun, Francesco Montorsi, Vincenzo Scattoni, Luigi Da Pozzo, Andrea Salonia, Federico Deho, Elena Farina, Aldo Bocciardi, Luc Valiquette, Andrea Gallina, Renzo Colombo, Roberto Bertini, Luigi Barbieri, Patrizio Rigatti, and Pierre I. Karakiewicz Alberto BrigantiAlberto Briganti More articles by this author , K.-H. Felix ChunK.-H. Felix Chun More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , Vincenzo ScattoniVincenzo Scattoni More articles by this author , Luigi Da PozzoLuigi Da Pozzo More articles by this author , Andrea SaloniaAndrea Salonia More articles by this author , Federico DehoFederico Deho More articles by this author , Elena FarinaElena Farina More articles by this author , Aldo BocciardiAldo Bocciardi More articles by this author , Luc ValiquetteLuc Valiquette More articles by this author , Andrea GallinaAndrea Gallina More articles by this author , Renzo ColomboRenzo Colombo More articles by this author , Roberto BertiniRoberto Bertini More articles by this author , Luigi BarbieriLuigi Barbieri More articles by this author , Patrizio RigattiPatrizio Rigatti More articles by this author , and Pierre I. KarakiewiczPierre I. Karakiewicz More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)33190-2AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "965: Extended Lymphadenectomy Should be Performed in Patients with PSA≥6, Biopsy Gleason Score 7-10 and Stage T2 or Higher Prostate Cancer." The Journal of Urology, 175(4S), p. 311 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 175Issue 4SApril 2006Page: 311 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Alberto Briganti More articles by this author K.-H. Felix Chun More articles by this author Francesco Montorsi More articles by this author Vincenzo Scattoni More articles by this author Luigi Da Pozzo More articles by this author Andrea Salonia More articles by this author Federico Deho More articles by this author Elena Farina More articles by this author Aldo Bocciardi More articles by this author Luc Valiquette More articles by this author Andrea Gallina More articles by this author Renzo Colombo More articles by this author Roberto Bertini More articles by this author Luigi Barbieri More articles by this author Patrizio Rigatti More articles by this author Pierre I. Karakiewicz More articles by this author Expand All Advertisement Loading ...

Limitierte chirurgische Resektion versus lokale endoskopische Therapie beim Frühkarzinom des ösophagogastralen Übergangs

Adenocarcinomas of the esophagogastric junction (especially Barrett's cancers) are increasingly diagnosed at early stages. The current standard treatment - radical resection with extensive lymphadenectomy - has been challenged. Limited resection or endoscopic mucosal ablation have been proposed as less invasive alternatives. Available data regarding limited surgical resections and endoscopic interventional procedures are evaluated with respect to short- and long-term results (mortality, morbidity, oncologic adequacy, quality of life). Limited resection of the esophagogastric junction has been proven as safe (low morbidity and mortality) and oncologically adequate procedure (low rate of recurrence/excellent long-term survival) with good quality of life. The procedure meets the oncological requirements (R0-resection, complete resection of potentially tumor-infiltrated lymph nodes and the entire precancerous Barrett's esophagus). Reconstruction with interposition of a pedicled isoperistaltic jejunal loop prevents reflux and is crucial for achieving good postoperative quality of life. In contrast, endoscopic mucosal resection (EMR) carries the risk of high recurrence rates (at least 30 %). This has to be regarded as an effect of the frequent incomplete resection, multicentric tumor growth, the persistence of precancerous Barrett's mucosa and persistence of gastroesophageal reflux. Consequently, from the oncological view point, EMR is only suited for unicentric mucosal tumors (T1a) in short segments of Barrett's esophagus. Reliable preoperative identification of such tumors is, however, currently not possible. For adequately selected patients with early Barrett's cancer, limited resection of the esophagogastric junction is an appropriate procedure. Endoscopic mucosa resection (EMR) might gain importance as staging tool.

Laparoscopic en bloc partial cystectomy with bilateral pelvic lymphadenectomy for urachal adenocarcinoma

Introduction Surgical options for treating urachal adenocarcinoma include radical cystectomy and en bloc partial cystectomy with excision of the urachus and umbilectomy. Recently, laparoscopy has been increasingly used to treat bladder and urachal pathologic findings efficaciously. We describe two techniques for performing laparoscopic en bloc partial cystectomy with bilateral extended pelvic lymphadenectomy. Technical Considerations We performed the procedure in 3 patients with established urachal adenocarcinoma. The anatomic boundaries of resection were similar to those described for open surgery. We used an inverted V-shaped, five-port configuration, with the camera port placed 3 cm supraumbilically. An antegrade approach was performed for tumors less than 5 cm in 2 cases. The steps of the procedure included an inverted V-shaped incision along the peritoneum lateral to the medial umbilical ligament on either side; urachal disconnection, dissection of the urachus using the “twist and roll technique”; anterior cystotomy, circumferential resection of the tumor-bearing bladder dome, under vision; tumor placement in a “lap-bag”; bladder reconstruction using intracorporeal suturing; bilateral extended pelvic lymphadenectomy; placement of catheter and drain; and specimen retrieval. We evolved a retrograde technique for larger size tumors (larger than 5 cm). The procedure was successfully completed in all patients, with a mean operative time of 180 minutes (range 150 to 210). No significant intraoperative or postoperative complications occurred, except for a left inferior epigastric artery injury in 1 case. The resected nodes (range 8 to 11) were free of tumor. No local or distant recurrences were observed at a mean follow-up of 6.5 months (range 4.5 to 9). Conclusions Laparoscopic en bloc partial cystectomy and bilateral extended pelvic lymphadenectomy is a safe, feasible, minimally invasive alternative to open partial cystectomy for urachal tumors.

Individualized surgery for early gastric cancer guided by sentinel node biopsy

We have reported that lymphatic mapping using indocyanine green (ICG) solution can be a good tool for identifying sentinel nodes (SNs) in gastric cancer. The purpose of this study was to evaluate individualized operations for gastric cancer guided by SN biopsy and to explore the possibility for more limited operative procedures using SN technology. SNs were identified by using (99m)Tc-labeled tin colloid and ICG solution in patients with clinically T1N0M0 gastric cancer. When pathologic examination by frozen section revealed metastasis in SNs, we performed a standard D2 gastrectomy. Less extensive lymphadenectomy preserving vagus and pylorus was applied when the SN biopsy was negative. Then, postoperative pathology was analyzed. Among the 80 enrolled patients, 7 patients with apparent node metastasis or T2-3 neoplasms and 10 patients with positive metastasis in SNs underwent D2 gastrectomy. Sixty-one patients with negative metastasis in SNs underwent a less extensive, function-preserving gastrectomy. The false-negative rate in sentinel node biopsy was 23% (3/13) for frozen section and 7% (1/14) for postoperative pathology. In 3 patients with a false-negative result, metastasis was found in lymph nodes located at the station where the tracers were distributed. Of the 7 patients in whom metastasis was detected in 2 or more SNs by frozen section, postoperative pathology revealed that 3 patients (43%) belonged to the N2 category. SN biopsy is a useful tool for individualizing the operative procedure for early gastric cancer. Dissecting the lymph node stations only where the tracers are distributed may be a promising procedure for patients with no metastatic SNs.

The Association Between Total and Positive Lymph Node Counts, and Disease Progression in Clinically Localized Prostate Cancer

We examined the association between the number of LNs removed, the number of positive LNs and disease progression in patients undergoing pelvic lymph node dissection and radical retropubic prostatectomy for clinically localized prostate cancer. We analyzed 5,038 consecutive patients who underwent radical retropubic prostatectomy between 1983 and 2003. Clinicopathological parameters, including the administration of neoadjuvant hormonal therapy, preoperative prostate specific antigen, specimen Gleason score, surgeon and pathological stage, were collected prospectively in our prostate cancer database. We excluded men treated with radiation or chemotherapy before surgery. BCR was defined as 2 postoperative prostate specific antigen increases greater than 0.2 ng/ml. Cox models were used to determine whether the number of nodes removed or the number of positive nodes predicted freedom from BCR after adjustment for prognostic covariates. The 4,611 eligible patients had a median of 9 LNs (IQR 5 to 13) removed. Positive nodes were found in 175 patients (3.8%). Overall the number of LNs removed did not predict freedom from BCR (HR per additional 10 nodes removed 1.02, 95% CI 0.92 to 1.13, p = 0.7). Results were similar in patients receiving and not receiving neoadjuvant hormonal therapy. Finding any LN involvement was associated with a BCR HR of 5.2 (95% CI 4.2 to 6.4, p <0.0005). However, in men without nodal involvement an increased number of nodes removed correlated significantly with freedom from BCR (p = 0.01). Nodal disease increased the risk of progression. Extensive lymphadenectomy enhances the accuracy of surgical staging. However, we were unable to determine that removing more nodes improves freedom from BCR uniformly. Since the proportion of patients with prostate cancer with positive nodes is low, the value of extensive lymphadenectomy requires a multi-institutional, randomized clinical trial.

Laparoscopic management of gastrointestinal stromal tumors

Surgery remains the standard for nonmetastatic gastrointestinal stromal tumors (GISTs). Laparoscopic surgery should be considered for these tumors as their biologic behavior lends them to curative resection without requiring large margins or extensive lymphadenectomies. A retrospective review was performed of patients who underwent laparoscopic treatment of GISTs by surgeons at the Mount Sinai Medical Center from 2000-2005. Records were reviewed with respect to patient demographics, medical history, diagnostic workup, operative details, postoperative course, and pathologic characteristics. Laparoscopic surgery was attempted in 43 patients with GISTs. The average age was 65 years and 21 were women. Fifty-six percent of patients presented with anemia or gastrointestinal bleeding. The tumors were located in the stomach (65%) and in the small bowel (35%). The mean tumor sizes were 4.6 cm (stomach) and 3.7 cm (small bowel). Gastric operations included laparoscopic wedge (29%), sleeve (21%), and partial (29%) gastrectomies. The three gastric conversions were due to local invasion of tumor into adjacent organs or proximity to the gastroesophageal junction. Small bowel operations included laparoscopic resections with extracorporeal (47%) and intracorporeal anastamoses (33%). Conversion in small bowel operations was associated with coincidental pathology in addition to the GIST. This consisted of an associated bowel perforation and a synchronous colonic carcinoma. There was one mortality and a 9% morbidity rate, including an evisceration requiring reoperation. All tumors were pathologically confirmed with CD117 immunohistochemistry. In light of their biologic behavior, GISTs should be considered for laparoscopic resection. This minimally invasive approach to these tumors can be performed safely and reliably.

Is common iliac lymph node dissection necessary in early stage cervical carcinoma?

Objectives. Nodal metastasis is one of the most important prognostic factors in early stage cervical carcinoma and has an immense impact on the subsequent management. Thus, searching for nodal metastasis by pelvic lymphadenectomy is an integral part in the surgical management of cervical carcinoma. Complete nodal clearance of lymphatic tissue up to 2 cm above the bifurcation of common iliac vessels is therefore performed as a routine in our unit. The aim of this study is to investigate the incidence and pattern of pelvic lymph node metastases in patients with early stage cervical carcinoma to determine the role of common iliac node dissection in the surgery. Methods. We retrospectively reviewed 174 operation and histopathology reports of patients who underwent pelvic lymphadenectomy because of stage IA2 to IIA cervical carcinoma. Lymph nodes collected below and above the bifurcation of common iliac vessels were labeled as pelvic nodes and common iliac nodes, respectively. The incidence and distribution of nodal metastases were analyzed. Results. Complete and selective pelvic lymphadenectomy was performed in 163 and 11 patients, respectively. Nodal metastasis was documented in 35 (20.1%) patients. Pelvic and common iliac nodes were involved in 34 and 8 cases, respectively. All except one patient with common iliac node metastases were also found to have pelvic node metastasis. Conclusions. In early stage cervical carcinoma, isolated common iliac lymph node metastasis is rare, especially in cases without associated high risk factors. Less extensive pelvic lymphadenectomy may be considered in these patients in order to reduce operation morbidity and time.

Gastric cancer: an audit of 122 consecutive cases and the results of R1 gastrectomy.

In a consecutive series of 122 patients with gastric carcinoma, 9 per cent had no operation, 27 per cent had incurable disease at laparotomy, and 64 per cent underwent gastric resection. R1 gastrectomy was performed in 73 of the 78 resections. The operative mortality after gastric resection was 4 per cent, but there were no deaths after potentially curative resections. The actuarial 5-year survival was 20 per cent overall, 60 per cent in patients undergoing a 'curative' resection with N0 disease, and 18 per cent in patients with N1 disease. Local or regional recurrence without evidence of distant metastases was identified in 11 per cent of cases after 'curative' resections. The probability of survival was adversely affected by N1 nodal involvement (P less than 0.005) and by the presence of poorly differentiated or anaplastic tumours (P less than 0.001). Only 6 per cent of patients had early gastric cancer, and absolute curative resections by Japanese criteria were possible in only 5 per cent of cases. The results suggest that the unfavourable presenting pathology is the principal determinant of the poor prognosis of gastric cancer. A more radical or extended lymphadenectomy (R2/3 gastrectomy) might have cured more patients with N1 metastases, but only 12 per cent of potentially curable patients had N1 disease in this study, and it appears that more radical surgery may have little effect on the overall survival rates for gastric cancer.

Sentinel node biopsy in cancer of the oral cavity

Sentinel lymph node biopsy represents a less invasive technique for detecting subclinical lymphatic metastases in patients with a known primary malignancy. This procedure was developed to address the management of the lymphatics for cutaneous lesions, especially malignant melanoma. For melanoma, lymphatic drainage patterns are very unpredictable, and the therapeutic value of extensive formal lymphadenectomies remains controversial. The technique is increasingly being applied to other malignancies. Multiple small patient series have been published evaluating the application of lymphatic mapping and sentinel lymph node biopsy to cancer of the oral cavity. The technique requires the selection of patients without clinical or radiologic evidence of gross lymphatic cancer who are at risk for subclinical metastases. Subsequently, primary tumors are injected with a radioactive tracer, followed by radiologic imaging, and then gamma probe-guided lymph node excision through a small incision. Rigorous serial sectioning and immunohistochemistry is essential. Sentinel lymph node biopsy has not yet been validated as safe for oral cavity cancer, and a multi-institutional trial is currently completing accrual to correlate the histopathologic results of sentinel lymph node biopsy and subsequent selective neck dissection. The goal is to establish the predictive value of the less invasive procedure relative to formal lymphadenectomy. In this article, the authors describe the details of their surgical technique for sentinel lymphadenectomy as applied to oral squamous cell carcinomas.

Surgery for early stage esophageal adenocarcinoma

Current treatment recommendations for early esophageal adenocarcinoma range from radical esophagectomy with extensive lymphadenectomy, limited surgical resection with/without regional lymphadenectomy to endoscopic mucosectomy or ablation. A comparison of treatment associated morbidity, tumor recurrence rates, and functional outcome suggests that none of these alternatives can be universally recommended. Rather, an individualized strategy should be employed based on depth of tumor penetration into the mucosa/submucosa, presence of lymph node metastases, multicentricity of tumor growth, length of the underlying Barrett mucosa and comorbidity of the affected patient. Endoscopic mucosectomy may suffice for an isolated focus of high-grade neoplasia or mucosal cancer, provided the neoplasia and underlying Barrett mucosa can be removed completely. Surgical resection is the treatment of choice for tumors invading the submucosa, multicentric tumors and recurrence after endoscopic mucosectomy. The extent of surgical resection must be guided by the length of the Barrett mucosa. In most instances a complete tumor resection and removal of the entire Barrett mucosa can be achieved by a limited transabdominal approach, and therefore subtotal esophagectomy may not be necessary. Application of the sentinel node technology may in the future allow to limit systematic lymphadenectomy to the rather small subgroup of patients who in fact have lymph node metastases.

Primary skin closure of large groin defects after inguinal lymphadenectomy for penile cancer using an abdominal cutaneous advancement flap.

PURPOSE Large groin defects may be created after inguinal lymphadenectomy for bulky metastatic penile cancer. We describe a new method of primary closure of a large groin skin defect. MATERIALS AND METHODS In 3 patients with large volume inguinal lymph node metastases with skin breakdown and secondary infection extensive inguinal lymphadenectomy was done with wide surgical excision of skin and subcutaneous tissue. The procedures resulted in a large groin defect. Sartorius muscle was transferred to cover the femoral vessels. An abdominal advancement cutaneous flap was placed for soft tissue and skin coverage of the wound. RESULTS Primary closure of a large skin defect was possible using an abdominal advancement flap. In all patients the wound healed primarily with good cosmesis. A single patient underwent postoperative external beam radiation therapy to the flap site with no untoward effect on graft survival. CONCLUSIONS Large groin skin defects can be closed primarily using an abdominal advancement flap. This technique may also be used for bilateral groin defects. Compared with other types of flaps advocated for this purpose the main advantages of the procedure are simplicity, lower morbidity and superior cosmetic results.

Clinicopathological features, surgical management, and disease outcome of perforated gastric cancer

Perforated gastric cancer is rare and generally not diagnosed preoperatively or intraoperatively, if a frozen section is unavailable. Therefore, the elucidation of its clinicopathological features and disease outcomes will help surgeons manage perforated gastric cancer. The clinicopathological features, surgical management, and disease outcomes of 13 patients with perforated gastric cancer from March 1989 to May 2003 were retrospectively analyzed. Disease outcomes were analyzed in-depth based on tumor stage, depth of tumor invasion, operative curability, and three treatment groups. All 13 patients (median age of 72 years) received emergent laparotomy. Malignant gastric perforation was diagnosed intraoperatively in eight (61.5%) patients. Four patients whose frozen sections exhibited perforated gastric cancer underwent radical surgery with curative intent and were assigned to Group 1. Another four patients with overt distal metastases underwent palliative surgery and were assigned to Group 2. The remaining five patients were misdiagnosed as having benign gastric perforation and underwent local surgery; these patients were assigned to Group 3. All patients received follow-up for a median of 26 months. The survival rates for Stage I disease (P = 0.0342), T1/T2 tumors (P = 0.0342), and curative resection (P = 0.0012) significantly exceeded those of Stage III/IV, T3/T4 tumors, and non-curative resection. Additionally, the survival rates of Group 1 (P = 0.0067) and Group 3 (P = 0.0067) significantly exceeded those of Group 2. Stepwise logistic regression analysis revealed no significant predictor of prognosis. In resectable cases, one-stage radical gastrectomy with possible extensive lymphadenectomy should be encouraged if conditions allow. In cases of misdiagnosis, non-radical local surgery with curative resection is sufficient to treat early-stage cancer.

Results of total gastrectomy with extended lymphadenectomy for gastric cancer in elderly patients

The incidence of gastric cancer, in people over 70 years of age, has increased remarkably. Aggressive lymphadenectomy with gastrectomy has been reported to improve survival in patients with gastric cancer. Because complication rates following gastrectomy increase with advancing age, we sought to determine whether this procedure was merited in elderly patients with gastric cancer. We performed a retrospective analysis of 202 patients who underwent total gastrectomy with extended lymphadenectomy for gastric carcinoma. Postoperative complication rates were compared between patients over and under 70 years of age. The 10-year survival rates of patients under and over 70 years of age following total gastrectomy with extended lymphadenectomy were not significantly different. Although medical comorbidities in each group were similar, pulmonary dysfunction was significantly more common following total gastrectomy in patients over 70 years than in patients under 70 years. Moreover, logistic regression analysis revealed that patient's age was the only variable that independently correlated with the presence of postoperative complications. The prognosis of the gastric cancer patients over 70 years of age was similar to that of younger patients after total gastrectomy with extensive lymphadenectomy. However, pulmonary dysfunction was significantly more common in patients over 70 years old.

Extended lymphadenectomy (D2) in patients with early gastric cancer

Aims To investigate the survival benefit of extended lymphadenectomy (D2) in EGC patients in one European Institution. Methods A review was made of our prospective gastric database from January 1980 to December 2001. Of 527 patients with primary gastric adenocarcinoma, 119 with EGC underwent potentially curative resection (R0) with D2 lymphadenectomy. Results There were two post-operative deaths. Of the 117 evaluable cases, 96 were classified as N0 and 21 as N+, with metastases in the perigastric lymph nodes (level 1) in 13, and beyond this site (level 2) in eight. Five-year survival was 85.9 and 83.0% in N0 and N+ patients, respectively. During a median follow-up of 90 months, five of the eight patients with level 2 metastases died of recurrent disease and three were alive. The estimated survival benefit for 119 patients with EGC was 2.5% (3/119 cases). Conclusions In patients with EGC, metastases to level 2 are rare. Our results indicate that D2 lymphadenectomy has a limited survival benefit and that in these cases a less extensive lymphadenectomy (D1) could be performed.

Extent of lymphadenectomy in radical cystectomy for bladder cancer

BackgroundThe benefit of pelvic lymphadenectomy in patients with cancer of the urinary bladder remains controversial. Though the inclusion of lymph node dissection in conjunction with radical cystectomy for patients with clinically negative nodes is well accepted, however, the extent of the nodal dissection remains contentious, particularly in patients with gross disease and T1G3 cancer. The extent of the primary bladder tumor, number of lymph nodes removed and the lymph node tumor burden are important prognostic variables in patients undergoing cystectomy. We analyzed the impact of the extent of lymphadenectomy during radical cystectomy on survival in the contemporary literature.MethodsA Pubmed search was carried out for the literature published over the last 15 years using bladder cancer, radical cystectomy, survival, lymphadenectomy and complications as the key words. We have discussed the extent of lymphadenectomy on survival and its anatomical basis to determine the optimal number of lymph nodes to be removed and the concept of node density.ResultsEvidence from contemporary literature indicate significantly increased survival rates after cystectomy in patients with bladder cancer diagnosed with stages III or IV disease who have had relatively more lymph nodes examined, suggesting that even some patients with higher stage disease may benefit from extended pelvic lymphadenectomy at the time of cystectomy. Studies also indicate that more extensive lymphadenectomy significantly improved the prognosis of patients with bladder cancer, not only by providing prognostic information but perhaps it is also due to its inherent therapeutic value.ConclusionExtended lymph node dissection improves local control and survival. However, in the absence of controlled randomized trial this remains a dubitable issue.

Effect of axillary lymphadenectomy on breast carcinoma survival

To determine the effect of axillary lymphadenectomy on breast carcinoma survival, and to determine racial and age differences in the extent of axillary lymphadenectomy. Cases were 257,157 women diagnosed with breast carcinoma in the Surveillance, Epidemiology and End Results program from 1988 through 2000. Variables included number of lymph nodes removed, number of positive lymph nodes, ratio of positive nodes to number of nodes removed, use of radiation therapy, surgery (breast conserving surgery versus mastectomy), stage, age, race, and hormone receptor status. Correlation statistics were used to determine associations between survival and lymph node variables for all cases and when stratified by stage. Kaplan-Meier survival analyses were used to compare survival by lymph node categories overall and stratified by stage. Cox regression analyses were used to determine factors associated with survival. Older women were significantly less likely to have lymph nodes examined and lymph node involvement compared to younger women, and black women were significantly less likely to have lymph nodes examined, but were significantly more likely to have lymph node involvement compared to white women. Risk of death was significantly reduced for cases who had lymphadenectomy compared to those who did not. For cases diagnosed at stage IIA or higher, risk of death increased significantly with increased number of positive nodes and increased ratio of positive to total nodes removed. Improved survival in node negative cases of breast carcinoma may be due to removal of undetected micrometastases. Women diagnosed at more advanced stages as well as black women may also benefit from more extensive lymphadenectomy.

Quality in the surgical treatment of cancer of the esophagus and gastroesophageal junction

Surgical treatment of cancer of the esophagus and gastroesophageal junction (GEJ) remains a complex and challenging task. Quality of care may be improved by concentrating these patients in high volume centres in order to decrease post-operative mortality. However, it appears that hospital mortality is a poor tool to measure the quality. More likely specialisation as well as appropriate hospital environment supporting a dedicated multidisciplinary team are key elements in improving both the short term and long term results. The dedicated specialist surgeon has a key role in improving these results through surgical quality. The most important goal in the surgical treatment of these cancers is to perform a complete resection (R0). Data from literature seem to indicate that R0 resection combined with extensive lymphadenectomy are resulting in improved disease free survival and possibly in improved 5 year survival, often reported to exceed 35% after such interventions. These results suggest that there is a great need for standardisation of surgery. Such a standardisation and the resulting improved quality most likely will result in a significant improvement of outcome of esophagectomy for cancer of the esophagus and GEJ. These improvements in outcome should become the gold standard to which all other therapeutic regimens should be compared. Poor surgical quality and related poor results should not be a justification for multimodality regimen.

Impact of lymphadenectomy and nodal burden in renal cell carcinoma: Retrospective analysis of the National Surveillance, Epidemiology, and End Results database

Objectives To analyze the additional impact of retroperitoneal lymphadenectomy on overall and cancer-specific survival (CSS) in patients with primary renal cell carcinoma (RCC) undergoing radical nephrectomy. The benefit of regional lymphadenectomy in patients with primary RCC remains controversial. Methods Of 33,016 patients diagnosed with primary RCC between 1983 and 1998, a subset of 4453 underwent radical nephrectomy with or without regional lymphadenectomy. The extent of lymphadenectomy was assessed using the number of nodes examined, and the tumor burden was assessed using the number of positive nodes and the ratio of the number of positive nodes to the total number of nodes examined. Associations between CSS and the number of nodes examined, number of positive nodes, and ratio of the number of positive nodes to the total number of nodes examined were assessed. Results An inverse correlation was found between the likelihood of CSS and the number of nodes examined, particularly for those with regional disease even after controlling for other factors. A correlation was noted between the number of nodes examined and the number of positive nodes. Significant differences in CSS were observed in node-negative patients with regional disease compared with node-positive patients. An increasing nodal burden was associated with worse CSS. Conclusions More extensive lymphadenectomy does not appear to increase further the probability of CSS in patients undergoing radical nephrectomy for RCC. An increased number of positive nodes, as well as an increasing nodal burden, although associated with a lower likelihood of survival, were not independent predictors of RCC-specific mortality.

Extracapsular Extension of Pelvic Lymph Node Metastases From Urothelial Carcinoma of the Bladder Is an Independent Prognostic Factor

To analyze the prognostic impact of risk factors for urothelial carcinoma of the bladder (UCB) with pelvic lymph node (LN) metastases. We analyzed a consecutive series of 507 patients with UCB who were preoperatively staged N0M0. One hundred one of 124 eligible patients who were treated with radical cystectomy and standardized extended bilateral pelvic lymphadenectomy with curative intent and had postoperatively confirmed LN metastases were evaluated in regard to recurrence-free and overall survival. A median of 22 nodes per patient (range, 10 to 43 nodes) were removed and examined. Median recurrence-free and overall survival durations were 17 months and 21 months (range for both, 1 to 191 months), respectively. In the multivariate analysis for recurrence-free survival, extracapsular extension of LN metastases was the strongest prognostic factor (P = .019). Other variables such as tumor stage (pT1/2 v pT3 and pT4), the number (< five v >/= five), and the percentage (< 20% v >/= 20%) of metastatic nodes had a significant influence on recurrence-free and overall survival in the univariate analysis. However, they all failed to be significant prognostic factors in the multivariate analysis. The results of this study indicate that radical cystectomy with bilateral lymphadenectomy can have a curative effect in a subset of patients with pelvic LN positive UCB. Provided that a representative number of LNs are removed by meticulous lymphadenectomy and that a thorough histologic examination is performed, prognosis for such patients can be determined quite reliably. In the multivariate analysis, extracapsular extension of LN metastases was the strongest factor predicting prognosis.