Extensive Lymphadenectomy Research Articles

Extensive lymphadenectomy for gastric cancer patients: what can the results of one trial tell us?

Extensive lymphadenectomy for gastric cancer patients: what can the results of one trial tell us?

Effectiveness of extended lymphadenectomy in noncurative gastrectomy

We examined the efficacy of extended lymph node dissection for prolonging survival in macroscopically or histologically proven incurable gastric cancer. We analyzed clinico-pathologic data on 119 patients with serosally invasive gastric cancer who underwent noncurative gastrectomy, with respect to the relation between the extent of lymphadenectomy and survival benefit. The 5-year survival rate was significantly higher among patients treated with extensive lymphadenectomy (R2/3) compared to simple gastrectomy (R1). Extensive lymphadenectomy significantly prolonged survival time even after noncurative gastrectomy in cases where there was no evidence of hepatic metastasis, peritoneal seeding, or extensive nodal metastasis beyond the tertiary lymph node, and regardless of the extent of direct invasion to adjacent organs. Gastrectomy combined with extended lymphadenectomy and/or resection of adjacent organs is recommended for gastric cancer patients without distant metastasis, even when the operation is histologically noncurative. Gastrectomy and perioperative intensive chemotherapy are called for when patients have distant metastasis.

Role of Extended Lymph Node Dissection in the Treatment of Gastrointestinal Tumours: A Review of the Literature

Over recent decades the long-term survival of patients operated on for gastrointestinal cancer has shown little if any improvement, despite sometimes aggressive surgical procedures and a significant fall in postoperative mortality. We went through the literature to see if there were any eventual effects of extended lymph node dissection or survival. We reviewed recent literature on the different types of gastrointestinal cancer. Japanese centres report excellent results when wide local excision is combined ith systematic extended lymph node dissection, especially in gastric and oseophageal cancer. The overall 5-year survival of over 50% for the large number of patients undergoing gastric resection for cancer seems to demonstrate convincingly the value of the extended lymphadenectomy. All oriental studies are uncontrolled, as are most reports from Western countries. The role of extended lymphadenectomy is therefore far from certain. The results from two randomized studies (British Medical Research Council and Dutch Gastric Cancer Trial) are awaited. It is evident from these prospective studies that the procedure adds a considerable operative risk. From non-randomized studies there is evidence that extended lymph node dissection in the treatment of pancreatic cancer might be of benefit to patients with small stage I and II tumours. In the treatment of proximal bile duct cancer the main goal of surgery is optimal relief of biliary obstruction. Whether there will ever be a role for extensive lymphadenectomy is doubtful. The extent of the surgical procedure in the treatment of gallbladder cancer is related to the depth of tumour infiltration. Extended resections are only recommended for patients with stage II to IV tumours. Extended lateral pelvic node dissection in the treatment of rectal cancer is demonstrated in Japanese retrospective studies to induce considerable urogenital problems, whereas the risk for local recurrence is still present. No firm conclusions can be drawn based on data as available from the studied literature. Trial results will have to be awaited. Specific subgroups such as gastric and rectal cancer might benefit from these more extensive procedures.

Patterns of lymphatic spread in thoracic esophageal cancer.

The cervical nodes have been excluded from the category of regional nodes in cases of thoracic esophageal cancer in the present TNM classifications. One hundred and forty-one patients with thoracic esophageal cancer who had undergone extensive radical lymphadenectomy were included in the study. The patterns of early lymph node metastasis from the disease, in terms of lymph node metastases from the intramural tumors or those found in patients with a single metastatic node, were studied. Prognostic significance of the removal of the positive nodes also was examined in relation to the metastatic sites. Of the 47 patients with intramural cancer, only 21% had nodal metastases confined to the mediastinum, 11% had positive cervical nodes, and 23% had jumping metastases to the extramediastinal nodes. Of the 31 patients with a single metastatic node, 61% showed metastasis in a jumping fashion, and 19% had a positive node in the neck. Seventy-four (79.6%) of the 93 patients with vessel invasion also had lymph node metastases, whereas 20 (41.7%) of the 48 patients without vessel invasion had metastases to the lymph nodes (P < 0.001). The 5-year projected survival rate for patients with positive cervical nodes was 27%, with no significant difference in survival rate compared with that for patients with metastatic nodes in the mediastinum or the abdomen. The number of involved nodes was related significantly to outcome: The 5-year survival rates for the 45 patients with negative nodes the 66 patients with one to four positive nodes were 71.8 and 34.2%, respectively (P < 0.01), whereas none of the 27 patients with five or more positive nodes survived more than 3 years after the operation (P < 0.001). The cervical nodes should be included in the category of regional nodes in cases of thoracic esophageal cancer on the basis of the patterns of early lymph node metastases and the prognostic significance of a lymphadenectomy for metastases to these nodes.

Factors Influencing Survival of Patients After Radical Surgery for Gastric Cancer: A regional study of 406 patients over a 10-year period

The present retrospective report presents a review of prognostic factors influencing the survival of 406 gastric cancer patients radically operated on in the Tartu Oncology Hospital, Estonia in 1978-1987. All patients underwent total (n = 170) or subtotal (n = 236) gastrectomies with extensive lymphadenectomy (260 R2- and 146 R3-resections) according to the General Rules for the Gastric Cancer Study in Surgery and Pathology established by the Japanese Research Society for Gastric Cancer, introduced in our hospital at the end of the 1970s and now used as the unavoidable procedure for curative gastric cancer surgery. The 30-day postoperative mortality was 5.9% and the overall 5-year survival 46.1%. The male:female ratio was 0.95 and the mean age 62.4 years. Only 7.6% of all our patients operated on had early gastric cancer with a 5-year survival of 80.7% whereas 76.8% had T3-T4 tumours with a 5-year survival of 41.0%. Lymph node involvement was found in 44.6% of the patients. Independent favourable prognostic factors were (the 5-year survivals are presented within parentheses): limited (N0-N1) lymph node involvement (56.4 vs. 22.6%), pT 1-2 stage (62.8 vs. 41.0%), papillary, tubular or poorly differentiated histological pattern (51.9 vs. 33.1%), subtotal gastrectomy (55.9 vs. 32.4%) and age below 70 years (51.9 vs. 35.2%). Sex of patients, Borrmann type, size and site of tumour were not statistically associated with prognosis at multivariate analysis. Our results also suggested that besides predetermined prognostic factors, the surgical policy had a great impact on the prognosis of gastric cancer patients. We conclude that gastrectomy with combined resections of neighbouring organs directly invaded and with extensive lymphadenectomy at least up to the second node group might be the procedure of choice for advanced gastric cancer.

Current Results of Randomized Studies about the Extent of Lymph Node Dissection

Between August 1989 and July 1993, a controlled randomized trial was performed in the Netherlands to compare the therapeutic efficacy of Dl resection with limited (N1 level) lymphadenectomy versus D2 resection with extended lymph node dissection (N1 and N2 level). In this trial, a total of 1,078 patients were randomized, of whom 996 (92%) were eligible for analysis. Of these, 711 (71 %) were operated on with curative intent and 285 (29%) underwent a non-curative procedure. The actual distinction between limited and extended lymphadenectomy was analyzed. Nonadherence to the protocol was evaluated on the basis of noncompliance (no yield of lymph nodes from indicated stations) and contamination (finding of one or more lymph nodes for which dissection was not indicated). In the first period, data of 237 patients (115 D1 and 122 D2) operated on with curative intent were available. Noncompliance occurred in 84% of both Dl and D2 resections, while contamination was seen in 48% of D1 and 52% of D2 resections. Contamination and noncompliance indicate a partial loss of distinction between the two types of resection, showing the tendency of performing an intermediate type of resection, D1.5. Additional measures were taken, such as stricter perioperative quality control, centralized lymph node retrieval and evaluation of protocol deviations per participating team to improve standardization of the surgicopathological team performance. After implementing these measures, in the second period, noncompliance did not decrease significantly; 236 (138 Dl and 98 D2) patients (p = 0.08), while in D2 the decrease was significant (p = 0.03). The contamination rate decreased significantly in both Dl (p < 0.05) and D2 (p = 0.02) resections. Furthermore, our results proved that extended lymphadenectomy induced a substantial stage migration. In conclusion, the implementation of measures improved standardization of the surgicopathological team performance. Stage migration is also demonstrated in our randomized controlled trial. Not only major changes in clinical practice, such as routine application of extended lymphadenectomy, but also more subtle changes in the performance of the surgicopathological team, such as contamination, noncompliance and diligence, strongly affect stage-specific survival rates.

CLINICOPATHOLOGICAL FEATURES OF RESECTED HILAR CARCINOMA OF THE BILE DUCT

Between 1983 and 1992, surgical intervention was attempted in 14 patients with hilar carcinoma of the bile duct. Local excision of the lesion alone was performed in four patients and hepatic resection in 10, in nine of whom resection of the caudate lobe was also undertaken. The histological free margin was observed in only five of 10 patients with hepatic resection (microscopic curative resection rate, 35.7%). The positive rate of surgical margins was 21% on the duodenal side, 36% on the resected side, 50% on the hepatic side and 21% on the paraaortic lymph-nodes. The modified Bismuth-Corlette classification was useful for selection of the type of surgical intervention in hilar carcinoma of the bile duct. It is suggested that rational resection of the bile duct including hepatectomy and extensive lymphadenectomy is necessary for widening the radical resection and to improve the surgical outcome of hilar carcinoma of the bile duct.

Extended Lymphadenectomy during Radical Nephrectomy for Renal Cell Carcinoma. A Prospective Study

The role and extension of lymphadenectomy during radical nephrectomy for renal cell cancer still remain a matter of debate. From June 1989 to March 1992, 137 consecutive extended lymphadenectomies were performed in patients undergoing radical nephrectomy for renal cell cancer at the Department of Urology of Padua. Ten patients (7.3%) had a pathologically proved nodal involvement. Only 2 patients had a distant nodal involvement in the absence of metastases to hilar nodes. Both patients with microscopic metastases had massive involvement of hilar nodes. Due to short median follow-up no clinical consideration on survival can be drawn.

Prognostic factors for noncurative gastric cancer: univariate and multivariate analyses.

We performed univariate and multivariate analyses of possible prognostic factors related to postoperative clinical course of patients with advanced gastric cancer. Noncurative resection was done for 119 patients with hepatic metastasis, peritoneal seeding, extensive lymph node metastasis, or direct invasion to adjacent organs, either alone or in various combinations. In the univariate analysis, 6 of 17 items such as peritoneal seeding, lymphatic invasion, vascular invasion, mode of invasion, extent of lymphadenectomy, and width of serosal invasion significantly correlated to the prognosis. The multivariate analysis indicated that three inherent pathologic factors, mode of invasion, lymph node metastasis, and hepatic metastasis, and one treatment factor, extent of lymphadenectomy, were significant variables predictive of the prognosis and that the prognosis was expected to be very poor in cases of infiltrative type, nodal involvement to tertiary nodes, presence of hepatic metastasis, and lymphadenectomy less than R3. Prognosis in terms of the extent of lymphadenectomy shows that extensive lymphadenectomy (R3) proved to be significantly effective in prolonging survival time, even after noncurative gastrectomy. We recommend extensive lymphadenectomy to prolong survival time for such patients.

Blended anesthesia in major urological surgery

The Authors report the results of a retrospective analysis of two groups of patients, who underwent major urological surgery, (extensive nephrectomies, radical prostatectomies, retroperitoneal lymphadenectomies and radical cystectomies with urinary diversion according to Bricker, VIP, US). Improvementiv surgery and clinical results is largely due to the improvement of the combined anaesthesiologic action — a light general and at the same time selective peridural anaesthesia — considering that both groups of patients were treated equally, in that they were nourished in the same way in the pre and post-operative phases and underwent the same intensive cures immediately after the operation, which was invasive and aggressive.

What are the Benefits of Extended Dissection of the Regional Renal Lymph Nodes in the Therapy of Renal Cell Carcinoma?

In a prospective study of 511 patients we compared the data of 320 who underwent systematically extended dissection of the regional lymph nodes with data of 191 who underwent only facultative dissection of the lymph nodes, which means that no lymph nodes had been removed or only a few were taken for staging purposes. Only patients without distant metastases and who were less than 72 years old were included. All patients were treated with a transabdominal approach. The incidence of positive nodes in the patients with systematically extended lymphadenectomy was 17.5% and for patients with facultative lymphadenectomy it was 10%. Survival rates of patients with facultative lymphadenectomy were 58% after 5 years and 40.9% after 10 years, compared to 66% and 56.1%, respectively, for patients with systematically extended lymphadenectomy (p <0.01). Patients with stage pT1-2 (Robson stage I) and pT3aN0M0 (Robson stage II) tumor obviously had the highest benefits with extended lymphadenectomy. Operative mortality was less than 1% after systematically extended lymphadenectomy and 3.8% after facultative lymphadenectomy. We conclude from our data that the systematic and extended lymphadenectomy improves the prognosis of patients with renal cell carcinoma without any additional operative risks.

The treatment of lymph node metastasis from esophageal cancer by extensive lymphadenectomy

During the period between 1965 and the end of 1988, 560 patients with esophageal cancer were surgically treated in our University hospital. In an attempt to improve patient survival, three-field lymphadenectomy of the bilateral neck, mediastinum and abdomen was performed in 117 patients treated since 1983. The present study was undertaken to reveal the substantial rate of lymph node metastasis in esophageal cancer and to decide if three-field lymphadenectomy is mandatory or not for surgery of esophageal cancer. Despite the increased radicality of the operation, the mortality and morbidity rates decreased in the 1980's compared to the earlier periods, the operative death being 12.5 per cent in the 1960's, vs. 2.0 per cent in the 1980's. Moreover, the mortality rate of the patients receiving the three-field lymphadenectomy was as low as 2.6 per cent. The metastatic rate of cervical nodes in the patients receiving three-field lymphadenectomy was 32.5 per cent, while that of mediastinal and abdominal nodes was 47.0 per cent and 46.0 per cent respectively. The metastatic rate in the mediastinum was high in the bilateral recurrent nerve lymph nodes, bifurcation nodes and paraesophageal nodes, while in the abdomen, it was high in the bilateral paracardial nodes. Recurrent nerve paralysis, which had been rarely seen was observed in 12.0 per cent of the patients. Metastasis from esophageal cancer is often seen in the cervical nodes, however, the clinical importance of three-field lymphadenectomy will be decided by the data of patient survival in the near future.

Radical Extensive Surgery for Renal Cell Carcinoma: Long-Term Results and Prognostic Factors

We studied 200 consecutive patients with renal cell carcinoma who underwent radical nephrectomy and extensive lymphadenectomy. Of the patients 25% already had distant metastasis at operation. Higher T stages tended to be associated with positive nodes (p less than 0.01) and distant metastasis (p less than 0.001). However, in patients with stage N0M0V0 tumors we found no statistically significant difference in survival in relationship to the T stage of the disease (5-year survival: stage T1 80%, stage T2 68% and stage T3 70%). Of all patients 10% had positive nodes without distant metastases and no venous spread of the tumor, and the 5-year survival rate was 52%.The 5-year survival rate of patients with distant metastases was 7%. Patient survival in the presence of a vena caval tumor thrombus is similar to that of patients with distant metastases. Based on our results the different stages in disease progression may be classified as having a good prognosis-intracapsular tumors (stages T1 to T2, N0M0V0) and tumors with involvement of perirenal fat (stage T3N0M0V0), an intermediate prognosis-tumors with nodal metastases alone (stages T1 to T3, N1 to 2, M0V0) and a poor prognosis-tumors with venous invasion and/or distant metastases. Histological grading and size of tumor can be used to assess prognosis but are not more accurate than pathological staging.

Renal artery thrombosis ? an unusual complication following removal of a neuroblastoma

A 2-month-old female infant with a retroperitoneal neuroblastoma on the left side was admitted to Niigata University Hospital. Her systolic blood pressure, as high as 220 mmHg, was attributed to renovascular hypertension because the plasma renin activity was increased up to 208 ng/ml per hour. Excision of the tumor, including the left kidney, and periaortic lymphnode dissection were performed. For safety during the lymphadenectomy, Nelaton catheters were placed around the inferior vena cava, aorta, superior mesenteric artery, and right renal artery. On the 2nd postoperative day anuria was noted, and aortography was performed revealing obstruction of the right renal artery, inferior mesenteric artery, and left common iliac artery. Thrombectomy via aortic incision was performed immediately to restore the blood flow. The patient developed chronic renal failure, however, and still requires hemodialysis or peritoneal dialysis. Pediatric surgeons should bear in mind that extensive periaortic lymphadenectomy may cause postoperative arterial thrombosis.

Is extensive lymphadenectomy necessary for surgical treatment of intramucosal carcinoma of the stomach?

This study was undertaken to elucidate those histological and gross features associated with gastric carcinoma that can be adequately treated by gastrectomy with less aggressive lymphadenectomy. The frequency of metastasis to the lymph nodes was analyzed in 514 cases of resected, solitary, gastric carcinomas. The frequency of metastasis to the lymph nodes increased in proportion to the increase in the extent of penetration by the cancer into the gastric wall. Lymph nodes were not involved in cases of intramucosal carcinoma of the intestinal type, by Laurén's histological classification. By contrast, metastasis to the lymph nodes was observed in cases of intramucosal carcinoma of the diffuse type, by Laurén's classification. We conclude that extensive lymphadenectomy is not mandatory for patients with intramucosal carcinoma of the stomach of the protruded type, since the lymph nodes do not become involved in this type of gastric carcinoma.

Extent of Lymph Node Dissection in Melanoma of the Trunk or Lower Extremity

The extent of lymph node dissection necessary to optimize survival and minimize local recurrence in patients with melanoma of the trunk or lower extremity is not well defined. We reviewed the records of 420 patients undergoing superficial or combined superficial and deep groin dissection for melanoma. Prognosis depended on the extent of lymph node involvement rather than the extent of surgery performed. Node-positive patients undergoing elective lymph node dissection had an improved survival over those undergoing therapeutic lymph node dissection. In no subgroup of patients was more extensive lymphadenectomy associated with significant improvement in survival or alteration in pattern of recurrence. Dissection of the deep pelvic nodes in patients with melanoma appears to be of more prognostic than therapeutic value.

Long-term survival in Japanese patients with far advanced carcinoma of the stomach.

AbstractAmong 1,220 Japanese patients with gastric carcinoma who had undergone resection in the Department of Surgery II, Kyushu University Hospital, Fukuoka, Japan from 1965 to 1980, there were 432 (35.4%) with far advanced carcinoma, designated as a lesion with factors such as peritoneal dissemination, hepatic metastasis, widespread nodal involvement extending to tertiary (hepatoduodenal, retropancreatic, and mesenteric) or quaternary (middle colic and paraaortic) nodes, or direct invasion to adjacent organs. The overall 5‐year survival rate in these 432 patients was 10.2%. The 5‐year survival rate in patients with a single factor was 16.3%, being significantly higher than the 2.8% or less in cases with more than 2 factors (p&lt;0.01). Patients with tertiary nodal involvement or directly invaded organs alone survived at a rate of 26.1% and 21.8% in the 5‐year follow‐up, respectively. Radical procedures such as extensive lymphadenectomy and combined resection of the invaded organs further lengthened the survival time. The 5‐year survival rates were less than 10% in patients with other factors, singly or more than 2 factors in combination. There appear to be 2 subgroups in whom the rates of survival differ: potentially curable and noncurable patients. More intensive therapeutic regimens corresponding to both groups need to be considered.

Influence of the extent of resection on survival after curative treatment of gastric carcinoma. A retrospective multivariate analysis.

The therapeutic value of extensive gastric resection and regional lymphadenectomy in the curative treatment of gastric adenocarcinoma is controversial. We undertook a retrospective study of 210 patients treated with curative intent from 1960 to 1980. A multivariate survival analysis using the Cox model revealed five significant variables predictive of death from gastric cancer--two inherent pathologic factors: (1) nonpyloric site and (2) metastases in more than three lymph nodes, and three treatment factors that could often be controlled by the surgeon: (3) microscopic positive gastric resection margin, (4) inadequate lymphadenectomy, and (5) total gastrectomy. These observations reaffirm the value of wide gastric resection and adequate lymphadenectomy but argue against a general policy of elective total gastrectomy in the curative treatment of gastric carcinoma.

Selection of initial therapy for renal cell carcinoma.

Complete surgical excision is the only effective method of treatment for renal cell carcinoma (RCC) and patients with extensive regional or distant metastases are incurable by any means. Accurate preoperative staging is therefore of critical importance, and computerized tomography and magnetic resonance imaging are the most accurate staging modalities. The traditional operative procedure for RCC has been the radical nephrectomy with excision of Gerota's fascia and its contents, resulting in a 60% to 70% 5-year survival of patients with localized tumors (T1-2 and N0 and M0). Extensive lymphadenectomy has not appreciably improved the cure rate. Indeed, less aggressive surgery has been recently proposed by some authors, based on the excellent results achieved after partial nephrectomy or for tumors in solitary kidneys, with survival after partial nephrectomy or enucleation similar to that after radical nephrectomy. Preoperative adjuvants such as angioinfarction or radiotherapy have not increased survival or local tumor control, and no regional or systemic postoperative adjuvant has proven to be of value. Until further data is accumulated, radical nephrectomy remains the treatment of choice for localized RCC.

Prognostic factors and operative treatment of Stages IB to IIB cervical cancer

Between 1971 and 1985, a total of 325 cases of cervical cancer, Stages IB to IIB, in which operation was performed were evaluated with a view toward prognostic factors and survival rates. In radical abdominal operations, a complete resection of parametrial tissue was the goal. Extensive lymphadenectomy of the pelvis was performed. Operative specimens were processed by giant sections comprising cervix, lateral parametria, and vaginal cuff. Lymph nodes were cut by step-serial sections. Exact measurements of tumor sizes were done along with investigations of parametrium and lymph nodes. Tumors were classified according to a ratio of tumor size to size of cervix. Incidence of lymph node involvement increased with tumor size, reaching a maximum of 68.3% in the group with a ratio from 70% to 80%. Direct spread into the parametrium was rarely found, even in larger tumors occupying the entire cervix. Parametrial lymph reached 88.1% in patients with no nodal involvement and 60.9% with nodal involvement. In the latter, the results depended on the number of nodal groups involved and the diameter of metastases. Parametrial involvement alone had no influence on healing rates, but when pelvic nodes were simultaneously involved, the results were less satisfactory. Survival rates based on tumor size differed only between the group with a ratio up to 20% and the large-tumor groups, with rates ranging from 97.5% to 70.9%. There was no statistical difference between Stages IB (31.1% positive nodes) and IIB (44.1% positive nodes) with regard to survival rates (82.2% and 76.9%, respectively).