Resection Of Regional Nodes Research Articles

Colon Cancer Nodal Metastasis: Biologic Significance and Therapeutic Considerations

The controversy surrounding the extent of lymphatic resection for colon carcinoma has spanned several generations of surgeons. At present, two schools of thought exist: (1) lymphadenectomy is important for staging and therapy, and (2) lymphadenectomy is predominately useful for staging and prognosis but has minimal influence on overall survival. In this article, we review colonic lymphatic anatomy and pathology, methods of lymphadenectomy, the results of extended and conservative lymphadenectomy, the patterns of failure following colectomy, the adjuvant therapy of regional nodal metastasis, the effect of colon cancer biology on nodal metastasis, and the implications of nodal metastasis on tumor immunology. After review of data, we conclude with a statement of our current philosophy and recommendations for regional lymph node resection in colon cancer.

Curative resection of hepatocellular carcinoma with intrabile duct tumor growth mimicking hilar bile duct carcinoma

A 62-year-old Japanese male was admitted with obstructive jaundice and underwent percutaneous transhepatic cholangiodrainage (PTCD). An initial diagnosis was made of hilar bile duct carcinoma, based on demonstrated irregular stenosis of the hilar hepatic bile ducts without obvious tumor within the liver and negative alpha-fetoprotein (AFP). Enhanced computed tomography (CT) showed an irregular low density area around the hepatic hilum and the umbilical portion of the portal vein, suggesting carcinomatous invasion with blood flow disturbances. In contrast, intraoperative ultrasonography (US) raised the suspicion of an ill-defined lesion in Couinaud's segment 2 (segment 2) and intrabile duct tumor formation. A radical extended left and caudate lobectomy of the liver was successfully performed, with additional resection of extrahepatic bile duct and enbloc resection of regional lymph nodes. Unexpectedly, histological analysis of the resected specimen showed the final diagnosis to be hepatocellular carcinoma (HCC) of segment 2 with intrabile duct tumor growth. This case demonstrates that HCC with intrabile duct tumor growth toward the heptic hilum can mimic hilar bile duct carcinoma, when the tumor itself is equivocal on preoperative imaging and AFP is negative. In such cases, intraoperative US and guided biopsy may be of value for definitive diagnosis and selection of the optimal procedure.

Merkel cell carcinoma. Diagnosis and treatment.

Merkel cell carcinoma is an uncommon malignancy of the skin that often portends a poor prognosis. Since its first description by Toker in 1972, a plethora of case reports and articles regarding the etiopathogenesis and treatment have been published spanning multiple medical and surgical disciplines. Much confusion still exists regarding the diagnosis and treatment of this ominous tumor. Through extensive review of the medical, surgical, and pathological literature, to collate the observations of multiple investigators and summarize these findings. Articles from journals of multiple subspecialties were carefully reviewed with particular emphasis placed on epidemiology, prognosis, histology, immunohistochemistry, electron microscopy, tumor origin, treatment, and work-up of Merkel cell carcinoma. Merkel cell carcinoma is an aggressive malignant neoplasm. Local recurrence develops in 26-44% of patients despite therapy. Up to three-fourths of patients eventually develop regional nodal metastases with distant metastases occurring in one-third of all patients. Reported overall 5-year survival rates range from 30% to 64%. Treatment recommendations unfortunately are based more on anecdotal than scientific data because of the rarity of the tumor and its recognized high risk. Most authors recommend wide local excision of the primary lesion and regional lymph node resection if lymph nodes are palpable followed by x-irradiation of both the postsurgical bed and lymph node basin. The role of elective lymph node resection in the absence of clinically positive nodes remains controversial.

Therapeutic significance of surgery in advanced neuroblastoma: A report from the study group of Japan

The role of surgery was evaluated in 19 stage III and 102 stage IV neuroblastoma patients, all of whom were treated with intensive induction chemotherapy by the Study Group of Japan between January 1985 and March 1990. For stage III neuroblastoma, surgical intervention at the primary site was performed in 18 of the 19 patients, 9 during and 9 after the first three cycles of A 1 regimen, consisting of high-dose cyclophosphamide, vincristine, THP-adriamycin, and cis-platinum. Gross complete resection of primary tumor and regional lymph nodes was feasible in 17 of the 19 patients (89%), and the survival rate for the 17 patients were 79%, 70%, and 70% at 2 years, 3 years, and 4 years, respectively. For stage IV, surgical intervention at the primary site was performed in 92 of the 102 patients (90%): 30 cases during the first 3 cycles of A 1 chemotherapy and 62 cases after that, with gross complete resection accomplished in 81 of the 102 patients (79%). The 81 patients with gross complete resection achieved had a better prognosis than those 11 patients with partial resection ( P < .05). Overall survival rate was 62% at 2 years for 27 patients who underwent complete resection after 3 cycles of A 1 when resolution of all metastases was obtained, whereas the survival was 52% at 2 years for 31 patients who similarly underwent complete resection but when evidence of persistent metastases was present. Patients in whom the ipsilateral kidney was preserved at surgery had an outcome superior to that of those with associated nephrectomy ( P < .05). The incidence of local recurrence was lower in patients who underwent gross complete resection than in those who had partial resection. It was concluded that gross complete resection of a primary tumor and lymph nodes has a significant value in achieving complete remission and survival in patients with advanced neuroblastoma, when they are treated together with a very intensive induction chemotherapy such as the protocol used in the present study.

Carcinoma of the Gallbladder

The records of 111 patients with gallbladder carcinoma operatively treated between 1972 and 1984 were retrospectively reviewed. Fifty-seven percent of patients had distant metastases; another 16% had nodal metastases without distant disease. Median survival was 0.5 years, and 5-year survival was 13%. Clinical jaundice, tumor stage, and tumor grade were all predictive of patient outcome. DNA ploidy, measured in 70 patients, was not a prognostic indicator. In 36% of patients, cholecystectomy (20%) or radical cholecystectomy (16%), which included adjacent liver and regional lymph node resection, was potentially curative. Median survival for patients undergoing radical procedures was 3.6 years, and survival was 0.8 years for patients following cholecystectomy. The 5-year survival rates were comparable (33% vs 32%). While radical cholecystectomy may benefit individual patients and can be accomplished with low morbidity, there was no overall survival advantage compared with cholecystectomy.

The Heritage of the Radical Neck Dissection

THE SUCCESS of the modern head and neck oncological surgeon in curing patients with head and neck cancer is due in large part to the principles that evolved from the astute clinical observations of George Crile, MD, and the truly imaginative and bold surgical concepts that he fostered. In his monumental article published in JAMA in 1906, he demonstrated the effectiveness of en bloc resection of regional lymph nodes and other lymphatic structures in the neck, including resection of the sternocleidomastoid muscle, the internal jugular vein, and the submaxillary salivary gland, in rendering patients free of disease. What led Crile to the surgical concepts he advocated was his observation that patients with head and neck cancer died primarily because the site of origin of the tumor was not controlled and/or the cancer had spread to regional neck structures. His basic premise was that each patient with cancer of the head

Preoperative irradiation in renal cancer. Evaluation of radiation treatment plans.

1. Analysis of radiation treatment plans of a preoperative irradiation study of the kidney indicates that the primary cancer has been treated to levels of 4,500 rads plus or minus 10 per cent in 90 per cent of the instances. 2. The major problem, from the point of view of the radiation therapist's treatment planning, is the delivery of adequate doses to the regional nodal volume. Only 25 per cent received the prescribed dose. Special booster fields are required. 3. Surgical resection of regional lymph nodes and renal vein thrombus, if present, is recommended, since the deliverance of full radiation doses is not likely without exceeding tolerance of vital normal tissues.