Use Of Lymphadenectomy Research Articles

Surgical Staging for Endometrial Cancer in the Elderly—Is There a Role for Lymphadenectomy?

AbstractMost gynecologic oncologists believe that use of lymphadenectomy (LND) after hysterectomy in women with advanced-stage endometrial cancer improves the 5-year disease-specific survival (DSS). At present, the role of postsurgical LND in the management of women with early-stage endometrial canc

Complications of lymphadenectomy for gynecologic cancer

IntroductionSymptomatic postoperative lymphocysts (SPOLs) and lower-limb lymphedema (LLL) are probably underestimated complications of lymphadenectomy for gynecologic malignancies. Here, our objective was to evaluate the incidence and risk factors of SPOLs and LLL after pelvic and/or aortocaval lymphadenectomy for gynecologic malignancies. MethodsSingle-center retrospective study of consecutive patients who underwent pelvic and/or aortocaval lymphadenectomy for ovarian cancer, endometrial cancer, or cervical cancer between January 2007 and November 2008. The incidences of SPOL and LLL were computed with their 95% confidence intervals (95%CIs). Multivariate logistic regression was performed to identify independent risk factors for SPOL and LLL. ResultsWe identified 88 patients including 36 with ovarian cancer, 35 with endometrial cancer, and 17 with cervical cancer. The overall incidence of SPOL was 34.5% (95%CI, 25–45) and that of LLL was 11.4% (95% confidence interval [95%CI], 5–18). Endometrial cancer was independently associated with a lower risk of SPOL (adjusted odds ratio [aOR], 0.09; 95%CI, 0.02–0.44) and one or more positive pelvic nodes with a higher risk of SPOL (aOR, 4.4; 95%CI, 1.2–16.3). Multivariate logistic regression failed to identify factors significantly associated with LLL. ConclusionComplications of lymphadenectomy for gynecologic malignancies are common. This finding supports a more restrictive use of lymphadenectomy or the use of less invasive techniques such as sentinel node biopsy.

Emerging concept of tailored lymphadenectomy in endometrial cancer.

Emerging concept of tailored lymphadenectomy in endometrial cancer.

Surgical approach and the use of lymphadenectomy and adrenalectomy among patients undergoing radical nephrectomy for renal cell carcinoma

ObjectivesWe assessed the influence of tumor size and surgical approach on the use of lymphadenectomy and adrenalectomy with radical nephrectomy. MethodsWe evaluated patients with renal cell carcinoma (RCC) enrolled in the U.S. Kidney Cancer Study, a case-control study in the metropolitan areas of Detroit and Chicago from 2002 to 2007. We identified patients who underwent open (ORN) or laparoscopic radical nephrectomy (LRN). We used medical records and Surveillance, Epidemiology, and End Results (SEER) data to determine the proportion of patients who underwent lymphadenectomy or adrenalectomy. Bivariate analyses were performed to evaluate associations between tumor size, surgical approach, and receipt of lymphadenectomy or adrenalectomy. ResultsWe identified 730 patients who underwent ORN (427, 58%) or LRN (303, 42%) for RCC from 2002 to 2007. Among this group, 11% and 24% underwent lymphadenectomy or adrenalectomy, respectively. Lymphadenectomy was more common among patients treated from an open surgical approach (14.1% ORN vs. 5.9% LRN, P < 0.01); this difference was most pronounced for cases with tumors between 4 and 7 cm (15.9% vs. 2.9%, P = 0.01). Patients treated with ORN were also more likely to undergo adrenalectomy, with the greatest discrepancy among cases with tumors ≤ 4 cm (21.7% vs. 11.4%, P < 0.01). ConclusionsAmong patients undergoing radical nephrectomy for RCC, the use of lymphadenectomy and adrenalectomy is relatively uncommon and varies by tumor size and surgical approach. With an increasing number of patients with small tumors, the diffusion of laparoscopy, and the emergence of clinical trials evaluating systemic adjuvant therapies, our findings highlight important considerations for optimizing surgical management of patients with RCC.

Retroperitoneal dissemination of colorectal ovarian metastases: Basis for rationale use of lymphadenectomy.

535 Background: Retroperitoneal lymph nodes are a common site of metastases in primary ovarian cancers and primary peritoneal carcinoma, therefore pelvic and paraaortic lymphadenectomy are recommended. Colorectal ovarian metastases are mostly associated to peritoneal carcionomatosis (PC), which treatment is based on complete cytoreductive surgery (CCRS) associated to intraperitoneal chemotherapy (IPC). The aim of this study was to compare the rate of nodal (pelvic, paraaortic) recurrences, between 2 groups of patients (pts) operated on PC with ovarian metastases (OM) or without OM. Methods: From January 1994 to December 2009, all consecutive women who underwent CCRS plus IPC, were selected from a prospective database. Demographics, tumor characteristics, surgical procedures and chemotherapy, were analyzed and compared. Results: One hundred and five pts were identified; 63 (60%) had ovarian metastasis (synchronous or metachronous). Groups were comparable for all variables, except for the median peritoneal cancer index which was lower in the OM group (9 vs.10.5, p&lt;.05). Nodal recurrences were diagnosed in 19 pts (18%), in paraaortic nodes in 14 pts (74%), pelvic nodes in 7 pts (36%), both in 2 pts (10%) and were associated to other relapse in 15 pts (80%). All these nodal recurrences occurred in the OM group (30% vs. 0, p&lt;.001). After a median follow-up of 74 months (10-196), 3-year overall survival rate was greater in pts without nodal recurrences (71 vs 41 %, p=0.37) and at the end of the study, there was significantly more patients died of disease in case of nodal recurrence (24/44 vs 5/19, p=.04). Conclusions: Nearly one third of patients with ovarian metastases experienced paraaortic and pelvic nodes recurrences. This may due to the specific pattern of lymphatic spread of ovary, well known in primary carcinomas. Therefore, systematic lymphadenectomy should be studied in patients with colorectal ovarian metastases treated in curative intent. No significant financial relationships to disclose.

The Role of Lymphadenectomy in Surgical Staging of Endometrial Cancer

Surgical staging, including lymph node sampling, for endometrial cancer was adopted by the International Federation of Gynecology and Obstetrics (FIGO) in 1988 based on reports demonstrating diagnostic and therapeutic advantages. This review focuses on the incidence of lymph node metastasis, risk factors for lymph node involvement, the effect of lymph node metastasis on prognosis, the therapeutic effect and diagnostic usefulness of lymphadenectomy, risks of lymph node dissection, and future directions in surgical staging of endometrial cancer. Surgical staging identifies most patients with extrauterine disease as well as uterine risk factors for recurrence, thereby allowing for a more informed approach to postoperative adjuvant therapy. Lymphadenectomy as a part of surgical staging is not required in patients assessed intraoperatively to be at low risk for lymph node metastasis (<2 cm grade 1 tumors with superficial myometrial invasion), however, a systematic lymph node dissection should be performed in most other patients with endometrial cancer. In the future, molecular markers may be useful to predict preoperatively tumor aggressiveness and lymph node metastasis. It is hoped that an approach of surgical staging with selective lymph node dissection will improve survival and spare patients additional surgical complications or unnecessary postoperative exposure to radiation and/or chemotherapy.

721 SURGICAL APPROACH AND THE USE OF LYMPHADENECTOMY AND ADRENALECTOMY FOR PATIENTS WITH RENAL CELL CARCINOMA

You have accessJournal of UrologyTechnology & Instruments: Robotics/Laparoscopy/Ureteroscopy I1 Apr 2010721 SURGICAL APPROACH AND THE USE OF LYMPHADENECTOMY AND ADRENALECTOMY FOR PATIENTS WITH RENAL CELL CARCINOMA Christopher Filson, David Miller, Julie Ruterbusch, Joanne Colt, Wong-Ho Chow, and Kendra Schwartz Christopher FilsonChristopher Filson Ann Arbor, MI More articles by this author , David MillerDavid Miller Ann Arbor, MI More articles by this author , Julie RuterbuschJulie Ruterbusch Detroit, MI More articles by this author , Joanne ColtJoanne Colt Bethesda, MD More articles by this author , Wong-Ho ChowWong-Ho Chow Bethesda, MD More articles by this author , and Kendra SchwartzKendra Schwartz Detroit, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1209AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There is no standard approach to management of the adrenal gland and regional lymph nodes in patients undergoing radical nephrectomy (RN). We therefore used data from the NCI's United States Kidney Cancer Study (KCS) to evaluate variation in the use of lymphadenectomy and adrenalectomy among patients undergoing RN for renal cell carcinoma (RCC). We specifically assessed the influence of tumor size and surgical approach on use of these adjuncts to RN. METHODS We evaluated patients with RCC enrolled in the KCS, a population-based, case–control study conducted in the metropolitan areas of Detroit and Chicago from 2002-2007. During the study interval, 1,136 patients with RCC consented to both an epidemiological interview and medical record review. We identified patients who underwent open (ORN) or laparoscopic radical nephrectomy (LRN). Next, we used medical records and routinely-collected data from the Detroit SEER registry to determine the proportion of patients who underwent concurrent lymphadenectomy or adrenalectomy. We performed bivariate analyses to evaluate associations between tumor size, surgical approach, and receipt of lymphadenectomy or adrenalectomy. RESULTS We identified 730 patients who underwent ORN (427, 58%) or LRN (303, 42%) for RCC from 2002-2007. Among this group, 11% and 24% underwent lymphadenectomy or adrenalectomy, respectively. Lymphadenectomy was more common among patients treated with an open surgical approach (14.3% vs 5.3%, p<0.01); this difference was most pronounced for cases with tumors between 4-7 cm (15.9% vs 2.9%, p=0.01) (Figure). Patients treated with ORN were also more likely to undergo adrenalectomy, especially among cases with tumors ≤ 4 cm (21.7% vs. 11.4%, p<0.01). CONCLUSIONS Among contemporary patients undergoing RN for RCC, the use of lymphadenectomy and adrenalectomy is relatively uncommon and varies by tumor size and surgical approach. In an era characterized by an increasing number of patients with small tumors, diffusion of minimally-invasive surgical techniques, and emergence of potential systemic adjuvant therapies, our findings highlight several important considerations for urologists interested in optimizing the surgical management of patients with RCC. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e280-e281 Peer Review Report Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Filson Ann Arbor, MI More articles by this author David Miller Ann Arbor, MI More articles by this author Julie Ruterbusch Detroit, MI More articles by this author Joanne Colt Bethesda, MD More articles by this author Wong-Ho Chow Bethesda, MD More articles by this author Kendra Schwartz Detroit, MI More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Pattern of retroperitoneal dissemination of primary peritoneum cancer: Basis for rational use of lymphadenectomy

Introduction The rationale for lymphadenectomy in primary peritoneal cancer (PPC) is unclear. We sought to define the pattern of lymphatic metastasis in PPC and propose evidence-based rationale for lymphadenectomy in relevant cases. Methods Patients with PPC undergoing primary surgery at Mayo Clinic were identified. Demographics, tumor characteristics, procedures performed and follow up were analyzed. Results Forty eight patients with PPC were identified; 39 had stage IIIC (81.2%) and 9 (18.8%) had stage IV. Residual disease (RD) after primary surgery was microscopic in 6 cases (12.5%), less than 1 cm in 33 (68.8%), more than 1 cm in 9 patient (18.7%) with median survivals of 5.8, 3.2 and 1.3 years, respectively. Overall, 24 patients had lymphadenectomy performed (pelvic (PND) or paraortic (PAND) or both). Pelvic nodes were involved in 12/23 (52.7%) cases, while para-aortic nodes were involved in 5/21 (23.8%) of cases. The rate of simultaneously positive pelvic and para-aortic nodes was 20% (4/20). Nodal involvement was a poor prognostic factor with 5 year overall survival 63% vs. 25% ( p = 0.014) in node positive vs. negative cases. Compared to patients with primary ovarian cancer (OC), OC cases had a higher rate of positive para-aortic nodes (57.6%: 77/132; p = 0.004). Conclusions Retroperitoneal lymph nodes are a common site of metastases in PPC, therefore it is logically consistent to perform PND and PAND if a patient can be cytoreduced to microscopic RD in other sites or remove grossly positive nodes in patients with RD < 1 cm.

The treatment and outcomes of early-stage epithelial ovarian cancer: have we made any progress?

The objective of this study is to determine the progress and trends in the treatment and survival of women with early-stage (I–II) epithelial ovarian cancer. Data were obtained from the SEER database between 1988 and 2001. Kaplan–Meier and Cox regressions methods were employed for statistical analyses. Of the 8372 patients, the median age was 57 years (range: 12–99 years). A total of 6152 patients (73.4%) presented with stage I and 2220 (26.5%) with stage II disease. Over the periods 1988–1992, 1993–1997, and 1998–2001, 3-year disease-specific survivals increased from 86.1 to 87.2 to 88.8% (P=0.076). The number of patients that underwent lymphadenectomy has increased significantly from 26.2 to 38.7 to 54.2% over the study period (P<0.001). Of those patients who underwent staging procedures with lymphadenectomy, there was no improvement in survival over the three study periods (from 93.2 to 93.5 to 93.1%; P=0.978). On multivariate analysis, younger age, nonclear cell histology, earlier stage, lower grade, surgery, and lymphadenectomy were significant independent prognostic factors for improved survival. After adjusting for surgical staging with lymphadenectomy, the year of diagnosis was no longer an important prognostic factor. In conclusion, the use of lymphadenectomy during surgery for early-stage ovarian cancer has doubled over the last 14 years. The marginal improvement in survival demonstrated over time is potentially attributed to the increased use of staging procedures with lymphadenectomy.

Randomized trial of systematic lymphadenectomy (LY) vs nodal sampling (SA) at second look surgery (SLS) in ovarian cancer patients: Final results

5068 Background: The role of systematic pelvic and para-aortic lymphadenectomy at SLS in ovarian cancer patients has not been addressed by randomized clinical trials (RCTs). We conducted a RCT to determine whether LY improves progression-free (PFS) and overall survival (OS) compared with SA. Methods: From January 1991 through December 1999, 303 eligible patients (i.e. patients with FIGO stage I-IV epithelial ovarian carcinoma at up front surgery and in complete remission after primary debulking surgery and first line chemotherapy) were randomly assigned to undergo LY (N = 156) or SA (N = 147) at the end of SLS. Survival was analyzed using a Cox multivariable regression analysis. All statistical tests were two-sided. Results: Median operating time was longer and the percentage of patients requiring blood transfusions was higher in the LY arm than the SA (240 vs 135 min., P &lt; .001, and 30% vs 10%, P &lt; .001, respectively). In the LY arm and SA arm the median number of removed nodes and the percentages of patients with nodal involvement was statistically different (44 vs 8, P &lt; .0001, and 24% vs 13%, P = 0.018, respectively). At a median follow-up of 59 months, 156 events (i.e., recurrences or deaths) were observed, and 98 patients had died. The 5-year progression-free and overall survival was 41% and 65% for LY, 49% and 61% for SA, respectively. The risk for first event (hazard ratio [HR] = 1.11, 95% CI = 0.81 to 1.53; P = .50) and death (HR = 0.79, 95% CI = 0.53 to 1.18; P = .24) after adjustment for residual tumor at first surgery was not significantly different between the two arms. Conclusions: Although LY at SLS seemed to improve overall survival, this survival gain (21% decrease in the hazard of death) was not statistically significant and therefore the routine use of LY at SLS for ovarian cancer is not supported by this RCT. No significant financial relationships to disclose.

Lymphadenectomy for papillary thyroid cancer: Changes in practice over four decades

Aims Lymphadenectomy in the management of papillary thyroid cancer (PTC) has evolved. The aim of this study was to examine the changing role of neck dissection as reflected in the practice of a large thyroid unit over four decades. Methods A retrospective cohort study of patients that underwent primary thyroid surgery for papillary cancer in a single unit in the period 1958–2002. Nine 5-year periods were considered and the data relevant to the treatment of the regional lymph nodes reviewed. Results Nine hundred patients with PTC underwent surgery between 1958 and 2002 of whom 32.7% underwent lymph node dissection (LND). The use of lymphadenectomy increased from 21.4% in 1958–1962 to 48.1% in 1998–2002 of which 84% underwent a selective lymph node dissection (SLND)—a dissection where the LND is determined by the extent of the disease encountered. The mean number of nodes removed during SLND was 12.6 (range 1–56) of which a mean of 3.1 (24.8%) (0–19) were involved by the disease. Cervical levels 6 and level 4 were those most frequently dissected. There was no statistically significant difference in the complication rates in patients undergoing neck dissection and those not. Conclusion The four decade experience reflects a move away from modified radical neck dissection and cherry picking towards SLND. Growing evidence suggests that lymphadenopathy in adult PTC is an adverse prognostic factor. SLND, a lymphadenectomy tailored to the extent of the disease process, is the coherent treatment for PTC since it serves the dual purpose of staging as well as control of local disease. This can be achieved with little morbidity when performed in a specialist centre.

Utilidad y ventajas de la inyección subareolar única del trazador en la biopsia selectiva del ganglio centinela en el cáncer de mama

Sentinel lymph node (SLN) biopsy is a reliable technique for determining axillary status in patients with early breast cancer. This technique is a minimally invasive procedure that can avoid the use of lymphadenectomy in patients without axillary involvement. We present a validation study of SLN biopsy with subareolar injection of 99mTc-nanocolloids. We studied 100 patients with early breast cancer (T1 and T2) over a 2-year period. All patients underwent deep subareolar-injection of 99mTc-nanocoloid for localization of the sentinel node. Images were obtained and when the sentinel node was seen, it was marked on the skin. All patients underwent tumor excision and radioguided SLN biopsy followed by complete lymphadenectomy. Histopathological analysis of sentinel nodes was performed by hematoxylin-eosin and immunohistochemistry with cytokeratins. The sentinel node was identified in all patients, and a mean of 1.95 sentinel nodes per patient were found. Lymphatic metastases in the sentinel node were found in 44 patients and in 15 of these tumoral spread was also found in the remaining axillary nodes. In the 56 remaining patients the sentinel node was free of metastasis, but in two of them a non-sentinel node was found to be positive (4.5% false negative rate). Sensitivity was 95.7% (44/46), specificity was 100% (54/54), the positive predictive value was 100% and the negative predictive value was 96.4% (54/56). SLN biopsy is an accurate alternative to complete axillary lymph node dissection in patients with early-stage breast cancer. This technique improves the staging of these patients and decreases the morbidity associated with lymphadenectomy. The advantages of subareolar injection are that a single injection site is required, the tumor does not have to be located by other techniques, it allows rapid visualization of the sentinel node and avoids the "shine through phenomenon" when the tumor is located near the axilla.

Combined mediastinal node assessment by lymphadenectomy and intraoperative mediastinoscopy

The purpose of this study was to determine the importance of combined mediastinal node assessment by lymphadenectomy and intraoperative mediastinoscopy to patients with left lung cancer. Forty-one patients with left lung cancer were divided into a group of 13 and a group of 28: in the first group, the aortic arch was mobilized, while in the second group the aortic arch was not mobilized. The mediastinal nodes of both groups were then dissected and mediastinoscopes were inserted into the operation field with an approach through thoracotomy to biopsy each mediastinal node. We compared nodal pathological assessment in these two groups. In the group with mobilized aortic arches, pathological assessment of lymphadenectomy at Naruke's station 3 was 11/13 (85%) and combined with intraoperative mediastinoscopy was 12/13 (92%). In the group without mobilized aortic arches, pathological assessment of lymphadenectomy of station 3 was 14/28 (50%) and combined use of intraoperative mediastinoscopy significantly improved the diagnoses to 24/28 (86%) (P=0.004). Combined use of lymphadenectomy and intraoperative mediastinoscopy could improve the assessment of station 3 in left lung cancer without mobilizing aortic arch.

Intraoperative mapping of renal lymphatic drainage: technique and application in a porcine model.

The use of lymphadenectomy in renal-cell carcinoma (RCC) is controversial. Proponents argue that lymphadenectomy improves survival, whereas opponents challenge the procedure on the basis of its morbidity and the variable lymphatic drainage of the kidney. Intraoperative gamma probes have been used to guide resection of radiolabeled sentinel nodes in cancers of the breast, penis, and head and neck and in melanoma. Our goal in applying this technique to RCC is to improve detection and to limit sampling of lymph nodes during lymphadenectomy. This preliminary study in a porcine model evaluated the feasibility and transit time of radiolabeled tracer injected into the kidney. Data were collected on four 40-kg Yorkshire pigs. The right kidney was exposed through a flank incision. Using both blue dye and technetium-99m, mapping and resection of the sentinel lymph nodes was performed with the assistance of an intraoperative gamma probe (Neoprobe). Remote cervical lymph nodes were utilized as controls. Vascular counts along the carotid vessels were obtained to confirm that the radioisotope was not being dispersed systemically. Within 10 minutes of renal injection of the tracer, excised sentinel lymph nodes demonstrated significant radioactive counts compared with controls. Vascular counts confirmed that radioisotope tracer did not enter the venous circulation. Sentinel lymph node sampling using a gamma probe and blue dye appears to be feasible in the porcine kidney. Further studies using this technique in humans will evaluate the impact of selective lymphadenectomy on survival in RCC.

Multizentrische Umfrage zum Stellenwert der Lymphonodektomie beim Endometriumkarzinom in Deutschland

Einleitung und Fragestellung: Im Management des Endometriumkarzinoms hat sich das primär chirurgische Staging etablieren können. Hierbei wird von verschiedenen Arbeitsgruppen auch die Lymphonodektomie empfohlen. Im Gegensatz zur prognostischen Bedeutung des Lymphknotenstatus ist der therapeutische Nutzen der Lymphonodektomie unklar. Methodik: Im Rahmen einer Querschnittsstudie im Zeitraum von Oktober 2001 bis Januar 2002 wurden insgesamt 1030 standardisierte Fragebögen an Frauenkliniken in Deutschland versendet. Ergebnisse: 595 Antworten (58%) konnten ausgewertet werden. Die Zusammensetzung war wie folgt: Universitätskliniken 5,2%, Kliniken der Maximalversorgung 69,7% und Regelversorgung 25%. Führen Sie eine Lymphonodektomie beim Endometriumkarzinom durch? Nur 7,3% (95% Kl: 5,3–9,7%) gaben an, nie eine Lymphonodektomie durchzuführen, 62,9% (95 Kl: 58,9–66,9%) führen diese in ausgewählten Fällen, 29,7% (95% Kl: 26–33.7%) regelmässig durch. Welche Methode der Lymphonodektomie wenden Sie an? 27,1% (95 Kl: 23,2–31,4%) setzen das «Sampling», 72,9% (95 Kl: 68,6–76,8%) die systematische Entfernung ein. 26,6% (95% Kl: 22,8–30,6%) lymphonodektomieren sowohl pelvin als auch paraaortal. Welche Intention verfolgen Sie mit der Lymphonodektomie? 31,7% (95% Kl: 22,8–30,6%) führen diese aus Gründen des Stagings, 3,1% (95% Kl: 1,8–4,9%) wegen des Überlebens und 65,2% (95% Kl: 60,9–69,3%) wegen beidem durch. 94,5% (95% Kl: 92,1–96,3%) gaben an, dass der Lymphknotenbefall einen Einfluss auf die Wahl der adjuvanten Behandlung besitzt. 76,8% (95% Kl: 72,8–80,4%) bzw. 36,9% (95 Kl: 46,9–56.5%) wählen in den Stadien I/II bzw. III/IV eine Radiotherapie, 20,4% (95% Kl: 16,9–24,2%) bzw. 51,7% (95% Kl: 46,9–56.5%) eine Radiochemotherapie. Schlussfolgerungen: Die vorliegenden Ergebnisse sollten als Grundlage für die Konzeption prospektiver, multizentrischer Studien zum operativen und zytostatischen Management dienen.

Book review

Book review

Management of the Recurrent, Benign Tumor of the Parotid Gland

On occasion, the salivary gland surgeon is faced with clinical management questions related to the treatment of parotid gland tumors. Some of these are intraoperative and include margin of resection, management of the facial nerve when tumor abuts its branches, judicious use of lymphadenectomy, and the appropriateness of nerve grafting. Other questions concern postoperative care-such as the use of radiation therapy, reoperation when a malignancy is reported after surgery, timing of follow-up, and management of a recurrent, benign tumor. Although all of these issues cannot be addressed in one review article, the author has attempted to offer a rational approach to one of the most perplexing-the recurrent, benign tumor. The recommendations offered are based on the literature and a clinical experience of two decades of salivary gland surgery. Within this review a number of other management issues noted above are also addressed.

THE TECHNIQUE OF RADICAL PERINEAL PROSTATECTOMY

The resurgence of the radical perineal prostatectomy for the treatment of localized prostate cancer has been facilitated by the current emphasis on reducing medical costs, the identification of more cases of localized disease, the selected use of lymphadenectomy, and the use of laparoscopic techniques to perform node sampling. This technique provides a cost-effective, low-morbidity, and efficacious means of treating localized prostate cancer.

Endometrial carcinoma.

Endometrial cancer is a common tumor of the female genital tract. The majority of women diagnosed with endometrial cancer present with early-stage disease. Although the optimal treatment for these patients requires hysterectomy, the use of lymphadenectomy is controversial. Growing scientific data support the use of lymphadenectomy in all patients diagnosed with endometrial cancer. When performed by an experienced surgeon, pelvic and para-aortic lymphadenectomy is a safe and potentially therapeutic procedure that provides prognostic information to the patient and physician. This information allows appropriate, cost-effective treatment strategies to be created for all women with endometrial cancer.

Surgical management of primary melanoma.

Melanoma precursor lesions and stage I malignant melanomas are preferentially removed by excisional surgery. Several studies have supported the concept of a more conservative excision strategy. Reduced safety margins with a maximum of 2-3 cm enable us to cover most defects by simple skin flap techniques. In critical anatomical sites and in lentigo maligna melanoma micrographic surgery has recently gained importance. The value of adjuvant surgical procedures remains controversial. Possibly, the technique of sentinel-node-biopsy provides a better approach towards a more selective use of lymphadenectomy in patients with clinically occult micrometastases.