Removal of the pelvic lymph nodes in cancer of the uterine cervix; transperitoneal (taussig) and retroperitoneal (nathanson) dissection.
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Cervix Uteri↗
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[Prospects for standardization of surgical procedures for carcinoma of the pancreas].
Since physicians need to guarantee the efficacy of medical therapy for patients, therapies for patients with cancer should be standardized to some extent. Carcinoma of the pancreas has the highest death rate of all cancers, with a resection rate as low as about 25% to 30% and a 5-year survival rate of around 9%. It is very difficult in such a situation to standardize the surgical strategy for carcinoma of the pancreas. Because pancreatic cancer is a general disease, the treatment strategy should include not only complete surgical resection but also local control methods with intraoperative radiation, prevention of liver metastasis, development of effective anti-cancer drugs, etc. Major progress in therapy for pancreatic carcinoma may be expected in the near future by with the cumulative use of effective therapies. Standard resection and extended resection: For carcinoma of the head of the pancreas, pancreaticoduodenectomy with regional lymph node dissection is performed in Japan, as is extended resection with thorough lymph node dissection of the retroperitoneal and paraaortic region. However, so far the prognosis of patients who undergo extended resection is not better than those who undergo standard resection. A randomized controlled trial of the two types of resection is now being conducted and its results are awaited. For carcinoma of the body and tail of the pancreas, distal pancreatectomy and splenectomy with lymph node dissection is performed if hematogenous or massive lymph node metastasis or direct invasion of the large vessels has not occurred. The Appleby procedure is performed in some cases. Reconstruction and complications of surgical procedures of carcinoma of the pancreas: It appears that a decrease in complications and a lower death rate have been achieved due to pancreaticoduodenectomy rather than due to the extent of lymph node dissection. In particular, progress in anastomosis techniques of the pancreas and intestine and in perioperative control has been marked. For prevention of complications, it is important that absorbable synthetic sutures be used in the pancreaticojejunal anastomosis, that the cut end of the pancreas be sutured and covered by the jejunum without dead space, and that the stent tube be inserted into the main pancreatic duct. The pancreaticojejunal anastomosis should be bordered by the greater omentum. This technique will prevent both the spread of the pancreatic juice into the intraabdominal cavity and rupture of the blood vessels, which can cause fatal postoperative bleeding. Sufficient intraabdominal drains should be in place, especially around the pancreaticojejunal anastomosis. Radiochemotherapy: There are no effective anticancer drugs for the treatment of carcinoma of the pancreas. It was reported that low-dose 5-fluorouracil and cisplatin (5-FU and CDDP) and gemcitabine plus either 5-FU, epirubicin, or CDDP has some effect. The efficacy of intraoperative radiotherapy has not been confirmed. It is not apparent whether radiochemotherapy is superior to surgery. Curable pancreatic carcinoma: Intraductal papillary-mucinous tumors of the pancreas (IPMT) take their name from the histological feature of mucin production and correspond to so-called mucin-producing tumors of the pancreas. This tumor is classified into two types, the main pancreatic duct type and the branch type. About 90% of the main pancreatic duct type and 20% of the branch type are malignant. The branch type of IPMT resembles a bunch of grasps in imaging procedures. Approximately 60% of cases with the branch type of IPMT can be followed up without surgery. Since the prognosis of IPMT is fairly good and the 5-year survival after surgery is about 70% to 80%, limited resection of the pancreas with organ preservation is under investigation. Mucinous cystic tumors of the pancreasin are characterized by development in the body and tail of the pancreas in middle-aged women, with histological ovarian-type stroma in the wall of the tumor, and round cystic lesions with a fibrous capsule containing multiple cystic components of various sizes, which resembles a Chinese citron upon imaging procedures. Surgery should be performed if such a diagnosis is made.
Digestive System Surgical Procedures↗
[Dissecting aneurysm of the aorta due to retroperitoneal lymph node tuberculosis].
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Adult↗
Outcome of advanced primary fallopian tube adenocarcinoma.
BACKGROUND: Because of the rarity of primary fallopian tube adenocarcinoma (PFTA), the outcome of advanced primary fallopian tube carcinoma has not been fully evaluated, especially in Taiwan. METHODS: We retrospectively studied patients with proven surgicopathologic stage III PFTA. Thirteen patients from 1965 to 1995 were identified. All patients received standard staging surgery including washing cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, retroperitoneal lymphadenectomy, infracolic omentectomy and excisional biopsy of all suspicious lesions. This was followed by adjuvant chemotherapy with four to eight courses of CAP or CEP (cyclophosphamide 500 mg/m2, adriamycin 50 mg/m2, or epirubicin 50 mg/m2, and cisplatin 50 mg/m2 intravenously, every 3 weeks) regimen. RESULTS: The accumulative disease-free survival rate was 15%. The incidence of retroperitoneal lymph node metastases was high, up to 69%, and the incidence of para-aortic lymph node metastases was 62%. Eighty-five percent of the cases were poorly differentiated carcinoma. Optimal debulking surgery was completed in 62% of patients, contributing to long-term patient survival (25% vs 0%), compared with those without optimal debulking surgery. CONCLUSIONS: The prognosis of stage III PFTA in our study was poor. Careful lymph node dissection in the retroperitoneal space including the para-aortic area is required. Optimal debulking surgery plus postoperative adjuvant chemotherapy appears to be the only option for enhancing long-term disease-free survival.
Adenocarcinoma↗
[Observations on the course of ejaculation in the posterior urethra].
Nine patients underwent retroperitoneal nerve-sparing lymph node dissection for bilateral nonseminomatous testicular tumours (path. St. I disease). While the isolated lumbar nerves L1, L2, L3 were electrostimulated (30 Hz, 5-20 V), the activity of these seminal vesicles, bladder neck and posterior urethra was recorded by way of suprapubic transvesical sonography and/or endoscopy. Emission started simultaneously on three different levels: contraction of the seminal vesicles in the periphery, bladder neck closure, and opening of the paracollicular space. Contraction of the seminal vesicles extends to the midline; the prostatic urethra closes, starting at the bladder neck. Secretion from the ductuli prostatici (milky) and from the ductucli ejaculatorii (transparent) follow. It was confirmed by the detection of PSA (11,000-21,000 ng/ml) in the ejaculate that prostatic secretion is also present in it. The significance of the postganglionic nerves for emission increased from L1 to L3. In three patients with salvage lymph node dissection the above-mentioned ultrasound monitoring allowed differentiate nerves relevant to emission from those not involved, allowing more comprehensive retroperitoneal resection.
Adolescent↗
Operation of choice for resectable carcinoma of the head of the pancreas.
What is the best procedure for resectable carcinoma of the head of the pancreas? In order to respond to the question, a retrospective study was performed based on 510 cases with carcinoma of the head of the pancreas that were experienced from 1975 to 1984 at nine major surgical institutions in Japan. Laparotomized cases (504) were divided into four groups according to operative procedures: pancreatoduodenectomy (PD), total pancreatectomy (TP), regional pancreatectomy (RP), and palliative operation (PO). The postoperative cumulative survival rate (PCSR) was calculated on each group. Although the five year survival rate of PO was 0, those of PD, TP, and RP were 11.2, 4.6, and 4.5%, respectively. There was a significant difference between PD and TP (p less than 0.01) according to generalized Wilcoxon's test. TNM stage grouping was applied to 447 cases that had adequate descriptions on T, N, and M categories. PCSR was calculated on PD, TP, and RP at each stage. It was found in Stage III that survival curve of PD was significantly higher than TP (p less than 0.01), according to generalized Wilcoxon's test. It seems that PD is the best procedure, but it should be accompanied by extensive lymph node and retroperitoneal tissue dissection.
Adult↗
Analysis of clinicopathologic factors predicting para-aortic lymph node metastasis in endometrial cancer.
The purposes of this study were to compare the relationships between para-aortic lymph node metastasis and various clinicopathologic factors to evaluate whether para-aortic lymph node dissection is necessary when treating endometrial cancer. A retrospective study was performed on 841 patients with endometrial cancer, who underwent the initial surgery at the Keio University Hospital. Clinicopathologic factors related to para-aortic lymph node metastasis significant on a univariate analysis were analyzed in a multivariate fashion using a logistic model. According to the multivariate analysis, the clinicopathologic factor most strongly related to the existence of para-aortic lymph node metastasis was positive pelvic lymph node metastasis (P < 0.01). Among the 155 patients who underwent pelvic and para-aortic lymph node dissection, the difference of 5-year overall survival by the presence of retroperitoneal lymph node metastasis was examined by Kaplan-Meier method. The prognosis was poor even if para-aortic lymph node dissection was performed in cases of positive para-aortic lymph node metastasis. In conclusion, when deciding whether to perform para-aortic lymph node dissection in patients with endometrial cancer, it is necessary to consider the pelvic lymph nodal status. If there is no pelvic lymph node metastasis, it could not be necessary to perform para-aortic lymph node dissection.
Adenocarcinoma↗
Is systematic scalene node biopsy in pretreatment evaluation of locally advanced cervical carcinoma necessary? Systematic dissection and histopathology of left scalene node biopsies in patients with locally advanced cervical carcinoma.
OBJECTIVE: Cervical carcinomas mainly spread via lymphatics, stepwise from pelvic to aortic and scalenic lymph nodes. Metastatic nodes are the major prognostic factor in this disease. When scalenic nodes are involved, cervical cancer is considered to be disseminated. Since there is a major discrepancy in reported percentages of metastatic scalene nodes in the literature (0 to 50%), we proceeded to systematic pretreatment scalene node biopsy and then evaluated the validity of this procedure. METHODS: From January 1998 to May 2003, 72 patients with locally advanced cervical carcinoma and no suspicious paraaortic or scalenic nodes (respectively on magnetic resonance imaging and clinically) had a systematic surgical pretreatment lymph node evaluation (retroperitoneal laparoscopic infrarenal paraaortic lymph node dissection and left scalenic lymph node biopsy). Scalene biopsy was examined using hematoxylin/eosin stain and immunohistochemistry (KL1 antibodies). RESULTS: Among the 72 patients, 20 were stage IB2, 4 were IIA, 14 were IIB, 4 were IIIA, 27 were IIIB, 1 was IVA and 2 had a recurrent cervical carcinoma. Fourteen women had histologically confirmed paraaortic metastases (11 macroscopic, 3 microscopic). No metastatic involvement of the scalene nodes was detected. Fifteen patients developed a recurrence within 12 months (3 to 19 months). None of the patients developed scalenic recurrence. CONCLUSION: Left scalene node biopsy does not appear to be mandatory in routine pretherapeutic lymph node evaluation of patients with advanced cervical carcinoma and no clinical suspicious nodes. It may be useful to prove disseminated disease in patients with suspicious clinical nodes or hot spots on PET-scan, if fine needle biopsy is unconclusive.
Adenocarcinoma↗
[Multimodality treatment of carcinoma of the pancreas].
Although surgical resection has been the mainstream treatment for carcinoma of the pancreas, the operative results have been so disappointing that most surgeons in western countries have given up performing the resectional procedure. On the contrary, Japanese surgeons have never abandoned their dream of surgical treatment as a cure for the disease. Therefore, more and more aggressive procedures have been performed. Our operative results have not so remarkably ameliorated, but we have become knowledgeable on the pathological features of the carcinoma and believe that the best procedure for carcinoma of the head of the pancreas is a pancreatoduodenectomy with extensive dissection of regional lymph nodes and retroperitoneal tissue, and that surgery itself can not cure the disease but multimodality treatment should be established. Two hundred cases with carcinoma of the pancreas in which cystadenocarcinoma and islet cell carcinoma were excluded, were encountered from 1969 to 1987 in our department. Of 200 cases, only 48 cases underwent resection. Resection was divided into curative and non-curative resection according to macroscopic findings and pathohistological examination of the resected specimen. In cases of curative resection group, the average survival period of cases which underwent multimodality treatment was much longer than that without any adjuvant treatment. However, in cases of noncurative resection group, average survival period of cases with multimodality treatment was almost the same as that without adjuvant therapy. Therefore, multimodality treatment should be applied for curatively resected cases in order to obtain better results. Radiation therapy, especially intraoperative radiation therapy is considered to be a promising alternative modality of extensive retroperitoneal dissection. Hepatic metastasis was found postoperatively in about 27 percent of the resected cases. It seems that this type of recurrence occurred by migration of malignant cells from the tumor into the portal vein due to operative manipulation during surgery. Therefore, intraoperative infusion of an anticancer agent through the portal vein is mandatory, and preoperative and postoperative adjuvant chemotherapy should be considered.
Combined Modality Therapy↗
Postoperative complications after pelvic lymphadenectomy for the surgical staging of endometrial cancer.
OBJECTIVE: To assess whether pelvic lymphadenectomy at surgical staging for endometrial carcinoma is an independent risk factor for the occurrence of postoperative complications. METHODS: Women with uterine cancer who underwent radical abdominal hysterectomy type I or II of Piver-Rutledge with or without pelvic lymph nodes dissection were considered. The occurrence of intraoperative and early postoperative complications (deep vein thrombosis, lymphocysts, febrile morbidity, extraoperative site infections, wound dehiscence, relaparotomy, and death) was prospectively recorded. Non parametric tests, receiver characteristic curve analysis, and multiple logistic regressions were used for statistical purposes. RESULTS: Two hundred six subjects were enrolled, of whom 133 underwent pelvic lymphadenectomy. The rate of postoperative complications was 26.7% (55 of 206). Women with complications had a higher median (range) number of lymph nodes removed than those without complications (17 [3-62] versus 11 [1-74], P <.01). The performance of a type II hysterectomy (OR = 2.49, P <.05) and the removal of more than 14 lymph nodes (OR = 3.05, P <.005) were significantly associated with the occurrence of at least one complication. Multiple logistic regression revealed that, after adjustment for the type of surgery, the removal of more than 14 nodes was the only condition associated with postoperative complications (OR = 2.56, P <.01). The only variable significantly associated with the development of two postoperative complications was the removal of more than 19 nodes (OR = 9.7, P <.01). CONCLUSIONS: The extension of retroperitoneal lymph nodes (more than 14) dissection is an independent risk factor for the occurrence of postoperative complications in patients undergoing surgical staging for endometrial carcinoma.
Adult↗
Successful management of inferior vena cava thrombus complicating advanced germ cell testicular tumor with temporary inferior vena cava filter.
We report a case of right testicular tumor with inferior vena cava (IVC) thrombus. Due to the risk of pulmonary embolization, a temporary IVC filter had been inserted during chemotherapy. There were no complications with the temporary IVC filter during the implantation period. The patient was safely treated with systemic chemotherapy using a temporary IVC filter followed by retroperitoneal lymph node and vena cava dissection.
Adult↗
Spermatic cord sarcoma in adults.
The cases of 16 adult patients with spermatic cord sarcoma were retrospectively reviewed. Patient ages had a bimodal distribution (median 57.5 years). Presentation was scrotal mass, inguinal mass or both, with an average diameter of 6.7 cm. Radical orchiectomy was performed in 9 patients, and simple tumorectomy in 7. Lymph node dissection was performed in 6 patients, including retroperitoneal dissection in 4 patients. Various types of soft tissue sarcomas were found. Embryonal rhabdomyosarcomas were evident only in young patients. Lymph node metastases were found in 2 out of 6 cases. Testicular atrophy was observed in 3 young patients, germline destruction by the tumor in 2, and partial spermatogenesis in 2 patients. The median time to first relapse in 13 patients was 5.5 months. Surgery was the primary treatment and the best salvage modality. The role of chemotherapy and radiation therapy as true adjuvant or post-salvage-surgery adjunctive treatments remains unclear.
Adult↗
[A case of synchronous cervical lymph node metastases from testicular and thyroid cancers showing mixed response to chemotherapy].
We report a case of synchronous presentation of thyroid cancer and testicular seminoma with lymph node metastasis. A 37-year-old man presented with right scrotal swelling and multiple lymph node swelling. We performed right radical orchiectomy, and histological examination revealed a seminoma of the testis. After systemic work-up for staging, we diagnosed the patient with multiple lymph node metastasis of the seminoma, and administered three cycles of bleomycin, etoposide, and cisplatin (BEP) therapy. Although the chemotherapy was very effective for the retroperitoneal and left cervical lymph node metastases, the right cervical tumor did not change. Retroperitoneal lymphadenectomy combined with right cervical lymph node dissection and hemi-thyroidectomy were performed on September 8, 1998. Pathological examination of the thyroid revealed papillary thyroid cancer and its right cervical lymph node metastasis. There was no evidence of viable cancer cells from either of the primary cancers in the retroperitoneal lymph node. Unresponsiveness to chemotherapy for metastatic lesions from testicular cancer might be a useful clue to detect primary tumors of other origins.
Adult↗
Combined surgery and chemotherapy for retroperitoneal metastases of testicular carcinomas other than pure seminoma.
The results of treatment in 210 patients with testicular carcinomas other than pure seminoma are analysed. Patients with negative retroperitoneal nodes had a very good prognosis following lymph node dissection alone. Patients with positive nodes did much better after adjunctive chemotherapy than after post-operative irradiation. Patients with advanced disease showed significant improvement with intensive chemotherapy combined with surgery. Presently retroperitoneal lymphadenectomy combined with intensive chemotherapy seems to be the treatment of choice for metastatic testicular carcinomas.
Bleomycin↗
Extraperitoneal laparoscopic paraaortic lymph node dissection: development of a technique.
Surgical assessment of cervical cancer spread primarily involves pathologic evaluation of the pelvic and paraaortic lymph nodes. Extended field radiation therapy, which may result in a survival advantage, is often based on such surgical findings, since clinical staging is inaccurate for this purpose. Extraperitoneal lymph node dissection is superior to a transperitoneal laparotomy approach, largely because of the absence of intraperitoneal adhesion formation and resulting bowel complications. Although transperitoneal laparoscopy may reduce adhesion formation when compared with laparotomy, it does not eliminate this problem. We developed an entirely extraperitoneal laparoscopic technique for paraaortic lymph node dissection in a pig model, using latex balloon dissection technology. The technique was quick, had a short learning curve, and eliminated bowel retraction or dissection. Excellent bilateral retroperitoneal exposure was achieved from the level of the renal to the iliac vessels for aortocaval lymph node dissection.
Animals↗
Dilemma in managing spontaneous pneumoperitoneum: a case report.
Pneumoperitoneum is often associated with an underlying severe life-threatening emergency. This emergency is always treated successfully by a surgical approach. When a patient situated in hopeless situation but is found with spontaneous pneumoperitoneum, it creates a dilemma. We deal with such a rare situation which occurred in a 58-year-old woman with recurrent cervical carcinoma. The patient received a radical hysterectomy, pelvic lymph node dissection and bilateral salpingo-oophorectomy 10 years ago. Recurrent retroperitoneal lymphadenopathy and inguinal lymphadenopathy were suspected by computed tomography and proven by excision biopsy of inguinal lymph node. She received a complete course of concurrent chemoradiation therapy; however, clinically persistent disease was suspected although it was very difficult to prove. Unfortunately, the case was complicated by severe radiation fibrosis over the whole abdominal wall, poor appetite and urinary tract infection. She was treated with supportive care treatment. Nevertheless, the patient was attacked by spontaneous pneumoperitoneum during hospitalization and died later and autopsy of the patient showed military carcinomatosis of the abdominal cavity and lower abdominal wall without any evidence of internal hollow organ perforation and intraabdominal infection. The cause of death might be related to her carcinomatosis with severe chacexia. Because pneumoperitoneum is always considered as a surgical emergency, we reviewed the possible causes of non-surgical pneumoperitoneum to avoid an unnecessary surgical approach.
Female↗
Exposure of the retroperitoneum for radical dissection of lymph nodes.
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Dissection↗
[Controlled pilot study with combination chemotherapy in testicular carcinomas (author's transl)].
In 24 previously untreated patients with advanced testicular carcinoma, the combination of adriamycin, vincristine and methotrexate (AVM) was tested in a prospective randomized study against a combination of non-cross resistant drugs including vinblastine, bleomycin and mithramycin (VBM). Complete and partial (greater than 50%) remission was observed in 4 out of 13 patients treated with AVM and in 3 out of 11 given VBM. In one patient receiving AVM and in two patients treated with VBM, the response at the level of previous inoperable retroperitoneal metastatic lymph nodes allowed a subsequent radical lymph node dissection. After cross-over a partial response for 6 months was obtained in only one patient treated with VBM while none was observed in 4 patients receiving AVM. Both combinations were well tolerated. However, their therapeutic activity seems to be definitely lower with respect to treatment with vinblastine followed by continuous infusion with bleomycin.
Antineoplastic Agents↗