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PubMed2005

Histologic survey of neuroblastomas after intensive induction chemotherapy.

BACKGROUND: Histology after intensive induction chemotherapy is expected to become a beacon indicating when and how extensively radical surgery and lymph node dissection should be performed in advanced neuroblastoma. A thorough histologic review of surgical specimens was undertaken. PROCEDURE: All specimens from 34 patients who were pretreated intensively (> or =3 cycles) with recent chemotherapy were reviewed. Thirty patients were >12 months of age with stage 3/4 disease, and 4 were <12 months of age but with MYCN-amplified stage 4 diseases. After 3 to 7 cycles (mean, 4.3 cycles) of induction chemotherapy, patients underwent radical surgery of the primary tumor and lymph nodes in all retroperitoneal sections. A single pathologist reviewed all of the specimens, and histologic chemotherapeutic effects were graded as: (+++), <1% viable tumor; (++), 1%-10% viable tumor; (+), 11%-50% viable tumor; (+/-), 51%-90% viable tumor; and (-), >91% viable tumor. RESULTS: Grade (+++) effects were observed in 56% of patients treated with the new regimens, whereas grade (+++) was seen in only 20% treated with regimens before 1991. Operation time and blood loss were 7 hr and 6 min (P = 0.087) and 646 ml (P = 0.064), respectively, in patients with >5 cycles (mean, 5.3 cycles) of chemotherapy, while they were 7 hr and 50 min and 1,168 ml, respectively, in those with approximately 3 cycles (mean, 3.2 cycles). Histologically, metastases were found in the contralateral nodes beyond the aorta in 92% of those whose tumor originated on the left, and in 80% of those with tumors occurring on the right. CONCLUSIONS: Five cycles of induction chemotherapy did not improve histologic chemotherapeutic effects, but helped to facilitate a shorter operation time and less blood loss than 3 cycles of chemotherapy. Surgery after 5 cycles of (98)A(3) also appears to be easier to perform than that after 3 cycles of A(1)/new A(1). Only 14% of the children treated before 1985 with the St. Jude protocols experienced grade (+++) chemotherapeutic effects, and 22% of the patients treated before 1991 with regimen A(1), or new A(1) of the Study Group of Japan showed grade (+++) effects, whereas 56% of the patients treated after 1991 with either regimen A(3) or (98)A(3) exhibited grade (+++) chemotherapeutic effects. Histologic chemotherapeutic effects were roughly parallel with a good prognosis.

Abdominal Neoplasms↗
PubMed1992

Extraperitoneal endoscopic pelvic lymph node dissection.

Laparoscopic pelvic lymphadenectomy has been found to be efficacious in the staging of genitourinary cancers. Technological advances in endoscopic instrumentation have allowed an extraperitoneal approach to be performed. Presented are two patients who underwent an extraperitoneal endoscopic lymph node dissection as a staging procedure for prostatic carcinoma. Technical aspects of the procedure and advantages relative to the laparoscopic intraperitoneal approach are discussed.

Adenocarcinoma↗
PubMed1977

Testicular tumors in infants and children.

Forty three children with testicular tumors have been presented. Eighty per cent of these tumors were malignant, and 60 per cent occurred in children less than two and one half years of age. Twenty of the 24 malignant germinal tumors were embryonal cell carcinomas. The mean age of the patients at presentation of these tumors was 18 months. Nine patients underwent orchiectomy alone, and five of these have died. Eleven received combined therapy, and all have survived. We currently recommend radical orchiectomy and extended unilateral retroperitoneal lymphadenectomy. If examination of the nodes reveals evidence of metastases, a bilateral dissection is done. Radiotherapy is given only in the presence of nodal metastases. Adjuvant chemotherapy with vincristine, actinomycin D, and Cytoxan is given for two years to all patients with malginant nonseminomatous germ cell tumors or sarcomas.

Adolescent↗
PubMed1984

The role of surgical resection when combined with chemotherapy and radiation in the management of pelvic rhabdomyosarcoma.

With the development of combined chemotherapy and radiation therapy for embryonal rhabdomyosarcoma, the role and extent of surgical resection of these pelvic tumors need to be defined. Thirty-six children with pelvic genitourinary rhabdomyosarcoma seen at St. Jude Children's were managed on protocols combining surgical resection and radiation, and chemotherapy. Ten children presented with cervical-vaginal tumors, which were managed with combined therapy; the surgical resection was histovaginectomy in eight and pelvic exenteration in one. Eight of the ten are free of disease from 1 to 14 years. Twelve children presented with bladder and prostate tumors, which were resected with segmental cystectomy in four cases, biopsy in five, and pelvic exenteration in three. All received combination therapy and six of the twelve are surviving free of disease from 6 months to 16 years. Fourteen children presented with paratesticular rhabdomyosarcoma. Chemotherapy was combined with radical orchiectomy in all cases. Retroperitoneal node dissection was done in nine and five had inguinal node dissection. Nine of the 14 are surviving NED from 2 to 16 years. One patient died, free of disease, with complications of combination therapy. The results of this review supports the approach of combining chemotherapy, radiation, and complete surgical resection.

Adolescent↗
PubMed1986

Thigh abscess. An uncommon presentation of intraabdominal sepsis.

Abscesses of the thigh are rare and, although easily diagnosed, their cause is often obscure. We present two cases of thigh abscesses which resulted from the extension of intraabdominal sepsis. A review of the literature reveals only 46 previously reported cases. The underlying pathologic abnormality is usually a retroperitoneal perforation of a colorectal neoplasm or diverticular disease, whereas origin from the small bowel or appendix is distinctly less common. Routes of extension of infection into the thigh can be either direct, through the subcutaneous tissues, or through naturally occurring defects in the abdominal wall. These include: (1) along the psoas muscle deep to the inguinal ligament; (2) through the femoral canal; (3) by way of the obturator foramen; and (4) through the sacrosciatic notch. The two cases presented are unusual in that they both followed radical cystectomy with lymph node dissection, which opens up these natural avenues to the spread of intraabdominal infection. The overall mortality in the literature is high (53 percent), but recognition of an abdominal source and appropriate treatment combined with local drainage of the thigh abscess appears to improve survival.

Abscess↗
PubMed2006

Retroperitoneal nodal metastasis in primary and recurrent granulosa cell tumors of the ovary.

OBJECTIVE: To describe the incidence of retroperitoneal pelvic or paraaortic lymph node metastasis in patients with primary and recurrent ovarian granulosa cell tumors. METHODS: At Memorial Sloan-Kettering Cancer Center, we conducted a retrospective chart review of all patients with ovarian granulosa cell tumors managed as inpatients from January 1991 to July 2005. The initial date of diagnosis ranged from 1971 to 2005. RESULTS: We identified 68 patients with a median age of 49 years (mean, 47.5 years; range, 19-78 years). Sixty-four (94%) patients had adult type and 4 (6%) had juvenile granulosa cell tumors. Fifty-three (78%) patients had their initial surgery at another institution and 55 (81%) were incompletely surgically staged at diagnosis due to the absence of pelvic and/or aortic lymph node dissection. Patients were assigned an International Federation of Gynecology and Obstetrics (FIGO) stage that included IA, 39; IC, 15; IIB, 3; IIC, 3; IIIC, 1. In 7 patients, the original stage was not assigned. Only 16 (24%) patients had a pelvic lymph node sampling and 13 (19%) also had a paraaortic lymph node sampling at primary surgery or at restaging surgery performed shortly following initial diagnosis; however, in these cases, lymph nodes were negative for metastasis. The median number of pelvic lymph nodes removed was 10 (mean, 11.6 nodes; range, 0-36 nodes). The median number of paraaortic lymph nodes removed was 4 (mean, 6 nodes; range, 0-19 nodes). Nine of 15 (60%) of patients managed initially at our institution were surgically staged compared to 4 of 53 (7.5%) who were managed initially elsewhere (P < 0.001). Thirty-four patients with recurrent granulosa cell tumors were managed during the study, 31 (91%) had adult type granulosa cell tumor, and 3 had juvenile histology. Thirty-three of 34 patients who recurred were incompletely surgically staged at the initial operation. Original "clinical" FIGO stage for patients who recurred included IA, 15; IC, 8; IIB, 1; IIC, 3; IIIC, 1; and in 6 patients, the original stage was not available. The median disease-free interval to first recurrence was 63 months (mean,69.4 months; range, 4-170 months). First recurrence sites included pelvis, 24/34 (70%); pelvis and abdomen, 3 (9%); retroperitoneum only, 2 (6%); pelvis and retroperitoneum, 2 (6%); pelvis/abdomen/retroperitoneum, 1(3%); abdomen only, 1 (3%); and bone, 1 (3%). CONCLUSIONS: Complete surgical staging was performed in approximately 1/5 women with ovarian granulosa cell tumors; however, in those initially surgically staged, no nodal metastasis was identified. Clinical stage IA disease was the most common original diagnosis in women who recurred, and approximately 15% of first recurrences appear to involve the retroperitoneum.

Adult↗
PubMed2004

Extraperitoneal laparoscopic lymph node staging: the University of Southern California experience.

OBJECTIVES: To describe our experience with extraperitoneal lymph node staging in gynecologic oncology. MATERIALS AND METHODS: The extraperitoneal approach was performed to assess the lymph node histology in patients with gynecologic malignancies. The nodes are approached from a lateral approach after dissecting open the extraperitoneal space bluntly and with insufflation. Bilateral aortic nodes are taken from a left-sided or right-sided approach depending on the patient's characteristics. RESULTS: Forty-six patients underwent this procedure over a 2.5-year period. Thirty-seven patients had cervical cancer. The median BMI was 27.1 (17.7-38.1). The median lymph node yield was 14 (0-60). Two patients had disruption of the peritoneum such that the aortic lymphadenectomy had to be completed transperitoneally. No patients required laparotomy. No patients required transfusion. DISCUSSION: This technique permits histologic evaluation of the retroperitoneal nodes with minimal risk of intraabdominal adhesions. Recovery is rapid and further therapy can be prescribed shortly. The data on the nodes can assist in treatment planning.

Adolescent↗
PubMed2000

Open technique for nerve-sparing retroperitoneal lymphadenectomy.

INTRODUCTION: Retroperitoneal lymphadenectomy (RPLND) is indicated in patients with testicular cancer of all stages for staging, prognostic, and therapeutic purposes. Modification of the classic RPLND to incorporate nerve sparing has reduced the morbidity associated with this procedure with respect to ejaculation and fertility. TECHNICAL CONSIDERATIONS: Performance of nerve-sparing RPLND requires an understanding of the anatomy of the sympathetic chains, their branches, and their relationship to the major structures of the retroperitoneum. The key element of this procedure is the prospective identification of the postganglionic nerves, which arise from the lumbar sympathetic chains and form an anastomosing network anterior to the aorta and surrounding the origin of the inferior mesenteric artery. Precise dissection of these nerves allows complete skeletonization of the great vessels and removal of all lymphatic tissue, without compromising cancer control. CONCLUSIONS: Nerve-sparing RPLND is the procedure of choice for patients with testicular cancer in whom surgical therapy of the retroperitoneum is indicated. The procedure is associated with minimal morbidity and results in preservation of ejaculation in virtually all patients with low-stage disease and in selected patients with advanced disease or after chemotherapy.

Humans↗
PubMed2000

[Is it able to simplify the classifications of staging and curability for pancreatic cancer?].

This study was undertaken to simplify the classifications of the staging and curability of pancreatic cancer by the Japan Pancreas Society (JPS). A total of 461 patients who underwent surgical resection from 1968 to 1997 were analyzed in this study in accordance with our new classification of staging and curability. This staging mainly consists of three factors based on tumor extent:invasion to the retroperitoneum (rp); invasion to the extrapancreatic nerve plexus (pl); and lymph node metastasis (n). Each factor is simply judged as + (positive) or - (negative). Curability is also judged simply based on whether the presence of tumor is detected or not, and the degree of lymph node dissection is not included in curability. Our staging and curability assessment is strongly associated with survival rates after surgery. The 5-year survival rate of stage I patients is 50% and curability of A is > or = 50%. It is concluded that it is possible to simplify the classification of the staging and curability of pancreatic cancer by the JPS.

Humans↗
PubMed1991

[Inguinal lymphatic metastasis of cancer of the testis: staging and therapeutic approach].

Inguinal lymph node metastases from testicular tumors are reported in 2% of cases. Between 1980 and 1990, two patients in a series of 54 testicular tumors, presented with inguinal node metastases. In there two cases and in the cases in the literature, it is well known, that testicular tumors in patients who have had the lymphatics disrupted by prior scrotal or inguinal surgery, or tumor-contaminated scrotum, can metastasize primarily to the ipsilateral inguinal nodes. Even in the absence of other retroperitoneal metastases, these testicular tumors must be considered to be stage IIA. Owing to the efficacy of primary or secondary chemotherapy, ipsilateral inguinal node dissection is not necessary in nonseminomatous testicular tumors. For testicular seminoma, an additional inguinoscrotal radiotherapy is necessary. Survival rate for testicular tumors with isolated metastatic inguinal nodes, particularly in tumor-contaminated scrotum, is not significantly different, compared to a group of patient without inguinal nodes.

Adult↗
PubMedDate not supplied

Surveillance programs for stage I nonseminomatous germ cell tumors of the testis.

Germ cell tumors of the testes constitute approximately 1-2% of all tumors in males 15-35 years of age. Half of those present as clinical stage I disease. The traditional approach was either a retroperitoneal node dissection or radiotherapy. A historical review of the literature suggested that 70% of these patients were cured and did not benefit from further therapy. This coupled with the advent of tumor markers, advanced diagnostic techniques, and cisplatin based chemotherapy led to the consideration for surveillance programs, thereby offering therapy only to those who required it. This article reviews the surveillance programs described in the literature to date with respect to both suitability and program design.

Adolescent↗
PubMed1994

Laparoscopic oncologic proctosigmoidectomy with low colorectal anastomosis in a cadaver model.

The purpose of this study was to demonstrate that a standardized approach to laparoscopic proctosigmoidectomy in a cadaver model with (1) initial proximal ligation of the inferior mesenteric (IM) vascular pedicle, (2) complete mobilization of the splenic flexure, and (3) intraperitoneal stapled colorectal anastomosis can be accomplished in complete accordance with oncologic surgical principles. Using nine cadavers in the fresh state, six abdominal wall cannulas were placed so as to allow good access to the left colon and rectum. After identifying the left ureter and gonadal vessel, the IM pedicle was divided close to the aorta and the left mesocolon was separated from the retroperitoneal structures. The sigmoid colon was transected at the proximal resection line with an endoscopic stapler; then the splenic flexure and descending colon were completely mobilized. The rectum was freed circumferentially, dissected first posteriorly, laterally, and anteriorly, and then transected in its middle portion with an endoscopic stapler. The specimen was removed through a widened left-lower-quadrant trocar incision and the anvil of a circular endoscopic stapler was placed into the proximal colon extraperitoneally. An intraperitoneal laparoscopic colorectal anastomosis was performed using a double-stapled technique. The median length of specimen was 53 cm (range 45-80 cm) and the median number of removed lymph nodes was 15 (range 11-20). A careful abdominal autopsy was carried out in all cadavers. Length of remaining inferior mesenteric artery was smaller than 1.5 cm in all cases and only one remaining lymph node (3 mm in diameter) was found adjacent to the IMA in one subject. No damage to either ureter occurred.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1983

The importance of one-stage median sternotomy and retroperitoneal node dissection in disseminated testicular cancer.

More than 350 patients with testicular germ cell cancer have been treated with cisplatin combination chemotherapy. Seventy-two with metastases to the thorax who had operation are discussed here. In a subgroup of 24 patients with additional retroperitoneal disease, a one-stage median sternotomy was performed in 18 patients, and a thoracotomy in 6, with retroperitoneal node dissection. Seventeen patients had similar pathological lesions in the thorax and retroperitoneum; in 7, the lesions differed. There was no operative mortality in the entire group. Overall, chemotherapy altered the metastases to mature teratoma in 28 patients, and 27 are long-term survivors. Among 22 patients with fibrotic, necrotic masses, 19 are long-term survivors; 6 of the 22 with persistent carcinoma had chemotherapy postoperatively and are long-term survivors. The overall cure rate for patients with disseminated testicular cancer is approximately 80%. Among those who had a one-stage thoracoretroperitoneal procedure, long-term survival is 83%; for the entire thoracic surgical group, it is 74%.

Adolescent↗
PubMed1998

Management of germ cell carcinoma: state of the art.

The management of all stages of germ cell carcinomas is fairly well defined with generally high rates of cure. In stage I disease surveillance and chemotherapy on relapse is as successful as initial adjuvant chemotherapy. More than 95% of patients will survive. In stage II disease either three to four cycles of chemotherapy, or retroperitoneal node dissection and subsequent chemotherapy if more than six nodes are positive or nodes are > 2 cm diameter, or there is extra nodal extension, are equivalent with survival > 95%. For stage III disease, a new international prognostic classification has determined that the level of tumour markers, presence of non pulmonary visceral disease, or a mediastinal primary, indicate a poorer prognosis. Long term follow up studies reveal an overall percentage of relapses (4-5%) beyond two years and the need for long term follow up.

Chemotherapy, Adjuvant↗
PubMed2003

Prospective evaluation of surgical staging of advanced cervical cancer via a laparoscopic extraperitoneal approach.

OBJECTIVES: To report on a large series of cervical cancer patients at risk for lymph node metastasis who underwent surgical staging by a novel technique. METHODS: Between 1/97 and 3/02, we identified 111 patients who underwent an infrarenal aortic and common iliac lymph node dissection via a laparoscopic extraperitoneal approach for either bulky or locally advanced cervical cancer. We reviewed the medical records and extracted pertinent information. RESULTS: There were no intraoperative complications. Mean patient age was 46 (+/- 9) years. Mean node count was 19 (+/- 12). Thirty (27%) patients had lymph node metastasis. The mean operative time was 157 (+/- 46) min, and mean postoperative stay was 2 days. The majority of complications in the early part of the series were symptomatic lymphoceles. Since 4/01, preventive peritoneal marsupialization has been performed without lymphocele occurrence (37 patients). Two patients (2%) required reoperation. In the node-positive group, extended-field radiation and chemotherapy were well tolerated, but prognosis was dismal (median survival, 27 months). In the node-negative group, the median survival after pelvic radiation limited to the lower level of the surgical dissection was not reached after an average follow-up of 16.6 months. CONCLUSIONS: This novel technique is feasible and combines the benefits of laparoscopy with those of a retroperitoneal approach. It can be used to tailor external radiation therapy. The benefits of extended-field radiation therapy remain unclear; however, this approach does not preclude later use of radiation therapy, whereas possibly minimizing associated toxicities secondary to adhesions.

Female↗
PubMed1997

A randomized study comparing retroperitoneal drainage with no drainage after lymphadenectomy in gynecologic malignancies.

OBJECTIVE: To evaluate the clinical effectiveness of retroperitoneal drainage following lymphadenectomy in gynecologic surgery. METHODS: One hundred thirty-seven consecutive patients undergoing systematic lymphadenectomy for gynecologic malignancies were randomized to receive (Group A, 68) or not (Group B, 69) retroperitoneal drainage. The pelvic peritoneum and the paracolic gutters were not sutured after node dissection. Perioperative data and complications were recorded. RESULTS: Clinical and surgical parameters were comparable in the two groups. Postoperative hospital stay was significantly shorter in Group B (P < 0.001), whereas the complication rate was significantly higher in Group A (P = 0.01). This was mainly due to a significant increase in lymphocyst and lymphocyst-related morbidity. Sonographic monitoring for lymphocyst showed free abdominal fluid in 18% of drained and 36% of not-drained patients (P = 0.03). Symptomatic ascites developed in 2 drained (3%) and 3 not-drained (4%) patients (NS), respectively. CONCLUSIONS: Prophylactic drainage of the retroperitoneum seems to increase lymphadenectomy-related morbidity and postoperative stay. Therefore, routine drainage following lymphadenectomy seems to be no longer indicated when the retroperitoneum is left open.

Adolescent↗
PubMed2003

Usefulness of lymphoscintigraphy and intraoperative gamma probe detection in the identification of sentinel nodes in cervical cancer.

The aim of our study was to prospectively assess the clinical usefulness of sentinel lymphoscintigraphy and intraoperative gamma probe detection in identifying sentinel nodes (SNs) in patients with early cervical carcinoma. Between 6 and 24 h before radical hysterectomy, lymphoscintigrams were obtained following peritumoural injection of technetium-99m antimony sulphur colloid in 26 patients (mean age 45 years, range 32-71 years) with cervical cancer (FIGO I-IIa). Scanning for radioactive nodes was performed using a hand-held collimated gamma-detecting probe in the initial stages of the main operation, during and before exposure of the retroperitoneal spaces. After separation and removal of radioactive, blue nodes, specimens were submitted for pathological evaluation. SNs were successfully localised using a combination of lymphoscintigraphy and intraoperative gamma probe detection in all 26 cases. However, in two of the 26 cases, SNs were only localisable using the gamma-detecting probe. A histologically positive SN was found in only one case. It is concluded that, in cervical cancer, lymphoscintigraphy and SN biopsy using a gamma-detecting probe are easy and reliable methods for the detection of SNs and are of value in defining the necessity and extent of node dissection.

Adult↗
PubMed1988

Practical usefulness of lymphatic and connective tissue clearance for the carcinoma of the pancreas head.

We performed a retrospective review of 59 pancreatic resections for ductal carcinoma of the pancreas head performed between 1971 and 1983. In addition to pancreaticoduodenectomy, 37 consecutive patients (from 1971 to 1981) received lymphatic dissection adjacent to the pancreatic head (Group R1), whereas another 22 patients (from 1981 to 1983) received a wider range of lymphatic and soft tissue dissection, including the para-aortic region (Group R2). These groups did not differ with regard to operative mortality rate or background factors in the patients who tolerated operation. The 3-year cumulative survival rate was 13% in the R1 group vs. 38% in the R2 group (p less than 0.05). Almost all of the deaths from cancer recurrence occurred within 3 years after operation; the cumulative rate of death from local recurrence decreased from 67 to 16% (p less than 0.05) at 3 years. Among the patients with nodal involvement, there was no 3-year survivor in the R1 group, but four (27%) in the R2 group (p less than 0.05) survived. Among the patients whose tumor size exceeded 4 cm with retroperitoneal invasion, there was no 3-year survivor in either group and most patients died of distant metastasis. Extended clearance of regional lymph nodes and soft tissue appears to benefit patients with ductal carcinoma of the pancreatic head whose tumor size is less than 4 cm without severe invasion to the retroperitoneal space.

Carcinoma, Intraductal, Noninfiltrating↗