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PubMed2000

Lymph-node dissection in breast cancer.

BACKGROUND: Along with the ongoing modifications in treatment of primary breast cancer, the purpose and extent of lymph-node dissection has changed. The following is an overview of the current knowledge and practice of lymph-node dissection in breast cancer, with special regard to expected developments in the near future. Axillary dissection is described as a ten-step procedure, including dissection of level-I and -II and Rotter's nodes, without level-III nodes, providing at least ten lymph nodes for accurate staging information. DISCUSSION: Axillary dissection still offers the most efficient local control in node-positive patients, whereas, in primarily node-negative patients, irradiation seems to be equally effective. In general, lymph-node dissection does not alter overall survival but there is no doubt that surgical therapy still contributes to cure in early-breast-cancer patients and seems to be curative for certain patients with stage-I carcinoma. The lymph node status of the axilla is crucial for the indication of adjuvant therapy in early invasive breast cancer, but an increasing number of clinical node-negative patients could be managed with information based on features of the primary tumor, regardless of the nodal status. The most promising new concept for the selection of node-positive patients, while avoiding unnecessary morbidity of axillary dissection in early-breast-cancer patients, is the sentinel-node concept. The principle is based on the identification of the first "sentinel" lymph node reached by lymphatic flow. Thus, only proven node-positive patients undergo axillary dissection. Local failure of internal mammary lymph nodes is rarely recognized; however, internal mammary lymph nodes seem to have an underestimated prognostic significance in about 10-20% of axillary node-negative patients. This may lead to the withholding of systemic therapy for patients with early breast cancer. Nevertheless, there is no indication for a routine parasternal dissection today. The sentinel-node concept may also support the selection of diagnostic internal lymph-node biopsy and subsequent adjuvant therapy in cases with no axillary lymph-node metastases but with internal lymph-node metastases.

Breast Neoplasms↗

PubMed1993

Predictors of major ischemic complications after coronary dissection following angioplasty.

Coronary dissection is a major cause of abrupt arterial closure after coronary angioplasty but may also be associated with no discernible event. Deciding which dissections should receive further treatment is often a dilemma if the artery remains patent. This case-control study examined predictors of major ischemic complications after coronary dissections. Fifty-eight patients with coronary dissections, but a patent artery at the completion of the angioplasty procedure, subsequently had in-hospital abrupt arterial closure, acute myocardial infarction, emergency coronary bypass surgery, or died; they were matched to 58 control subjects with dissection but no event. Analysis of each angiogram was performed with the examiner unaware of patient's history. Baseline angiographic and clinical characteristics of cases and controls were similar except for an excess of current smokers among the cases (31 vs 16%; p = 0.048). Residual luminal diameter at the dissection site was 1.2 +/- 0.6 mm (cases) versus 1.6 +/- 0.6 mm (controls; p = 0.001) with relative stenosis of 59 +/- 21% vs 43 +/- 21%, respectively (p = 0.0001). Dissections among cases were longer than among controls (11 +/- 7 mm vs 7 +/- 4 mm; p = 0.001). No significant difference was found in dissection morphology using 2 classification schemes or in final Thrombolysis in Myocardial Infarction study flow grade. Transient occlusion during the procedure, however, occurred in 47% of cases versus 5% of controls (p = 0.0001). Transient occlusion, residual percent stenosis > or = 70%, and dissections > or = 6 mm were independently predictive of major ischemic events.

Acute Disease↗

PubMed2005

Assessment of node dissection for clinical stage I primary lung cancer by VATS.

OBJECTIVE: The feasibility of systematic node dissection (SND) for stage I primary lung cancer by video-assisted thoracic surgery (VATS) remains controversial. The aim of this study was to assess the feasibility of SND by VATS. METHODS: Four hundred and eleven patients with clinical stage I primary lung cancer were enrolled in this study. Two hundred and twenty-one patients, VATS group, underwent a major pulmonary resection with SND by VATS through a minithoracotomy (30-70mm) and two access ports; 190 patients, open thoracotomy (OT) group, did so through anterolateral thoracotomy. The two groups were compared regarding clinical data including number of dissected nodes in each nodal station for evaluating the feasibility of SND by VATS. RESULTS: In the right side, the total number (N) of nodes dissected (VATS 31 vs OT 31, P=0.899), N of mediastinal nodes dissected (20 vs 21, P=0.553), and N of dissected nodes in each nodal station were similar between the two groups. In the left side, total N of nodes dissected (28 vs 27, P=0.714), N of mediastinal nodes dissected (16 vs 17, P=0.333), and N of dissected nodes in each nodal station were similar between the two groups. There were three (1.4%) and five (2.6%) operation related deaths in the VATS group and OT group, respectively (P=0.48). Chest tube duration was shorter in the VATS group than the OT group (5.8 vs 7.6 days, P=0.001). The incidences of chylothorax, recurrent laryngeal nerve injury and pleural effusion requiring thoracentesis after surgery were similar between the two groups (3 vs 4, P=0.709; 5 vs 3, P=0.480, 3 vs 8, P=0.122). The 5-year actuarial recurrence-free survival rate and cumulative survival rate of pathological stage IA cases were similar between the two groups (88.6 vs 92.4%, P=0.698; 92.9 vs 86.5%, P=0.358). CONCLUSIONS: The SND by VATS was as technically feasible as SND through OT regarding number of dissected nodes and morbidity. It seems acceptable as an oncological treatment for clinical stage I lung cancer.

Adenocarcinoma↗

PubMed2007

Limited pelvic lymph node dissection at the time of radical prostatectomy does not affect 5-year failure rates for low, intermediate and high risk prostate cancer: results from CaPSURE.

PURPOSE: Limited bilateral pelvic lymph node dissection performed at radical prostatectomy provides staging information that is used to guide further disease management. Given the effects of widespread prostate specific antigen testing and stage migration, most procedures in the United States are performed for low risk disease, which has a low probability (less than 1%) of lymph node metastasis. We compared 5-year treatment failure rates in patients with low, intermediate and high risk disease who underwent radical prostatectomy with or without pelvic lymph node dissection. MATERIALS AND METHODS: We compared treatment failure rates for radical prostatectomy in 4,693 patients enrolled in the CaPSURE database who underwent radical prostatectomy with or without limited pelvic lymph node dissection. Secondary analysis was performed as a function of pelvic lymph node dissection and risk group based on pretreatment stage, grade and prostate specific antigen. Treatment failure rates were estimated by Kaplan-Meier analysis. RESULTS: The 5-year failure-free survival rate was 70% in the no pelvic lymph node dissection group and 74% in the limited pelvic lymph node dissection group (p = 0.11), while the rates in the low, intermediate and high risk groups were 81% and 82% (p = 0.83), 71% and 63% (p = 0.21), and 42% and 48% (p = 0.45) in the no vs limited pelvic lymph node dissection groups, respectively. Multivariate analysis demonstrated that pelvic lymph node dissection status was not a predictor of treatment failure (p = 0.93). CONCLUSIONS: This study demonstrates in a large cohort of patients that limited pelvic lymph node dissection at radical prostatectomy has no effect on treatment failure rates at 5 years in those at low, intermediate and high risk.

Aged↗

PubMed1993

Exposure, dissection, and laser versus electrosurgery in laparoscopic cholecystectomy.

The technical complications of laparoscopic cholecystectomy occur while creating the pneumoperitoneum, placing trocars, obtaining exposure, and performing the initial dissection of the cystic duct and artery. The errors most feared are intestinal injury, vascular injury, and common bile duct injury. Bile duct injury usually results from the misinterpretation of the extrahepatic biliary anatomy. Confusion is most likely if the gallbladder infundibulum is pushed superiorly and medially, pulling the common bile duct out from behind the duodenum and into line with the cystic duct and gallbladder. Other dissection errors resulting in bile duct injury include the failure to begin dissection on the gallbladder, routine dissection of the cystic duct all the way to the common bile duct, failure to identify anomalies of the cystic and hepatic ducts, failure to open all folds of the gallbladder infundibulum, and entrapment of a narrow common bile duct by a cystic duct clip "slid" too far proximally. Proper dissection strategy includes posterolateral traction on the gallbladder infundibulum and initiation of dissection at the most medial point where the gallbladder is clearly seen. Pedunculation of the gallbladder will reveal most ductal anomalies but should be supplemented with routine digital fluoroscopic cholangiography. The controversy over optimal sources for thermal dissection of the gallbladder has largely been resolved. Electrosurgical dissection is a more rapid, hemostatic, and economical dissection.

Cholecystectomy, Laparoscopic↗

PubMed1988

Critical assessment of supraomohyoid neck dissection.

During a recent 5-year period, 115 patients had 131 supraomohyoid neck dissections. Eighty-one percent of these procedures were performed for squamous carcinoma. Seventy-nine percent of the primary tumors were located in the oral cavity and 16 percent arose in the oropharynx. Almost 80 percent of the necks dissected for primary squamous carcinoma were clinically N0, and occult nodal disease was discovered in 31 percent of these neck specimens. When the supraomohyoid neck dissection specimen showed no involvement, the overall incidence of treatment failure in the neck at 2-year follow-up was 5 percent. Almost all patients with occult squamous carcinoma in the supraomohyoid neck dissection specimen received postoperative radiotherapy, and the failure rate in the neck was 15 percent. When neck nodes were both clinically and pathologically involved, neck recurrence developed in 29 percent of the patients despite the addition of adequate postoperative radiotherapy. Among those patients with nonsquamous primary tumors and a pathologically negative supraomohyoid neck dissection specimen, there was only one subsequent treatment failure in the neck. Supraomohyoid neck dissection appears to be a valid staging procedure for clinically N0 patients with primary squamous carcinomas located in the oral cavity or oropharynx, with an appropriate yield of occult nodal disease, and infrequent treatment failure in the dissected neck when the supraomohyoid neck dissection specimen is pathologically uninvolved. When nodal disease is clinically obvious, treatment failure is more frequent, even with the addition of postoperative radiotherapy. The role of supraomohyoid neck dissection in this setting deserves further study.

Carcinoma, Squamous Cell↗

PubMed1997

Laparoscopic pelvic lymph node dissection for prostate cancer: comparison of the extended and modified techniques.

PURPOSE: We compared the results of extended (obturator, hypogastric, common and external iliac nodes) to modified (obturator and hypogastric nodes only) laparoscopic pelvic lymph node dissection in patients with clinically localized prostate cancer. MATERIALS AND METHODS: A total of 189 patients with stage T1 to T3 prostate cancer underwent modified (150) or extended (39) laparoscopic pelvic lymph node dissection for pelvic nodal assessment before definitive treatment. RESULTS: Twice as many lymph nodes were removed via extended than modified laparoscopic pelvic lymph node dissection (mean 17:8 versus 9.3). The overall positivity rate was 23 of 189 lymph nodes (12.2%), including 14 of 150 (7.3%) for modified and 9 of 39 (23.1%) for extended dissection (p = 0.02). Two patients (22%) who underwent extended dissection had positive lymph nodes in the external iliac area. Patients who presented with the high risk features of prostate specific antigen (PSA) greater than 20 ng./ml., Gleason score 7 or greater, or stage T2b disease or greater had a 26.5% (p = 0.0002), 22% (p = 0.0006) or 16.4% (p = 0.003) likelihood of positive lymph nodes, respectively. For extended versus modified laparoscopic pelvic lymph node dissection node positivity in high risk patients was 27% versus 18.8% (p = 0.4), 30 versus 26.4% (p = 0.8) and 25.4 versus 14.6% (p = 0.17) for Gleason score 7 or greater, PSA greater than 20 ng./ml. and disease stage T2b to T3a, respectively. Patients who underwent the extended procedure had a higher complication rate (35.9 versus 2%, p < 0.0001). No laparotomy was required. CONCLUSIONS: Despite yielding a 2-fold higher node count and higher node positivity rate, extended laparoscopic pelvic lymph node dissection offers no advantage over modified laparoscopic pelvic lymph node dissection for diagnosing positive lymph nodes when results are analyzed by prognostic factors. The extended procedure is associated with a much higher complication rate. In patients with the high risk features of PSA greater than 20 ng./ml., Gleason score 7 or greater and stage T2b to T3a disease modified laparoscopic pelvic lymph node dissection can be performed safely and effectively to help identify those who may benefit most from curative therapy.

Aged↗

PubMed1998

Combined neck dissection and postoperative radiation therapy in the management of the high-risk neck: a matched-pair analysis.

PURPOSE: The purpose of this study was to determine the efficacy of postoperative adjuvant radiation therapy with regard to reducing the rate of recurrence in the neck, cancer-related death, and death from any cause in patients with squamous cell carcinoma of the head and neck region metastatic to neck nodes. METHODS: This was a retrospective review of patients with pathologically confirmed nodal metastases who underwent neck dissection and postoperative adjuvant radiation therapy for squamous cell carcinoma of the head and neck region. Time to recurrence in the dissected area of the neck, any recurrence in the neck, cancer-related death, and death from any cause were estimated with the Kaplan-Meier method. A matched-pair analysis was performed utilizing a cohort of patients who underwent neck dissection without postoperative radiation therapy. The patients from the two cohorts were matched according to previously reported high-risk features for cancer recurrence and death. Cox hazards models for the matched pairs were used to evaluate the relative risk of subsequent recurrence in the dissected side of the neck, any neck recurrence, cancer-related death, and overall survival. MATERIALS: The medical records and pathologic slides of 95 consecutive patients with pathologically confirmed nodal metastases from squamous cell carcinoma of the head and neck region who underwent neck dissection and postoperative adjuvant radiation therapy between January 1974 and December 1990 were reviewed. Previously published data from 284 patients with squamous cell carcinoma of the head and neck region treated with neck dissection alone between January 1970 and December 1980 were used for a matched-pair analysis. RESULTS: The relative risks for recurrence in the dissected side of the neck, any neck recurrence (dissected neck or delayed undissected neck metastasis), cancer-related death, and death from any cause for patients treated with operation alone relative to those treated with operation and postoperative radiation were 5.82, 4.72, 2.21, and 1.67, respectively. CONCLUSION: This study provides evidence that postoperative adjuvant radiation therapy for the high-risk neck can reduce the rate of recurrence within a dissected neck, delayed metastasis within an undissected neck, cancer-related death, and death from any cause.

Adult↗

PubMed1997

D2 dissection for gastric cancer.

Theodore Billroth successfully performed the first gastrectomy for cancer in Vienna in 1881. This was the beginning of modern gastric cancer surgery and provided the first real hope for cure from this form of cancer. Gastric cancer is a leading cause of cancer related mortality world wide, particularly in Central and South America, Japan and Korea, and in the Baltic Sea countries. In the United States, the incidence of gastric cancer has been on the decline since the 1930s. In 1996, it was estimated that there were 24,000 new cases of gastric cancer with 80-90% expected to die of their disease. The Japanese Research Society for Gastric Cancer has classified the draining lymph nodes of the stomach and assigned 16 different lymphatic stations. The nodes were then assigned to one of four echelons (N1-N4). Different locations of the cancer within the stomach require different forms of gastric resections. The Japanese have defined four levels of lymph node dissections (D1-D4), where specified lymph nodes from assigned lymphatic stations are dissected for a given type of resection. This was defined by the General Rules for the Gastric Cancer Study in Surgery and Pathology by the Japanese Research Society for Gastric Cancer in 1962 and revised in 1994. When a tumor has progressed to the muscularis propria or subserosa (T2), 8-31% of the second echelon lymph nodes (N2) will contain metastases. When a tumor has penetrated the serosa (T3), more than 40% of the second echelon lymph nodes will have metastases. Therefore, less than a D2 dissection will inadequately stage a significant population of patients. When retrospective series are reviewed at institutions committed to performing D2 dissections, the overall survival repeatedly shows improved results for patients undergoing D2 dissections when compared to D1 dissections. Moreover, there have been several large trials from all areas of the world which have shown similar morbidity and mortality results when D1 and D2 dissections have been compared. To date, there have been no trials which have been reproducible that have shown an improved survival in patients receiving adjuvant chemotherapy. Intergroup 0116 is currently studying the use of adjuvant radiation therapy in gastric cancer. We have not come far from the days of Theodore Billroth in the treatment modalities for gastric cancer. As surgical expertise and technology have improved, and the field of anesthesia has developed, survival of patients has improved. Only the extent of lymphatic dissection (D2 dissection) has proven beneficial to the outcomes of patients with this disease.

Gastrectomy↗

PubMed1999

The declining use of axillary dissection in patients with early stage breast cancer.

OBJECTIVES: To determine any changes in usage of axillary dissection over time from 1983 to 1993, and to characterize those patients who do not receive axillary node dissection. METHODS: A total of 129,946 female patients receiving cancer-directed surgery for early stage breast cancer, who were identified from the SEER (Surveillance, Epidemiology and End Results) program and diagnosed from 1983 to 1993, were included in the study. The surgical treatment and axillary dissection were based on treatment data collected by the SEER during the first course of therapy. Logistic regression analyses were used to assess the effect of patient and tumor characteristics on the likelihood of not receiving different types of treatment. RESULTS: The percentage of women not receiving axillary dissection has increased over time, from 14.4% in 1983 to 16.8% in 1993. Nearly a quarter of women undergoing breast conserving surgery for local stage breast cancer receive neither axillary dissection nor radiotherapy. Older, unmarried, and non-white women and those with very small (< 0.5 cm) or very large (> or = 4 cm) tumors were most likely to receive neither axillary node dissection nor irradiation. Among those not receiving axillary dissection, 42% had tumors 1-3 cm in size and were not receiving radiation therapy. CONCLUSIONS: There is an apparent divergence between the type of patient who has been recommended as an appropriate candidate for avoiding axillary dissection (those with small tumors and those who will receive adjuvant therapy) and those who are actually not receiving axillary dissection in the community.

Adult↗

PubMed2002

Is there a role for axillary dissection for patients with operable breast cancer in this era of conservatism?

BACKGROUND: The trend in breast cancer surgery is toward more conservative operative procedures. The new staging technique of sentinel node biopsy facilitates the identification of pathological node-negative patients in whom axillary dissection may be avoided. However, patients with a positive sentinel node biopsy would require a thorough examination of their nodal status. An axillary -dissection provides good local control, and accurate staging and prognostic information to inform decisions about adjuvant therapy. In addition, the survival benefit of axillary treatment is still debated. The objectives of the present study were to examine the pattern of lymph node metastases in the axilla, and evaluate the merits of a level III axillary dissection. METHODS: Between June 1997 and May 2000, 308 patients underwent a total of 320 level III dissections as part of their treatment for operable invasive breast cancer. The three axillary levels were marked intraoperatively, and the contents in each level were submitted and examined separately. The patterns of axillary lymph node (ALN) metastases were examined, and factors associated with > or =4 positive nodes, and level III ALN metastases were evaluated by univariate and multivariate analyses. RESULTS: An average of 25 lymph nodes were examined per case (range: 8-54), and using strict anatomical criteria, the mean numbers of ALN found in levels I, II and III were 18 (range: 2-43), 4 (range: 0-19), and 3 (range: 0-11), respectively. Axillary lymph node involvement was found in 45% of the cases (143/320). Of the 143 cases, 78% (n = 111) had involvement of level I nodes only, and 21% (n = 30) had positive ALN in levels II and, or, III, in addition to level I. Involvement of lymph nodes in level II or III without a level I metastasis was found in two cases only (0.6%). By including level II, in addition to level I, in the dissection, four cases (1%) were converted from one to three positive nodes to > or =4 positive nodes (P = 0.64). By the inclusion of level III to a level I and II dissection, three cases (1%) were converted from one to three positive nodes to > or =4 positive nodes (P = 0.74). Involvement of lymph nodes in level III was found in 22 cases (7%), and 51 cases (16%) had > or =4 positive nodes. Palpability of ALN, pathological tumour size, and lymphovascular invasion (LVI), were sig-nificantly associated with level III involvement and > or =4 positive nodes by univariate and multivariate analyses. The frequencies of level III involvement and > or =4 positive nodes in patients with palpable ALN were 22% and 42%, respectively. The corresponding frequencies in patients with a clinically negative axilla, and a primary tumour which was >20 mm and LVI positive, were over 14% and 31%, respectively. CONCLUSION: Level III axillary dissection is appropriate for patients with palpable ALN, and in those with a tumour which is >20 mm and LVI positive, principally to reduce the risk of axillary recurrence. Staging accuracy is achieved with a level II dissection, or even a level I dissection alone based on strict anatomical criteria. Sentinel node biopsy is a promising technique in identifying pathological node-positive patients in whom an axillary clearance provides optimal local control and staging information.

Adult↗

PubMed2002

Gene expression profiles in the acutely dissected human aorta.

OBJECTIVES: heritable connective tissue abnormalities and arterial hypertension may predispose to aortic dissection. This study evaluates gene expression profiles in the acutely dissected human aorta. DESIGN, MATERIALS AND METHODS: Atlas Human Broad Arrays I, II, and III (Clontech) were used to compare gene expression in acutely dissected (6 patients) and normal ascending aortas (6 multiorgan donors). The tissues were also compared macroscopically. RESULTS: of 3537 genes analysed, 1250 (35%) were expressed in aortic tissue. For statistical analysis we focused on 627 genes, which had an intensity>0.95 of the mean patients or controls. Dissected and adjacent macroscopically intact aorta displayed similar gene expression patterns. On the contrary, 66 genes were expressed significantly different in dissected aorta, compared with undiseased control aorta of multiorgan donors. Genes, predominantly upregulated in dissection, are involved in inflammation, in extracellular matrix proteolysis, in proliferation, translation and transcription. Predominantly downregulated genes code for extracellular matrix proteins, adhesion proteins and cytoskeleton proteins. CONCLUSION: our results demonstrate for the first time the complexity of the dissecting process on a molecular level. The ultimate dissection seems to be the dramatic endpoint of a long-lasting process of degradation and insufficient remodelling of the aortic wall. Altered patterns of gene expression suggest a pre-existing structural failure of the aortic wall, resulting in dissection.

Acute Disease↗

PubMed1999

Patterns of nodal metastases in palpable medullary thyroid carcinoma: recommendations for extent of node dissection.

OBJECTIVE: To establish the frequency, pattern and location of cervical lymph node metastases from palpable medullary thyroid carcinoma (MTC). Recommendations are made regarding the extent of surgery for this tumor. SUMMARY BACKGROUND DATA: Medullary thyroid carcinoma is a tumor of neuroendocrine origin that does not concentrate iodine. Surgical extirpation of the thyroid tumor and cervical node metastases is the only potentially curative therapeutic option. Patterns of node metastases in the neck and guidelines for the extent of dissection for palpable MTC are not well established. METHODS: Seventy-three patients underwent thyroidectomy for palpable MTC with immediate or delayed central and bilateral functional neck dissections. The number and location of lymph node metastases in the central (levels VI and VII) and bilateral (levels II to V) nodal groups were noted and were correlated with the size and location of the primary thyroid tumor. Intraoperative assessment of nodal status by palpation and inspection by the surgeon was correlated with results of histologic examination. RESULTS: Patients with unilateral intrathyroid tumors had lymph node metastases in 81% of central node dissections, 81% of ipsilateral functional (levels II to V) dissections, and 44% of contralateral functional (levels II to V) dissections. In patients with bilateral intrathyroid tumors, nodal metastases were present in 78% of central node dissections, 71% of functional (levels II to V) node dissections ipsilateral to the largest intrathyroid tumor, and 49% of functional (levels II to V) node dissections contralateral to the largest thyroid tumor. The sensitivity of the surgeon's intraoperative assessment for nodal metastases was 64%, and the specificity was 71%. CONCLUSION: In this series, >75% of patients with palpable MTC had associated nodal metastases, which often were not apparent to the surgeon. Routine central and bilateral functional neck dissections should be considered in all patients with palpable MTC.

Adult↗

PubMed2003

Complications of primary nerve sparing retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors of the testis: experience of the German Testicular Cancer Study Group.

PURPOSE: Nerve sparing retroperitoneal lymph node dissection has been the standard diagnostic and therapeutic approach to clinical stage I nonseminoma. However, the application of prognostic risk factors and introduction of laparoscopy have recently called into question the clinical usefulness of nerve sparing retroperitoneal lymph node dissection. We assessed the therapeutic efficacy and associated complications of this procedure in patients with clinical stage I nonseminomatous germ cell tumor treated at 7 tertiary referral centers to evaluate its role in the modern management of low stage testis cancer. MATERIALS AND METHODS: Between January 1995 and September 2000, 239 patients with clinical stage I nonseminomatous germ cell tumor underwent nerve sparing retroperitoneal lymph node dissection in standardized fields of dissection. For retrospective analysis patient charts were reviewed. A minor complication did not prolong hospital stay and a major complication prolonged hospitalization for at least 2 days. Early complications developed within the first 30 days after retroperitoneal lymph node dissection and late complications occurred from postoperative day 31 and thereafter. RESULTS: Nerve sparing retroperitoneal lymph node dissection was performed unilaterally in 209 patients (88.2%) and bilaterally in 30 (11.8%). Median operative time was 214 minutes (range 90 to 395), mean hospital stay was 8 days (range 4 to 39) and mean blood loss was less than 150 ml. A mean of 18.5 lymph nodes (range 9 to 57) were dissected with metastases detected in 67 patients (28%). An average of 2.9 lymph nodes (range 1 to 14) with a mean diameter of 2.6 cm. (range 0.3 to 6.0) showed metastasis. Disease was pathological stage I in 172 patients (71.7%), 52 (17.6%) had 3 or fewer metastatic lymph nodes, and 15 (6.3%) had 4 to 5 and 10 (4.2%) had greater than 5 positive lymph nodes. Minor complications occurred in 14.2% of the cases and major complications were observed in 5.4%. Antegrade ejaculation was preserved in 93.3% of the patients, recurrence developed in 14 (5.8%) and retroperitoneal recurrence was observed in 3 (1.2%), including 1 in field and 2 out field. CONCLUSIONS: Primary diagnostic and therapeutic nerve sparing retroperitoneal lymph node dissection still has a role in the primary management of clinical stage I nonseminomatous germ cell tumor. Surgery is associated with low morbidity and patient followup is easy and cost-effective due to the concentration on extraretroperitoneal locations. Primary nerve sparing retroperitoneal lymph node dissection is curative in about 70% of clinical stage I nonseminoma cases with a maximum of 3 positive lymph nodes.

Adult↗

PubMed2003

Is there a therapeutic role for post-chemotherapy retroperitoneal lymph node dissection in metastatic transitional cell carcinoma of the bladder?

PURPOSE: We identified a subset of patients with bladder cancer (transitional cell carcinoma) and regional nodal metastasis to the retroperitoneal lymph nodes without detectable systemic dissemination. While the majority of these patients respond initially to chemotherapy, most have disease relapse at the same site within a year. We report the results of a phase II study exploring the potential benefit of retroperitoneal lymph node dissection in patients with transitional cell carcinoma of the bladder in whom disease has shown a significant response to chemotherapy. MATERIALS AND METHODS: A total of 11 patients with biopsy proven metastatic transitional cell carcinoma in the retroperitoneal lymph nodes and no evidence of visceral metastatic disease in whom disease showed a significant response to chemotherapy underwent complete bilateral retroperitoneal lymph node dissection. The end point of study was disease specific survival, calculated from the time of retroperitoneal lymph node dissection to death from transitional cell carcinoma of the bladder. RESULTS: Four patients underwent delayed retroperitoneal lymph node dissection. Seven patients underwent concurrent cystectomy, and pelvic and retroperitoneal lymph node dissection. There was no perioperative mortality. Nine patients had evidence of residual disease in the retroperitoneal nodes. Seven patients have recurrence outside of the original surgical field with a median time to recurrence of 7 months and 6 died at a median time to death of 8 months (range 5 to 14). One patient with retrocrural recurrence attained a complete response to salvage chemotherapy and remained disease-free 57 months after retroperitoneal lymph node dissection. For all 11 patients median disease specific and recurrence-free survival rates were 14 and 7 months, respectively. Four-year disease specific and recurrence-free survival rates were 36% and 27%, respectively. We stratified the patients based on the number of involved lymph nodes at retroperitoneal lymph node dissection and noted that viable tumor in no more than 2 lymph nodes correlated with greater disease specific and recurrence-free survival (p = 0.006 and 0.01, respectively). CONCLUSIONS: Retroperitoneal lymph node dissection can be safely performed for metastatic transitional cell carcinoma. Retroperitoneal lymph node dissection has curative potential, particularly in patients with viable tumor in no more than 2 lymph nodes after chemotherapy.

Carcinoma, Transitional Cell↗

PubMed2004

Two-step three-field lymph node dissection is beneficial for thoracic esophageal carcinoma.

Aggressive surgery including extensive lymph node dissection is considered necessary to improve the long-term survival of patients with esophageal carcinoma. While three-field lymph node dissection is widely performed for patients with thoracic esophageal carcinoma, cervical lymph node metastasis is uncommon. In order to reduce surgical stress, we have developed a two-step three-field lymph node dissection procedure for thoracic esophageal carcinoma. In the first-step operation, total thoracic esophagectomy through a right thoracotomy is performed. Mediastinal and abdominal lymph node dissection is performed synchronously. When recurrent nerve lymph node metastasis is pathologically positive, cervical lymph node dissection is performed about 3 weeks after the first operation (second step). Of 343 patients with carcinoma of the esophagus surgically treated in our department between 1990 and 2001, 146 underwent the operation described above. Three-field dissection was performed in 68 patients (group A), while two-field dissection was performed in 78 patients (group B). In the 68 group A patients, cervical lymph node metastasis was positive in 15 patients (22%). There was no marked difference in the onset of major complications between the two groups. The 5-year survival rate was 58% for group A and 61% for group B, not a statistically significant difference. In 78 of the 146 patients, it was possible to avoid cervical lymph node dissection without negatively affecting therapeutic outcomes. Two-step three-field lymph node dissection can reduce surgical stress of patients with good clinical outcome.

Aged↗

PubMed1994

Predictors of coronary dissection following percutaneous transluminal coronary balloon angioplasty.

To determine predictors of acute coronary dissection after coronary angioplasty, we studied 170 consecutive patients who underwent arterial dilatations of 234 arteries. Coronary dissection occurred in 103 (44%) arteries. More dissections occurred in women [40/73 (55%) versus 63/161 (39%), p < 0.03] and in patients with long lesions [45/74 (61%) versus 56/158 (35%), p < 0.0005]. Balloon/arterial diameter ratio was higher in patients with dissection (1.1 +/- 0.2 versus 1.0 +/- 0.2, p < 0.02). Complications did not differ in patients with and without dissection except for non-Q wave myocardial infarctions which were more frequent in patients with coronary dissection [10/12 (83%) versus 2/12 (17%), p < 0.01]. Thus coronary dissection during angioplasty is relatively frequent. However, most dissections are not associated with complications. Balloon dilatation of lesions in female patients and in patients with long lesions are more likely to result in dissection.

Acute Disease↗

PubMed1985

Influence of intimal dissection on restenosis after successful coronary angioplasty.

We studied 986 patients who underwent follow-up angiography after successful percutaneous transluminal coronary angioplasty (PTCA) to determine the influence of uncomplicated intimal dissection on restenosis rate. Angiographic evidence of intimal dissection after PTCA was present in 248 patients or 25%. After a mean follow-up time of 7 +/- 5 months (SD) the restenosis rate in patients without intimal dissection was 30% compared with 24% in patients with intimal dissection (p = .08). Patients with available transstenotic pressure gradients were divided according to the hemodynamic result into two subgroups: those with final gradients at the conclusion of PTCA of 15 mm Hg or less (n = 638) and those with gradients greater than 15 mm Hg (n = 244). Patients with intimal dissection had a significantly lower restenosis rate than patients without intimal dissection if the final gradient was 15 mm Hg or less (19% vs 28%; p less than .05). If the final gradient was greater than 15 mm Hg, the presence or absence of intimal dissection had no significant influence on restenosis rate, which was 35% and 39%, respectively (p = NS). We conclude that an uncomplicated intimal dissection after a successful coronary angioplasty has no adverse influence on angiographic restenosis. An excellent angiographic long-term outcome can be expected if the intimal dissection is associated with a favorable hemodynamic result.

Angioplasty, Balloon↗