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PubMed2000

When is pelvic lymph node dissection necessary before radical prostatectomy? A decision analysis.

PURPOSE: In recent years the role of pelvic lymph node dissection before or at radical prostatectomy has been questioned. We compared the outcome of performing or omitting pelvic lymph node dissection in patients undergoing radical retropubic prostatectomy by formal decision analysis. MATERIALS AND METHODS: We created a decision tree for patients undergoing radical retropubic prostatectomy that accounts for all possible branch points and outcomes. Outcome probabilities applied to the model were derived from published data. Utility values were determined for each outcome state by a panel of experts. Decision analysis was done using decision analysis computer software. Sensitivity analysis was performed to determine which elements in the model were most important and to calculate threshold values. RESULTS: Using probability data from the literature and our assigned outcome values, decision analysis initially favored omitting pelvic lymph node dissection. Sensitivity analysis revealed that the threshold values for the incidence of positive lymph nodes and the sensitivity of lymph node dissection and frozen section analysis at which outcomes were equivalent were 18% and 80%, respectively. Analysis was insensitive to the pelvic lymph node dissection complication rate. CONCLUSIONS: We performed formal decision analysis to determine the incidence of lymph node metastasis below which pelvic lymph node dissection is not warranted at radical retropubic prostatectomy. Our results suggest that lymph node dissection is unnecessary in the subset of patients in which the risk of lymph node involvement is less than 18%.

Decision Support Techniques↗

PubMed1975

Control of acute aortic dissection.

An experimental model of acute aortic dissection has been designed in an effort to examine myocardial contractility and systolic arterial pressure as factors influencing the progression of dissection. Thirty mongrel dogs divided into three experimental groups underwent left thoracotomy and construction of a standard intimal tear in the proximal descending aorta. Nine of ten animals in the control group showed progression of the aortic dissection a mean of 81.5 percent of the distance from the aortotomy to the celiac axis. Group II consisted of ten dogs pretreated with propranolol. The myocardial contractility (dp/dt) was significantly depressed in this group without change in systolic pressure. However, progression of dissection occurred in nine of ten animals as in the control group. In Group III, ten dogs were pretreated with trimethaphan lowering the systolic blood pressure to 90 mm. Hg and depressing the dp/dt to levels equal to those of Group II. There was no progression of aortic dissection in any of the animals in this group. The results indicate that, under these experimental conditions, depression of myocardial contractility alone has no inhibitory effect on the progression of dissection. When controlled hypotension is added to myocardial depression, aortic dissection is inhibited completely.

Animals↗

PubMedDate not supplied

Limited effectiveness of extended lymph-node dissection for node-negative patients with proximal gastric cancer.

BACKGROUND: The optimal surgical treatment with respect to the extent of lymph-node dissection for node-negative patients with gastric cancer remains to be established. MATERIALS AND METHODS: A total of 101 node-negative patients with proximal gastric cancer (62 males and 39 females; age range 33 to 79 years; mean 58.0 years), who had undergone curative total gastrectomy, were retrospectively evaluated to determine whether any correlation existed between survival and the extent of lymph-node dissection (D1, limited; D2, extended lymph-node dissection). RESULTS: The 10-year survival rates of patients with T1 (n = 59), T2 (n = 31) or T3 tumors (n = 11) were 100%, 90.0% and 46.7%, respectively. Significant differences in survival were found between patients with T1 and T2 tumors (p = 0.018), T2 and T3 tumors (p = 0.003), and T1 and T3 tumors (p < 0.0001). Despite the fact that only 9 patients with a T1 tumor underwent a D2 lymph-node dissection, all other patients had an excellent prognosis. On the other hand, the 10-year survival rates of patients with T2 or T3 tumors who underwent a D1 or D2 lymph-node dissection were 83.3% and 76.8%, respectively, representing no significant difference between the two procedures for advanced stage cases (p = 0.590). Multivariate analysis showed that depth of invasion was the only statistically significant prognostic factor (p < 0.0001; relative risk, 19.018). CONCLUSIONS: Conventional radical prophylactic D2 lymph-node dissection does not improve the survival of node-negative patients with proximal gastric cancer when compared to limited D1 dissection.

Adult↗

PubMed2001

[Collateral blood flow showing dissection-like filling defect on coronary arteriography: a case report].

A 51-year-old man presented under a diagnosis of angina pectoris manifesting as exertional chest pain. First coronary angiography showed severe stenosis with ulceration and spontaneous dissection at the proximal right coronary artery and linear dissection-like filling defects extending to the distal right coronary artery. After about 3 months, repeat coronary angiography showed the previously observed stenosis with unclear dissection, and better developed collaterals from the left coronary artery to the right coronary artery showing the linear dissection-like filling defects. The bilateral coronary angiography did not clearly show filling defects. This phenomenon suggested that the collateral flows were related to filling of the defects. Intravascular ultrasonic imaging demonstrated severe atherosclerotic lesions at the proximal right coronary artery, but no dissection in the distal right coronary artery. Percutaneous transluminal coronary angioplasty for the stenosis was performed successfully with a stent. Coronary angiography after the angioplasty showed no collaterals, and the right ventricular branch appeared, suggesting that the linear dissection-like filling defects extending to the distal right coronary artery were due to the collateral flows. Filling defects extending distal to a severe stenosis must be distinguished carefully from coronary dissection.

Angioplasty, Balloon, Coronary↗

PubMedDate not supplied

[Endo-surgical dissection of the upper urinary tract through the retroperitoneal and transperitoneal route: an experimental study with pigs and cadavers].

In order to define the best method for endosurgical dissection of the upper urinary tract, an experimental study comparing the retroperitoneal and transperitoneal approaches was performed. Between September 1991 and February 1992, 15 female pigs and 8 human cadavres underwent endosurgical dissection of the upper urinary tract. The retroperitoneal approach was used in 8 pigs and 5 cadavres. In the lateral supine position, the retroperitoneum was insufflated at the lower pole of the kidney, via a 2 cm cutaneo-muscular incision, followed by a blind dissection with the finger to create a space in the retroperitoneal fat. Four trocars were inserted into the retroperitoneal space allowing dissection of the ureter, kidney and its vascular pedicle. The renal vessels and the ureter were then clipped or stapled with the endo-GIA then sectioned. The operation was successfully performed in all of the pigs with a mean operating time of 2 hours. Complications were limited to two peritoneal effractions. Retroperitoneal endosurgical dissection was much longer and more difficult to perform on the cadavre (mean operating time: 3 hours). Satisfactory retropneumoperitoneum was never able to be obtained due to the large amount of retroperitoneal fat and the proximity of the twelfth rib and posterior iliac crest interfered with the insertion of the trocars and made dissection more difficult. The transperitoneal approach was performed in 7 pigs and three cadavres. In the lateral supine position, after creating pneumoperitoneum using a Veress needle, 4 trocars were inserted into the peritoneal cavity. Toldt's fascia was gripped and incised allowing retraction of the colon towards the midline, thereby exposing the renal region. The ureter and the renal vessels were dissected. The renal artery and vein were then clipped or stapled with the endo-GIA then sectioned, while the ureter was clipped and sectioned. The complications of the transperitoneal route were: an injury to the small intestine during insertion of a trocar and haemorrhage due to accidental section of a lower pole renal artery, which was able to be controlled by application of clips. In the pig, the transperitoneal approach was as simple to perform as the retroperitoneal approach and the mean operating time was the same (two hours).(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

PubMed2004

Craniocervical artery dissection: diagnosis and follow-up with MR imaging and MR angiography.

BACKGROUND: Our aim was to determine the value of MR angiography (MRA) in combination with MRI in the diagnosis and follow-up of craniocervical artery dissections (CCAD) and to document the effectiveness of conservative medical treatment in these patients. MATERIAL/METHODS: In seven patients, six internal carotid artery dissections and two vertebrobasilar artery dissections were studied with 2D and 3D TOF MRA and fat-saturated T1W images. MRA projection images, source images, and T1W images with fat saturation were evaluated for the presence or absence of criteria for dissection. RESULTS: MRA projection images showed narrowing and/or occlusion of lumen in all patients. Dissection flap was identified in 5 of the 8 dissections. Both MRA source images and T1W images with fat saturation were useful in showing the increased external diameter of the dissected vessel and the mural hematoma; although the latter proved to give better results. Almost complete resorption of hematoma and normalization of flow were achieved between 1.5 to 7 months. CONCLUSIONS: This study further supports the approach that MRA accompanied by T1W images with fat saturation should be the method of choice in the diagnosis and follow-up of CCAD. Fat-suppressed T1W images improve detection of the mural hematoma, especially in the late sub-acute phase and during follow-up. Conservative medical treatment may be effective, obviating the need for aggressive treatment options.

Adult↗

PubMed2005

[Operative technique aiming at en bloc dissection in esophageal surgery].

The lymph node metastases of esophageal cancer occur over a wide area. It is essential for radical surgery of such metastases to aim at en bloc dissection. Otherwise, it can easily become a combination of blunt esophagectomy and lymph node sampling through a right thoracotomy. In the intrathoracic procedure, all the nodes to be dissected can be harvested while attached to the esophagus together with the surrounding connective tissue, except for the pretracheal nodes in front of the cardiac branches of the right vagus nerve and the subaortic arch nodes. It is important to dissect the left paratracheal nodes en bloc, preserving the left recurrent laryngeal nerve. In the abdomen, nodes around the celiac axis and nodes on the common hepatic artery and proximal part of the splenic artery are all removed en bloc with the perigastric nodes in the left gastric arterial basin. The cervical paratracheal and paraesophageal nodes are removed separately from the resected esophagus, but the continuity of dissection can be ensured when the dissection from the neck meets the empty space made by the dissection along the bilateral recurrent laryngeal nerves through the thoracotomy. We believe that such en bloc dissection is the key to improving the long-term results of esophageal cancer surgery.

Esophageal Neoplasms↗

PubMed1991

Survival after groin dissection for malignant melanoma.

Groin dissection was performed in 158 patients with malignant melanoma (superficial dissection, 76 patients; radical dissection, 82 patients). Of 63 patients with palpable nodes, 57 patients (90%) had histologic involvement. Of 93 patients with nonpalpable nodes, 31 patients (33%) had histologically positive nodes. The 5-year survival rate for patients with histologically negative nodes (n = 69) was 77%; the 5-year survival rate for patients with histologically positive nodes (n = 89) was 43%. The respective 5-year disease-free survival rates were 72% and 34%. Of 57 patients with palpable, positive inguinal nodes, 21 patients (37%) had involvement of the deep nodes. Of 31 patients with nonpalpable, histologic involvement of the inguinal nodes, six patients (19%) had or developed involvement of the deep nodes. One of two patients with uncertain clinical status of the nodes preoperatively had positive deep nodes. In prophylactic node dissection, frozen section of the inguinal group of the nodes does not provide a reliable method, because of sampling errors, in determining microscopic involvement of the nodes and in deciding whether a superficial or radical groin dissection is to be done. For patients with positive nodes the 5-year survival rate was 48% when only the inguinal group was involved and was 28% when both inguinal and deep nodes were involved; the respective 5-year disease-free survival rates were 39% and 20%. Survival after therapeutic groin dissection may partly depend on the thoroughness of the procedure. Patients who have positive, deep nodes and who are undergoing an incontinuity dissection of the inguinal, iliac, and obturator nodes have an appreciable 5-year survival rate.

Female↗

PubMed1989

[Evaluation of the collo-thoraco-abdominal dissection for the intrathoracic esophageal carcinoma].

Five hundred and forty three cases of intrathoracic esophageal carcinoma were reviewed. Of these, one hundred and sixty one cases had collo-thoraco-abdominal (CTA) dissection and three hundred and eighty two cases had thoraco-abdominal (TA) dissection. Postoperative pulmonary complications occurred in 35.5% of the patients who had CTA dissection and in 18.0% of those who had TA dissection. Incidences of postoperative hoarseness of voice and anastomotic leakage were almost similar in the two groups. However, the mortality rates within 30 postoperative days was 4.3% for the CTA groups compared to 1.8% for the TA group. The average number of lymph nodes resected per case was much higher in the CTA group than than the TA group. This implied that the dissection was more extensively performed in the CTA group involving not only bilateral cervical regions but also the upper mediastinum continuing into the neck. Better 1, 2 and 3 years survival rates were observed in the CTA group than the TA group, but for the 4, 5 years survival rates there was no statistical difference noted. For stage-0 and stage-4 carcinoma of the upper third esophagus, marked improvement in the survival rates were obtained in the CTA dissection cases. In conclusion, collo-thoraco-abdominal dissection can be justified for the surgical treatment of intrathoracic esophageal carcinoma despite its postoperative mortality rate of 4.3%.

Abdomen↗

PubMed1989

[The discussion of the need of mediastinal lymph node dissection in the surgical treatment of lung cancer].

The need of lymph node dissection in the case of operative lung cancer with negative mediastinoscopy was discussed. As a preliminary study, the N-number obtained from the mediastinoscopy and that of postoperative examination was compared. The rate of agreement of N-number was as high as 96%. Secondary, 183 cases of lung cancer with squamous-or adenocarcinoma pathologically T-1 or 2. N-0 and P-0 or 1 were picked up and examined. In those cases, the result of 3 years survival rate was 80% in the cases of absolute curative operation and 60% in that of relative non-curative cases, and 5 years survival rate was 70% and 52% respectively, and the cases of absolute curative operation was statistically excellent than that of another group. However, the background of the two groups was different to some degree on account of the advancement of the cancer and the age of the patients. Therefore, the randomized study as for the lymph node dissection in the cases of negative mediastinoscopy was finally performed. In the 30 cases of squamous cell carcinoma where dissection was carried out in 13 cases and not done in 17 cases, the result of 3 years survival was 84% (dissecting group) and 89% (non-dissecting group), and 5 years survival was 73% and 63% respectively. In 23 cases of adenocarcinoma (13; dissecting, 10; non-dissecting), the result of 3 years survival was 100%, 63% and that of 5 years survival rate was 100%, 63% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenocarcinoma↗

PubMed1989

Magnetic resonance imaging in the exploration of dissection of the internal carotid artery.

Five patients with recent spontaneous or post-traumatic dissection of the internal carotid artery (ICA) were explored by magnetic resonance imaging (MRI), using T1-weighted axial sections in all cases. In four patients examined during the subacute phase (after 7 days) the diagnosis of ICA dissection was strongly suspected on the association of a very high intensity signal produced by the parietal haematoma with a contiguous signal void area corresponding to the lumen of the ICA. A control MRI examination performed in two patients 2 months after the onset of dissection showed that it had regressed and that the carotid arteries were patent, which was confirmed by angiography. In the fifth patient MRI provided evidence for the evolution of a post-traumatic dissection towards thrombosis. The MRI image of carotid dissection at the subacute phase seems to be characteristic. MRI is also useful to follow up dissections under treatment and to postpone angiography. The latter, however, remains necessary to investigate for associated arterial dysplasia and to evaluate the sequelae of dissection.

Adult↗

PubMed1984

[Method of radical transabdominal tumor nephrectomy with facultative or systemic lymph node dissection and results in 381 patients].

The prognosis of 381 patients without metastases operated on renal cell carcinoma depends on the extent of the lymph node dissection. After facultative lymph node dissection (FLD) the uncorrected actuarial survival rates (SR) are 64 +/- 8% after 3 years and 50 +/- 9% after 5 years compared to 77 +/- 7% (3 years) and 60 +/- 11% (5 years) when systematic lymph node dissection (SLD) was performed. For stage I the better results in the SLD-group (80 +/- 10% 5 years SR for SLD; 67 +/- 13% 5 years SR for FLD) are partially to be explained as a staging-effect, whereas in stage II the difference (92 +/- 10% 5 years SR for SLD; 45 +/- 25% 5 years SR for FLD) is due to the higher radicality of the systematic dissection. In stage III (35 +/- 14% 5 years SR for SLD; 37 +/- 12% 5 years SR for FLD) the predominant influence of the tumor invasion in renal veins cannot be influenced by local extension of the operation. The incidence of lymph node metastases was 16% (n = 170) in the FLD and 23% (n = 211) in the SLD group. When only facultative dissection is done, 30% of lymph node metastases escape detection. Without any lymph node dissection the number of unrecognized lymphmetastases can be expected to be still higher. The controversies about the role of lymph node dissection in radical tumor nephrectomy are mainly caused by the lack of standardized criteria for operative and patho-histological staging procedures. Any conclusions drawn from comparing reports in the literature should be related to these modalities.

Aged↗

PubMed1984

[Effect of extent of lymph node dissection on prognosis of esophageal cancer].

The lymph node metastasis of the esophageal cancer are located in three main regions such as neck (H), thoracic cavity (T) and abdominal cavity (B). We studied on the relation between the extent of lymph node dissection and prognosis, and that between the lymph node metastasis and prognosis in each region (H.T.B). The long-term survival among the cases with adequate dissection, especially with the adequate dissection in the thoracic region, was better than that among the cases without adequate dissection. Furthermore, adequately dissected cases got better survival compared to the cases without adequate dissection with post-operative prophylactic irradiation. However, in the prognosis of the esophageal carcinoma, hematogenous metastasis have to be taken into consideration as well as lymph node metastasis. Therefore, in order to improve the prognosis of esophageal cancer, it is indispensable to treat the multidisciplinary therapy with immunochemotherapy as well as complete lymph node dissection.

Combined Modality Therapy↗

PubMed1995

Sentinel lymph node dissection for penile carcinoma: the M. D. Anderson Cancer Center experience.

PURPOSE: We determined whether an extended sentinel lymph node dissection is effective for staging penile squamous carcinoma associated with clinically negative inguinal lymph nodes. MATERIALS AND METHODS: A retrospective review was done of 20 consecutive patients who underwent extended sentinel lymph node dissection between 1985 and 1994. RESULTS: Of the patients 14 underwent bilateral extended sentinel lymph node dissection, and 6 underwent ipsilateral extended sentinel lymph node dissection plus contralateral inguinal or ilioinguinal lymphadenectomy. All lymph nodes included in the extended sentinel node dissection were negative for metastases. Five patients had inguinal metastases at a median of 10 months (range 3 to 21) after negative extended sentinel lymph node dissection. CONCLUSIONS: Although it is a more extensive procedure than sentinel lymph node biopsy, extended sentinel lymph node dissection is still associated with a significant false-negative rate (25%). Thus, its routine use can no longer be recommended.

Adult↗

PubMed1993

Correlation between membrane glycoprotein and detergent dissected membrane protein in the assessment of LMIF: a report of 51 ALA cases.

Assessment of 51 amoebic liver abscess cases for leukocyte migration inhibition factor released using membrane glycoprotein and detergent dissected membrane protein (DDMP) of axenic Entamoeba histolytica (NIH:200). Lymphokines release by T lymphocytes in response to purified amoebic membrane glycoprotein (PAMG) against whole amoebic lysate (WAL), dissect out protein against whole amoebic lysate and membrane glycoprotein against dissected protein was tested by leukocyte migration inhibition test on blood samples from proved amoebic liver abscess cases. A significant increase was noted in the release of lymphokines and 100% positivity was observed with both PAMG and DDMP compared to 78% with whole amoebic lysate. The difference between means leukocyte migration indices of the membrane glycoprotein and whole amoebic lysate, detergent dissected protein and whole amoebic lysate with regards to release LMIF were found to be highly significant (P < 0.001), (P < 0.005) respectively. But insignificant difference and very much similarity was noted between the means of membrane glycoprotein and dissect out protein sensitized T lymphocytes with regards to lymphokine release in vitro. This shows the patients had high degree of leukocyte sensitized to pure amoebic membrane glycoprotein and detergent dissected membrane protein compared to whole amoebic lysate. These findings indicate that detergent dissected protein has similar antigenicity with membrane glycoprotein in elicitation cell mediated immune response in amoebic liver abscess cases.

Animals↗

PubMed1996

Retroperitoneal laparoscopic lymph node dissection for staging non-seminomatous germ cell tumors before and after chemotherapy.

We describe our experience with laparoscopic retroperitoneal lymph node dissection in 19 patients with non-seminomatous germ cell tumors. Twelve patients had stage I disease with no clinical evidence (CT-scan, ultrasound, tumor markers) of metastases; 7 patients (stage IIb=2, stage IIc=5) had residual tumor after chemotherapy but with negative tumor markers. A laparoscopic dissection was used to asses more fully the pathologic status of the relevant retroperitoneal lymph nodes of both groups. The patient was positioned and trocars introduced at sites similar to that used for transperitoneal laparoscopic nephrectomy (flank position, five ports - 3 x 10 mm; 2 x 5 mm). After reflecting the colon anteromedially, the landmarks of the lymph node dissection were isolated-namely the ureter, aorta, inferior vena cava, and both renal veins. The lymph node dissection included the paracaval, interaorto-caval, upper preaortic, and right common iliac zonal nodes for right-sided tumors, and paraaortic, upper preaortic zones for left-sided tumors. Retrieval of the lymph nodal chains was accomplished using a small organ bag. The mean duration of the procedure was 298 (range 150-405) minutes. In only one patient was a lymph node positive for tumor (stage I). Otherwise nodes showed extensive necrosis (after chemotherapy). No intraoperative complications were encountered but three patients developed a delayed complication (ureteral stenosis, pulmonary embolism, and retrograde ejaculation, respectively). Whereas we completed the dissection in each patient with stage I tumors, the laparoscopic procedure was more difficult in patients with stage II tumors after chemotherapy. In two patients with stage IIb disease laparoscopic lymphadenectomy was successful. In four other patients parts of the dissection had to be done after conversion to an open (conventional) operation using a small incision (suprainguinal or pararectal); in one patient the laparoscopic approach was abandoned and converted to an open operation. In the post-chemotherapy group the outcome depended primarily on the tumor bulk prior to drug treatment. In two patients in whom all residual necrotic tissue was removed laparoscopically they had "minor" disease (stage IIb); the others had stage IIc tumors. Our preliminary experience suggests that a modified laparoscopic lymph node dissection is feasible for stage I tumors and in selected patients with marker negative residual tumor after chemotherapy (stage IIb).

Feasibility Studies↗

PubMed1996

Nerve sparing post-chemotherapy retroperitoneal lymph node dissection for advanced testicular cancer.

PURPOSE: Nerve sparing techniques are used routinely during retroperitoneal lymph node dissection in patients with low stage testis cancer in an attempt to preserve postoperative ejaculation. Preservation of ejaculation without an increased retroperitoneal recurrence rate in such patients prompted us to reevaluate the role of nerve sparing techniques in select patients undergoing post-chemotherapy retroperitoneal lymph node dissection. MATERIALS AND METHODS: Of 472 patients who underwent post-chemotherapy retroperitoneal lymph node dissection between March 1988 and January 1995, 93 (19.7%) underwent a nerve sparing procedure. Two patients died of disseminated cancer within 6 months after post-chemotherapy retroperitoneal lymph node dissection. In 10 patients the ejaculatory status could not be established from the clinical notes and the patient was lost to followup. The remaining 81 patients form the basis of this report. Disease status, complications and ejaculatory status were evaluated. Mean followup was 35.5 months. RESULTS: Of the patients 76.5% reported normal ejaculation after post-chemotherapy retroperitoneal lymph node dissection. Testis cancer recurred after nerve sparing surgery in 6 patients but no tumor was retroperitoneal. Ten pregnancies have been reported to date with uneventful term deliveries in 7. CONCLUSIONS: Select patients are candidates for nerve sparing post-chemotherapy retroperitoneal lymph node dissection. Although indications for nerve sparing techniques in the post-chemotherapy population have expanded, the local recurrence rate has not increased. Nerve sparing post-chemotherapy retroperitoneal lymph node dissection can preserve the inherent fertility potential of the patient without increasing retroperitoneal relapse rates.

Adolescent↗

PubMed1997

The role of axillary dissection in mammographically detected carcinoma.

BACKGROUND: Axillary dissection remains a standard component of the treatment of invasive carcinoma of the breast. The presence of metastases to the regional lymph nodes guides adjuvant therapy and aids in determining prognosis. Mammography results in the discovery of small and often node-negative carcinomas of the breast. STUDY DESIGN: This 15-year, retrospective analysis investigated whether certain patients with small tumors could be spared the morbidity of axillary dissection. RESULTS: Medical records showed that from January 1980 to May 1995, 4,543 needle localization biopsies were done at York Hospital because of abnormalities detected on mammograms. Of these, 703 (15.5 percent) proved to be carcinoma. Of the carcinomas, 68 percent were infiltrating ductal carcinoma, 26 percent were ductal carcinoma in situ, and 5.4 percent were infiltrating lobular carcinoma. Axillary dissection was done on 588 patients, and 88.1 percent of the patients had no metastases to axillary lymph nodes. No axillary metastases were present in 109 patients with ductal carcinoma in situ who underwent axillary lymph node dissection or in 21 patients with microscopic invasive tumors. Only two of 54 patients with a T1a tumor (tumor [T], < or = 0.5 cm) had positive axillary nodes. Only one of 29 patients with a well-differentiated T1b tumor (T, > 0.5 to < or = 1 cm) had metastatic axillary nodes. In the presence of negative axillary lymph nodes, 19.2 percent of patients with a T1a tumor, 33.7 percent of patients with a T1b tumor, 60 percent of patients with a T1c tumor (T, > 1 to < or = 2 cm), and 78.9 percent of patients with a T2 tumor (T, > 2 cm) were given adjuvant chemotherapy or hormonal therapy. CONCLUSIONS: Patients with ductal carcinoma in situ and microscopic invasive tumors do not require node dissections. Possibly patients with T1a tumors and patients with well-differentiated, estrogen-receptor positive, progesterone-receptor positive, T1b tumors can also be spared axillary node dissection. By following this approach on occasion, patients with positive nodes might not undergo axillary lymph node dissection, but they may still be offered adjuvant therapy.

Breast Neoplasms↗