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PubMed1994

Axillary lymph node dissection for T1a breast carcinoma. Is it indicated?

BACKGROUND: Axillary dissection has been a routine part of breast cancer treatment for more than 100 years. Axillary node involvement is the single most important prognostic variable in patients with breast cancer. Recently, routine node dissection has been eliminated for intraductal carcinoma because so few patients had positive nodes. With the availability of numerous histologic prognosticators and the development of new immunochemical prognostic indicators, it is time to consider eliminating routine node dissection for lesions more advanced than duct carcinoma in situ (DCIS) but with extremely low likelihood of axillary involvement. METHODS: Axillary node positivity, disease-free survival, and breast cancer-specific survival were determined for six breast cancer subgroups by T category: Tis (DCIS), T1a, T1b, T1c, T2, and T3. RESULTS: Nodal positivity for DCIS was 0%; for T1a lesions, 3%. A large increase in nodal positivity was seen in lesions larger than 5 mm. (T1b, 17%; T1c, 32%; T2, 44%; T3, 60%). The rate of nodal positivity was statistically different as each T category was compared with the next more advanced T category. The disease-free survival and breast cancer-specific survival decreased with every increment in T value. CONCLUSIONS: Axillary node positivity increases as the size of the invasive component increases and is an excellent predictor of DSF and breast cancer-specific survival. Consideration should be given to eliminating axillary node dissection for T1a lesions because of the low yield of positive nodes. Axillary node dissection should be performed routinely for T1b lesions and larger.

Axilla↗
PubMed2000

Iatrogenic coronary artery dissections extending into and involving the aortic root.

We set out to determine the incidence of iatrogenic coronary artery dissection extending into the aorta and to characterize the aortic lesions. We reviewed the data from 43,143 cardiac catheterizations from September 1993 through September 1999 and found 9 coronary artery-aortic dissections for an overall incidence of 0.02%. Four of these patients were undergoing treatment for acute myocardial infarction (AMI) and aortic dissection was more common than for non-AMI patients (0.19% vs. 0.01%, P < 0.0006). Histologic analysis of tissue samples from 2 cases revealed age related changes only and no evidence of predisposing pathology. Patients with limited aortic involvement were successfully managed with stenting of the coronary dissection entry point whereas aortic dissection extending up the aorta >40 mm from the coronary os required surgical intervention.

Aged↗
PubMed1992

Adequacy of paracardial dissection in subtotal versus total gastrectomy.

Right and left paracardial dissection represents an obligatory step in gastrectomy for gastric cancer of the lower half of the stomach because a second-level lymphadenectomy is part of the radical surgery for malignancy at this site. Whereas right and left paracardial dissection is easily accomplished during total gastrectomy, there is doubt as to whether subtotal gastrectomy achieves the same radical clearance of these groups of lymph nodes. This study therefore compared the number of lymph nodes dissected and the frequency of metastases in these compartments in 14 patients undergoing total gastrectomy and 22 submitted to subtotal gastrectomy. The mean number of lymph nodes dissected in the right paracardial compartment was 7.1 per patient undergoing total gastrectomy and 6.7 per patient in subtotal gastrectomy (P = 0.7). The mean numbers of left paracardial lymph nodes dissected in total and subtotal gastrectomy were 3.4 and 4.1 per patient respectively (P = 0.3). These data show that the same degree of radical clearance can be achieved in these nodal compartments, irrespective of the extent of gastric resection.

Adult↗
PubMed1994

Lateral lymph node dissection for rectal carcinoma below the peritoneal reflection.

Lateral lymph node dissection has been advocated for advanced low rectal tumours. However, its benefit is debatable because of the possibility of postoperative bladder and sexual impairment. To assess the role of lateral lymph node dissection 95 patients who underwent the procedure between 1981 and 1991 were reviewed and compared with 83 who had resection of rectal cancer without lateral node dissection. Only ten (11 per cent) of the 95 patients had lateral lymph node involvement; all had Dukes' C tumours. Lymphovascular invasion was present in 50.6 per cent of all patients and neural invasion in 27 per cent of 65 examined specimens. Local recurrence, distant metastasis and overall 5-year survival rates were 7, 9 and 76 per cent respectively in patients undergoing extended lymphadenectomy and 16, 7 and 72 per cent respectively in those who had resection alone. There were no statistically significant differences in survival between the two groups for any Dukes' stage. Recurrence, metastasis and survival were related more to venous or neural invasion and tumour spread than to node dissection. These results demonstrate that patients with Dukes' A tumours do not benefit from lateral lymph node dissection, and that local recurrence rates in those with Dukes' B and C lesions are not significantly decreased. It is concluded that extended lymphadenectomy is unlikely to provide significant benefit to patients with low rectal cancer.

Adenocarcinoma↗
PubMed2002

Sequelae of axillary lymph node dissection in older women with stage 1 and 2 breast carcinoma.

BACKGROUND: There are few data on the long-term sequelae of axillary dissection among older breast carcinoma patients. We describe the impact of axillary dissection in a cohort of older women. METHODS: A longitudinal cohort of 571 patients with Stage 1 and 2 breast carcinoma, 67 years and older, diagnosed between 1995 and 1997 from 29 hospitals in five regions, and followed for 2 years. Data were collected from patients and medical charts. The primary outcome was posttreatment quality of life. Generalized estimation equation longitudinal modeling was used to evaluate the outcome, controlling for baseline function, comorbidity, age, clinical status, and other factors. RESULTS: Sixty percent of women reported arm problems at some time in the 2 years after surgery. The cumulative risk of having arm problems 2 years posttreatment was three times higher (95% confidence interval 1.94-4.67) for women who underwent axillary surgery compared with women without axillary surgery, controlling for covariates. The effects of having axillary dissection and arthritis were multiplicative 2 years postsurgery. Arm problems were, in turn, the primary determinate of lower physical and mental functioning (P = 0.0001 and 0.04, respectively), controlling for other factors. Undergoing axillary dissection did not lessen fears about recurrence. CONCLUSIONS: Arm problems after axillary dissection have a consistent negative impact on quality of life, suggesting that the risks may outweigh the potential benefits in this population.

Aged↗
PubMed2003

Neck level-specific nodal metastases in oropharyngeal cancer: is there a role for selective neck dissection after definitive radiation therapy?

PURPOSE: To determine the extent of the required neck dissection for patients with persistent lymphadenopathy after definitive radiation therapy for oropharyngeal cancer. If feasible, a conservative approach using selective neck dissection would likely minimize the extent of neck fibrosis and other adverse sequelae. METHODS: Analysis of pretreatment and posttreatment radiologic scans and pathology reports of 76 patients with oropharyngeal carcinoma (35 tonsil; 41 base of tongue), who had radiologic evidence of persistent nodal disease for level-specific involvement. Patients were treated with twice-daily fractionations of external-beam radiation therapy (median dose, 76.8 Gy to the primary tumor) and planned neck dissection (levels I-V) for bulky nodes (N2-3) or salvage neck dissection for N1 disease. RESULTS: The distribution of clinical nodal disease by neck level on the basis of pretreatment and posttreatment radiologic scans indicated levels II and III to be most commonly involved. The false-negative rate for the restaging radiologic scans for each neck level was as follows: level I, 0%; level II, 8%; level III, 6%; level IV, 5%; and level V, 1.5%. Of the eight hemi-necks found to contain positive pathologic nodes in a neck level judged to be negative on the basis of restaging scans, five of the patients subsequently had disease recurrence in the primary site. Patients who had evidence of residual neck disease had a significantly lower rate of locoregional control (77% vs 100%, p =.0005). CONCLUSIONS: The extent of neck dissection for patients with nodal disease associated with oropharyngeal cancer treated with radiation therapy should include levels II-IV. It is reasonable to spare levels I and V in patients without radiologic and clinical evidence of positive nodes in levels I and V.

Adult↗
PubMed2002

Early and late morbidity associated with axillary levels I-III dissection in breast cancer.

BACKGROUND AND OBJECTIVES: Axillary dissection may cause substantial morbidity in breast cancer patients. The purpose of this study was to investigate the value of a registration method of morbidity of the arm and shoulder, which is frequently used by surgeons and which includes the measurement of range of movement, strength, and pain. METHODS: We surveyed 148 patients who had received an axillary dissection as part of breast cancer surgery. Of these patients, 77 had undergone axillary dissection 6-12 months ago and 71 patients more than 5 years ago. In all patients, an objective measurement of shoulder movement and a subjective measurement of pain and arm strength was performed. RESULTS: A difference of more than 20 degrees in abduction, ventral elevation, or dorsal elevation occurred in 12% of the patients. Pain or loss of strength were measured in half of the patients. Shoulder movement, pain, and arm strength were not significantly different between the patients who underwent mastectomy or breast conserving surgery. Also, no significant difference could be found in shoulder movement, pain, and arm strength between the patients who underwent axillary dissection 6-12 months ago and those who underwent it more than 5 years ago. CONCLUSIONS: Pain, loss of arm strength, and limitation of shoulder movement are frequent complaints after axillary dissection for breast cancer and appear to be independent of the length of follow-up and the type of surgery (i.e., breast-conservation or mastectomy).

Adult↗
PubMed2005

Comparison of laparoscopy-assisted by conventional open distal gastrectomy and extraperigastric lymph node dissection in early gastric cancer.

BACKGROUND AND OBJECTIVES: Laparoscopy-assisted gastrectomy with lymph node dissection for gastric cancer is considered technically more complicated than the open method. Moreover, the safety and efficacy of laparoscopy-assisted distal gastrectomy (LADG) with extraperigastric lymph node dissection in patients with gastric cancer have not been established yet. To evaluate short-term surgical validity, surgical outcome of the laparoscopy-assisted distal gastrectomy (LADG) with extraperigastric lymph node dissection was compared with that of the conventional open distal gastrectomy (CODG) in patients with early gastric cancer. METHODS: One hundred and forty-seven patients with early gastric cancer received radical distal gastrectomy during 2002 and 2003, where LADG was undergone in 71 patients. The clinicopathologic characteristics, postoperative outcomes and courses, and postoperative morbidities and mortalities were compared between the two groups. Data were retrieved from the stomach cancer database at Dong-A University Medical center. RESULTS: Baseline characteristics, including sex, age, body mass index (BMI), American Society of Anesthesiology (ASA) class, tumor size, T stage, and lymph node metastasis were similar between the two groups. No significant differences were found between these groups in terms of the number of retrieved lymph nodes with respect to D1 + alpha (D1 + no. 7) and D1 + beta (D1 + no. 7, 8a, and 9) lymphadenectomy. In the LADG group, wound size was smaller (P < 0.0001), but operation time was longer (P = 0.0001) than in the CODG group. Perioperative recovery was faster in the LADG group than in the CODG group, as reflected by a shorter hospital stay (P = 0.0176) and less times of additional analgesics (P = 0.0370). Serum albumin level in LADG was higher (P = 0.0002) on day 7 than that in CODG, and the leukocyte count in LADG lower (P = 0.0445) on day 1 than that in CODG. Postoperative morbidities and mortalities were not significantly different between the two groups. CONCLUSIONS: Our data confirmed that LADG with extraperigastric (no. 7, 8, and 9) lymph node dissection proved to be feasible and acceptable surgical technique for early gastric cancer. At least taking a surgical point of view, LADG with extraperigastric lymph node dissection is suggested to be a preferred surgical option for patients with early gastric cancer. Its oncologic validity awaits larger and prospective multicenter trials.

Aged↗
PubMed2006

Axillary recurrence in women with a negative sentinel lymph node and no axillary dissection in breast cancer.

OBJECTIVES: Sentinel lymph node biopsy (SLNB) is widely used for staging breast cancer. SLNB accurately determines axillary lymph node status with a low false negative rate. There remains concern that omitting axillary dissection may lead to recurrence in the axilla, and impact long term survival. The purpose of this study was to determine the frequency of axillary lymph node recurrence in patients who had a negative sentinel lymph node and did not undergo axillary node dissection. METHODS: Data was collected on all patients who had negative SLNB at Roswell Park Cancer Institute between July 1997 and June 2002. Demographics, type of operation, postoperative systemic, and radiation therapy, co-morbidity score, hormone receptor status, and the pathologic features of the tumor were abstracted for each patient. For each woman with recurrence, the dates of recurrence, the site(s) of recurrence, and the treatment for recurrence were recorded. RESULTS: With a median follow-up of 33 months, 15 of 335 (4.5%) women who had negative SLNBs and who did not undergo completion axillary dissection developed a cancer recurrence. Only two patients (0.6%) had an axillary recurrence. CONCLUSIONS: The rate of axillary recurrence following a negative sentinel node biopsy is the same or less than axillary lymph node dissection (ALND) alone. Concerns that omitting completion axillary dissection following a negative SLNB will increase the rate of axillary recurrence appear unfounded.

Adult↗
PubMed1996

Extraperitoneal laparoscopic para-aortic lymph node dissection.

Extraperitoneal cervical cancer "staging" is considered superior to a transperitoneal approach. We developed an entirely extraperitoneal laparoscopic technique for para-aortic lymph node dissection in a pig model, followed by human subject application. Using latex balloon dissection technology, the technique is as follows. A retroperitoneal space is created via a 15-mm left flank incision. The collapsed balloon trochar is inserted and the balloon is inflated under direct visualization. Subsequently, a CO2 pneumoretroperitoneum is established with 12-15 mm Hg and dissection is carried out using a total of three to four left flank port sites. For initial technique development and improvement, four pigs were used. Excellent bilateral retroperitoneal exposure was achieved. A complete dissection was performed from the renal to the iliac vessels. Subsequently, a bilateral sampling procedure from the level of the inferior mesenteric artery to the liac vessels was performed in four human subjects. A mean of 5 nodes (range 1-9) was removed with an EBL of <50 cc. Operative times were 120-140 min. There were no intra- or postoperative complications. This initial experience demonstrates that laparoscopic extraperitoneal para-aortic access and node sampling is feasible. Further study is ongoing to determine the extent of dissection possible using this approach. However, since this approach mimics the extraperitoneal laparotomy technique, it may have all the advantages of adhesion avoidance combined with an outpatient procedure.

Animals↗
PubMed2000

Radical hysterectomy: An anatomic evaluation of parametrial dissection.

OBJECTIVES: This study was designed to demonstrate a reduction in the amount of blood loss for vesicouterine ligament dissection and to investigate the intrapelvic autonomic nerve pathway and its preservation by means of anatomic analysis. METHODS: The anchoring mechanism of the pelvic viscera to the pelvic wall was divided into a supporting system facing laterally and a suspensory system facing dorsoventrally. An operative procedure was designed in which both systems were separated and dissected independently. RESULTS: Between the two systems, an artificial space was developed, which required a new dissection method for the parametrium and revealed a new anatomic pathway for the ureter and autonomic nerve. The amount of blood loss (mean +/- SD) during dissection of the vesicouterine ligament was ultimately 260.1 +/- 114.8 ml. Postoperatively, the maximum capacity of the bladder was 393.9 +/- 40.4 ml, maximum detrusor pressure 6.3 +/- 4.1 cm H(2)O, mean compliance >10 ml/cm H(2)O, residual urine 23.8 +/- 9.4 ml, and maximum flow rate 25. +/- 8 2.2 ml/s, respectively. CONCLUSION: A new classification for the parametrium and its dissection method have been established. Development of this new operative procedure has also contributed to a decrease in blood loss and preservation of bladder function.

Blood Loss, Surgical↗
PubMed1995

What is optimum neck dissection for T3/4 buccal-gingival cancers?

Buccal-gingival (BG) cancers are an integral part of oral cancers but are biologically distinct, particularly with regard to the propensity and pattern of neck metastases. This study was undertaken to examine the adequacy of limited neck dissection in the management of these tumors. Between 1980 and 1989, 527 T3/4 BG cancers were treated surgically at Tata Memorial Hospital, Bombay. These cases were reviewed retrospectively. Among these, 178 underwent radical neck dissection (RND), 166 supradigastric dissection (SD) and 183 supraomohyoid dissection (SOHD) after confirming the negativity of levels II and III for nodal disease on frozen section. The overall incidence of histological node positivity was 42.5% (224/527). Level I was the most frequent site of metastases, with a skip rate of only 9%. The incidence of pure regional failure (primary controlled) was 3% with RND (67/178), 12% with SD (11/95) and 5% with SOHD (7/141) in patients with N0 necks. In the N+ category the regional failure was 18% with RND (20/111), 34% with SD (24/71) and 19% with SOHD (8/42). These findings show that a limited (SD) dissection is grossly inadequate in the management of T3/4 BG cancers, whereas an SOHD when neck levels II and III are confirmed negative on frozen section yields results comparable to RND for both N0 and N+ necks.

Carcinoma, Squamous Cell↗
PubMed1990

[Endoscopic microsurgical dissection of the esophagus: a contribution to the reduction of pulmonary complications following esophageal resection? A comparative animal experiment study].

A new endoscopic microsurgical technique for dissection of the esophagus has been developed and tried out in animals. With this technique the esophagus is dissected and removed via a cervical approach by means of a new operating endoscope. In a randomized animal study we compared endoscopic versus blunt dissection and versus abdominothoracic resection. During endoscopic dissection we saw significantly lower bleeding and no laceration of the pleural cavity or damage to the recurrent laryngeal or to the vagus nerve. Significant changes of hemodynamics or gas exchange were observed in the blunt dissection group: increase of heart frequency, decrease of arterial pressure and decrease of paO2. In contrast these parameters did not change in the endoscopic group.

Animals↗
PubMed1989

Spontaneous dissection of both extracranial internal carotid arteries.

Neurological examination and Doppler sonography of a 50-year-old patient were suggestive of a spontaneous dissection of the left internal carotid artery (left-sided headaches, amaurosis fugax, Horner's syndrome and hemispheric stroke). Four-vessel angiogram performed several days after the onset of the symptoms showed dissection of both extracranial carotid arteries, more pronounced on right side where the dissection was clinically asymptomatic. Angiogram follow-up demonstrated a recanalization of both carotid arteries. A review of 15 other documented reports indicates that bilateral internal carotid dissection is usually associated with fibromuscular dysplasia. A large majority of cases does not clinically differ from unilateral carotid artery dissection.

Carotid Artery Diseases↗
PubMed1995

Rationale for extent of lymph node dissection for right colon cancer.

PURPOSE: The extent of lymph node dissection optimal for the prognosis of right colon cancer is investigated. METHODS: Between 1946 and 1991, 275 patients had curative operation for right colon cancer. A retrospective analysis of rate and degree of lymph node metastasis was performed in each of the 275 patients, and survival rate was estimated in 197 patients who could be followed over a period of three years or more. RESULTS: In most of the curative operative cases of right colon cancer, metastasis to epicolic and paracolic nodes was restricted up to 10 cm proximal or distal to the tumor margin, and metastasis in the central direction was restricted up to main nodes. When cancer metastasized to infrapyloric lymph nodes, dissection of the nodes resulted in a higher rate of long-term prognosis. The five-year cumulative survival rates showed no statistically significant difference between any two of the N0 to N3 lymph node metastasis groups. CONCLUSION: The dissection procedure for right colon cancer involved removal of 10 cm of normal bowel both proximal and distal to the lesion and, in the central direction, dissection of regional lymph nodes along the main trunk artery up to main nodes, i.e., nodes situated anterior to the surgical trunk, which was confirmed to have a therapeutically satisfactory benefit. Infrapyloric lymph nodes must be dissected when metastasis to the nodes is suspected. In cases of cecal or ascending colon cancer in which the middle colic artery is no longer the main trunk artery, a right hemicolectomy with resection of only the right branch of the middle colic artery will usually suffice.

Adult↗
PubMed1993

Randomized trial comparing diathermy hemorrhoidectomy with the scissor dissection Milligan-Morgan operation.

Twenty consecutive patients (12 male and 8 female) with second-degree, third-degree, or thrombosed hemorrhoids were randomly allocated to undergo either diathermy hemorrhoidectomy (n = 10) or a scissor dissection Milligan-Morgan hemorrhoidectomy (n = 10). No significant difference was found in the postoperative pain score between the groups. On a scale of 0 to 10, the mean daily pain score in the diathermy group was 4.0, and it was 4.1 in the scissor dissection group. Nor was there any significant difference in the length of inpatient stay (diathermy group, 3.5 days; scissor dissection group, 4.0 days) or in the time between the operation and the first bowel action (diathermy group, 2.0 days; scissor dissection group, 3.0 days). Diathermy hemorrhoidectomy has no significant advantage over the scissor dissection classical Milligan-Morgan hemorrhoidectomy.

Adult↗
PubMed1998

Role of axillary lymph node dissection after tumor downstaging with induction chemotherapy for locally advanced breast cancer.

BACKGROUND: Induction chemotherapy has become the standard of care for patients with locally advanced breast cancer (LABC) and currently is being evaluated in prospective clinical trials in patients with earlier-stage disease. To better gauge the role of axillary lymph node dissection in patients with LABC this study was performed to assess initial axillary status on physical and ultrasound examination, axillary tumor downstaging following induction chemotherapy, and the accuracy of physical examination compared with axillary sonography in predicting which patients will have axillary lymph node metastases found on pathologic examination. METHODS: Between 1992 and 1996, 147 consecutive patients with LABC were registered in a prospective trial of induction chemotherapy using 5-fluorouracil, doxorubicin, and cyclophosphamide. Physical and ultrasound examinations of the axilla were performed at diagnosis and after induction chemotherapy. Segmental resection with axillary lymph node dissection or modified radical mastectomy was performed, followed by postoperative chemotherapy and irradiation of the breast or chest wall and regional lymphatics. RESULTS: Following induction chemotherapy, 43 (32%) of the 133 patients with clinically positive lymph nodes on initial examination had axillary tumor downstaging as assessed by physical and ultrasound examination. The sensitivity of axillary sonography in identifying axillary metastases was significantly higher than that of physical examination (62% vs. 45%, P=.012). The specificity of physical examination (84%) was higher than that of sonography (70%), but the difference did not reach statistical significance. Among the 55 patients in whom the findings of both physical and ultrasound examination of the axilla were negative following induction chemotherapy, 29 patients (53%) were found to have axillary lymph node metastases on pathologic examination of the axillary contents. However, 28 (97%) of these patients had either 1 to 3 positive lymph nodes or only micrometastases 2 to 5 mm in diameter. CONCLUSIONS: Preoperative clinical assessment of the axilla by physical examination combined with ultrasound examination is not completely accurate in predicting metastases in patients with LABC following tumor downstaging. However, patients with negative findings on both physical and ultrasound examinations of the axilla may be potential candidates for omission of axillary dissection if the axilla will be irradiated because minimal axillary disease remains. Patients who have positive findings on preoperative physical or ultrasound examinations should receive axillary dissection to ensure local control. A prospective randomized trial of axillary dissection versus axillary radiotherapy in patients with a clinically negative axilla following induction chemotherapy is currently underway.

Antineoplastic Combined Chemotherapy Protocols↗