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PubMed1994

Groin dissection in malignant melanoma.

BACKGROUND: There is controversy about the extent of groin dissection necessary (whether superficial or radical) and about its utility when the deep nodes are affected. METHODS: A total of 198 groin dissections (1977-1991) were reviewed; 94 (48%) were superficial and 104 (52%) were radical dissections. Of 72 patients with palpable positive inguinal nodes, 31 (43%) had involvement of the deep nodes; of 39 patients with nonpalpable, histologically positive inguinal nodes, seven (18%) had or later manifested involvement of the deep nodes. RESULTS: The mean number of positive nodes (median) in the group with clinically palpable disease was six (two), and in the group with occult disease the number was two (one). The estimated overall (disease-free) 5-year and 10-year survival rates for patients with negative nodes were 73% (67%) and 64% (58%), respectively, and for those with positive nodes they were 36% (27%) and 30% (23%), respectively. Survival was significantly poorer for patients with positive nodes (p < 0.0001). The respective 5-year and 10-year survival rates for patients with positive nodes and involvement of the inguinal nodes only were 41% (33%) and 36% (29%), and for those with involvement of the inguinal and deep nodes the rates were 28% (17%) and 19% (13%). Survival was significantly poorer for patients with deep node involvement (p = 0.006). CONCLUSIONS: The survival rates after therapeutic groin dissection are substantial and unattainable with any other treatment at the present time. Incontinuity dissection of the deep nodes is advisable in the presence of palpable inguinal nodes, since the incidence of deep node involvement is considerable and the survival rate appreciable after removal of involved deep nodes.

Adult↗

PubMed1996

[Lymph node dissections in malignant melanoma].

Elective lymph node dissection and its potential as a staging procedure, the prognosis of established lymph node metastases and the sentinel lymph node identification procedure are the most important aspects of lymph node dissection in malignant melanoma. It is widely accepted that subgroups of patients benefit from elective lymph node dissection. The question of which parameters identify the relevant patients properly is still under discussion. pT-categories are the most important prognostic factor; however, localisation and type of tumour and the sex of the patients are additional parameters influencing patient selection. Recently, the first studies have identified subgroups of nodal positive patients who would profit from adjuvant chemo-/immunotherapy. Therefore, lymph node dissection as a staging procedure has to be discussed in the future. Identification of the sentinel lymph node is receiving increasing attention because of its potential influence on the reassessment of elective lymph node dissection. However, this method needs further evaluation. If lymph node metastases have occurred, the prognosis of malignant melanoma decreases by 20%-50%, depending on the extent of metastasis in the individual case. The relevant topics and results are discussed on the basis of data of the Surgical Department of the University Hospital of Erlangen-Nuremberg.

Female↗

PubMed1996

[Principles and results of systematic lymph node dissection in surgically treated bronchial carcinoma].

Lymphatic spread of bronchial carcinoma can reach any part of the mediastinum, irrespective of the localisation of the primary tumor. Metastatic spread may not affect all topographical lymph node positions, but this is unpredictable. The number of lymph nodes in each position varies. Therefore, systematic mediastinal lymph node dissection includes all ipsilateral compartments of the mediastinum. It is also possible to reach contralateral sites. In right-sided thoracotomies the lymph node dissection is standardized. Mobilizing the aortic arch and the large vessels also allows complete mediastinal dissection by a left-sided approach. The surgical technique is described. Perioperative morbidity does not increase. Systematic mediastinal lymph node dissection is the gold standard for evaluation of an exact pN stage. The stage-related survival rate is significantly improved. Therefore, it should be required that systematic mediastinal lymph node dissection be standard in the surgical treatment of bronchial carcinoma.

Carcinoma, Bronchogenic↗

PubMed2006

[Acute aortic dissection. Differential diagnosis of a thoracic emergency].

Acute aortic dissection is an infrequent but important differential diagnosis of acute chest pain. The variability of presenting symptoms makes it difficult to diagnose correctly. Important clinical indicators - besides chest pain - are symptoms related to acute aortic insufficiency and/or pericardial tamponade, variable acute neurologic alterations, or signs of peripheral or visceral malperfusion. The spontaneous prognosis depends on the location and extent of the dissection, and left untreated dissection carries a high mortality. The key goal of preclinical treatment is stabilization with analgesia, mild sedation (opioids, benzodiazepines) and treatment of hypertension (beta-blockers) or hypotension (fluid administration). If the patient presents with a high probability of dissection, early transfer to a specialized center appears advisable. Initial clinical diagnostic studies include transthoracic echocardiogram and computed tomography. If the ascending aorta is involved (Stanford type A) immediate replacement of the proximal aorta is necessary. Isolated dissections of the descending aorta (type B) require aggressive blood pressure control, but can be managed conservatively in most cases. A high level of vigilance is necessary in all patients to detect and treat visceral ischemia.

Acute Disease↗

PubMedDate not supplied

Multidetector CT colonoscopy: evaluation of the perspective-filet view virtual colon dissection technique for the detection of elevated lesions.

BACKGROUND: The purpose of our study was to determine the usefulness of a virtual computed tomography colon dissection visualization technique for the detection of polypoid lesions in comparison with conventional virtual colonoscopy analysis and optical colonoscopy. METHODS: Twenty-three patients were evaluated with optical colonoscopy and computed tomography colonoscopy using 16-row MDCT on the same day. CT images were analyzed by the colon dissection workup with unfolded haustra visualization and also using the conventional virtual colonoscopy technique (axial images and endoluminal views). The CT analysis was performed by an experienced radiologist using both viewing methods in a randomized order and blinded to optical colonoscopy results. RESULTS: Optical colonoscopy revealed 35 colonic lesions; 15 < 5 mm, 18 between 5-9 mm and 2 > 9 mm. For conventional virtual colonoscopy analysis the overall sensitivity was 86.67%; for the colon dissection visualization technique, the overall sensitivity was 82.86%. The average reading time for conventional virtual colonoscopy was 15 +/- 3 vs. 8 +/- 2 min for the colon dissection visualization technique. CONCLUSIONS: Our results showed that there is a significant reduction in the reading time using the colon dissection visualization technique without detriment to the detection rate, that is, competitive to conventional virtual colonoscopy interpretation results.

Adult↗

PubMed2000

Appraisal of surgical resection of gallbladder cancer with special reference to lymph node dissection.

BACKGROUND: Radical lymph node dissection in surgery for advanced gallbladder cancer is controversial. The purpose of this study is to evaluate the role of lymph node dissection based on the clinico-pathologic results. PATIENTS: Seventy-three patients who underwent radical surgery including systematic dissection of the N1+N2 region lymph node plus some of the para-aortic nodes were reviewed. RESULTS: pT1 patients had no lymph node metastasis, but pT2 and pT3/pT4 patients had lymph node metastasis at a rate of 50.0% (13/26) and 83.3% (25/30), respectively. As infiltration of the hepatoduodenal ligament (Binf) became severe, the rate and extent of lymph node metastasis increased. There were four 5-year survivors with lymph node involvement. The 5-year survival rates are 77.0% in pN0 cases and 27.3% in pN1 cases (P<0.01). There was no difference in survival between pN1 and pN2 patients. However, significant differences in survival were observed between pN0/1 and pN2/3 patients when these patients were limited to Binf0/1. Examination of the recurrence pattern showed that most patients with pN0/1/2 had no regional lymph node recurrence, but there was para-aortic lymph node recurrence in patients with pN3 outside the dissected region. Significant prognostic factors influencing survival after surgery by multivariate analysis were pN2/3, pT, and residual tumor. CONCLUSION: Systematic lymph node dissection of N1, N2, and part of the para-aortic region improves survival in advanced gallbladder cancer patients, especially in those without either para-aortic lymph node metastases or Binf2/3.

Adult↗

PubMed2003

Laparoscopic lymph node dissection for gastric cancer with intraoperative navigation using three-dimensional angio computed tomography images reconstructed as laparoscopic view.

BACKGROUND: Laparoscopic extended lymph node dissection for gastric cancer is difficult to perform because it requires dissection with preservation of vessels. Therefore, an intraoperative navigation system for the angioarchitecture would be helpful. Recent enhanced volume-rendering computed tomography (CT) can produce clear intraluminal three-dimensional (3D) images. This advanced radiological technology can provide 3D angiographic images reconstructed in the same view as would be observed from a laparoscope inserted into the abdominal cavity. We report our experience with laparoscopic gastrectomy with radical lymph node dissection using this advanced radiological technology. METHODS: 3D CT angiographic images from the celiac axis to the proper hepatic artery were reconstructed in two ways preoperatively. The first was only 3D angiographic images that were reconstructed as the laparoscopic view (LapView 3D CT angiography). The second was LapView 3D CT angiography with images of the body of the pancreas, which was more useful for intraoperative navigation in comprehensing anatomy. Two monitors were placed over the shoulder of the patient during surgery. One monitor, which was controlled by the image mixer, projected the laparoscopic images with picture in picture of 3D CT angiographic images. The surgeon performed the surgery with reference to this monitor during lymph node dissection. RESULTS: 3D angiographic CT clearly showed all vessels of interest in laparoscopic lymph node dissection for gastric cancer in 10 cases. The anatomy of vessels appeared as if looking beyond visible surface. LapView 3D CT angiography was useful for laparoscopic navigation surgery.

Adult↗

PubMed2001

Endoscopic-assisted subcutaneous mastectomy and axillary dissection with immediate mammary prosthesis reconstruction for early breast cancer.

BACKGROUND: Endoscopic surgery has been applied successfully in breast lump excision, breast augmentation, subcutaneous mastectomy for gynecomastia, and axillary dissection. Since subcutaneous mastectomy has been proven to be oncologically safe for early breast cancer, we have sought to develop a reproducible minimally invasive endoscopic-assisted technique to address this condition. METHODS: Between December 1998 and May 1999, endoscopic-assisted subcutaneous mastectomy and axillary dissection with immediate reconstruction using a mammary prosthesis was performed in nine patients with early breast cancer at the Prince of Wales Hospital, Hong Kong. A 5-cm skin incision was made along the line of the lowest axillary skin crease. Dissection was continued down to the lateral border of the pectoralis major muscle. A subpectoral pocket was gently created by an endoscopic breast dissector. The endoscopic breast retractor and 10-mm/30 degrees scope were introduced into the subpectoral pocket, and further dissection was carried out using a 7-in harmonic scalpel under endoscopic vision down to a level 1 cm caudal to the inframammary fold. This subpectoral space was used for the insertion of the mammary prosthesis later on. Endoscopic-assisted subcutaneous mastectomy was performed afterward. Combined level I and level II axillary dissection was carried out via the same incision under direct vision. RESULTS: Apart from minor skin flap bruises in our first two patients, there were no major complications. Histological examination of all the specimens showed clear margins. Postoperative radiotherapy and chemotherapy were given in the usual manner. All patients were satisfied with the reconstructive outcome. CONCLUSIONS: We have described a novel endoscopic technique for subcutaneous mastectomy with immediate mammary prosthesis reconstruction in treating early breast cancer patient. This technique can minimize skin incision, reduce blood loss, and improve reconstructive outcome. It is easy to learn and well accepted by patients.

Adult↗

PubMed2005

Circumferential intramural esophageal dissection successfully treated by endoscopic procedure and metal stent insertion.

Spontaneous intramural esophageal dissection is a rare disorder characterized by a lengthy laceration between the mucosal and submucosal layers of the esophageal wall, without perforation. The majority of previously reported cases of spontaneous intramural esophageal dissection were partial, and the circumferential type of intramural esophageal dissection has not been reported previously. Most spontaneous intramural esophageal dissection responds to conservative management, and usually it dose not lapse into a long protracted course of dealing with sequelae. We report an unusual case of circumferential intramural esophageal dissection, in which initial conservative management failed to alleviate the patient's dysphagia, necessitating the use of several endoscopic treatments, including incision of the septum between the false and true lumens, transection of the true esophageal wall, balloon dilatation, and metal stent insertion.

Deglutition Disorders↗

PubMedDate not supplied

The impact of prophylactic axillary node dissection on breast cancer survival--a Bayesian meta-analysis.

BACKGROUND: Because of the general acceptance of the NSABP B-04 study, prophylactic axillary node dissection for women with clinically negative axillae is considered diagnostic, but not therapeutic, by many oncologists. Nevertheless, several authors have shown that B-04 did not include enough patients to exclude a small survival advantage. METHODS: A Bayesian meta-analysis of the available literature was performed comparing standard treatment to standard treatment without axillary node dissection. Six randomized controlled trials were identified, consisting of nearly 3000 patients and spanning four decades. RESULTS: All six trials showed that prophylactic axillary node dissection improved survival, ranging from 4% to 16%, corresponding to a risk reduction of 7%-46%. Combining the six trials showed an average survival benefit of 5.4% (95% CI = 2.7-8.0%, probability of survival benefit > 99.5%). Adjusting for biases in the individual studies did not alter the conclusions, nor did subset analysis of Stage I patients. CONCLUSIONS: Axillary node dissection improves survival in women with operable breast cancer. Nevertheless, two important limitations of this analysis are noteworthy. Few of the patients in the six trials had T1a tumors, so extrapolation of these results to this subset (and those with nonpalpable tumors) may be inappropriate. Essentially no patients in the six trials were treated with adjuvant therapy, as contrasted to current clinical practice. It is possible that the risk reduction seen in this meta-analysis may be diminished in patients receiving adjuvant chemotherapy. Despite these limitations, this study suggests that axillary dissection should be performed in most women with palpable tumors for diagnostic, as well as therapeutic, purposes.

Axilla↗

PubMed1975

Echocardiographic criteria for aortic root dissection.

Echocardiographic findings from 10 patients without clinical indications of aortic root dissection or aortic valve disease from 1 patient with angiographic confirmation of aortic root dissection are reported and compared. Previously reported echocardiographic findings were confirmed in the patient with aortic root dissection. These include (1) a widened posterior or anterior aortic wall, or both; (2) parallel motion of the separated margins of the aortic walls; and (3) aortic root dilatation (42 mm or more at end-systole). However, all three findings were also noted in 5 of the 10 patients without clinical indications of aortic root dissection or aortic valve disease, and at least two of the three findings were noted in the remaining 5 patients. Echocardiographic detection of aortic root dissection appears to be most reliable when clinical indications of the anomaly are present.

Adult↗

PubMed1986

Extraperitoneal lymph node dissections with use of a midline incision in patients with female genital cancer.

Recent investigations have suggested that extraperitoneal, as compared to transperitoneal, lymph node dissections may result in significantly less morbidity in patients who later have external beam irradiation. Some incisions designed to perform such dissections do not afford easy access to the opposite side. With use of a midline incision carried down to the preperitoneal space, 30 patients underwent bilateral pelvic lymph node dissections. When necessary, access to the para-aortic nodes by an extraperitoneal approach was accomplished by use of a modification of this midline incision. Operating time to complete the pelvic dissection ranged from 35 to 90 minutes. The mean estimated blood loss for the dissection was 135 ml. The advantages of this extraperitoneal approach include easy access to lymph nodes on either side, ability to use the peritoneum as a pack, and an easier access to the obturator space nodes.

Adolescent↗

PubMed1984

Management of regional lymph nodes in penile carcinoma. Five-year results following therapeutic groin dissections.

Twenty-two patients with squamous carcinoma of the penis underwent groin dissections for histologically proved inguinal lymph node metastases, either around the time that the primary tumor was treated (early therapeutic dissection, 14 patients) or later, after they had been clinically judged free of regional nodal metastases at diagnosis (late therapeutic dissections, 8 patients). Three- and five-year survival rates for the patients who underwent early therapeutic dissections were 71 per cent and 57 per cent, respectively, as opposed to 50 per cent and 13 per cent, respectively, for patients who underwent late therapeutic dissections. These findings suggest that a "wait and watch" policy in patients with clinically negative nodes at diagnosis is no longer justified.

Adult↗

PubMed1990

Radical wide excision and selective inguinal node dissection for squamous cell carcinoma of the vulva.

Limited resection of some vulvar cancers may provide cure rates equivalent to those obtained with radical vulvectomy and bilateral inguinal node dissection. Rapid recovery, fewer complications, and better functional result have been described as advantages to less extensive procedures. Since 1978, 32 patients with invasive squamous cell cancer of the vulva (depth greater than 1 mm) and clinically negative inguinal lymph nodes underwent radical wide excisions as primary therapy. Mean age at diagnosis was 61 years. Seventeen patients had T1 and 15 had T2 tumors. Resection of the primary lesion was tailored to lesion location and size, and dissection was carried to the deep perineal fascia. Twenty-two patients had unilateral superficial inguinal lymph node dissections, five with midline lesions had bilateral superficial dissections, and five had node samplings which included deep inguinal nodes. Depth of invasion ranged from 1.5 to 13.0 mm. Mean largest lesion dimension was 23 mm. Five-year lifetable survival for the entire group was 84%. Univariate analysis of potential prognostic variables showed no significant recurrence or survival differences for patient age (P = 0.56), symptom duration (P = 0.57), FIGO stage (P = 0.67), tumor grade (P = 0.20), tumor location (P = 0.26), depth of invasion (P = 0.56), or resection margin status (P = 0.63). Thirty-one percent of patients had perioperative complications, and 16% developed delayed complications. Mean hospital stay was 10 days. Three patients (10%) developed new or recurrent vulvar disease and underwent additional therapy. None have died of disease, although one is alive with persistent tumor. Radical wide excision and selective inguinal lymphadenectomy constitute a reasonable alternative to radical vulvectomy with bilateral inguinal node dissections for squamous tumors clinically limited to the vulva. Outcome may not be strongly influenced by lesion size or depth of invasion.

Adult↗

PubMed1992

Value of axillary dissection in addition to lumpectomy and radiotherapy in early breast cancer. The Breast Carcinoma Collaborative Group of the Institut Curie.

Axillary dissection in early breast cancer remains controversial because of its substantial side-effects and because its value with respect to recurrence or survival has not been unequivocally proven. Between 1982 and 1987, 658 patients were included in a prospective randomised comparison of lumpectomy alone with lumpectomy plus axillary dissection. All patients had a unilateral breast tumour not exceeding 3 cm in diameter and lymph-node involvement or metastases. Radiation therapy was given to both groups. The two groups of patients were similar with respect to mean age, TNM stage, and presence of hormonal receptors. Median follow-up was 54 months. 5-year survival of the patients was 94.2% (95% Cl: 92.1-96.4). There was a significant advantage in survival in the axillary dissection group (p = 0.014). Recurrence of tumour in the breast was similar in the two groups but visceral metastases, supraclavicular metastases, and lymph-node recurrences were less frequent in the axillary dissection group. Survival was related to the age of the patients (p = 0.005), the presence of positive nodes (p = 0.006), the histological grading (p less than 0.0001), and the presence of hormonal receptors (progesterone p = 0.0008, oestrogen p less than 0.0001). Treatment-adjusted relative risk was 2.4 (95% Cl: 1.3-4.2). The findings show that axillary dissection is justified for treatment of small breast cancers, although whether the better survival is due to axillary clearance itself or to adjuvant treatment for lymph-node involvement is unclear.

Adult↗

PubMed1992

Origin of arterial wall dissections induced by pulsed excimer and mid-infrared laser ablation in the pig.

To study adjacent tissue damage after delivery of holmium, thulium and excimer laser pulses, porcine thoracic aortas were irradiated in vivo. After 3 days, microscopic analysis of 67 craters produced by all three lasers demonstrated large dissections extending from the craters. The mean diameter of the dissections was smaller for excimer-induced craters (1.38 +/- 0.42 mm; n = 22) than for holmium-induced (2.7 +/- 0.87 mm; n = 22) and thulium-induced (2.37 +/- 0.42 mm; n = 14) craters (p less than 0.01 vs. mid-infrared dissections). In addition, microscopic analysis demonstrated necrosis adjacent to the crater. The lateral necrotic zones of the thulium-induced craters were smaller than the holmium- and excimer-induced necrotic zones (p less than 0.01). To identify the origin of the excessive tissue tearing, laser-saline and laser-tissue interaction were compared in vitro by time-resolved flash photography. In saline solution, the mid-infrared lasers showed bubble formation on a microsecond time scale. The excimer laser produced similar bubbles in the vicinity of tissue. For all three lasers, elevation of the tissue surface was shown during in vitro ablation. Dimension (diameter up to 4 mm) and time course (rise time of 100 to 300 microseconds) of bubble formation and tissue elevation were strikingly similar. Thus, tissue dissections are caused by the expansion of a vapor bubble within the target tissue. Coronary dissections after excimer and mid-infrared laser angioplasty might be related to the forceful bubble expansion.

Angioplasty, Laser↗

PubMed1994

Audit of complete axillary dissection in early breast cancer.

The role of complete axillary dissection (CAD) in the management of breast cancer is controversial and largely unresolved. Acceptance of the results of trials incorporating CAD assumes that the axillary dissection is truly complete. To address this point, and also to define quality control criteria for this operation within our unit, we audited 100 consecutive axillary dissections as follows: the primary surgeon performed what he/she felt to be a thorough CAD and submitted separately the contents of level I, II and III for pathological evaluation; a second surgeon then independently assessed the dissection and arbitrarily labelled any further excised tissue as level IV. Level IV nodes were retrieved in 38% of cases. Tumour involvement of level IV nodes was noted in 5% (2/38) of dissections where lymph nodes were retrieved, but in neither instance was pathological staging altered. There was a significant decrease in the incidence of level IV node retrieval from 47% (28/60) in the first 6 months of audit to 20% (8/40) subsequently. This novel approach to our continuing audit identified quality control criteria for this procedure in our unit and suggested that audit of this kind benefits training.

Breast Neoplasms↗

PubMedDate not supplied

Cold dissection versus bipolar cauterizing tonsillectomy for bacteriemia.

OBJECTIVE: The purpose of this study is to compare transient bacteriemia ratios between cold dissection tonsillectomy and bipolar cauterizing tonsillectomy, and also to analyze the bacteria detected with superficial/central tonsillar cultures. METHODS: A total of 86 patients that were grouped as 46 patients of cold dissection tonsillectomy and 40 patients of bipolar cauterizing tonsillectomy were included in this study. Preoperative surface swab cultures, intraoperative central swab cultures of tonsils, and preoperative and postoperative blood culture samples were obtained. Antibiotic sensitivity tests were determined. Fischer exact chi 2 test was performed to compare the results of postoperative bacteriemia of both techniques statistically. RESULTS: Postoperative bacteriemia was detected in 6 (13%) patients of cold dissection tonsillectomy group. In 5 (83.3%) of the 6 postoperative bacteriemia patients of cold dissection tonsillectomy group, isolated microorganism was confirmed both in the blood cultures and in the central swab cultures of tonsils, and resistance to penicillin was established. No patient of bipolar cauterizing tonsillectomy group appeared with postoperative bacteriemia. There was a statistically significant difference (P=.028) for postoperative bacteriemia between cold dissection tonsillectomy group and bipolar cauterizing tonsillectomy group. CONCLUSION: We recommend bipolar cauterizing tonsillectomy for high-risk patients.

Bacteremia↗