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Excision of lymph nodes on the lateral margin of the sterno-cleido-mastoid muscle may result in damage to the accessory nerve. Most commonly the branch to the trapezius is involved. The treatment in five cases of iatrogenic lesions is described. Contrary to the widespread assumption that these lesions are irreversible, there was significant improvement in all cases.
When a lymph node is excised, lymphangiogenesis occurs to maintain flow in the affected area. However, a complex network of small vessels replaces the node and these newly formed vessels might increase resistance to lymph transport. To test this in sheep, the popliteal lymph node from one hind limb was removed surgically. The contralateral node was left intact. After 4 to 6 weeks (a period that allowed regenerated vessels to restore flow), a prenodal lymphatic vessel in each limb was cannulated with a polyethylene catheter to permit saline infusion into the node or lymphatic regeneration site. Infusion pressures were monitored from t-pieces inserted between the infusion pump and the point of entry of the catheters in the prenodal ducts. We observed that the flow rate versus perfusion pressure relationships were significantly different in the 2 experimental preparations (node intact limbs, n = 13; node excised limbs, n = 10). In the limbs undergoing lymphangiogenesis, much higher infusion pressures were required to generate a given flow rate. Additionally, the regenerated lymphatic network provided a significantly increased resistance to flow. The data suggested that lymphangiogenesis restored fluid continuity to some extent in the area occupied originally by the popliteal lymph node. However, the transport properties exhibited by the newly formed lymphatics were insufficient to restore flow parameters to their original state.
Preoperative ultrasound exploration of the cervical node regions was performed for 207 patients; US findings were compared with data obtained by physical examination and histopathologic analysis. Ultrasonography offers multiple advantages: detection of subclinical lymph nodes, accurate measurement of node volume, facilitating classification, evaluation of vascular relations, and particularly diagnosis of internal jugular vein thrombosis. Despite the limitations of ultrasonography, the rapidity and noninvasiveness of this technique make it the procedure of choice for the initial workup of patients with a cervicofacial epithelioma.
OBJECTIVE: To determine the pathological features of lymph nodes removed by axillary liposuction. METHODS: A prospective study of 34 axillary dissections performed from July 1995 to September 1996 in patients with breast cancer N0. After lipolysis, the fat was drained from the axillary cavity by means of liposuction (Karman nozzle ch.8; suction pressure of 1 Bar). The remaining nodes were removed by an endoscopic dissection in conservative treatments. The remaining nodes were removed during modified radical mastectomy in non-conservative treatments. Lymph nodes were fixed in formol and examined by the pathologist. RESULTS: An average of 15 lymph nodes (8-35) were removed. 502 lymph nodes were examined: 458 (91%) were not involved and 44 (9%) were involved, including 21 (4%) with rupture of the capsule. No pathological traumatism was seen. CONCLUSION: Axillary liposuction did not alter the pathological features of lymph nodes in our study.
Elective lymph node dissection in high-risk melanoma has been hotly debated for years. The technique of sentinel node (SN) biopsy may be a solution to the problem. Consequently, radical lymph node dissection is restricted to patients with an actual metastatic involvement of the SN (20-25%). The use of a hand-held gamma probe increases accuracy of SN detection.
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The prognostic value of lymph node metastases in thyroid cancer has been a matter of controversy for many years. However, during the past decade most multivariate analyses have shown a prognostic influence of lymph node metastases in papillary as well as medullary thyroid carcinoma constituting the basis for a standardized concept of lymphadenectomy oriented to the lymph node classification of the UICC (1993). Due to the frequency of lymph node metastases in the ipsilateral cervicocentral compartment (42-86%), in the ipsilateral cervicolateral compartment (32-68%), in the contralateral cervicolateral compartment (12-24%), and in the mediastinal compartment (3-20%), these compartments can be defined as the lymph node regions of the first, second, third and fourth order, respectively. Cervicocentral systematic lymphadenectomy should be part of the en bloc resection of the thyroid gland and the first lymph node region in any thyroid cancer. Cervicolateral as well as mediastinal lymphadenectomy should be performed according to the extent of lymph node involvement, i.e. systematically when multiple lymph node metastases are present, otherwise selectively. One exception is in medullary thyroid carcinoma, where a four-compartment lymphadenectomy is recommended in any patient with positive lymph nodes. Performing a gentle technique using magnifying glasses and bipolar coagulation forceps, systematic lymphadenectomy does not increase the rate of complications, can decrease the recurrence rate and improve survival.
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In a retrospective study 143 patients with 155 axillary lymphadenectomies were observed with a maximum of 8 years of follow-up (mean 51.9 +/- 25.8 months). At the time of their lymphadenectomies, 39 patients had histologically negative nodes (stage I), 85 patients lymph-node metastases (stage II), 19 patients axillary node involvement and distant metastases (stage III). The estimated 5-year survival rates were 77.5% in stage I and 28.6% in stage II. Axillary recurrence after dissection of tumor-free lymph nodes rarely happened, but in stage II the probability of recurrence was as high as 30.7%. All axillary recurrences occurred in the first 20 months after lymphadenectomy. In a multivariate analysis (Cox model), the only prognostic factor of probability of recurrence in stage II was the development of regional in-transit cutaneous metastases (p = 0.048). Factors that did not affect the appearance of recurrent metastases in the node dissection field were: epidermal ulceration, vascular invasion, tumor thickness, degree of lymph-node involvement, age, sex, and adjuvant chemotherapy. Median survival after axillary recurrence following therapeutic lymph-node excision (5 months) was comparable with survival after lymphadenectomy in stage III (7 months). There was a high incidence (> 30%) of regional in-transit cutaneous metastases in both groups. Regardless of the poor prognosis, we found 15% axillary recurrences after lymph-node clearance in stage III.
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Similar to squamous cell esophageal cancer, the lymph node status constitutes the major prognostic factor after complete tumor resection (R0-resection) in patients with adenocarcinoma of the distal esophagus (the so-called Barrett's cancer). Lymphatic spread in patients with Barrett's cancer, however, appears to follow certain rules. Lymphatic spread is closely correlated to the pT-category of the primary tumor, starts only after infiltration of the submucosa und is initially limited to the regional lymph nodes. Distant lymph node metastases are almost exclusively found in patients with multiple positive regional nodes, skipping of regional lymph nodes is rare. These observations set the stage for tailored lymphadenectomy-strategies based on the, sentinel-lymphadenectomy' concept.
Lymph node involvement is the major prognostic factor in gastric carcinoma. The benefit of extended regional lymph node dissection D2 is still controversial. For Japanese, these dissection can improve significantly long-term survival, while in western countries discussion is still open. Rationale for extensive lymphadenectomy in Japan is based on the results of many studies about lymph node (number involved, number resected per station, ratio, location, grouping, radical clearance ...). However, these studies are not controlled studies. Four prospective randomized controlled studies comparing D2 to D1 in the curative treatment of gastric cancer were performed during the 10 last years. Currently, all have failed to demonstrate any improvement on survival after D2. But in the two last studies, final survival results are pending for two years. On the other hand, mortality and morbidity of D2 are significantly higher, particularly because of anastomotic leakage, and distal pancreatectomy and/or splenectomy. Benefit of D2 dissection in general practice of curative gastric cancer surgery is not proved. A middle position, as a D "1.5" dissection, avoiding distal pancreatectomy, might be suggested. Final survival results could counterbalance the negative effects of D2 on morbidity and mortality, and would question present data.