Value of thyroglobulin post hemithyroidectomy for cancer: a literature review.

BACKGROUND: An increasing number of patients with low and moderate risk differentiated thyroid cancer (DTC) are now managed with lobectomy alone. The value of serum thyroglobulin (Tg) in the follow up of these patients remains poorly defined. METHODS: A review of the MEDLINE and EMBASE databases was performed to assess the utility of Tg in the follow up of patients undergoing thyroid lobectomy for DTC. RESULTS: A total of five retrospective reviews were identified including 1136 patients undergoing hemithyroidectomy with or without prophylactic central neck dissection. The overall locoregional recurrence rate was 3.7%. Changes in serum Tg following hemithyroidectomy for cancer were found to be clinically useful in one study only. The proposed cut-off value of 30 ng/mL following hemithyroidectomy as a predictor of recurrent disease was not validated by any study. CONCLUSION: Serum Tg values are not useful in the follow up of DTC patients managed with lobectomy alone. Good quality neck ultrasound appears to be an effective modality in the detection of locoregional recurrence in these patients while research efforts continue to identify and validate novel biomarkers.

The Lymphatic Anatomy of the Lower Eyelid and Conjunctiva and Correlation with Postoperative Chemosis and Edema.

BACKGROUND: There are minimal data in the literature regarding the lymphatic drainage of the conjunctiva and lower eyelid and the relationship with postoperative chemosis and edema. METHODS: Injection, microdissection, and histologic and radiologic studies were conducted on 12 hemifacial fresh cadaver specimens. Indocyanine green lymphography was conducted in five volunteers. RESULTS: Histology identified lymphatic vessels superficial and deep to the orbicularis oculi. Cadaveric dissection, injection, and radiographic studies identified interconnecting superficial and deep facial lymphatic systems and a conjunctival lymphatic network draining through the tarsal plate to the deep lymphatic system. The superficial lymphatic collectors traveled in subcutaneous fat within the lateral orbital and nasolabial fat compartments. The lateral deep lymphatic collectors traveled beneath orbicularis oculi, then through the superficial orbicularis retaining ligament, and into the sub-orbicularis oculi fat in the roof of the prezygomatic space. These vessels descended to preperiosteal fat at the level of zygomaticocutaneous ligaments to travel adjacent to the facial nerve into preauricular nodes. Indocyanine green lymphography identified correlating draining pathways laterally to the parotid nodes and medially to submandibular nodes. CONCLUSIONS: The authors have found that the lower eyelid and conjunctiva are drained by interconnecting superficial and deep lymphatic systems of the face. The superficial system is vulnerable to damage in incisions and dissection in the infraorbital area. The deep system is vulnerable to damage in dissection around the orbicularis retaining ligament and the zygomaticocutaneous ligaments. The authors suggest that concurrent damage to both the superficial and deep lymphatic systems, especially laterally, may be responsible for postoperative chemosis and edema.

Long-Term Patency of Lymphovenous Anastomoses: A Systematic Review.

BACKGROUND: With advancements in technology and microsurgical techniques, lymphovenous anastomosis has become a popular reconstructive procedure in the treatment of chronic lymphedema. However, the long-term patency of these anastomoses is not clear in the literature. METHODS: A systematic review of the MEDLINE and EMBASE databases was performed to assess the reported long-term patency of lymphovenous anastomoses. RESULTS: A total of eight studies satisfied the inclusion criteria. Pooled data from four similar experiments in normal dogs showed an average long-term (≥5 months) patency of 52 percent. The only experiment in dogs with chronic lymphedema failed to show any long-term patency. CONCLUSIONS: The creation of peripheral lymphovenous anastomoses with a moderate long-term patency rate has become technically possible. However, the long-term results in chronic lymphedema are limited.

Vascularized Lymph Node Transfer: A Review of the Current Evidence.

Over the past decade, lymph node transfer has rapidly gained popularity among plastic surgeons for the treatment of chronic lymphedema because of the initial promising results and its unique technical advantages compared with the other reconstructive options. However, its functional mechanism is still a matter of great debate, and some concerning reports have emerged regarding the safety of this procedure in patients with chronic lymphedema. The authors review the literature on the experimental and clinical evidence for lymph node transfer, discuss its proposed functional mechanisms, review the potential risk of iatrogenic lymphedema following this procedure, and discuss the suggested strategies to avoid this complication.

Scarpa Fascia Preservation in Abdominoplasty: Does It Preserve the Lymphatics?

BACKGROUND: The course of the cutaneous lymphatic collectors of the abdominal wall in relation to the Scarpa fascia is unclear in the literature. Preserving the Scarpa fascia in the lower abdomen to reduce the seroma rate following abdominoplasty has been suggested based on the assumption that the lower abdominal lymphatics run deep to this layer along their entire course. METHODS: Using the previously described technique, the superficial lymphatic drainage of eight hemiabdomen specimens from four fresh human cadavers was investigated. RESULTS: The upper and lower abdominal collectors originated at the umbilical and midline watershed areas in a subdermal plane by the union of precollectors draining the dermis. In the lower abdomen, the depth of the collectors gradually increased in the subcutaneous fat as they coursed toward the groin. They eventually pierced the Scarpa fascia before draining into the superficial inguinal nodes located deep to this layer. The transition from the supra- to the infra-Scarpa fascia plane occurred within 2 to 3 cm of the inguinal ligament in 95 percent of the collectors. CONCLUSION: In the four cadavers studied, preserving the Scarpa fascia during abdominoplasty would not preserve the lower abdominal collectors.

Laparoscopy and peritoneal cytology: important prognostic tools to guide treatment selection in gastric adenocarcinoma.

BACKGROUND: Previous studies have suggested that patients with occult peritoneal metastases not seen on preoperative imaging have poor prognosis. In this study, we aim to evaluate the utility and impact of staging laparoscopy and peritoneal cytology in patients with gastric adenocarcinoma. METHODS: A retrospective analysis of patients with gastric adenocarcinoma managed at two major metropolitan hospitals in Melbourne, Australia, between January 1999 and July 2010 was undertaken. The main outcome measures were the number of patients in whom laparoscopy and/or peritoneal cytology changed treatment intent, and the overall survival of patients with occult metastases detected by laparoscopy/cytology. RESULTS: Staging laparoscopy as an independent procedure was performed in 74.3% (148/199) of patients who had neither unequivocal metastases (M1) on preoperative imaging nor early T1 disease on endoscopic ultrasound. Laparoscopy/cytology detected occult metastases in 38 (25.6%) patients (27 macroscopic M1 and 11 microscopic M1 with positive peritoneal cytology only), leading to change in the treatment intent in 37 cases. The median overall survivals of patients with metastatic disease detected at staging laparoscopy (8.3 months, 95% confidence interval (CI) 5.4-16.5) or on peritoneal cytology (4.9 months, 95% CI 4.2-48) were as poor as those with M1 disease seen on preoperative imaging (6.7 months, 95% CI 4.2-8.9), P = 0.97. CONCLUSIONS: Laparoscopy and peritoneal cytology add incremental value to modern imaging in the staging of gastric adenocarcinomas by detecting occult metastatic disease. Their utility needs to be optimized to allow better treatment selection for gastric cancer patients.

Understanding the three-dimensional anatomy of the superficial lymphatics of the limbs.

BACKGROUND: There are minimal data in the current literature regarding the depth of the superficial lymphatic collectors of the limbs in relation to the various subcutaneous tissue layers. METHODS: Injection, microdissection, radiographic, and histologic studies of the superficial lymphatics and the subcutaneous tissues of 32 limbs from 15 human cadavers were performed. RESULTS: Five layers were consistently identified in the integument of all the upper and lower limb specimens: (1) skin, (2) subcutaneous fat, (3) superficial fascia, (4) loose areolar tissue, and (5) deep fascia. Layer 2 was further divided into superficial (2a) and deep (2c) compartments by a thin, transparent, horizontal septum (layer 2b). The main superficial veins and the superficial nerves coursed in layer 4. The lymphatic collectors were found at layer 2c and layer 4. CONCLUSIONS: The use of consistent nomenclature to describe the subcutaneous tissue layers facilitates a greater understanding and discussion of the anatomy. In lymphovenous anastomosis for the treatment of lymphedema, indocyanine green lymphography is an unreliable method for identification of the superficial collectors of the thigh. The medial proximal leg, the dorsum of the wrist over the anatomical snuffbox, and the volar proximal forearm provide suitable areas for locating superficial collectors with nearby matching size veins. In vertical medial thigh lift, choosing a dissection plane superficial to the great saphenous vein is unlikely to preserve the collectors of the ventromedial bundle.

Anatomy of the superficial lymphatics of the abdominal wall and the upper thigh and its implications in lymphatic microsurgery.

BACKGROUND: The recent advent in the surgical treatment of lymphedema necessitates a more detailed understanding of the anatomy of the lymphatic system. Lymphovenous anastomosis (LVA) requires a precise knowledge of the anatomy of the superficial lymphatic collectors in relation to the superficial veins. In vascularized lymph node transfer (VLNT), donor site lymphatic function must be preserved. METHODS: Using the previously described technique, the superficial lymphatic drainage of 8 anterior hemi-abdomen/upper thigh specimens from 4 fresh human cadavers was investigated. RESULTS: The upper and lower abdominal collectors were found above Scarpa's fascia immediately below the subdermal venules. They were thin-walled and translucent and their diameter ranged between 0.2 and 0.8 mm. In the upper thigh two distinct groups of superficial collectors were found. The collectors of the ventromedial bundle constituted the majority of the superficial collectors, were deep in the subcutaneous fat, measured 0.6-1 mm in diameter, had thick walls, and consistently drained into two large nodes inferolateral to the saphenous bulb. The local collectors of the thigh were immediately deep to the subdermal venules, measured 0.3-0.5 mm, had thin walls, and drained into the superolateral group of the superficial inguinal nodes which also drained the lower abdomen, the lower back and the upper gluteal region. CONCLUSIONS: When raising the groin lymphatic flap for VLNT, the medial extent of the dissection should be limited to the lateral border of femoral artery. When following up patients after VLNT with a groin donor site, circumference measurements must include the upper thigh.