Surgical resection of pulmonary metastases from colorectal cancer. 10-year follow-up.

Pulmonary resection of metastatic lesions from colorectal cancer was performed in 62 patients, and their cumulative 5-year and 10-year survival rates were 42% and 22%, respectively. The overall median survival was 24 months. The survival curve decrease even after 5 years after pulmonary resection; four of 13 patients who survived more than 5 years subsequently died of metastatic disease and only two patients survived more than 10 years. The number and size of the pulmonary metastases were significantly correlated with postthoracotomy survival. Solitary metastases less than 3.0 cm in diameter were good indicators of favorable postthoracotomy survival. There were no significant differences in survival based on Dukes' classification or location of the primary lesion. Sex, age, disease-free interval between the primary tumor and appearance of metastasis, and extent of pulmonary resection had no influence on survival. It is impossible to say from our experience that surgical resection of pulmonary metastases increased the cure rate. Presumably a good 5-year survival rate after thoracotomy would be a reflection of a length bias caused by the biologic behavior of the metastatic pulmonary lesions.

Peroperative diagnosis and treatment of metastases to the regional lymph nodes in papillary carcinoma of the thyroid gland.

The management of two groups of patients with papillary carcinoma of the thyroid gland (n = 165) was evaluated retrospectively. Total thyroidectomy was the standard procedure in both groups, but the peroperative diagnosis and treatment of metastases to the regional lymph nodes differed. In group 1 (n = 84), only clinically positive lymph nodes were resected, and if residual postoperative 131I uptake was found, an ablation dose of 131I was given. In group 2 (n = 81), all of the tissue in the tracheoesophageal groove was removed routinely at total thyroidectomy and frozen section was done of the lymph nodes lying along the internal jugular vein. If metastases were found, a modified radical dissection of the neck was performed on the affected side. The two patient groups were comparable with regard to risk factors--local tumor stage, age and sex. Almost twice as many patients were found to have metastases to the lymph nodes in group 2. There was no significant difference in the ten year over-all or recurrence free survival time between the two groups. In group 1, there were more recurrences on the explored side of the neck but fewer distant metastases; however, both findings were not significant. In group 2, significantly more instances of hypoparathyroidism and palsy of the accessory nerve were found (p less than 0.05). Thus, when a more extensive search was carried out, more metastases to the lymph node were discovered and treated, but this did not prevent recurrences in the neck nor did it improve survival time. This approach resulted in more postoperative morbidity. There seems to be no justification for prophylactic removal of regional lymph nodes in instances of papillary carcinoma of the thyroid gland, but modified radical neck dissection may be beneficial if clinically suspect regional lymph nodes are present in the lateral part of the neck.

Radiotherapy or surgery for subclinical cervical node metastases.

This retrospective study compared elective neck dissection with elective neck radiotherapy for the control of subclinical nodal metastases. Four hundred ninety-eight patients with head and neck primary cancers and no clinically apparent neck metastases on initial presentation comprised the study population. Each patient was followed up for at least 5 years to detect failure to control neck metastases and control of the primary tumor at the time of neck recurrence. Analysis of neck recurrences occurring in patients with control of the primary tumor showed that there was no statistically significant difference between elective radiation therapy to the neck and elective neck dissection for oral cavity, oropharyngeal, and laryngeal cancers. The only statistically significant difference was noted for hypopharyngeal cancers, with radiation therapy being more effective than surgery.

[Malignant fibrous histiocytoma of the breast]. / Malignus fibrosus histiocytoma az emlöben.

In connection with the mammary tumor of a 41-year-old woman the authors draw attention to the rare occurrence of malignant fibrous histiocytoma in the mamma. The histology of the mammary malignant fibrous histiocytoma, role of immunohistochemical reactions in the diagnosis are described. The literature dealing with the malignant fibrous histiocytoma in the mamma is reviewed. This is the 11th case reported in the literature. The authors discuss the possibilities of the therapy of the malignant fibrous histiocytoma in the mamma.

Strategy for lymphadenectomy of gastric cancer.

To determine the extent of lymphadenectomy necessary to cure early gastric cancer, the relationship between the frequency of nodal involvements and the extent of the primary invasion was examined in 274 patients with primary cancer of the stomach. We also evaluated the relationship between the number of metastatic lymph nodes, the pattern of metastases to the nodes, and the histologic type of the primary tumor. In early gastric cancer, lymph node metastasis was more frequent in protruded-type cancer with invasion into the submucosa more than 3 cm in diameter and located in the lower third of the stomach, but was limited to the group 1 lymph nodes, which were defined as being anatomically located nearest to the cancer. In cancer invading into the muscularis propria, metastasis to the group 2 or 3 lymph nodes, which were defined as being anatomically located farther from the cancer than group 1, was found. The number of lymph nodes involved and extent of cancer metastasis in these lymph nodes metastasis, differentiated early gastric cancer had more lymph node involvement and wider extent of metastases than undifferentiated cancers. The cancer cells sometimes replaced most of the node and invaded the perinodal fatty tissue, even in early gastric cancer. In addition, it is occasionally difficult to distinguish macroscopically early gastric cancer with submucosal invasion from cancer invaded into the muscle layer. In conclusion, group 1 and 2 lymph nodes, including perinodal fatty tissue, should be removed completely, even in early gastric cancer, except for carcinoma in situ, particularly when the cancer is of the differentiated type.

[The value and limit of extended surgery in colorectal cancer].

Since the majority of colorectal cancers are well differentiated adenocarcinomas and grow rather slowly and well limited, surgery is the most available and favored treatment. The cancer-related 5-year survival rates of patients having undergone an extended operation versus those undergoing the conventional operation in our hospital (1969-1983) were 86% and 70% for Dukes B stage, and 60% and 38% for Dukes C stage. The survival superiority of the extended operation was confirmed as statistically significant (p less than 0.05). However, this survival advantage not true for patients with lateral lymphnode metastasis. A more extended operation with lateral dissection cutting the iliac internal vessels was performed for patients suspected of having lateral metastasis. Reduction of the incidence of local recurrence is really observed by this procedure. Urine-voiding and sexual dysfunction were observed more frequently in patients with the extended operation than the conventional one. By selectively preserving only 4th pelvic nerve, it becomes possible to preserve the urine voiding function without losing the benefits of the extended operation. In cases of far advanced cancer invading to adjacent organs, value of combined resection was also confirmed. Metastatic lesions to the liver or the lung should be removed by enucleation or partial resection of these organs, unless a multiple case. The 5-year survival of patients were 35% for liver metastasis and 40% for pulmonary metastasis.

Extent of lymph node dissection in melanoma of the trunk or lower extremity.

The extent of lymph node dissection necessary to optimize survival and minimize local recurrence in patients with melanoma of the trunk or lower extremity is not well defined. We reviewed the records of 420 patients undergoing superficial or combined superficial and deep groin dissection for melanoma. Prognosis depended on the extent of lymph node involvement rather than the extent of surgery performed. Node-positive patients undergoing elective lymph node dissection had an improved survival over those undergoing therapeutic lymph node dissection. In no subgroup of patients was more extensive lymphadenectomy associated with significant improvement in survival or alteration in pattern of recurrence. Dissection of the deep pelvic nodes in patients with melanoma appears to be of more prognostic than therapeutic value.

Lymph node involvement as the only prognostic factor in curative resected gastric carcinoma: a multivariate analysis.

The aim of this study was to evaluate the independent influence of clinical and pathological variables on survival of patients with gastric carcinoma using the Cox regression proportional hazard model. Of 156 patients operated on for gastric carcinoma, 46 (29.5%) underwent palliative operation, 24 (15.5%) had a palliative resection, and 86 (55%) had a curative resection. The overall 5-year survival rate was 25 +/- 4%. After curative resection, the 5-year survival rate was 44 +/- 6%. Univariate analysis applied to these patients showed that poor survival was related (p less than 0.01) to: age (over 80 years), absence of epigastric pain, vomiting and dysphagia, total gastrectomy, tumor size (more than 4 cm), lymph node involvement (LNI), invasion through the muscularis propria, absence of intestinal metaplasia near the tumor, and linitis plastica. In multivariate analysis, lymph node involvement was found to be the only independent prognostic factor. The 5-year survival rate was 75.5 +/- 8% without LNI, 28 +/- 10% with proximal LNI, and 7 +/- 6% with distal LNI. Our results suggest that classification into 3 LNI groups is the best staging system for curative resection in gastric carcinoma.

Modern thoughts on lymph nodes in breast cancer.

Axillary lymph node status remains the single most useful prognostic parameter in breast cancer patients. As clinical examination, imaging techniques, and lymph node sampling methods cannot accurately assess the axillary node involvement, a complete axillary dissection should always be performed. Moreover, this technique provides an excellent treatment modality for regional disease, abolishing the need for radiotherapy to the axilla. The status of the internal mammary lymph nodes is of less importance in the management of the breast cancer patient.

[Postoperative lymph node scintigraphy in patients with malignant melanoma]. / Postoperatív nyirokcsomó-szcintigráfiás vizsgálatok lymphadenectomizált melanoma malignumban szenvedö betegeken.

Completeness of regional lymph node dissection was controlled in 23 patients with melanoma malignum. For that purpose 3--6 weeks after block-dissection lymph node scintigraphy was performed, by administration of intercostal and interdigital radiopharmacutical. Blockdissection was considered as complete, when neither after intercostal, nor after interdigital administration, any lymph nodes were delineated. On the basis of investigations until now, postoperative lymph node scintigraphy proves to be suitable, held to be a non-invasive method for controlling completeness of blockdissection.

Recurrence and morbidity in differentiated thyroid carcinoma in children.

The management of differentiated thyroid cancer in childhood is controversial. In particular, the role of aggressive surgical treatment has been questioned. This study was performed to identify those factors that are predictive of recurrence and morbidity following treatment through use of a multivariate model. The records of all patients 17 years of age or less admitted in the last 35 years with histologically confirmed differentiated thyroid carcinoma were reviewed. Data were sufficient for multivariate analysis in 93. The mean age at diagnosis was 13.3 years, and the median period of follow-up was 20 years. Seventy-one percent of the patients had nodal metastases. There were no deaths from thyroid carcinoma in this series, and the overall recurrence rate after initial treatment was 34%. Multivariate analysis demonstrated that only age (p less than or equal to 0.07) and histologic subtype (p less than or equal to 0.01) were predictive of time to recurrence. Major morbidity was a function of age (p less than or equal to 0.007) and extent of thyroid surgery (p less than or equal to 0.01). Probability of minor complications was predicted by use of radical neck dissection (p less than or equal to 0.02). Use of total or subtotal thyroidectomy or of radical neck dissection in children does not prevent recurrence and is associated with an increased risk of complications. We conclude that these procedures should be avoided in pediatric patients.

Modified inguinal lymphadenectomy for carcinoma of the penis with preservation of saphenous veins: technique and preliminary results.

The controversy surrounding the management of patients with invasive carcinoma of the penis and clinically negative nodes is discussed. The rationale, technique and preliminary results of a modified inguinal lymphadenectomy in which the lateral and caudal extents of nodal excision are reduced, and the saphenous veins are preserved also are presented. This modified lymphadenectomy has been performed in 6 patients with invasive carcinoma of the penis or distal urethra without major or troublesome complications.

Fluorescence of metastasized lymph nodes in esophageal cancer following the administration of intravenous eosin yellow using a laser beam.

Fifteen patients with esophageal carcinoma received the photosensitizing dye Eosin Yellow (10 mg/kg) intravenously prior to surgery, and their para-esophageal lymph nodes were then examined for fluorescence using a laser beam at the time of operation. When the time interval between the injection of Eosin Yellow and the operation was 48 hours, 21 out of 22 (95.4 per cent) metastatic lymph nodes exhibited fluorescence and 25 out of 26 (96.2 per cent) non-metastatic lymph nodes did not exhibit fluorescence. This method proved to be invaluable for detecting metastatic lymph nodes macroscopically at the time of surgery for esophageal carcinoma.

Mediastinal nodes in bronchogenic carcinoma: comparison between CT and mediastinoscopy.

Computed tomography (CT) and mediastinoscopy were compared in 151 patients with bronchogenic carcinoma. In all patients in whom findings at mediastinoscopy were negative, all accessible nodes were either removed or sampled at thoracotomy. Several size criteria for identifying nodes as enlarged on CT scans were compared. The long axis greater than or equal to 15 mm and short axis greater than 10 mm had very low sensitivity (61%), and the long axis greater than 5 mm had a low specificity (23%). CT (long axis greater than 10 mm) allowed sensitivity equal to that of mediastinoscopy (79%) in the detection of mediastinal metastases, but the specificity with CT was lower (65% vs. 100%). In seven of 44 patients with nodes greater than 10 mm on CT scans and with positive findings at mediastinoscopy, tumor was present not in the enlarged nodes but rather in normal-sized nodes in a different nodal station. The sensitivity of CT for actual nodal stations involved with tumor was only 66%. Eighty-three percent of patients with false-negative findings at mediastinoscopy but only 33% of patients with false-negative findings at CT had surgically resectable stage IIIa disease.

5-year results of postoperative extended-field irradiation on 76 patients with nodal metastases from cervical carcinoma stages IB to IIIB.

Extended-field irradiation was administered after radical surgery to 76 patients with nodal metastases from cervical carcinoma Stages IB (37 patients), IIA (six patients), IIB (29 patients), and IIIB (four patients). The first recurrent sites of disease were distant organs via hematogenous routes of 12 patients and in the pelvic fields of eight patients. The 5-year disease-free survival rates were 95% for 27 patients with one positive node, 64% for 37 patients with multiple positive nodes, and 44% for 12 patients with unresectable nodes; 72% in total. Poor disease-free survival rates were associated with Stage IIB (60%), more than 30 mm invasion depths (44%), small cell cancer (0%), adenocarcinoma (57%), adenosquamous carcinoma (50%), and premenopause (60%). In 52 patients with nonkeratinizing large cell carcinoma, the disease-free survival rates were significantly different between Stage IB and IIB (87% versus 47%, P less than 0.05). This dissimilarity was caused by significant differences between Stage IB and IIB patients with less than 30 mm invasion depths (90% versus 53%, P less than 0.05), with parametrial extension (100% versus 39%, P less than 0.005), and with unresectable nodes (100% versus 0%, P less than 0.05). These results indicate that postoperative extended-field irradiation can control distant spread via lymphatic routes with significant improvement of patient survival, and that the number of positive nodes, tumor cell types, depth of tumor invasion, and clinical stages are important prognostic factors subsequent to this combined therapy.

Lymphadenectomy for cure in patients with early gastric cancer and lymph node metastasis.

The anatomic distribution, size, and histologic mode of involvement of 98 metastatic lymph nodes in 49 of 370 patients were examined to determine to what extent lymphadenectomy should be performed in addition to gastrectomy in patients with early gastric cancer. Nodal involvement in the marginal sinus (30 nodes) and partial medullary sinus (37 nodes) were commonly seen, and the lymph nodes of those types were enlarged compared with 1,086 patients with no metastatic lymph nodes (control group). Lymph nodes of the wide medullary sinus (11 nodes), small nodule (3 nodes), and massive involvement types (17 nodes) did not enlarge compared with those of the other types and those of the control group. Most of the metastatic sites (76.6 percent) were in the perigastric lymph nodes along the lesser and greater curvatures, about a fifth were in the extraperigastric nodes along the left gastric, common hepatic, celiac, and splenic arteries, and the least were in the extraperigastric nodes (3.1 percent) along the hepatoduodenal ligament. Since the rate of macroscopic diagnosis during operation was so poor, regardless of the histologic modes of nodal involvement, and also in cases of metastatic lymph nodes less than 15 mm in widest diameter, for curative operation of patients with early gastric cancer, perigastric and extraperigastric lymph nodes along the main arteries near the stomach should be completely dissected, in addition to resection of the stomach.