Impact of the extent of axillary surgery in patients with N2-3 disease in the de-escalation era: a propensity score-matched study.

BACKGROUND: Reduction of surgeries in axillary has been proved feasible in breast cancer with negative and limited involved axillary lymph nodes. However, for women with a heavy axillary burden, the extent of dissection is still arguable. PATIENTS AND METHODS: From a total of 7042 patients with breast cancer who underwent surgical treatments between 2008 and 2014, 692 (9.85%) patients with the axillary staging of N2-3M0 were classified into Level I-II dissection group and Level I-III dissection group. 203 pairs of patients were matched by the propensity score. RESULTS: The positive rate of level-III lymph nodes is 62.4% in patients who underwent Level I-III dissection. There are 67 (22.1%) patients who experienced rise in staging from N2 to N3 due to level-III dissection. With a median follow-up of 62.4 months, no significant difference was observed in RFS (P = 0.897), MFS (P = 0.610) and OS (P = 0.755) between level I-II group and level I-III group. The same results were observed in the independent analysis of neoadjuvant and non-neoadjuvant subgroups. The binary regression model showed the positivity of level-III is only associated with involved lymph nodes in level-II. CONCLUSION: Additional level-III dissection has a limited impact on survival but still valuable in an accurate stage. The reduction of surgeries in axillary should be treated with discretion in breast cancer patients with a heavy axillary burden.

Comparative study of three types of lymphadenectomy along the left recurrent laryngeal nerve by minimally invasive esophagectomy.

BACKGROUND: The objective of this study was to compare three kinds of lymphadenectomy methods along the recurrent laryngeal nerve (RLN) and assess the safety and effectiveness of the new method. METHODS: A total of 194 patients with esophageal cancer who underwent minimally invasive esophagectomy (MIE) at our institution from May 2013 to May 2017 were analyzed retrospectively. According to the method of lymphadenectomy along the left RLN, the patients were divided into three groups: 75 cases underwent the conventional method (A group), 80 cases the skeletonized method (B group) and 39 cases the modified Bascule method (C group). The number of dissected lymph nodes and surgical outcomes were recorded and compared to identify differences among the three groups. RESULTS: The frequency of metastasis to the LRLN lymph node was 18.6% among all patients, and 12%, 20% and 28% in groups A, B and C, respectively. The number of harvested lymph nodes (total/chest/LRLN/LRLN+) in group B and group C were significantly greater than that of group A, but not significant between group B and group C. The hoarseness rate in group C was 15.4%, which was lower than the rate in group B (21.3%) and higher than the rate in group A (13.3%), but there was no statistical significance. CONCLUSIONS: The new method for lymphadenectomy along the left RLN during MIE in the semi-prone position is safe and reliable. It provides sufficient lymph node dissection along the left RLN.

Proposal of a new classification system for complete mesocolic excison in right-sided colon cancer.

BACKGROUND: Although complete mesocolic excision has been performed for 10 years there remains no published prospective data. The lack of a classification which includes completeness of mesocolic tissue removal as well as plane of surgery contributes to the problem of comparing studies. The aim of the present study was to develop such a classification for right hemicolectomy. METHODS: In a prospective, non-randomized trial we collected specimens of right hemicolectomies from 38 German hospitals between February 2012 and October 2016. The degree of radicality of resection was reported. Photographs were taken of the specimens. After screening the images it became apparent that the specimens could be divided into four main groups according to the degree of missing mesocolic tissue, and three subgroups reflecting the plane of surgery. RESULTS: Of 1373 patients 1097 images were available. Grading was possible in 1077 (98.2%). Distribution was Type 0 (best) 38.6%, Type I 43.3%, Type II 8.5%, Type III (poorest) 7.8%. Surgery was considered to be in a suboptimal plane of surgery in 15.2% overall, highest in Type III (37%) and lowest in Type 0 (7.8%, p < 0.001). CONCLUSIONS: The proposed classification may be a relevant tool for the further investigation of CME for right colon cancer because it allows us to differentiate the aspects of lymphadenectomy and the preservation of the integrity of the mesocolon.

Metástasis incisional de carcinoma broncogénico tras linfadenectomía mediastínica transcervical extendida / Incisional metastasis from lung cancer after transcervical extended mediastinal lymphadenectomy

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Modelo predictivo multiparamétrico del estatus axilar en pacientes con cáncer de mama: carga tumoral total y perfil molecular. Estudio multicéntrico / A multiparametric predictive model of axillary status in patients with breast cancer: total tumoral load and molecular signature. A multicenter study

Objetivo. El objetivo de nuestro estudio es evaluar el impacto combinado de cada uno de los perfiles moleculares del cáncer de mama, subrogados inmunohistoquímicamente junto con la carga tumoral total del ganglio centinela como predictores de afectación metastásica en los ganglios axilares no centinela. Material y métodos. Se incluyeron 373 pacientes de carcinoma infiltrante de mama con ganglio centinela metastásico y linfadenectomía axilar, procedentes de seis hospitales españoles. Se aplicaron los criterios de ST Gallen para definir el perfil molecular. Se realizó un análisis multivariante para definir diferentes modelos predictivos y se estudiaron las distribuciones de densidad de probabilidad de la carga tumoral para cada perfil molecular en los casos con axila metastásica y no metastásica en los ganglios no centinela. Resultados. Hubo un 66% de linfadenectomías axilares metastásicas. Se obtuvieron 7 modelos predictivos cuyas áreas bajo la curva ROC oscilaron entre 0,65 y 0,77. El mejor modelo fue el basado en la carga tumoral total, tipo histológico, diámetro tumoral, grado, invasión linfovascular, perfil molecular y número total de ganglios centinela. Las mayores diferencias de densidad de probabilidad de la carga tumoral total se producen entre las distribuciones de casos positivos y negativos de los perfiles moleculares BH, TN y HER2. Conclusión. La inclusión del perfil molecular en el modelo mejora el área bajo la curva ROC, especialmente si se incluye también el número total de cganglios centinela. Se observan diferencias entre los distintos perfiles moleculares para el valor predictivo de la carga tumoral total (AU)

Objective. To evaluate the combined impact of each of the immunohistochemically surrogated molecular signatures (PM) of breast cancer subtype along with the total tumor load (CTT) of the sentinel node (SN) as a predictor of non-SN metastatic involvement. Methods. We included 373 patients diagnosed with infiltrating breast cancer with metastatic SN who underwent subsequent axillary lymph node dissection (ALND) from six hospitals. The surrogate MS for each case was defined as per ST Gallen definitions. A multivariate analysis was conducted to estimate the predictive model and normal kernel functions to fit the density distributions of the total tumoral load for each molecular signatures. Results. Metastatic involvement of the axillary lymph node was identified in 66% of the patients. We obtained seven different predictive models with an area under curve (AUC) ranging from 0.65 to 0.77. The best model was based on the CTT, histological type, tumor size, stage, lymphatic invasion, MS, and the total number of SN. The greatest differences in the density functions of the CTT were found in the PM for positive and negative cases of the BH, TN and HER2 subtypes. Conclusions. The inclusion of PM in the multivariate model improved the AUC, especially when the total number of sentinel nodes were included. Differences were observed in the impact of the CTT among the different smolecular profiles subtypes (AU)

[Current advances in diagnosis and surgical treatment of lymph node metastasis in head and neck cancer]. / Aktuelle Fortschritte in der Diagnostik und chirurgischen Therapie der Halslymphknotenmetastasen bei Kopf-Hals-Karzinomen.

Still today, the status of the cervical lymph nodes is the most important prognostic factor for head and neck cancer. So the individual treatment concept of the lymphatic drainage depends on the treatment of the primary tumor as well as on the presence or absence of suspect lymph nodes in the imaging diagnosis. Neck dissection may have either a therapeutic objective or a diagnostic one. The selective neck dissection is currently the method of choice for the treatment of patients with advanced head and neck cancers and clinical N0 neck. For oncologic reasons, this procedure is generally recommended with acceptable functional and aesthetic results, especially under the aspect of the mentioned staging procedure. In this review article, current aspects on pre- and posttherapeutic staging of the cervical lymph nodes are described and the indication and the necessary extent of neck dissection for head and neck cancer is discussed. Additionally the critical question is discussed if the lymph node metastasis bears an intrinsic risk of metastatic development and thus its removal in a most possible early stage plays an important role.

Padronização da nomenclatura dos linfonodos axilares baseada em critérios anatômicos / Anatomical criteria based padronization on the axilary lymph nodes nomenclature

Os linfonodos axilares recolhem a linfa de todo membro superior e de parte da parede torácica. A glândula mamária drena 80% de sua linfa para estes linfonodos. O conhecimento da drenagem de cada quadrante mamário para os respectivos grupos axilares é de suma importância para o cirurgião que vai realizar o esvaziamento axilar, bem como para o radioterapeuta na instituição do tratamento complementar. As literaturas anatômica, cirúrgica e oncológica denominam os linfonodos axilares em grupos com diferentes números de componentes e com as mais diversas nomenclaturas, fato este que causa confusão na difusão dos conhecimentos a respeito das patologias malignas nesta área. Visando esclarecer estas dúvidas, realizou-se uma revisão bibliográfica, bem como a efetuação de dissecações, no sentido de padronizar o número e a nomenclatura dos diferentes grupos de linfonodos dentro da axila. Foram dissecadas seis axilas de cadáveres adultos, não fixados, de ambos os sexos e de variados grupos éticos. Na literatura mundial encontram-se 21 diferentes denominações para estes linfonodos. Segundo os achados, a melhor nomenclatura a ser seguida é a que classifica os linfonodos axilares em cinco grupos: apicais, centrais, laterais, torácicos laterais e subescapulares.

Systematic (complete) para-aortic lymphadenectomy: description of a novel surgical classification with technical and anatomical considerations.

The clinical indications for a complete para-aortic lymphadenectomy in the surgical management of gynaecological malignancies remain controversial. The debate on complete para-aortic node dissection is hindered by the absence of an identifiable and accepted definition for the procedure of systematic (complete) para-aortic node dissection. In this paper we propose a classification of para-aortic lymphadenectomy. We have identified and imaged the most common and rare para-aortic vascular anomalies that we have encountered. An understanding of the anatomical anomalies in this area also provides a useful reference for the surgical technique that is adopted in order to ensure the completeness of excision.

[About expediency of terminology and classification modification for lymphadenectomy in the surgery for pancreatic cancer].

While doing pancreatic gland resection for cancer the lymphadenectomy is performed in volume, recommended on a congress of pancreatologists in Castelfranco-Venetto (standard, radical, extended radical) or in manuals of Japanese investigators (D1, D2). These classifications have got several shortages: terminological inaccuracies, lack of information, concerning the borders of the vegetative neural plexuses dissection etc. The authors have proposed a modified terminology and classification of lymphadenectomy, in accordance to which four types of lymphadenectomy are delineated: D1p, D2p, D3p, corresponding to lymphatic collectors N1, N2, N3, as well as D4p--complete excision of lymphatic nodes in all three regions while total pancreatectomy performance. The symbols 9n-dex/sin and 14n-dex/sin were recommended to name the lymph nodes of the ninth and fourteenth groups, indicating availability of the nervous plexuses dissection performance of right/left hemicircumference of vessels only. The retroperitoneal dissection borders and criterions for the lymphadenectomy volume choice were proposed.

Selective neck dissection in the management of the neck after (chemo)radiotherapy for advanced head and neck cancer. Proposal for a classification update.

For patients with advanced regional disease, neck dissection following (chemo)radiotherapy remains controversial. Selective neck dissection (SND) was reported as suitable after chemoradiation in patients with advanced regional disease. Reduced morbidity represents the major advantage of SND. In a situation in which there is a major fibrosis around the previously invaded nodes, resection of 1 or more nonlymphatic structures may be required. The current classification of SND could be implemented by the addition of extended selective neck dissection (ESND). The standard basic procedures for SND spare the sternocleidomastoid muscle (SCM), the internal jugular vein (IJV), and the spinal accessory nerve (SAN). When an SND is associated with the resection of 1 or more nonlymphatic structures, it should be termed ESND. All additional nonlymphatic structure(s) removed should be identified in parentheses. The proposal to subclassify SND not only in accord with the resected lymph node levels but also upon the nonlymphatic structures removed may be of some help to avoid potential misinterpretation.

Pelvic lymphadenectomy in cervical cancer--surgical anatomy and proposal for a new classification system.

BACKGROUND: Pelvic lymphadenectomy is an integral component of gynecologic cancer surgery, yet there is a lack of standardization in the terminology used, the extent of the procedure, and the definition of anatomic landmarks. This lack of standardization if corrected will likely facilitate a more clear communication and analysis of outcomes from various institutions, and reduce confusion to trainees about the procedure being performed. METHODS: We summarize the anatomic data concerning pelvic lymphatic drainage; describe the procedure based on clearly defined anatomic landmarks; and finally propose a new classification system to facilitate standardization, communication, and comparison of results. The accompanying video demonstrates the anatomic landmarks. RESULTS: We list and define four commonly used terms related to pelvic lymph node harvesting: sentinel node mapping, excision of bulky nodes, pelvic lymph node sampling, and systematic pelvic lymphadenectomy. We list the five specific anatomic regions of the pelvic lymphatic basin: external iliac, obturator, internal iliac, common iliac, and presacral. We highlight the important neural structures located in regions of the pelvic lymphadenectomy: genitofemoral nerve, obturator nerve, cranial part of the lumbosacral plexus, hypogastric plexus, and splanchnic nerves. Finally, we propose a new, four-part classification system of types of pelvic lymph node dissection. CONCLUSION: In this report and video, we demonstrate anatomy and offer a new classification system for pelvic lymphadenectomy.

Three classes of pelvic and aortic lymphadenectomy in patients with cervical cancer.

Currently, the extent of pelvic and aortic lymphadenectomy is currently described by numerous and ambiguous terms. The aim of this study is to present a classification of pelvic and aortic lymphadenectomy in cervical cancer patients. On the base of the data from the literature, pelvic and aortic lymphadenectomies have been assigned to three different classes, depending on surgical technique, the extent of the lymphadenectomy and the specificity of the removed lymph node groups. Class I equals removal of selected lymph nodes; Class II: removal of lymph nodes situated ventrally and laterally to large extraperitoneal vessels and the obturator nerve and of lymph nodes situated ventrally and laterally to the aorta and vena cava; Class III: total removal of lymphatic tissue around the iliac vessels and from the obturator fossa dorsally to the obturator nerve and from the presacral region and lymphatic tissue around the aorta and vena cava. The presented classification allows for a unequivocal assessment of pelvic and aortic lymphadenectomy.

Aggressive D2 lymphadenectomy is required for accurate pathologic staging of gastric adenocarcinoma.

The therapeutic efficacy of aggressive regional D2 lymphadenectomy as an adjunct to gastrectomy for adenocarcinoma of the stomach remains controversial. It is hypothesized that D2 lymphadenectomy compared with limited D1 lymphadenectomy increases nodal yield without adding to operative morbidity or mortality, and is necessary to allow accurate pathologic staging according to current American Joint Committee on Cancer (AJCC) criteria. A 10-year retrospective review of a consecutive series of 105 gastrectomies for adenocarcinoma at an urban public teaching hospital was performed. Of 69 intended curative gastrectomies, 55 (80%) included D2 lymphadenectomies, whereas of 36 palliative gastrectomies, only 9 (25%) included D2 lymphadenectomies (P = 0.0041). Only D2 and not D1 lymphadenectomy achieved the AJCC minimum guideline of the 15 lymph nodes required for accurate pathologic staging (mean 25.2 vs 12.4 nodes, respectively; P = 0.0001). For D2 cases, 86 per cent had greater than 15 nodes excised compared with only 20 per cent for D1 cases (P = 0.0002). The morbidity and mortality rates for D2 and D1 operations were 22 per cent and 2 per cent, and 41 per cent and 2 per cent, respectively. We conclude that there was no increased morbidity or mortality associated with D2 lymphadenectomy; that reliable harvesting of an adequate number of lymph nodes for accurate AJCC pathologic tumor staging requires D2 lymphadenectomy; and that D2 lymphadenectomy should be performed as part of virtually all gastrectomies for invasive adenocarcinoma having curative intent.

Correlation between the current TNM staging and long-term survival after curative D1 lymphadenectomy for stomach cancer.

BACKGROUND AND AIMS: This study aims to assess the tumour-related factors that influence long-term survival after curative gastrectomy with standard D1 lymphadenectomy for patients with stomach cancer. PATIENTS AND METHODS: Patients who had undergone curative gastrectomy for carcinoma of the stomach at North Shore Hospital between 1990 and 2000 were identified from theatre records and the hospital database. Medical records were reviewed and included tumour location, type of operation, in-hospital mortality, gross morphology of tumour, histological type, and Helicobacter status; pathology slides were reviewed, and tumours were staged according to the new TNM staging. Patients were followed-up for 2-11 years. Length of survival was obtained for each patient from medical records or from family doctors. RESULTS: R0 gastrectomy was performed on 70 patients; median survival was 23 months, and all patients with early gastric cancer are currently still alive. T stage, nodal stage and histological type correlated significantly with survival, but multivariate analysis showed that T stage is the most significant predictor. Five-year survival was 26%. Significant survival difference was seen between T2a and T2b. CONCLUSION: Histological subtype, lymph node metastases and depth of invasion are factors that affect survival of patients with gastric cancer; however, depth of invasion is more important than other variables. Tumour location and type of gastrectomy has no effect on survival. The latest TNM classification (sixth edition) gives a better prognostication than the previous classification.

[Radiological and surgical classification of head and neck lymph node anatomy]. / La classification radio-chirurgicale des niveaux ganglionnaires cervicaux.

OBJECTIVE: The purpose of this review is to present a systematic description of cervical lymph drainage by nodal level. MATERIAL AND METHODS: We present, in French, the radiological and surgical classification of the cervical lymph nodes with numerous illustrations. A critical analysis of the advantages and limitations of this tool is presented together with practical guidelines. RESULTS: This classification system is a useful tool for the evaluation of cervical metastases. It provides for more precise treatment and better understanding and communication between specialists, offering the standardization necessary for comparing results obtained by different teams and for multicenter studies. CONCLUSION: This classification of cervical lymph nodes by level is a useful tool for the management of cervical node involvement in head and neck cancer.

Inter-observer variability in systematic nodal dissection: comparison of European and Japanese nodal designation.

BACKGROUND: Systematic nodal dissection is accepted as an important component of the intrathoracic staging of patients undergoing thoracotomy for lung cancer. Several lymph node maps have been proposed in an attempt to ensure uniformity in designating lymph node stations. The Japan Lung Cancer Society has published detailed definitions for each nodal station adopting the Naruke map. However, since these definitions had not been interpreted into other languages, they have not been universally accepted. The objective of this study was to assess the inter-observer variability in the interpretation of lymph node stations. METHODS: A total of 424 lymph node stations were removed from 41 patients undergoing thoracotomy for non-small cell lung cancer. All nodal stations were labeled using the Naruke map. As each station was excised, it was designated in a blind fashion by one of two surgeons trained in the UK and one surgeon trained in Japan. The designation accorded to each nodal station was analyzed. RESULTS: The total concordance was 68.5% (right side 67.0%, left side 69.9%). The concordance rate for individual nodal stations varied from 0% to 100%. Considerable discordance existed between the Japanese and European surgeons in the designation of nodal stations 2, 4, 8 and N1 station 12. In 14 (34.1%) patients, discordance in the labeling of lymph nodes led to disease being categorized as N1 by one observer, whereas the other considered the same nodes to be N2. CONCLUSIONS: Considerable discordance in the designation of nodal station has been demonstrated. We would expect similar inter-observer variability elsewhere between surgeons, institutions, or countries. More detailed nodal charts and precise, easily understood definitions of nodal stations are needed for intrathoracic staging. The first English version of the Japan Lung Cancer Society staging manual goes some way to address this.