DISSECTION OF PARA-AORTIC LYMPH NODE METASTASIS AFTER SURGERY FOR A CANCER OF THE TRANSVERSE COLON
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An operated case of para-aortic lymph node recurrence after surgery for a cancer of the transverse colon is reported. A 64-year-old woman underwent an operation for cancer of the transverse colon on September 26, 1995. Six months after the operation, increases in serum CEA and CA19-9 level were found and further exermination revealed para-aortic lymph node swelling from the level of the It. renal vein to the bifurcation of the aorta. Para-aortic lymph node metastasis of the colonic cancer was suspected. There was no evidense of another metastasis in Ga scintigraphy. We judged that the patient was a candidate for operation and performed para-aortic lymphadenectomy. The patient has no sign of recurrence at present, 16 months after the operation. No case of para-aortic lymphadenectomy after operation for the colonic cancer has been reported to this time in Japan. It is suggested that this operation is beneficial for proloning the survival time in case of no evidence of another metastasis.Keywords:
Lymphadenectomy
Aortic bifurcation
Transverse colon
Lymph node dissection is a standard part of surgical resection of rectal cancer which helps to avoid local recurrence and allows for accurate staging of the disease. Three types of lymph node dissection have been considered. Mesorectal lymphadenectomy should remove the mesorectum systematically and should extend at least 5 cm distal to the tumor. Inferior mesenteric lymphadenectomy should extend at least to the origin of the left colic artery. Lateral lymphadenectomy removing iliac and obturator nodes results in complications and has not been shown to improve survival; it is not routinely recommended. Omission of lymph node dissection is only proposed for the smallest T1 tumors with favorable histology.
Mesorectum
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It is unclear whether gastric cancer prognosis is improved by extended lymph node dissection more than by lymph node dissection limited to the contiguous N1 perigastric lymph nodes.Four hundred and thirty-eight patients treated by curative gastrectomy were evaluated. Outcomes of D1/D1.5 lymphadenectomy, limited lymph node dissection and of D2/D2.5 lymphadenectomy, extended lymph node dissection and histopathological prognostic factors as in the 1993 TNM staging classification supplement were analyzed.Estimated overall 5-year survival was 54.9%. Five-year survival was 58.4% in the limited lymph node dissection group and 54% in the extended lymph node dissection (P n.s.). Stage I 5-year survival was 59% after D2.5 lymph node dissection, 58% after D1.5 and 50% after D2 dissection (P n.s.). Stage II 5-year survival was 86% in D2.5 group and 56% in D1.5 group (P = 0.041). Stage IIIa survival was 61% in the D2.5 group and 22% in the D1.5 group (P = 0.001). Stage IIIb 5-year survival was 42% after D2.5 resection and 0% in D1.5 group (P = 0.001). In the pT3 group 5-year survival was 72% after D2.5 dissection and 33% after D2 dissection (P = 0.001). In the positive N1 lymph nodes group 5-year survival was better after extended lymph node dissection than after limited lymph node dissection. In pN2a patients 5-year survival was 57% after D2.5 resection and 0% after D2 resection (P < 0.001). In pN2b and pN2c patients extended lymph node dissection did not statistically improve survival.Even if no statistical differences were found in overall survival, prognosis was improved by extended lymph node dissection in stage II and III, particularly in T2 and T3 subgroups and in N1 and N2a subgroups. When large numbers of positive nodes were found, improved survival was dependent upon resection of extragastric nodes distal to the uppermost echelon of positive nodes.
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Esophageal cancer is a common malignant tumor in China. For resectable ones, surgery is still the primary treatment. At present, the extent of lymph node dissection remains controversial. Extended lymphadenectomy makes metastatic lymph nodes more likely to be resected, which contributed to pathological staging and postoperative treatment. However,it may also increase the risk of postoperative complications and affect prognosis. Therefore, it is controversial how to balance the optimal extent/number of dissected lymph nodes for radical resection with the lower risk of severe complications. In addition, whether the lymph node dissection strategy should be modified after neoadjuvant therapy needs to be investigated, especially for patients who have a complete response to neoadjuvant therapy. Herein, we summarize the clinical experience on the extent of lymph node dissection in China and worldwide, aiming to provide guidence for the extent of lymph node dissection in esophageal cancer.食管癌是我国常见的恶性肿瘤，对于可切除的食管肿瘤，手术仍是最主要治疗方式。目前，对于手术治疗过程中的淋巴结清扫范围仍有较大争议。一方面，彻底地进行淋巴结清扫，可以尽可能多地摘除转移淋巴结，获得精准分期，以指导下一步诊疗；另一方面，彻底地进行淋巴结清扫可能会带来更多的术后并发症，从而影响患者预后。因此，如何在肿瘤根治性所需淋巴结清扫范围或数量与可能带来的严重并发症之间获得平衡，目前尚有争论。此外，新辅助治疗后淋巴结的清扫策略是否应该有所改变也是值得探讨的问题，尤其是在新辅助治疗后完全缓解的食管癌中。本文将总结国内外关于淋巴结清扫范围或清扫程度的临床经验，以期为食管癌外科治疗中的淋巴结清扫范围提供参考。.
Lymphadenectomy
Esophagectomy
Neoadjuvant Therapy
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To examine the relationship between the dissected lymph-node number and the prognosis in D(2) gastrectomy for gastric cancer.From January 1996 to January 2005, 457 patients with primary gastric cancer undergone gastrectomy with different extent of lymphadenectomy in our hospital were followed-up in term of prognostic benefit.In lymph-node metastasis group, the 1-, 3-, 5-year survival rates were 82.4%, 49.0%, 33.4% with dissection of >20 nodes and 71.5%, 49.7%, 40.1% with dissection of 16-20 nodes. In the group without lymph-node metastasis, the 1-, 3-, 5-year survival rates were 98.2%, 92.7%, 84.7% with dissection of >20 nodes and 94.0%, 89.7%, 81.4% with dissection of 16-20 nodes. Whether or not it had lymph-node metastasis, the survival curve failed to show any significant difference with regard to the extent of lymph node dissection.As to lymphadenectomy for gastric cancer, it is enough to excise the lymph node between 16 and 20. The number of excised lymph node should not be overemphasized unless it is metastasized.
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So far, D2 lymphadenectomy has been recognized as the key one of the procedures in curative resection for gastric cancer. In summary, the standardized implementation of D2 lymphadenectomy can contribute to both surgical quality and patients' prognosis. Lymph node dissection, as an important basis for local surgical treatment of gastric cancer, involves certain technical risks due to complex adjacent relationship and anatomical variation of organs or blood vessels, and so on. There is a certain incidence of side injuries in D2 lymphadenectomy for a surgeon, regardless of the experience of learning curve. Complying with specification of surgical procedures and summarizing the vital points of lymph node dissection in each curative gastrectomy for gastric cancer is the principal method to reduce or avoid the occurrence of relevant complications after surgery.D(2)淋巴结清扫，是目前公认的胃癌根治性手术中重要的操作步骤，其规范地实施可直接影响整个胃癌根治术质量和患者预后。淋巴结清扫是胃癌外科局部治疗的重要基础，鉴于其解剖位置及与邻近脏器、血管等存在的复杂关系甚至出现变异，淋巴结清扫存有一定风险和技术难度，学习曲线的经历是必然的。即使对于临床经验丰富的外科医师而言，D(2)淋巴结清扫仍然不可避免地会出现一定的副损伤。遵守规范操作、且不断总结每例胃癌根治术中D(2)淋巴结清扫的要点，是减少或避免术后相关并发症出现的主要方法。.
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Our aim was to evaluate detection of nodal metastasis during radical cystectomy with standard pelvic lymph node dissection versus en bloc lymphadenectomy for the treatment of bladder cancer.Hospital records of a total of 77 patients with radical cystectomy and either standard pelvic lymph node dissection or en bloc lymphadenectomy were reviewed. Nodal dissection specimens during standard lymphadenectomy were sent for pathology examination in 6 separate containers marked as external iliac, internal iliac, and obturator groups from both sides. En bloc dissection specimens were sent in 2 containers marked as the right and the left pelvic nodes. Clinical and pathological findings of these two groups were compared in terms of the number of dissected lymph nodes, number of nodes with metastasis, lymph node density, and clinical outcomes.There were 34 patients with standard lymph node dissection and 43 with en bloc lymphadenectomy (anterior pelvic exenteration). Age, sex, duration of the disease, number of transurethral resections prior to cystectomy, pathological grade at cystectomy, and stage of the primary tumor were comparable in the two groups of patients. The median numbers of nodes removed per patient were 15.5 (range, 4 to 48) and 7.0 (range, 1 to 24) in those with standard and en bloc lymphadenectomy, respectively (P < .001). Nodal involvement was detected in 10 (29.4%) and 9 (20.9%) patients, respectively (P = .43).Although nodal involvement was not significantly different between the two groups, standard lymphadenectomy submitted in 6 different containers significantly improved the nodal yield over en bloc resection. Obturator nodes were the most commonly involved nodes in our study.
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