Endoscopic ultrasonography in the local staging of primary gastric lymphoma

Endoscopic ultrasonography (EUS) and endoscopy were prospectively performed and compared to the histopathologic findings of the resection specimens in 24 patients with primary gastric lymphoma (PGL). On EUS, three types of PGL could be differentiated, a superficial type (n = 10), an infiltrating type (n = 12) and a tumorous type (n = 2). In the correct assessment of surface extension of the tumors, endoscopy and EUS agreed in 37.5% of cases and EUS showed more extensive disease than endoscopy in 58% of cases. However, in comparison to the resection specimens, EUS still underestimated the tumor surface extension in 37.5% of cases; this was mainly in low grade malignant PGL. The depth of tumor infiltration was correctly determined on EUS compared to the resection specimens in 91.5% of cases. Sensitivity, specificity and accuracy of diagnosing lymph node metastases were 100%, 80% and 83%, respectively. We conclude that EUS is a useful pre-therapeutic staging tool for primary gastric lymphoma but there remain some problems in determining the longitudinal and circular tumor spread in order to accurately guide the extent of gastric resection.     

Axillary node metastasis from T1N0M0 breast cancer: possible avoidance of dissection in a subgroup

BACKGROUND: Axillary lymph node dissection is now no longer considered to be the standard treatment in all patients with invasive breast cancer. We have attempted to identify a sub-group of patients with invasive breast carcinoma who may not need to undergo axillary lymph node dissection. METHODS: Patients (n = 823) with T1 N0M0 invasive breast cancer treated at our hospital between 1970 and 1994 were studied. We investigated the relationship between positive axillary lymph nodes and the following clinico-pathological factors: patient age, menopausal status, contralateral breast cancer (synchronous or asynchronous), tumor location, tumor size (T:cm), histopathology, histological grade, presence or absence of malignant microcalcification or spiculation on mammography and estrogen receptor status. RESULTS: The incidence of axillary lymph node metastases in patients with T1N0M0 invasive breast cancer was 25% (208/823). The node-negative group was significantly older than the node-positive group. Premenopausal patients had a higher rate of lymph node metastases although this was not significant. The frequency of nodal metastases when related to the tumor size was as follows: T< or =1.0 cm, 17%; T< or =1.5 cm, 25%; T< or =2.0 cm, 29%. Mammography revealed that patients with malignant calcification or spiculation had a significantly higher rate of nodal metastases than those without these findings. Certain tumor types (medullary, mucinous and tubular carcinomas) had lower positive rates for lymph node involvement. With regard to the histological grade, lymph node positivity increased significantly with high-grade tumors. No correlation was observed between any other factors and the presence or absence of lymph node metastases. CONCLUSIONS: It may be possible to avoid axillary lymph node dissection in postmenopausal patients (50 years or older) where the histological type is favorable when the tumor diameter is < or =1.0 cm and when microcalcification or spiculation is absent on mammography.     

Surgical treatment of gastric adenocarcinoma: the role of lymph node dissection

In this retrospective study, 652 patients who had curative resections for gastric cancer from 1977 to 1991 were reviewed to evaluate improvements in gastric cancer surgery and the influence of the extent of lymphadenectomy on survival. The patients were grouped into three time periods: 1977 to 1981, 1982 to 1986 and 1987 to 1991. The percentage of patients with early gastric cancer increased from 17.7% during 1977 to 1981, to 24.3% during 1987 to 1991. The average number of dissected lymph nodes was 7.5 +/- 8.1 during 1977 to 1981 and 16.4 +/- 10.3 during 1987 to 1991, when more radical lymphadenectomy was adopted. Total gastrectomies increased from 10.9% to 25.9% in the same time periods while combined visceral resections increased from 26.7% to 38.1%. Operative mortality decreased from 5.0% to 1.7%. The overall 5-year survival rate increased from 34.8% to 59.4%. In subgroup analysis, significant improvement of the 5-year survival rate was noted in the following groups: patients with stage I, II and III tumors but not stage IV; both proximal and distally located tumors; tumors with or without lymph node metastases; T1 and T2 but not in T3 and T4 (cancer invasion beyond the serosa). The decreased surgical mortality in recent years suggests that curative resection with extensive lymph node dissection can now be safely performed. Radical gastrectomy with extended lymphadenectomy may be adopted in gastric cancer resection for better control of regional disease.     

MR imaging in squamous cell carcinoma of the head and neck with no palpable lymph nodes

PURPOSE: To assess the efficacy of MR imaging in the detection of lymph node metastasis in patients with no palpable lymph nodes ("N0 neck") who have squamous cell carcinoma of the head and neck region. MATERIAL AND METHODS: MR neck imagings in 18 patients who underwent neck dissection (bilaterally in 2) for squamous cell carcinoma of the head and neck region were examined preoperatively for the purpose of detecting lymph node metastases. The imaging features taken into consideration were: size (cutoff point 10 mm), grouping, presence of central necrosis, and appearance of extracapsular spread. The MR examinations comprised spin-echo T1- and T2-weighted sequences. The MR findings were compared with those of surgery and histopathological examination. RESULTS: MR suggested metastatic lymph node involvement in 5 necks. In 2 of these, central necrosis was seen in the enlarged lymph nodes. In a third, a grouping of the lymph nodes was noted. Extracapsular spread was not present. Histopathological examination revealed metastatic lymph nodes in 7 of the 20 necks, the rate of clinically occult disease being 35%, and 4 of them had been accurately graded by MR. There was one false-positive MR examination. The MR sensitivity was 57.1% and specificity 92.3%. CONCLUSION: MR may reveal metastatic lymph nodes in patients with no clinical evidence of metastasis. However, conventional MR techniques are not always sufficient for decision-making on surgery in cases of "N0 neck".     

Staging of oesophageal carcinoma with high resolution endoluminal ultrasonography

Oesophageal carcinoma is a disease with poor prognosis despite improved treatment and diagnostic methods. The most important prognostic features are the degree of wall invasion and the presence of lymph node metastasis. Endoscopic ultrasonography (EUS) in the region of 7.5-12 MHz has improved the accuracy of tumour staging. In the course of 1 year, 21 patients with oesophageal carcinoma were examined with 20 MHz high-resolution intraluminal ultrasonography (HRES). In 11 (52%) patients, both ultrasound catheter and fiber gastroscope could pass the tumour, in 5 (23%) only the ultrasound catheter could pass. In the remaining patients the ultrasound catheter could only partially pass without prior dilatation. One patient was classified as having a stage T2 tumour, 14 (67%) had T3 and 4 (19%) had T4. In 2 patients the tumour could not be fully classified but was at least T3 When comparing our results with findings at computed tomography (CT), the T stage coincided in 9 patients (42%), in 9 patients (42%) CT could not differentiate between T2 and T3 and in 3 investigations HRES showed a higher T stage than CT. In 3 patients (14%) ultrasonography found N1 stage where CT staged N0. In one patient, CT found lymph nodes not seen with HRES. Further studies comparing EUS, HRES and surgical findings are planned to assess our view that HRES is a useful method in preoperative staging of oesophageal carcinoma.     

An evaluation of lymphography in localized carcinoma of the prostate

Lymph node biopsies were positive in 20% (7/35) of stage T1 and T2 (stage B) tumors and 64% (21/33) of stage T3 (stage C) tumors in 69 previously untreated and unselected patients with apparently localized carcinoma of the prostate. One patient with a To (stage A) tumor had no evidence of lymph node metastasis. Prospective analysis demonstrated an overall lymphographic accuracy of 78%, sensitivity of 57% and specificity of 92%. The detection of lymph node metastases in the lymphogram is limited by the frequency of microscopic metastasis and the frequency of benign changes within pelvic lymph nodes in this older patient population. Diagnostic criteria for metastatic disease which gives a low incidence of false-positive interpretations should be maintained, since relaxing the criteria will not necessarily improve the detection rate of metastases and would decrease specificity.     

Axillary lymph node metastases from bronchogenic carcinoma

BACKGROUND: Axillary lymph node metastases (ALNMs) from bronchogenic carcinoma are rare and their significance may be questioned. A surgical approach may allow a better understanding of the mechanism of their occurrence. METHODS: A retrospective study of 1,486 cases of surgically removed non-small cell lung carcinoma was performed. Twenty-two patients (1.5%) had extrathoracic nodal metastases. Nine of them were ALNMs (<1%). These cases form the basis of this study. RESULTS: In 1 patient ipsilateral ALNM was removed during a lung operation. It was a left non-small cell lung carcinoma invading the chest wall (T3 N2). In the other patients (n = 8) ALNMs were observed during postoperative follow-up; 4 underwent ALNM resection, 2 had radiotherapy, and 2 had symptomatic treatment only. For these 8 patients, in the TNM classification performed after an initial bronchogenic carcinoma operation, the lymph node status was, respectively, N0 in four cases, N1 in three cases, and N2 in one case. Survival ranged from 1 to 10 months, except for one patient who is still alive after more than 5 years. In this case, the ALNM was discovered 4 months after a right lower lobectomy for a T2 N0 adenocarcinoma. CONCLUSIONS: Axillary lymph node metastases may be involved through direct chest wall invasion of bronchogenic carcinoma or retrograde spread from supraclavicular lymphnode block. However, another mechanism seems to be the systemic vascular route.     

Skip metastasis to the mediastinal lymph nodes in non-small cell lung cancer

BACKGROUND: Whether any difference exists in clinical characteristics between resected non-small cell lung cancer with either skip or ordinary mediastinal lymph node metastases (N2 disease) needs to be clarified. METHODS: There were 110 patients with stage IIIA N2 disease. Thirty-three patients demonstrating no metastasis at the hilar nodes [skip (+) group] were compared with the other 77 patients [skip (-) group]. To investigate the extent of nodal involvement, we classified the mediastinal lymph nodes into three regions (superior, inferior, or aortic). RESULTS: There were no significant differences regarding histologic type, T status, or the site of the primary tumors between the skip (+) and the skip (-) N2 groups. In the skip (+) group, mediastinal node metastasis was found in only one region (level 1) in 30 patients (90.9%) and in two regions (level 2) in 3 (9.1%), whereas 28 patients (36.4%) from the skip (-) group revealed mediastinal metastasis at two or three regions (level 2 or 3). The overall survival rate at 5 years after operation was 35% in the skip (+) group and 12.7% in the skip (-) group (p = 0.054). This favorable clinical outcome in the skip (+) group could be explained partially by the higher proportion of patients with level 1 metastases. Furthermore, regarding patients with level 1 disease, the skip (+) group tended to have a better prognosis than the skip (-) group (p = 0.096). CONCLUSIONS: These results suggest that patients with skip mediastinal lymph node metastases represent a unique subgroup of N2 disease.     

Interest of gene amplification by PCR for the diagnosis of Mycoplasma pneumoniae infections in the child

The relationship between preoperative serum carcinoembryonic antigen (CEA), CA 19-9 and alpha-fetoprotein (AFP) levels and their clinicopathological features were evaluated in gastric cancer patients. The positive rates of CEA, CA 19-9 and AFP were 24.8, 27.6 and 12.7%, respectively. Gastric cancer with deeper tumor invasion was significantly more common among patients positive for these tumor markers. Patients with positive CEA or CA 19-9 values had a significantly high risk of lymph node metastases (p = 0.045 and p = 0.002, respectively). Synchronous liver metastases was more commonly found in patients with a positive CA 19-9 value. A significant difference (p < 0.001) in survival rate was found between patients with positive CA 19-9 values and those with negative values. CA 19-9 is useful for the prognosis of gastric cancer patients, whereas CEA, although unsuitable for prognosis, contributes to the prediction of cancer invasion.     

Gamma-probe-guided resection of the sentinel lymph node in breast cancer

Regional lymph node metastases in patients with breast cancer have fundamental staging, prognostic, and treatment implications. Classically, axillary lymph node sampling requires a dissection under general anesthesia. The concept that a primary, or sentinel, lymph node is the first node to receive drainage from a tumor has been established in patients with malignant melanomas using radiolabeled tracers and vital dyes. This study proposed two hypotheses: (1) radiolabeled sentinel lymph nodes can be identified in most patients with breast cancer, and (2) radiolabeled sentinel lymph node biopsy accurately predicts axillary lymph node metastases in those patients. Patients with operable breast cancer had Tc-99 sulphur colloid injected around their breast tumors 1-6 hours preoperatively. Patients underwent gamma probe identification of sentinel lymph nodes that were biopsied. All patients underwent axillary lymphadenectomy in conjunction with lumpectomy or mastectomy. Fifty female patients ages 26 to 90 years underwent lumpectomies with axillary dissections (40 patients) or modified radical mastectomies (10 patients). Sentinel lymph nodes were identified in 42 of 50 patients (84%). Eight patients (16%) had metastases to the axillary lymph nodes. In 7 patients, sentinel lymph nodes correctly predicted the status of the axillary nodes. There was one false negative result. A total of 550 lymph nodes were resected for an average of 11.2 nodes per patient. Sentinel lymph node scintigraphy and biopsy accurately predicted the axillary lymph node status in 41 of 42 patients (98%). Scintigraphy can identify sentinel lymph nodes in a large majority of patients. Sentinel lymph node biopsy is an accurate predictor of axillary lymphatic metastases.     

Laparoscopic pelvic lymph node dissection for prostate cancer: comparison of the extended and modified techniques

PURPOSE: We compared the results of extended (obturator, hypogastric, common and external iliac nodes) to modified (obturator and hypogastric nodes only) laparoscopic pelvic lymph node dissection in patients with clinically localized prostate cancer. MATERIALS AND METHODS: A total of 189 patients with stage T1 to T3 prostate cancer underwent modified (150) or extended (39) laparoscopic pelvic lymph node dissection for pelvic nodal assessment before definitive treatment. RESULTS: Twice as many lymph nodes were removed via extended than modified laparoscopic pelvic lymph node dissection (mean 17:8 versus 9.3). The overall positivity rate was 23 of 189 lymph nodes (12.2%), including 14 of 150 (7.3%) for modified and 9 of 39 (23.1%) for extended dissection (p = 0.02). Two patients (22%) who underwent extended dissection had positive lymph nodes in the external iliac area. Patients who presented with the high risk features of prostate specific antigen (PSA) greater than 20 ng./ml., Gleason score 7 or greater, or stage T2b disease or greater had a 26.5% (p = 0.0002), 22% (p = 0.0006) or 16.4% (p = 0.003) likelihood of positive lymph nodes, respectively. For extended versus modified laparoscopic pelvic lymph node dissection node positivity in high risk patients was 27% versus 18.8% (p = 0.4), 30 versus 26.4% (p = 0.8) and 25.4 versus 14.6% (p = 0.17) for Gleason score 7 or greater, PSA greater than 20 ng./ml. and disease stage T2b to T3a, respectively. Patients who underwent the extended procedure had a higher complication rate (35.9 versus 2%, p < 0.0001). No laparotomy was required. CONCLUSIONS: Despite yielding a 2-fold higher node count and higher node positivity rate, extended laparoscopic pelvic lymph node dissection offers no advantage over modified laparoscopic pelvic lymph node dissection for diagnosing positive lymph nodes when results are analyzed by prognostic factors. The extended procedure is associated with a much higher complication rate. In patients with the high risk features of PSA greater than 20 ng./ml., Gleason score 7 or greater and stage T2b to T3a disease modified laparoscopic pelvic lymph node dissection can be performed safely and effectively to help identify those who may benefit most from curative therapy.     

Carcinoma of the tonsillar fossa: prognostic factors and long-term therapy outcome

PURPOSE: To identify prognostic parameters and evaluate the therapeutic outcomes for patients with carcinoma of the tonsillar fossa treated with three treatment modalities. METHODS AND MATERIALS: The results of therapy are reported in 384 patients with histologically proven epidermoid carcinoma of the tonsillar fossa; 154 were treated with irradiation alone (55-70 Gy), 144 with preoperative radiation therapy (20-40 Gy), and 86 with postoperative irradiation (50-60 Gy). The operation in all but four patients in the last two groups consisted of an en bloc radical tonsillectomy with ipsilateral lymph node dissection. RESULTS: Treatment modality and total irradiation doses had no impact on survival. Actuarial 10-year disease-free survival rates were 65% for patients with T1 tumors, 60% for T2, 60% for T3, and 30% for T4 disease. Patients with no cervical lymphadenopathy or with a small metastatic lymph node (N1) had better disease-free survival (60% and 70%, respectively) at 5 years than those with large or fixed lymph nodes (30%). Primary tumor recurrence (local, marginal) rates in the T1, T2, and T3 groups were 20-25% in patients treated with irradiation and surgery and 31% for those treated with irradiation alone (difference not statistically significant). In patients with T4 disease treated with surgery and postoperative irradiation, the local failure rate was 32% compared with 86% with low-dose preoperative irradiation and 47% with irradiation alone (p = 0.03). The overall recurrence rates in the neck were 10% for N0 patients, 25% for N1 and N2, and 35-40% for patients with N3 cervical lymph nodes, without significant differences among the various treatment groups. The incidence of contralateral neck recurrences was 8% with the various treatment modalities. On multivariate analysis the only significant factors for local tumor control and disease-free survival were T and N stage (p = 0.04-0.001). Fatal complications were noted in 7 of 144 (5%) patients treated with preoperative irradiation and surgery, 2 of 86 (2%) of those receiving postoperative irradiation, and 2 of 154 (1.3%) patients treated with radiation therapy alone. Other moderate or severe nonfatal sequelae were noted in 30% of the patients treated with preoperative irradiation and surgery, in 53% treated with postoperative irradiation, and in 19% receiving radiation therapy alone. CONCLUSION: Primary tumor and neck node stage are the only significant prognostic factors influencing locoregional tumor control and disease-free survival. Treatment modality had no significant impact on outcome. Radiation therapy remains the treatment of choice for patients with stage T1-T2 carcinoma of the tonsillar fossa. In patients with T3-T4 tumors and good general condition, combination surgery and postoperative irradiation offers better tumor control than single-modality and preoperative irradiation procedures, but with greater morbidity.     

Neuronal expression of Fos and Jun protein in the rat medulla and spinal cord after anoxic and hypercapnic stimulations

The levels of the new tumour marker CYFRA 21-1 were assessed in 115 patients with non-small cell lung cancer (NSCLC) and in 45 patients with non-malignant lung disease. Increased levels of CYFRA 21-1 were observed in 47.8%, mostly in patients with squamous cell carcinoma (SCC; 69.1%). Serum CYFRA 21-1 levels were correlated with the stage of SCC type. Positive CYFRA 21-1 levels in patients with SCC were present in 40% of stage I, 61.1% of stage II, and 85.2% of stage III. In addition, SCC patients who presented mediastinal lymph nodes (N2) demonstrated higher serum CYFRA 21-1 levels, compared with patients without mediastinal lymph nodes metastases (N0 or N1). With regard to tumour size, significant difference was observed between T1, T2 and T3. The study also showed that the percentage of patients who survived 18 months with normal preoperative level of CYFRA 21-1 was higher compared with those patients with elevated preoperative levels of this marker, but the differences were not statistically significant.     

Prognosis in pT3b infiltrating tumors of the bladder treated by adjuvant chemotherapy

OBJECTIVE: To evaluate the prognosis of stage pT3bM0 invasive urothelial bladder tumours treated by cystectomy alone or combined with adjuvant chemotherapy according to the MVAC protocol (methotrexate, vinblastine, adriamycin and cisplatin). MATERIAL AND METHODS: From 1987 to 1996, 90 patients with stage pT3M0 urothelial bladder tumours were treated with isolated cystectomy (n = 69) or followed by MVAC chemotherapy (n = 21). Lymph node stage was N0 (n = 55), N+ (n = 29) or Nx (n = 6). Essentially selected because of their good general status, patients treated with chemotherapy had a lymph node stage N0 (n = 7) or N+ (n = 14). Chemotherapy had to be suspended in 2 cases and with a fatal outcome during treatment in 4 cases, due to tumour progression, surgical complication or bone marrow aplasia. RESULTS: 65 deaths have occurred with a follow-up of 2 to 120 months (m = 15), including 2 postoperative deaths, 39 cancer deaths and 14 intercurrent deaths. The 1-year, 2-year and 5-year actuarial survival rates were 70%, 48% and 19% for stage N0 and 54%, 25% and 3% for stage N+, respectively, with corresponding median survivals of 20 and 12 months (p < 0.005). The recurrence rate increased from 40% at stage N0 to 62% at stage N+ (p = 0.05), and the corresponding recurrence-free survivals were 16 months and 7 months (p < 0.02). The median survival without chemotherapy ranged from 11 months at stage N+ to 20 months at stage N0 and, with chemotherapy, from 19 months at stage N+ to 67 months at stage N0. The median recurrence-free survival with and without chemotherapy, was 43 months and 17 months at stage N0 and 12 months and 7 months at stage N+. CONCLUSION: The prognosis after cystectomy for stage pT3b bladder cancer is severe, especially in the presence of lymph node involvement. Adjuvant chemotherapy according to the MVAC protocol tends to improve survival, especially recurrence-free survival, and appears beneficial at stage N0. However, the value of this adjuvant treatment, which is associated with a high specific morbidity appears to be more relative at stage N+.     

Spiral computed tomography and operative staging of gastric carcinoma: a comparison with histopathological staging

BACKGROUND: Much controversy exists as to the value of computed tomography (CT) in the preoperative staging of gastric cancer, because of its limited ability to identify correctly lymph node (LN) metastases, invasion of adjacent organs, or hepatic and peritoneal metastases. Spiral CT scanners have a number of potential advantages over conventional scanners, including the absence of respiratory misregistration, image reconstruction smaller than scan collimation permitting overlapping slices and optimisation of intravenous contrast enhancement. AIM: To compare the performance of spiral CT and operative assessment against formal (TNM) pathological staging. PATIENTS AND METHODS: A study of 105 consecutive patients who underwent both spiral CT and operative staging was performed. All CT scans were reviewed by a radiologist who commented on tumour location and size, evidence of adjacent organ invasion, lymph node metastases to both N1 and N2 nodes, and evidence of hepatic and peritoneal metastases. All patients underwent careful operative assessment at the time of surgery, along the lines suggested by Rohde and colleagues. RESULTS: Spiral CT remained poor at identifying LN metastases to both N1 and N2 lymph nodes, with sensitivity ranging from 24 to 43%; specificity, however, was 100%. Operative staging was superior, with sensitivities between 84 and 94%, but specificity was much lower (63-74%). Spiral CT correctly detected 13 of 17 cases of invasion of either the colon or the mesocolon (sensitivity 76%) compared with 16 of 17 cases at operative staging (sensitivity 94%). Spiral CT correctly identified three of six cases with invasion of the pancreas (sensitivity 50%) compared with six of six cases on operative staging (sensitivity 100%). Spiral CT correctly identified 12 of 17 cases of peritoneal metastases (sensitivity 71%) and four of seven cases of hepatic metastases (sensitivity 57%). CONCLUSION: Whilst spiral CT remains poor at identifying lymph node metastases, it correctly identified most cases with invasion of either the colon or the mesocolon and half the cases of pancreatic invasion. It was of value in detecting peritoneal metastases and some cases with hepatic metastases. At present, at Leeds General Infirmary spiral CT is performed routinely on all patients with gastric cancer and a selective staging laparoscopy policy is adopted in those patients in whom the status of the peritoneal cavity and liver is in doubt.     

Staging of breast cancer: what standards should be used in research and clinical practice?

BACKGROUND: Bone scan (BS), chest X-rays (CXR), liver ultrasonography (LUS) and laboratory parameters (LP) are frequently used as routine staging procedures for breast cancer patients. These procedures are not always appropriate in either clinical or research settings, regardless of the stage. The aim of this study was to identify groups of patients with differing risks for metastases in order to select more precise standard staging procedures. PATIENTS AND METHODS: The staging data relating to 406 breast cancer patients consecutively referred to our institution between November 1989 and October 1996 were analysed including pathological TNN grading and biological parameters. All of the cases with a positive or suspicious pre-operatory staging and who proved to have metastatic disease before surgery or during the first six months of follow-up were considered true-positive; all of the other cases with a positive or suspicious initial staging but with no evidence of distant metastasis before surgery and with a disease-free survival longer then six months were considered false-positive. In the same way all cases with negative initial staging who relapsed during the first six months of follow-up were considered false-negative and those with negative initial staging and with a disease-free survival longer then six months were considered true-negative. Statistical analysis was performed using Fisher's exact test. RESULTS: BS, CXR and LUS, 388, 399 and 398 examinations respectively, were considered available, and 17 (4.38%), six (1.5%) and four (1%), respectively, proved to be true-positive. A statistically significant difference was observed when our cases were grouped according to T status (T4 vs. T1-T2-T3, P < 0.01) and nodal status (N0-N1 cases with less than three involved nodes and N1 with more than three positive lymph nodes N2 patients, P < 0.01). CONCLUSIONS: The present study suggests that breast cancer patients can be divided into three subgroups with different detection rates for distant metastases at staging (0.59%, 2.94% and 15.53%), and that the standard practice should be changed. In the first (T1N0 and T1N1 patients with < or = 3 positive lymph nodes--41.13% of the patients) and the second group (T2N0, T2N1 with < or = 3 positive lymph nodes, T3N0 and T3N1 patients with < or = 3 positive lymph nodes--33.49% of the patients) there is no need for a complete set of staging procedures, whereas full procedural staging is needed in the third group of patients (T4, N1 with > 3 lymph nodes and N2, 25.37% of the patients).     

Intra-operative diagnosis of N2 lymph node metastasis of gastric cancer

BACKGROUND/AIMS: Limited lymph node dissection for gastric cancer, which is prevalent in Western countries, leaves cancer cells in the second tier of nodes in patients who have metastasis in those nodes. It is, however, difficult to correctly diagnose nodal status during surgery. The present study was, therefore, designed to examine how to detect N2 metastasis intra-operatively. METHODOLOGY: Five hundred and eight patients undergoing extended lymph node dissections for gastric cancer were retrospectively analyzed. Accuracy of the intraoperative diagnosis of node involvement based on macroscopic findings was investigated, according to the N stage and histological type of the tumor. Furthermore, the distributions of N2 metastasis were clarified, according to tumor site. RESULTS: Intra-operative macroscopic findings were frequently assessed as being less severe than histological findings in cases with N2 metastasis (61.9%, 39/63). Intra-operative recognition of N2 metastasis was significantly lower in the cases with undifferentiated adenocarcinoma (28.2%, 11/39) than in those with differentiated adenocarcinoma (56.5%, 13/23). The distributions of N2 metastasis revealed nodes along the left gastric and common hepatic arteries to be the key junctions for lymphatic flow from the middle and lower thirds of the stomach, respectively. CONCLUSIONS: Intra-operative diagnosis of N2 metastasis is difficult to make based on macroscopic findings, especially in undifferentiated tumors. To detect N2 metastasis intra-operatively, the nodes along the left gastric or common hepatic artery should be submitted to frozen section examination for primary tumors located in the middle or lower third of the stomach, respectively.     

Clinicopathological study on patterns of cervical lymph node metastases from squamous cell carcinomas (SCC) of the head and neck

In order to investigate the patterns of cervical lymph node metastases from head and neck SCC, serial sections were performed on 384 radical neck dissection (RND) specimens. Positive lymph node was found in 60.4% RNDs. The cervical lymph node spread from SCC in the head and neck regions including oral cavity, oropharynx, hypopharynx and larynx has some predictable patterns, i.e., for primary SCC of the oral cavity, the majority of cervical lymph node metastases were clustered at levels I, II and III; and for primary carcinoma of the oropharynx, hypopharynx and larynx, a majority of node metastases were located at levels II, III and IV. The positive lymph nodes mainly distributed at only one level or consecutive levels. The rates of pathologically positive lymph node and extranodal spread grew with the increase of the clinical N-staging. It is suggested that supraomohyoid neck dissection (levels I, II and III) is particularly applicable to carcinomas of the oral cavity, and lateral neck dissction (levels II, III and IV) is applicable to carcinomas of the oropharynx, hypopharynx and larynx in patients with limited (N0 and N1) neck nodules, but for patients with N2 and N3 nodules, RND is neccessary to eradicate the nodal metastases. Moreover, the postoperative radiotherapy is indispensable for ruling out the occult cervical lymph node metastaese in selective neck dissection.     

Operative risk and prognostic factors of typical bronchial carcinoid tumors

BACKGROUND: This study estimated operative risk and examined factors determining long-term survival after resection of typical carcinoid tumors. METHODS: From 1976 to 1996, 139 consecutive patients (66 male and 73 female patients with a mean age of 47 +/- 15 years) underwent thoracotomy for typical carcinoid tumor. The tumors were centrally located in 102 patients (73.4%). RESULTS: Radical resection was performed in 106 patients (7 pneumonectomies, 13 bilobectomies, and 86 lobectomies) and conservative resection in 33 (3 segmentectomies, 3 wedge resections, 20 sleeve lobectomies, and 7 sleeve bronchectomies). There were no postoperative deaths. Complications occurred in 19 patients (13.7%). The morbidity rate was not increased after bronchoplastic procedures (chi 2 = 0.033, not significant). Staging was pT1 in 107 patients (77.0%) and pT2 in 32 (23.0%); 13 patients (9.4%) had nodal metastases. Seventeen patients have died (12.2%), during follow-up, but only three deaths were related to the disease. The overall survival rate at 5, 10, and 15 years was estimated to be 92.4%, 88.3%, and 76.4%, respectively; estimated disease-free survival was 100% at 5 years and 91.4% at 10 and 15 years. Estimated survival of patients with lymph node metastasis was 100% at 5, 10, and 15 years. Univariate analysis failed to demonstrate any prognostic significance for sex, tumor size (T1 versus T2), tumor location (central versus peripheral), and type of resection. CONCLUSIONS: These data confirm an excellent prognosis after complete resection of typical carcinoid tumors, including those with lymph node metastases. Parenchyma-saving resections should be preferred.     

Accuracy of endoscopic ultrasonography in the diagnosis and staging of gastric cancer and lymphoma

BACKGROUND: There is a need to assess the sensitivity, specificity, and predictive value of endoscopic ultrasonography (EUS) in the diagnosis and staging of gastric cancer and lymphoma. METHODS: A prospective study was performed on 86 patients with endoscopic gross appearance suspicious for cancer or lymphoma. Biopsies with endoscopic forceps were always carried out before EUS. All patients underwent laparotomy for final diagnosis, staging, and eventually treatment. The results of EUS were correlated with the histologic findings of the resected specimens, when possible, or with the surgical findings. There were 42 gastric cancers and 44 primary gastric lymphomas. RESULTS: EUS made a correct diagnosis of cancer in 35 of 42 patients, with a sensitivity of 83%. Positive predictability was 87%, specificity was 97%, and negative predictability was 96%. Diagnostic accuracy was 95%. In the evaluation of cancer depth invasion, EUS was correct in 91% of cases. EUS displayed perigastric metastatic lymph nodes in 14 of 25 patients, with a sensitivity of 56%. Positive predictive value was 93%, specificity was 93%, and negative predictive value was 54%. Diagnostic accuracy was 69%. EUS made a correct diagnosis of lymphoma in 39 of 44 patients, with a sensitivity of 89%. Positive predictability was 87%, specificity was 97%, and negative predictability was 97%. Diagnostic accuracy was 95%. In the evaluation of lymphoma depth invasion, EUS was correct in 92% of cases. EUS displayed metastatic perigastric lymph nodes in 8 of 18 patients, with a sensitivity of 44%. Positive predictability was 100%, specificity was 100%, and negative predictability was 72%. Diagnostic accuracy was 77%. CONCLUSIONS: From these data it appears that in these diseases EUS has demonstrated specific ultrasonographic features that allow correct diagnosis and staging in the majority of patients. In difficult cases EUS may help to achieve the correct diagnosis. EUS also appear to be a useful tool for staging of gastric cancer and lymphoma. It shows not only tumor depth and local spread but also the passage from a pathologic to a normal wall and lymph node metastasis. With this accurate noninvasive staging procedure, in the near future many patients will no longer undergo exploratory laparotomy for surgical staging. Thanks to EUS, the choice of conservative or surgical treatment can be strongly affected. In case of surgery, EUS can orient the kind of surgical approach. Moreover, the use of EUS for evaluation of therapy during follow-up will probably become of major importance.