Review of US medical school finances, 1995-1996

We discussed the rational extent of the lymph node dissection for carcinoma of the lower third of the esophagus of T2 or T3 stage with abdominal lymph node metastasis. Lymph node metastasis developed in 89.5% of patients. Cervical lymph node metastasis was seen in 35.8%. In the cases with positive abdominal lymph node, 40.9% of the patients had cervical node metastasis. The most frequent site of the positive node in the neck is the area along the right recurrent laryngeal nerve. On the stand point of removal of metastatic lymph node, neck dissection should be required. Three-field dissection yielded better survival rate than two-field dissection but statistical significance was not obtained. When the patients have cervical lymph node metastasis, they have greater possibility of developing blood borne metastasis. However, this observation does not deny the validity of the three-field dissection. Because this dissection may help reducing nodal spread and nodal recurrence. We have to wait for accumulation of the patients to analyze the definite extent of node dissection for T2 or T3 stage of carcinoma of the lower third of the esophagus with positive abdominal lymph node.     

Expression of CD44 variant 6 and lymphatic invasion: importance to lymph node metastasis in gastric cancer

Lymph node metastasis is a critical prognostic factor for gastric cancer. In the present investigation we examined clinicopathologic factors influencing the metastatic processes to the lymph mode and their prognostic importance. A randomly selected group of 98 patients with adenocarcinomas of the stomach who underwent gastrectomy plus systematic lymph node dissection at Osaka Police Hospital from 1991 to 1996 were analyzed. Altogether 37 (38%) cancers were positive for CD44 variant 6 (v6) staining, 31 (32%) were intermediately stained, and 30 (30%) were negative. CD44-v6 expression correlated well with lymph node metastasis. Expression of CD44-v6 and lymphatic invasion were independent risk factors for metastatic lymph nodes. Among the patients with CD44-v6-positive and lymphatic invasion-positive cancers, 88% had lymph node metastasis, whereas only 13% of patients negative for both factors had lymph node metastasis. Although CD44-v6 expression and lymphatic invasion have been reported to be risk factors for recurrence and a poor prognosis, in this investigation these factors were found not to be significant for hematogenous and lymphatic recurrences or overall survival rates. Thus expression of CD44-v6 and lymphatic invasion may regulate lymph node metastases from gastric cancer.     

Prognostic factors in oligodendrogliomas

Among 601 patients with early gastric cancer (EGC), the clinicopathological findings of 5 patients (invasion of the mucosal layer in 2 and of the submucosal layer in 3) with distant lymph node metastasis according to TNM classification (third- or fourth-tier lymph node metastasis according to the Japanese classification) were investigated. The proliferating-cell nuclear antigen (PCNA) expression of EGC was also examined immunohistologically. The sites of distant metastasis were the nodes at the root of the mesentery, in the hepatoduodenal ligament, and the paraaortic nodes. While the PCNA-positive rate of EGC with distant lymph node metastasis (35.4%) was significantly higher than that of EGC without lymph node metastasis (14.7% P = 0.01), it was similar to that of EGC with perigastric lymph node metastasis. The cumulative survival rate of the EGC patients with distant lymph node metastasis (5-year survival rate 20.0%) was significantly lower than that without lymph node metastasis (88.2%, P < 0.0001), first-tier lymph node metastasis (76.9%, P < 0.04), or second-tier lymph node metastasis (77.1%, P < 0.04). Thus, although the prognosis of EGC patients with distant lymph node metastasis was poor, a dissection of the distant lymph nodes should be performed when metastasis is suspected.     

Diagnosis of extension and treatment of carcinoma of the gallbladder

Diagnosis of extension by intraoperative ultrasonography (IOUS) and treatment based on the degree of histological extension in carcinoma of the gallbladder are discussed. IOUS is a useful technique for the diagnosis of the depth of wall invasion and direct invasion of the liver. The authors diagnose the depth of wall invasion based on the layer structure, unequal width, and discontinuity of the layer echogram. By this technique, mucosal cancer (m cancer) or cancer extending to the proper muscle layer (mp cancer) can be differentiated from cancer with submucosal invasion (ss cancer), and also ss cancer from cancer exposing the serosa (se) or cancer infiltrating to the serosa (si). However, differentiation between m cancer and mp cancer is not possible by IOUS or by other diagnostic techniques. In terms of histological extension, lymph node metastasis or vascular and nerve invasion is not found in m cancer, but in some cases of mp cancer vascular invasion is present. As a radical operative procedure for early m and mp cancer, full-thickness cholecystectomy or partial resection of the liver bed and dissection of lymph nodes 8, 12, and 13 should be conducted. As lymph node metastasis and vascular and nerve invasion are frequent in ss or more advanced cancer, complete lymph node dissection should be performed. Cholecystectomy, partial resection of the liver bed, bile duct resection, and dissection of lymph nodes 8, 12, and 13 is the preferred radical operative procedure for ss cancer. In the cases with in metastasis to lymph nodes 8 and 13, pancreatoduodenectomy is combined. The basic operative procedure for se and si cancer has not been established, but is should be radical and safe. Considering the poor prognosis and frequency of lethal postoperative complications, at present we should not only expand the resected area but select a reasonable and well-balanced operative procedure depending on the degree of cancer extension.     

The treatment of excessive somnolence with stimulant drugs

In this paper we report on the long-term results achieved in 75 patients with superficial carcinoma of the thoracic esophagus who have been treated since 1965 with esophagectomy at our institute. In three of these patients, the carcinoma was limited to the epithelium (intra-epithelial carcinoma), while in 13 cases it was confined to the mucosa, and in 59 cases to the submucosa. There was no lymph node metastasis in patients with intra-epithelial or mucosal carcinoma, but lymph node involvement was found in 13 (22.0%) of the 59 cases of submucosal carcinoma. The five-year survival rate of patients with intra-epithelial carcinoma and mucosal carcinoma was 100%, which was significantly better than that for carcinoma invading the submucosa (49%). The five-year survival rate for patients with lymph node involvement was only 46%, which was significantly worse than that for patients without lymph node involvement (60%). No recurrence occurred in patients with intra-epithelial carcinoma or mucosal carcinoma, while recurrent disease occurred in 19 (32.2%) of the 59 patients with submucosal carcinoma. Lymph node recurrence and hematogenic recurrence such as lung and bone metastasis were the most frequent developments in patients with submucosal carcinoma of the esophagus.     

Surgical management for lymph node recurrence of resected fibrolamellar carcinoma of the liver: a case report

Fibrolamellar carcinoma of the liver (FLC), which is very rare in Japan, is reported to be frequently accompanied by lymph node metastasis in Europe and the United States. We describe a 22-year-old man with recurrent FLC in the lymph nodes after undergoing partial hepatectomy. He underwent a second operation for removal of recurrent lymph node tumors in the mediastinum and abdominal cavity one year after initial surgery. However, a third operation became necessary seven months later, because of recurrence in a lymph node in the abdominal cavity. We discuss the management of lymph node metastasis from FLC.     

Medical Information Bus usage for automated IV pump data acquisition: evaluation of usage patterns

SUMMARY: lymph node involvement in renal cell carcinoma is factor of very poor prognosis. In a series of 55 node-positive patients, 33 (60%) had simultaneous renal vein or vena cava invasion and 32 (58.2%) had metastases. Gross lymph node involvement was found in 39 patients (70.9%). Patients without venous invasion or metastasis may have a prolonged survival. In this group, those with microscopic nodal involvement can be cured, as the 10 and 15-year the actuarial survival rate is 54.5% Formal lymphadenectomy might have played a role in these results. Surgery can be performed when vein invasion is present without metastasis, but the prognosis is generally poor. Survival does not seem to be influenced by surgery when metastasis is present, regardless of the vein status.     

A case of stage IV breast cancer showing long-term complete response to combination therapy with 5'-DFUR and MPA

We report a 62-year-old woman with supraclavicular lymph node, pleural and bone metastases from breast cancer showing a long-term complete response to combination therapy with 5'-DFUR and MPA. A large amount of pleural effusion was drained followed by administration of ADM, which improved the amount of effusion. Treatment with CAF and TAM decreased tumor size, but CAF was abandoned due to severe leukopenia. Mastectomy was performed for local control. However, levels of tumor markers increased progressively. Administration of CMF was tried, but tumor markers continued to increase. Therefore, combined chemoendocrine therapy with 5'-DFUR and MPA was undertaken. Levels of tumor markers normalized and a complete response was obtained 13 months after starting this combination therapy. There are no further metastatic lesions evident, and this status has been consistently maintained for more than three years (six years and five months after diagnosis of breast cancer). There were no significant side effects of this combination therapy except for mild weight gain and moon face. This combination regimen with 5'-DFUR and MPA is considered useful as a second-line treatment for advanced breast cancer.     

Varicella in pregnancy

We report six cases of hyperplastic mesothelial cells located in the sinuses of lymph nodes. All patients but one had a concurrent serosal fluid collection (two pericardial, two pleural, one abdominal) at the time of the lymph node biopsy. All effusions cleared with treatment of the underlying disorder, which included lymphoproliferative processes, congestive heart failure, and inflammatory diseases (Dressler syndrome, vasculitis, and glomerulonephritis). Four cases were associated with vascular prominence of the involved nodal sinuses, a feature that may reflect the cause of the underlying effusion or support the transient persistence of benign mesothelial cells in lymph nodes. Two cases were characterized by distention of the nodal sinuses by sheets of mitotically active mesothelial cells. The differential diagnosis includes metastatic carcinoma, keratin-positive dendritic cells native to lymph nodes, and metastatic malignant mesothelioma. Because the latter shares both clinical and morphological features with cases of benign mesothelial cells in lymph nodes, we believe that this distinction may not always be possible in a given biopsy specimen and therefore that careful clinical follow-up is required in such cases.     

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.     

Axillary lymph node metastases of bronchogenic carcinoma

BACKGROUND: Metastasis of bronchogenic carcinoma to axillary lymph nodes is rare. The pathways and possible significance of axillary lymph node metastasis from bronchogenic carcinoma were investigated. METHODS: Seventeen patients with probable axillary lymph node metastases from bronchogenic carcinoma were identified by computed tomography. There were 15 nonsmall cell lung cancers and 2 small cell lung cancers. Axillary lymph node metastasis was proven by biopsy in six cases. Metastases were presumed because of an increase in the size of axillary lymph nodes compared with prior studies in six patients and enlarged axillary lymph nodes associated with biopsy-proven ipsilateral supraclavicular lymph node metastasis in five patients. RESULTS: Four of 10 right-sided lung cancers had ipsilateral and six had contralateral axillary lymph node metastases. Six of seven left-sided cancers had ipsilateral and one had contralateral axillary lymph node metastases. Patients with ipsilateral lymph node disease had chest wall involvement and/or supraclavicular and mediastinal lymph node metastases. All seven patients with contralateral axillary lymph node metastases had supraclavicular and/or mediastinal lymph node metastases. CONCLUSION: Bronchogenic carcinoma may involve ipsilateral axillary lymph nodes via either chest wall invasion or retrograde spread from supraclavicular lymph nodes. Contralateral axillary lymph node involvement requires involvement of contralateral mediastinal and supraclavicular lymph nodes with retrograde spread to the axillary lymph nodes.     

"Sociosomatics": the contributions of anthropology to psychosomatic medicine

We report an unusual case of T 0 N 2 M 0 small cell lung cancer in a patient with Lambert-Eaton myasthenic syndrome (LEMS). A 52-year-old man began to notice muscle weakness in a left limb in January 1996, which was followed by muscle weakness in his left arm and fingers, appetite loss, and general fatigue. An electromyogram (EMG) showed the waxing phenomenon in response to high-frequency repetitive stimulation. Lambest-Eaton myasthenic syndrome was diagnosed, based on his symptoms and EMG findings. Chest computed tomography (CT) was done, and left paratracheal, tracheobronchial, subaortic, and hilar lymphadenopathy were found. No mass was seen in either lung field. Cytologic examination of the sputum and bronchial lavage fluid were done, but no malignant cells were found Small cell lung cancer was diagnosed after thoracoscopic resection of the subaortic lymph nodes. No metastases were detected by bone scintigraphy, abdominal CT, or magnetic resonance imaging of the brain. Complete response and resolution of symptoms were obtained by chemotherapy and irradiation.     

Salivary duct carcinoma: a clinicopathologic study of three cases with a review of the literature

Three cases of salivary duct carcinoma are presented. They occurred in a 60 year old man, a 66 year old man and a 57 year old woman. All of the lesions were located in the parotid gland. The tumor size ranged from 3 to 5 cm across the largest diameter. Facial paralysis was observed in two cases. Histologically, intraductal and invasive adenocarcinoma showing papillary, cribriform, and solid patterns with comedolike necrosis was observed. Immunohistochemically, the tumor cells were positive for keratin and epithelial membrane antigen. No myoepithelial cells were demonstrated within the tumor by staining for S-100 protein, alpha-smooth muscle actin or muscle specific actin. Ultrastructurally, intracytoplasmic lumina with microvilli, a moderate number of mitochrondria, lysosomes, and tight junctions were found. Regional lymph node metastasis was observed in one case, and distant metastasis developed in two cases. All of the patients were treated with adjuvant postoperative irradiation. One patient died of disease at 11 months after the initial diagnosis, another was alive with disease at 8 months, and the third patient was alive without disease at 2 years and 3 months. Salivary duct carcinoma should be differentiated from low-grade salivary gland carcinomas using morphologic and clinical criteria because of its poor prognosis even with aggressive therapy.     

Endoscopic treatment of submucosal invasive colorectal carcinoma with special reference to risk factors for lymph node metastasis

A clinicopathological analysis of the risk factors for lymph node metastasis was performed in 177 patients with submucosal invasive colorectal carcinoma (CRC). The submucosal deepest invasive portion was histologically subclassified as well (W), moderately (M), or poorly (Por) differentiated. M type was further subdivided into moderately-well (Mw) and moderately-poorly (Mp) differentiated. The pattern of tumor growth was classified as polypoid growth (PG) and non-polypoid growth (NPG). Lymph node metastasis was detected in 21 (12%) of the 177 patients. Macroscopically, type IIc and IIa + IIc lesions showed a significantly higher incidence of lymph node metastasis (44% and 30%) than type IIa and I (4% and 8%). Regarding the histologic subclassification, Por and Mp lesions showed a significantly higher incidence of lymph node metastasis (67% and 37%) than W and Mw lesions (4% and 14%). NPG tumors showed a significantly higher incidence of lymph node metastasis (29%) than PG tumors (7%). The depth of submucosal invasion and lymphatic invasion (ly) were also significantly correlated with the incidence of lymph node metastasis (submucosal scanty (sm-s) invasion 4%, massive invasion 20%; ly(+) 23%, ly(-) 5%). None of the lesions with both sm-s invasion and of W or Mw type showed lymph node metastasis. These results indicate that submucosal invasive CRC with both sm-s invasion and of W or Mw type, which shows no ly, is the appropriate indication for endoscopic curative treatment.     

Early metastases in regional lymph nodes and prognosis of malignant melanoma. Histological and clinical examinations in 104 lymphadenectomized patients

In 104 malignant melanoma patients who underwent lymphadenectomy (67 females, 37 males), correlations were studied between histologically diagnosed lymph node metastasis, the type of malignant melanoma and the depth of invasion according to Clark, as well as other parameters. In 35.6% of the patients, metastases of the primary tumor were found in one or several regional lymph nodes. In about one third of the patients, the clinical and histological lymph node findings were proven to diverge. The female:male ratio of generally about 2:1 shifted to 1:1 in the group of patients with lymph node metastasis, i.e. cases with lymph node metastasis were found significantly increased in the male sex, and also, when primary tumors were localized on the trunk. A prognostic correlation between the two parameters, sex and localization, is suggested by the high incidence of histologicallly diagnosed metastases in 1 or 2 lymph node regions, when malignant melanomas were localized on the trunk in males. As to the types and the micro-stages of primary tumors, the number of cases collected until now does not permit establishing clear correlations with the incidence of lymph node involvement. Calculating the 5-year-survival rates for patients with and without lymph node metastasis according to the "actuarial method", we found the prognosis to depend largely on the presence or absence of lymph node involvement, even at a time as early as at primary tumor excision. Our results support the indication for prophylactic lymphadenectomy in malignant melanoma, provided the primary tumor has reached or surpassed the micro-stage 3.     

High-dose epirubicin in platinum-pretreated patients with ovarian carcinoma: the EORTC-GCCG experience

A follow up study of 20 cases of renal cell carcinoma with regional lymph node metastasis at the department of urology in Niigata Cancer Center Hospital from 1979 to 1993 is presented. During this period, we treated 249 patients with renal cell carcinoma with or without lymph node metastasis. Lymph node metastasis could be estimated in 188 out of 249 patients. Histologically, lymph node metastasis was classified as pN1 in 8 cases, pN2 in 7 cases, and pN3 in 5 cases. The 3- and 5-year survival rates of 20 patients with lymph node metastasis were 45.0% and 16.4%, respectively. Nine of the 20 cases had no distant metastasis and 11 cases had distant metastasis. Three of the 9 patients with distant metastasis had no recurrence. Two of these 3 patients are still alive after 10 years and 3 years and 1 patient died because of acute heart failure. These 3 patients had pN1 metastasis smaller than 1 cm lymph node. Four of the 11 patients with distant metastasis had more than a two-year survival. However, 3 patients died due to renal cell carcinoma although primary and metastatic regions were resected and IFN with chemotherapy were given. Only one patient is still alive without recurrence after 3 years. This case detected as right renal cell carcinoma with pN2 metastasis and bilateral pulmonary metastasis was treated with radical nephrectomy with regional lymph node dissection and administered Methotrexate, VP16 and CisPlatinum chemotherapy and IFN.(ABSTRACT TRUNCATED AT 250 WORDS)     

Para-aortic lymph node metastasis in carcinoma of the distal bile duct

BACKGROUND/AIMS: Lymph node dissection plays an important role in radical surgery for pancreaticoduodenal carcinomas. The aim of this study was to identify the critical areas of lymph node dissection in carcinoma of the distal bile duct. METHODOLOGY: Between January 1995 and December 1996, 20 consecutive patients with distal bile duct cancer underwent pancreaticoduodenectomy with extended lymph node dissection (including the para-aortic nodes). Histopathologic findings were examined with special reference to lymph node metastasis. RESULTS: Histological evidence of lymph node metastasis was found in 11 patients (55%). The areas with frequent metastases were the posterior pancreaticoduodenal lymph nodes (35%), and the nodes around the hepatoduodenal ligament (35%) and around the common hepatic artery (30%). Para-aortic lymph node involvement was identified in 5 patients (25%). Most of these existed in the inter-aorticocaval space. Pancreatic parenchymal invasion was present in 10 patients. Half of the patients with pancreatic invasion had para-aortic nodal involvement. Para-aortic lymph node metastasis was significantly associated with pancreatic parenchymal invasion (p<0.05). CONCLUSIONS: In carcinoma of the distal bile duct with pancreatic parenchymal invasion, extended lymph node dissection (including para-aortic nodes) should be undertaken because of the relatively high incidence of metastasis.     

Surgical treatment for advanced carcinoma of the gastric remnant

BACKGROUND/AIMS: Carcinoma of the gastric remnant has increased in recent years, but a therapeutic strategy for this disease has not been established. This retrospective study was performed to determine the most appropriate surgical procedure for carcinoma of the gastric remnant. METHODOLOGY: A total of 25 patients who underwent operation for advanced carcinoma of the gastric remnant that had developed after distal gastrectomy (13 for benign gastric diseases, B group; 12 for gastric carcinoma, M group) were studied. Clinicopathological features, as well as the status of lymph node metastasis, were investigated in the B and M groups. RESULTS: There were more patients with carcinoma invading other organs, stage IV disease, and with N2 or more lymph node metastasis (especially, with a high metastatic rate to lymph nodes along the splenic artery) in the M group than in the B group. Forty percent of patients in the M group were treated by left upper abdominal evisceration (LUAE), but only 8% in the B group. The survival rate (5-year, 46.0%) of the B group was significantly higher than that (5-year, 11.9%) of the M group. When we compared the survival rate of carcinoma of the gastric remnant with that of primary carcinoma of the upper third of the stomach, there was no difference between the two groups in the curative resection cases. CONCLUSIONS: Almost the same surgical strategy can be adopted for the B group as for primary gastric carcinoma. On the other hand, for the M group, a radical surgical procedure, LUAE, should be recommended.     

Metastatic basal cell carcinoma presenting as unilateral lymphedema

BACKGROUND: Metastatic basal cell carcinoma (MBCC) is rare, occurring in only 0.0028-0.55% of all basal cell carcinomas (BCCs). Patients with MBCC may present with a variety of findings, related to the site of metastasis. OBJECTIVE: Clinical presentation of a MBCC that became symptomatic due to unilateral lymphedema and a review of the relevant literature. METHODS: Case report with literature review. RESULTS: Patients may present with lymphadenopathy, ulcerations, anemia, bone pain, or muscle weakness related to the site of metastasis. In this reported case, MBCC presented as unilateral lymphedema. Risk factors for MBCC include radiation, large and invasive tumors, and a history of recurrence. The average survival time for localized lymph node metastasis in BCC is 3.6 years. This patient is currently 2 years since MBCC presentation and is currently without evidence of recurrence. CONCLUSION: To our knowledge, we report the first case of MBCC that presented as unilateral lymphedema.