Peripharyngeal space invasion of head and neck cancer--incidence, mechanisms, and management

We studied the incidence and mode of development of peripharyngeal invasion from head and neck cancers by both retrospective examination of our 127 patients and tracing the dynamics of lymph flow from the hypopharyngeal wall to the peripharyngeal space. We also presented three experiences of the surgical approach to the peripharyngeal invasion by our modification of Attia's technique. Peripharyngeal space invasions occur frequently in a direct or indirect way when meso- or hypopharyngeal or posterior oral cancer invades deeply into the muscle layers and extends to the palatine arch, retromolar region, pharyngoepiglottic fold, pharyngeal tongue, or posterior buccal mucosa. The lymph flow was revealed to move quickly from the lateral hypopharyngeal wall to the base of the skull and occasionally to the opposite side. The peripharyngeal space invasions were successfully removed under a wide surgical field without injuring the important nerves and vessels and with preservation of mandibular function. We should cover all routes for extension of head and neck cancers, including the peripharyngeal space, in the diagnosis and management of these conditions.

[Primary lymphoma of the breast]

Analysis of 5 cases of primary breast lymphoma highlights the marked rarity of the lesion and the extreme difficulty of pre-operative diagnosis. It is also shown that the disease generally runs a rapid course and that prognosis is usually unfavourable. The most effective treatment appears to be a combination of surgery and radiation therapy, while chemotherapy--although widely used--still requires further confirmation.

A technique of ilioinguinal lymph node dissection for carcinoma of the penis

A technique has been described for ilioinguinal lymph node dissection that provides good exposure for both the pelvic and inguinal dissections and circumvents the anatomic barrier presented by the inguinal ligament. It also enables one to evaluate the pelvic lymph nodes unilaterally or bilaterally prior to the inguinofemoral dissection if one elects to do so. A limited experience demonstrates the practical feasibility of this procedure. Although the results with this technique compare favorably with those of other techniques, experience is too small to permit categoric assessment of its relative advantages and disadvantages.

Incidence and control of occult neck node metastases from squamous cell carcinoma of the anterior two-thirds of the tongue

Cervical lymph node metastases developed in 45% of patients with T1N0 squamous cell carcinomas of the oral tongue in spite of local control of the primary lesions in 79%. The control rate for the neck of those who converted from a negative to a positive neck (N0-N+) was 33%. Neck node metastases developed in 49% of patients with T2N0 tumors. The control rate of the primary tumor was 32%, and the control rate of the neck of those whose neck nodes converted (N0-N+) was 16%. Neck node metastases developed in 42% of patients with T3N0 tumors. The control rate of the primary tumors was 33%, and the control rate of the neck of those who converted (N0-N+) was 7%. The development of neck node metastases in patients after treatment of the primary tongue carcinoma is of grave prognostic significance. The use of elective treatment to the neck at initial treatment can prevent metastases in the neck from developing if the primary tumor is under control.

Combined surgery and postoperative irradiation in the treatment of cervical lymph nodes

One hundred seventy-three patients with squamous carcinomas of the laryngopharynx, oral cavity, and oropharynx received planned, combined resection of the primary neoplasm and radical neck dissection (when N1, N2, or N3 lymphadenopathy was present) followed by megavoltage irradiation to the primary sites and bilateral cervical regions between 1975 and 1982. Radical neck dissections were performed in all patients with N2 and N3 cervical lymphadenopathy, in 90% of those with N1 necks, but in only 4% whose necks were staged NO. Neck failures occurred in 10%, 22%, 19%, and 38% of patients with stages N0, N1, N2, and N3 necks, respectively. The most ominous pathologic feature was soft-tissue extension in the radical neck dissection specimen. Initially clinically benign contralateral lymph nodes became involved in only 9% of these patients.

[Surgical therapy of breast cancer: to operate radically or to preserve the breast?]

Surgical treatment, i.e. partial resection (R) versus modified radical mastectomy (M) in lymph node negative T1/2 patients and M versus the classical Halsted procedure (RM) in lymph node positive cases, as well as adjuvant treatment forms, namely chemotherapy (B) and chemoimmunotherapy (C) versus a control group treated by surgery only (A) have been evaluated in 241 patients with breast cancer follow up over a median observation time of 48 months. Whereas M showed significantly better results than R, no difference was detected between M and RM. The incidence of recurrence in the R group did not appear to be markedly reduced by cytotoxic treatment. In the same way, the data from a retrospective study on non-randomized patients treated by breast resection, showed a relatively high local recurrence rate (23.6%) at a median observation level of 10 years. Considering the various forms of surgical treatment for operable breast cancer by analysing the data from retrospective studies and prospective randomized trials from the literature as well as our own results, the only recommendation for the standard treatment of patients with primary operable breast cancer should be nothing less than modified radical mastectomy. Breast-conserving treatment forms should be tested only within the framework of controlled clinical trials.

Therapeutic and prognostic problems in lung cancer with mediastinal lymph node involvement

From January 1st, 1978 to 31st December, 1981, 28 patients with lung cancer and mediastinal lymph node metastases, underwent surgery. In four patients, only exploration was performed, in five patients, an incomplete resection and in 19 patients, a complete resection (resectability rate 86%). In the first two groups of patients, survival never exceeded two years. In the 'complete resection' group, 78% of the patients survived for one year, 61% for two years and 47% for three years. Patients with adenocarcinoma had a higher three year survival rate than those with squamous cell carcinoma (60% vs. 37%). No 30-day mortality was observed. All patients were treated postoperatively with MACC + BCG. The prognosis of lung cancer classified as N2 is strongly influenced by a series of factors some of which are included in the TNM system. In any case, it would still appear that the best treatment for this kind of tumor is radical surgical resection followed by adjuvant radiotherapy and/or multichemotherapy.

Paraaortic lymphadenectomy is not necessary in the treatment of localized paratesticular rhabdomyosarcoma

Paraaortic lymphadenectomy is routinely recommended to treat paratesticular rhabdomyosarcoma (RMS) because of the high incidence of lymph node involvement. Taking into account the effectiveness of chemotherapy to sterilize micrometastases and aiming to reduce short-term and long-term side effects due to lymph node dissection, the RMS Group of the SIOP decided to avoid lymphadenectomy in Stage I paratesticular RMS defined by (1) complete tumor removal with negative cord section and (2) negative pedal lymphangiography. A series of 19 children (mean age 5 years, 6 months), treated between 1971 and 1981, were analyzed. Eighteen of 19 patients received adjuvant chemotherapy, using vincristine, actinomycin, cyclophosphamide, singly or alternately with vincristine, Adriamycin (doxorubicin) every 3 weeks. Duration was either 18 months (7 cases) or 8 months (11 cases). Fourteen patients are in first remission with a follow-up of more than 3 years (median 5 years); three are disease-free 35, 23, and 20 months since diagnosis; two patients are alive without evolutive disease, 32 and 56 months after an abdominal relapse. Results obtained in this series demonstrate the ineffectiveness of systematic paraaortic lymphadenectomy in Stage I paratesticular RMS and the effectiveness of chemotherapy to eradicate occult micrometastases, which obviously may exist in paraaortic lymph nodes in spite of apparently normal lymphographic findings.

Computed tomography for evaluation of mediastinal lymph nodes in lung cancer: correlation with surgical staging

Computed tomography (CT) of the chest (late model) was done preoperatively in 56 candidates for resection of lung cancer. Precise borders for each node region were defined by the American Thoracic Society modification of the classification of the American Joint Committee for Cancer Staging and were used to "map" nodes seen on CT and nodes removed surgically. Metastatic involvement of mediastinal nodes was proven by mediastinoscopy in 11 patients; nodes were removed from multiple regions at thoracotomy in 45 patients. The mediastinum was clearly delineated by CT in 46 patients with determinate scans and was judged normal in 32 (CT-negative scans) and abnormal in 14 (CT-positive scans). A node was considered metastatically involved if it measured greater than 1.5 cm in diameter. Positive nodes were found at surgical staging in 3 of 32 patients with CT-negative scans and in all patients with CT-positive scans. Thus, for the 46 patients with determinate scans, sensitivity was 82%, specificity was 100%, and accuracy (true positive and true negative) was 93%. The high accuracy of CT in these patients suggests that mediastinoscopy is not necessary before thoracotomy in the patient with a CT-negative scan, but that for the patient with a CT-positive or CT-indeterminate scan, the indications for mediastinoscopy remain the same.

Occult metastases in cancer of the larynx and their relationship to clinical and histological aspects of the primary tumor: a four-year multicentric research

The authors have tried to verify whether some clinical or pathological features of laryngeal cancer may favor the occurrence of occult metastases in the lymph nodes of the neck in N0 cases. The purpose of the investigation was to define the possible existence of tumors, where elective neck dissection, in the absence of palpable nodes, could be done without, thus contributing to settlement of a long debated problem. Different parameters, both clinical and pathological, have been considered. The result of a cross comparison of such parameters in 237 cases of cancer of the larynx without palpable nodes, submitted to surgery on the primary and elective neck dissection, indicates that, although the frequency of occult metastases is significantly related to the site and size of the tumor, its grading, and the degree and type of stromal reaction, the favorable concurrence of all said parameters occurs in 2% of cases only. However, if only clinical parameters, viz. site and size of tumor, are taken into account, a favorable concurrence occurs in 18% of cases with an incidence of occult metastases lower than 2%. These cases are almost exclusively represented by T1N0 supraglottic and T2N0 glottic tumors. We can conclude by saying that clinical and pathological preoperative findings may offer a useful clue in evaluating the risk of occult metastases, and hence advising, or not, an elective neck dissection in N0 cases. Nevertheless, in the vast majority of cases, an elective functional neck dissection still offers the best guarantee of oncologic safety while avoiding unnecessary mutilation.

[The role of transcutaneous fine-needle aspiration biopsy of the regional lymph nodes in the management of cancer of the penis]

Knowledge of the status of the regional lymph-nodes is essential for establishing the stage and the optimal treatment of carcinoma of the penis. Lymphadenectomy cannot be performed routinely because of its morbidity (30-50%) and mortality. Various noninvasive procedures such as lymphography, T.A.C. and echography have been proposed but are of limited diagnostic value because of the unacceptable frequency of the false positive and false negative findings. The transcutaneous fine-needle aspiration biopsy of the draining nodes visualized by lymphography is an innocuous, non invasive, excellent procedure, alternative to staging surgery in determining or excluding the presence of the nodal metastases. The positive cytology is conclusive of stage III and implies early, sometime, curative lymphadenectom. If the aspirate is abundant and largely representative the negative findings may also be considered to indicate the reactive nature of the lymphadenopathy.

Diagnosing metastases of differentiated thyroid carcinoma with 201 thallium scan: a case report

A case of supraclavicular metastatic follicular carcinoma which occurred 7 years after the patient had undergone total thyroidectomy is presented. By means of whole body 210-thallium scan, a precise diagnosis was made, while the whole body 131-I scan was negative. The thyroglobulin serum levels were high before surgery but significantly decreased after lymphadenectomy. The clinical use of this tracer to detect functioning and non-functioning metastases of thyroid carcinomas is discussed.

The contribution of regional lymph nodes in the resistance against breast cancer: practical implications

Experimental evidence suggests that regional lymph nodes (RLN) are important in the initiation and possibly the maintenance of tumor immunity. "Negative" nodes denote strong tumor immunity and "positive" nodes low. The latter also serve as markers of systemic disease. From histological and immunological studies, and mostly from recent clinical studies in breast cancer, the following practical recommendations are made: (1) Clinically positive axillary nodes are best eliminated by surgery. (2) Resection of positive internal mammary nodes appears to increase survival of patients with central and inner quadrant lesions; however, destruction of these nodes by irradiation, although improving local disease control, may decrease survival. (3) Negative RLN should be preserved, as they appear to prevent lymph node metastases and stimulate systemic immunity. Only a small fraction of unresected RLN harboring micrometastases will ultimately develop palpable disease, and their elimination at that late phase yields the same results as when these nodes are treated prophylactically.

Lucy Wortham James Lecture. Subclinical disease

A number of patients with cancer later develop metastases in the draining lymphatics, which initially were clinically negative. These occult deposits represent subclinical disease in lymphatic areas accessible to palpation, like the neck, axillae, and groin. The concept applies also to the microscopic disease left in an area after a surgical procedure is known to have removed all gross cancer, yet some patients later develop a recurrence. The term "subclinical disease" refers only to disease in a specific anatomic area, based on clinical facts. Radiobiological parameters account for the fact that subclinical disease requires less irradiation to be eradicated than gross cancer. The concept has two main applications, elective irradiation of clinically negative peripheral lymphatics and locoregional irradiation combined with surgery, which are determined by site and disease. The concept of subclinical disease also has implications for chemotherapy, which bear a direct relationship between chemotherapy both with radiation therapy and surgery.

Surgical treatment of carcinoma of the clitoris

Thirty-eight consecutive patients were treated with either vulvectomy (14) or in combination with groin dissection (24) according to the same treatment protocol. The crude 5-year survival was 50% and the corrected 5-year survival was 66%. Three patients died postoperatively. Endophytic tumor, poor degree of differentiation, and involvement of lymph nodes resulted in higher mortalities. No patient with involvement of deep inguinal or pelvic nodes could be cured. The study concludes that invasive squamous cell carcinoma of the clitoris should be treated, in the same was as the same tumor in other areas of the vulva, with radical surgery.

Individualization of treatment for stage I squamous cell vulvar carcinoma

Of 177 cases of invasive squamous cell vulvar cancer seen at the University of California at Los Angeles and the City of Hope National Medical Center from 1957 to 1980, 84 (47.5%) had stage I disease. Seventy-seven patients with stage I disease (91.7%) had stromal invasion of 5 mm or less. Correlation between lymph node status and depth of invasion was as follows: 1 mm or less, none of 34 (0%); 1.1 to 2 mm, two of 19 (10.5%); 2.1 to 3 mm, two of 17 (11.8%); 3 to 5 mm, one of seven (14.3%); more than 5 mm, three of seven (42.9%). Fifty-six patients had radical vulvectomy for the primary lesion, and 28 had more conservative excision, but the incidence of local invasive recurrence (4%) was the same in each group. None of 58 patients treated with inguinal-femoral lymphadenectomy developed a groin recurrence, but three of 26 patients (11.5%) who had omission or modification of inguinal-femoral lymphadenectomy died with groin recurrence within 12 months. These data suggest that although some modification of the standard radical vulvectomy is appropriate for the primary lesion in patients with stage I disease, patients with greater than 1 mm of stromal invasion require at least an ipsilateral inguinal-femoral lymphadenectomy.