[The significance of pelvic lymph-node status in prostatic cancer]

The formation of metastases of carcinoma of the prostate has become more significant since the introduction of en-bloc pelvic lymphadenectomy using the serial-cut method. Lymphogenous evacuation of the pelvis occurs increasingly with advanced and dedifferentiated primary tumours. However, it can be found with low categories of tumours and differentiated carcinomas. pLA is superior to all other procedures for N-determination. If suitably indicated it allows a localized tumour process to be confirmed. Lymphatic oedemas are the most frequent complications. These can be largely avoided by retention of lacunary lymph nodes or primary fitting of lympho-nodo-venous anastomoses.

Carcinoma arising in a benign lymphoepithelial lesion

A rare case of carcinoma arising in a benign lymphoepithelial lesion of the parotid gland is reported and compared with seven previously reported cases. The carcinomas were poorly differentiated squamous cell carcinoma in two cases, acinic cell carcinoma in one case, and undifferentiated carcinoma in five cases. This group of tumors differs from undifferentiated carcinoma with lymphocytic infiltration in their association with a benign lymphoepithelial lesion. There has been no distinct racial or geographic distribution noted.

Radical prostatectomy for localized prostate cancer

Radical prostatectomy is a proven and successful operation that can be curative for localized prostatic cancer. With advances in staging methods and attention to the grading of prostatic tumors, there is good reason to believe that radical prostatectomy will have and should have an expanded role in the treatment of prostatic cancer. Overconcern with potential complications from this operation is no longer justified.

The preoperative detection of axillary lymph node metastases in breast cancer by isotope imaging

Axillary lymphoscintigraphy using 99Tcm-labelled liposomes was carried out in 40 patients with breast cancer as a part of pretreatment staging in an attempt to improve the accuracy of axillary evaluation. Patients were injected interstitially in the periareolar region of each breast with 250–300 μCi of 99Tcm-labelled liposomes. Subsequently the patients were imaged with a gamma-camera using computerized data processing. Interpretation of images was based on prior experimental data; a diminished uptake of isotope by the primary regional lymph node (PRLN) and the group of axillary regional lymph nodes (RLN) draining the tumour, when compared to the control side, was considered to be abnormal and to suggest node metastases. An equal or enhanced uptake by the PRLN or RLN draining the tumour, when compared to the control side, was considered normal, indicating an absence of lymph node metastases. Eighteen patients (45 per cent) had abnormal scans and 14 patients (35 per cent) had normal scans. Eight patients (20 per cent) had technically unsatisfactory images where axillary nodes could not be identified. Twenty-two patients of the 32 with evaluable scans had correlation of preoperative images with postsurgical axillary lymph node histopathology. One patient out of 12 with an abnormal scan had normal lymph nodes on serial sectioning, and 2 patients out of 10 with normal scans had lymph node metastases. Eight of the 32 patients (25 per cent) with evaluable images had enhanced uptake of isotope by the PRLN and RLN draining the tumour. In 3 of these cases a marked reactive hyperplasia only was shown on histopathological examination, in 2 cases the reactive hyperplasia was associated with lymph node metastases, accounting for the 2 false negative interpretations. This preliminary study suggests that axillary lymphoscintigraphy may be of value in preoperative staging in breast cancer. Long term studies are needed to evaluate the prognostic potential of such a test as a measure of macrophage function. Further studies, by blind replication, are required to evaluate the accuracy of axillary lymph node imaging.

Lymphedema after groin dissection

Groin dissection was performed in 67 patients, of whom 40 had superficial groin dissection and 27 had ilioinguinal dissection. The incidence of overall lymphedema of a mild to moderate degree was 21 percent. Lymphedema was observed more frequently (26 percent) in patients with primary lesions in the leg when compared with those with lower trunk lesions (6 percent, p less than 0.001), and in those who did not follow a prophylactic regime of leg elevation and use of a fitted elastic stocking (45.8 percent) when compared with those who adhered to the regime (7 percent, p less than 0.004). Sex, age, wound problems, histologic status of lymph nodes, and the duration of follow-up did not significantly affect the occurrence of lymphedema.

Therapeutic groin dissection in malignant melanoma

In a retrospective review of therapeutic dissections of the groin, 22 patients underwent radical groin dissection and seven were alive at five years, whereas 26 patients underwent a superficial groin dissection and two were alive at five years, p less than 0.05. Involvement of the deep nodes is not always equivalent with systemic disease. A radical groin dissection should be used to eradicate the disease locally. The survival rate for the patients following groin dissection correlated significantly with the disease-free interval prior to occurrence of inguinal lymphadenopathy.

Primary adenocarcinoma of the gastro-oesophageal junction in childhood. A case report

Primary adenocarcinoma of the gastro-oesophageal junction, oesophagus or stomach is very rare in childhood (3, 5). Within that small patient population, dysphagia is an unusual presenting feature. We wish to report such a condition, occurring in a 14-year-old boy, to emphasise that dysphagia in childhood should always be taken seriously.

Synchronous bilateral neck dissection

The type of treatment used to control evident or possible metastatic cancer in the cervical region remains in dispute. When clinically positive lymph nodes are present in both sides of the neck, treatment to both sides is mandatory. If surgery is elected as the primary treatment, the neck dissection can be done bilaterally, either in one or two stages. Synchronous bilateral radical neck dissection has been associated with a high morbidity rate. It was the purpose of this paper to report the indications, complications, and results in a series of 179 synchronous bilateral neck dissections done between 1967 and 1979. In all except one instance, the internal jugular vein was saved on one or both sides. The mortality rate was 3.4 percent. Patients with histologically positive lymph nodes that were present bilaterally were found to have a reasonable prospect for cure. The rate of recurrence was related more to the inability to control the primary cancer than to treatment failure in the neck.

Pelvic lymphoscintigraphy with 99mTc-colloid in lymph node metastases

Twenty-four patients with cervical cancer stage Ib were examined by pelvic lymphoscintigraphy with 99mTc-colloid prior to operation. Four of the patients had histologically verified lymph node metastases. No difference in the lymphoscintigrams was found between the patients with pelvic metastases and those without. The removed involved lymph nodes did not contain less radioactive colloid than the histologically normal nodes. In two involved lymph nodes the uptake of radioactivity was far above any of the noninvolved nodes.

Intralymphatic and regional surgical adjuvant immunotherapy in high-risk melanoma of the extremities

A prospective, controlled study of surgical adjuvant immunotherapy with intralymphatic methanol-extractable residue (MER) of bacillus Calmette-Guerin (BCG) is preliminarily reported in 25 consecutive patients with high-risk malignant melanoma of the extremities. Patients were allocated on a random basis to receive preoperative intralymphatic immunotherapy with MER-BCG, surgical excision with regional lymphadenectomy and intraoperative infiltration of MER-BCG, and postoperative monthly intradermal vaccinations with BCG; or surgery and lymphadenectomy alone. Twenty patients followed for more than 1 year are the basis of this report. Fifteen patients accepted randomization, whereas four patients entered the immunotherapy group and one entered the control group at their own insistence. Immunotherapy improved the disease-free survival of patients in this trial. There was one recurrence with death in the 13 patients treated with preoperative intralymphatic MER-BCG; whereas four of seven patients in the control group had recurrence (P = 0.015), at all four of these patients died during the same interval.

Adenocarcinoma of the appendix

The experience in Hamilton, Ontario, with adenocarcinoma of the appendix, between 1974 and 1980, is reviewed and the findings are compared with those of a previous report from Hamilton. There were seven patients (five men and two women) in the current series. The average age was 55.6 years. The unusual presenting signs and symptoms of this tumour are noted; the diagnosis is rarely made preoperatively. This tumor often cannot be distinguished from cecal or ileal malignant tumours. Detailed histologic examination of all specimens is essential to identify epithelial types and to plan treatment. While appendectomy alone may suffice for tumours confined to the appendiceal mucosa, radical right hemicolectomy is still the standard therapy. The authors' study shows no improvement in preoperative diagnosis, or in prognosis, over the earlier report. The authors recommend (a) that this condition be considered in the diagnosis of any appendiceal mass that is not obviously inflammatory, and (b) the frequent use of frozen-section examination to confirm the diagnosis.

Results of ilioinguinal dissection for stage II melanoma

Eighty-two Stage II melanoma patients with inguinal lymph node metastases have undergone ilioinguinal node dissections at UCLA during the past 10 years. Twenty-four (29.3%) patients had involvement of both inguinal and iliac nodes, whereas 58 (70.7%) patients had only inguinal metastases. The frequency of iliac metastases did not relate to location, Clark's level or thickness of the primary tumor or interval from diagnosis of primary tumor to lymphadenectomy, but was related to the number of inguinal nodes involved with metastases, rising from 14.6% with one positive inguinal node to 50% with four or more inguinal node metastases. Twenty of 24 (83.3%) patients with inguinal and iliac node metastases developed recurrent disease, whereas 32/58 (55.2%) patients with only inguinal node metastases and no tumor in the iliac nodes recurred. The time to recurrence was much shorter if iliac nodes were diseased (median disease-free interval 5.8 months versus 25.6 months). Three of five patients with clinically negative but histologically positive inguinal and iliac nodes survived 5 years, while only 1/18 patients with clinically positive inguinal nodes and diseased iliac nodes lived 5 years. Those with clinically negative but histologically positive inguinal nodes and iliac metastases had recurrence and survival rates similar to those with clinically negative but histologically positive inguinal nodes and no iliac metastases. Ilioinguinal lymphadenectomy provides significant prognostic information for Stage II patients with inguinal metastases and may be therapeutic for those with iliac metastases. Therefore, ilioinguinal dissection is the operation of choice for melanoma patients with regional metastases to the inguinal area.

Metastases in malignant melanoma

A study has been made of 76 cases of metastatic melanoma presenting over a ten year period. Of this group, 64.5 per cent developed clinical metastases within 12 months of presentation with the primary disease while 80 per cent had developed metastases by three years. Fifty per cent of our patients had ulcerated lesions, and most patients had thick lesions on histological examination. The site of the first metastasis occurred in the regional lymph nodes in 65 per cent and in viscera in 22 per cent. Subsequent clinical metastases were widespread and their distribution is recorded. Of those patients with nodal involvement, 75 per cent had only one node involved in histological examination. Only 14 of the 76 patients are alive and of these nine are alive without disease. The surviving patients had regional node, intransit or local metastases present. Disease beyond these areas was fatal. We have recorded the therapeutic modalities used without attempting to study them objectively.

Carcinoid tumours of the appendix: 21 cases, with a review of the literature

Twenty-one carcinoid tumours of the appendix are reviewed. These represented 77 percent of all appendiceal primary tumours over a 16 year period and presented at a mean age of 32.3 years. No difference in sex incidence or significant racial trends were revealed. Discovery of the tumour followed presentation as appendicitis in most cases (14) and was incidental after routine appendicectomy at laparotomy in the rest. Most tumours were less than 2 cm in diameter, and five involved the appendix wall diffusely. All were argentaffin and contained significant areas of type A histological pattern. Lymphatic permeation was noted in nearly half the cases and invasion of the mesoappendix in 33 percent. Treatment was by simple appendicectomy in nineteen patients, appendicectomy with removal of a wedge of caecum in one, and right hemicolectomy in another. The literature is reviewed.

Necessary extent of lymph node dissection in testicular tumours. A histopathological investigation

The findings of a prospective topographic histopathological study of the lymphatic spread of testicular tumours are reported. The study includes 150 patients, 9 of whom were subjected to exploratory laparotomy while 141 patients underwent retroperitoneal lymph node dissection. Lymphatic spread occurs in accordance with a quite definite pattern, atypical metastases were observed in only 3 of the 150 patients. The material was analyzed with respect to the possibilities of using limited unilateral dissections. The results show that by observing appropriate safety precautions, including frozen section histology, limited unilateral dissections can be used more frequently.

Lymphoedema following ilio-inguinal lymph node dissection

The results of 90 consecutive cases of ilio-in guinal lymph node dissection have reviewed, with special regard to healing complications and the development of postoperative lymphoedema. An overall healing complication rate of 54.5% was found with reported postoperative oedema in 55.5% of cases. The 37 patients still alive at the time of the study were all examined at a special review clinic. 80% of these patients who had had healing complications developed postoperative oedema, whilst 42% of them with no healing complications developed postoperative oedema. On examination 30% had severe oedema, 50% detectable oedema, and 20% no oedema. The oedema, if it had appeared, developed early postoperatively and was worst in the first 6 months. It gradually improved, but persisted despite time and treatment. The only conservative treatment which appeared to help was the use of elastic support bandage. One-quarter of the patients found mobility was affected to some degree. Good correlation was found between the measurement of the circumference of the leg with a tape measure and the volume of the leg measured by the water displacement method and it would seem that the simplest methods suffice in detecting the oedema.

Regional lymph node metastasis from bladder cancer

The prognosis for patients with bladder cancer metastatic to regional lymph nodes is dismal and only minimally altered by current treatment modalities. The 5-year survival rate after radical cystectomy for 134 bladder cancer patients with positive regional lymph nodes was only 7 per cent and 82 per cent of the patients died of bladder cancer. Stratification of patients into groups with varying extent of nodal disease showed a correlation between the level of nodal involvement and the interval to recurrence. While 38 per cent of the patients died of distant disease alone 25 per cent had only pelvic recurrence, indicating a possible therapeutic effect of a systmatic bilateral pelvic lymphadenectomy and implicating extrapelvic disease as a major determinant of patient survival.

The management of squamous cell carcinoma in cervical lymph nodes in the clinical absence of a primary lesion by combined surgery and irradiation

Sixty-three patients who had either previously treated primary tumors or unknown primary tumors and developed metastatic cervical adenopathy in their previously untreated necks received the combination of surgery and megavoltage irradiation. Within two years, 12 patients died of intercurrent disease, nine patients died with distant metastases only, and five patients had disease recur at a primary site. The remaining 37 patients were evaluable for control of neck disease; 26 patients had previous treatment to a primary head and neck cancer that was under control at the time cervical adenopathy was treated; and 11 patients had an unknown primary tumor that was believed to be in the head and neck area. The combination of pre- or postoperative irradiation and surgery controlled neck disease in 86% of the evaluable patients. Because of the extent of neck disease, these patients would have been at a high risk of failure in the treated area if only a single modality of treatment were used. Analysis of the data shows an association of extranodal connective tissue involvement with both a decreased rate of control within the treated area and distant metastases.