[Extended resection of pancreatic and periampullar carcinoma: regional, total and partial duodenopancreatectomy (author's transl)]

The prognosis of exocrine carcinoma of the pancreas is still quite bad; because of that, total duodenopancreatectomy following the procedure by Fortner has been our surgical approach since January 1978. Since that time surgery of periampullary carcinoma was extended as well in such a way, that first and second order lymph nodes were excised systematically. Following the introduction of these procedures the percentage of patients with exocrine pancreatic carcinoma operated upon rose from 12 to 35%, - the percentage of patients operated upon because of periampullary carcinoma correspondingly rose from 61 to 91% of all patients carrying these tumors. The incidence of lymphogenous metastases was 88% in 17 patients, which had surgery because of ductal pancreatic carcinoma, and 27% in 22 patients with periampullary carcinoma. 29% of patients with pT1-3 tumors and 71% of patients with pT4 tumors did have already lymphogenous metastases. In 22% of the cases, who would have been operated upon by conventional total duodenopancreatectomy metastases were found in the second order lymph nodes which were taken out according to the new more radical surgical approach; the corresponding figure for patients, who were operated upon by partial duodenopancreatectomy was 5%. Mortality of regional partial duodenopancreatectomy was 4% in our series, and mortality after regional total duodenopancreatectomy was similar to that of conventional pancreatectomy without dissection of lymph nodes.

[Isolated tumor of the rectum as primary manifestation of Burkitt lymphoma (author's transl)]

Burkitt tumors are malignant lymphoblastic lymphomas occurring predominantly in Africa in children and young adults and involving in many cases the intestinal tract; these tumors occur rather seldom outside Africa. A case report is given of a white 21 old female suffering from this disease; that first manifestation was an isolated ulcerating tumor of the rectum without involvement of other organs of lymph nodes. Diagnosis was confirmed by rectum biopsy. X-ray therapy, cytostatic therapy and amputation of the rectum did not prevent a fast progression of the disease and final death, which is the usual course of the disease when it occurs outside Africa.

The results of node resection for clinically enlarged lymph nodes in malignant melanoma

Patients with malignant melanoma who require a block dissection for clinically enlarged lymph nodes have a relatively good prognosis if only one node is involved histologically and the primary is on the lower limb. Sixty per cent of these patients with single nodes show a 10 year disease-free survival rate, compared with 9% for those with multiple node involvement. The local recurrence rate at the resection site of hyperplastic nodes was 26% but fell to 10% when only a single node was involved. The disease-free interval and the survival time are a useful measure of the effectiveness of node resection.

Surgical management for malignant melanoma of the trunk

A group of 525 patients with primary cutaneous malignant melanoma of the trunk was treated by a uniform surgical approach that included regional lymph node dissection for selected patients; 266 (50.6%) had regional lymph node dissections in addition to wide and deep excision, all with primary lesions extending below the superficial papillary dermis. Of 171 patients treated over five years ago, 130 had histologically negative nodes; 94 (72%) are alive with no evidence of disease (NED). Of 41 with histologically positive nodes, 12 (29%) are alive with NED. A comparison of the 21 patients with clinically occult micrometastases shows eight (38%) alive with NED, whereas four of 20 (20%) with clinically demonstrable as well as histologically proven nodal metastases are alive with NED. Though there may be a modest benefit to lymph node dissection for microscopic rather than gross nodal metastases for invasive melanoma of the trunk, for most such patients melanoma in regional nodes indicates the presence of systemic metastatic disease.

Experience of the Curie Institute in treatment of cancer of the mobile tongue: II. Management of the neck nodes

Treatment of neck nodes of 602 patients with cancer of the mobile tongue was mainly surgical. Three-hundred-eighty-three (64%) were clinically N0, and 244 had elective neck dissection. Thirty-four percent (84/244) had occult metastasis. Thirteen percent (33/244) had major nodal involvement (greater than 3N + and/or extracapsular spread) and received postoperative radiotherapy. Twenty-one percent (7/33) recurred in the neck. Thirty-six percent (12/33) were alive, NED, at five years. Sixty-six percent (160/244) were N-, and 21% (51/244) had minimal nodal disease (less than or equal to 3N+) and did not receive postoperative radiotherapy; recurrence in neck was similar (7% and 14%) as well as the five-year survival (54% and 51%). Twenty-one patients had preoperative radiotherapy to the neck. Only one (5%) experienced recurrence of disease. Fifty had radiotherapy only. Seven (14%) failed in the neck. There were 219 patients who had clinically positive nodes and 120 who had radical neck dissection. One-hundred-one of these patients did not receive preoperative radiotherapy. Sixty-three percent (64/101) had nodal metastasis, and 27% (27/101) had major nodal involvement. In this group of patients, for the same degree of nodal involvement, postoperative recurrences in neck and the survival were similar to that of patients with clinically N0 neck, except for those with major nodal involvement. This latter group had a dismal five-year survival (12%). Nineteen had preoperative radiotherapy, and three (16%) had recurrence of disease in the neck. At present, patients with clinically N0 neck and small primary (less than or equal to 3 cm), who are therefore at low risk of failure at primary, receive brachytherapy and conservative neck dissection. Postoperative radiotherapy is given if major nodal metastasis exists. Those with larger primary (high risk of failure) receive neck irradiation only, since many will require combined resection at a later date. All patients with clinically positive nodes are treated preoperatively with 5500 rads before neck dissection.

Manifestations of carcinoma of the uncinate process by means of superior mesenteric arteriography

Identification of carcinoma arising in the uncinate region of the pancreas is difficult because of the peculiar topographic relationship of this lesion with adjacent structures. Among the various diagnostic procedures performed upon ten patients with this malignant lesion, superior mesenteric arteriography provided the most helpful information, including signs of invasion in the main trunk of the superior mesenteric artery and vein and in the proximal portion of the jejunal arteries. A clearer visualization of these vascular involvements was attained in the right posterior oblique projection rather than in the anteroposterior projection. On the contrary, the arterial and portal vessels belonging to the celiac territory, such as superior pancreaticoduodenal arteries, dorsal pancreatic artery, gastroduodenal artery, splenic vein and portal vein, were almost free of involvement. At laparotomy, almost all of the patients had direct extension of the tumor to the superior mesenteric vessels, forming a cancerous core in the root of mesentery. All died of cachexia within six months after a palliative surgical procedure. Serial roentgenograms of superior mesenteric artery, especially taken in the oblique projection, are the best means of confirming carcinoma of the uncinate process, for which only a few available methods have been established to evaluate the clinical aspects.

[Radical lymphadenectomy in non-seminomatous testis tumors using radionuclide detector (author's transl)]

This paper presents first experiences with a new method of bilateral retroperitoneal lymph node dissection in cases of nonseminomatous testis tumors: lymph node-bearing tissue - labeled by conventional lymphoscintigraphy - is intraoperatively directly detected by means of a semiconductor and then removed. In our experience this nuclide detector-directed lymph node dissection seems to be a remarkable improvement of retroperitoneal lymph node dissection because of higher effectiveness, more careful surgical technique and shortened time of operation.

Surgical management of regional lymph nodes in cutaneous melanoma

The initial evaluation of melanoma patients should include an assessment of the regional lymph nodes for metastatic disease. Clinical palpation of the nodes is an important but relatively crude index of metastatic melanoma. In clinically normal nodes, the risk of microscopic metastatic melanoma can be predicted by such prognostic factors as thickness, ulceration, and anatomic location of the melanoma. Other prognostic factors, including the level of invasion and growth pattern (nodular and superficial spreading) provided no additional predictive information after these dominant factors were accounted for. Stage I patients with intermediate thickness melanoma (0.76-4.00 mm) have an improved survival rate with elective lymphadenectomy, while those with thin (less than 0.76 mm) and thick (greater than or equal to 4.00 mm) melanomas do not benefit from elective node dissection. Stage II melanoma patients with documented nodal metastases have relatively poor survival rates because of a high risk for distant microscopic metastases. A surgical strategy for deciding about the timing, the extent, and the treatment goals of regional node dissection in melanoma patients is reviewed.

[Secondary metastases after neck dissection (author's transl)]

Hundredfourty-eight patients who underwent three types of neck dissection for cervical lymphadenopathy for squamous cell cancer of the head and neck were analysed retrospectively. In patients with no recurrence of the primary tumour the secondary metastases appeared in 44% after suprachyoid neck dissection, in 33% after classical and in 19% after modified neck dissection.

The surgical treatment of cancer of the stomach

From 1965 to 1977, 2421 patients with gastric cancer underwent operation in our hospital. 66% were males (mean age 55.9 years) and 34% females (mean age 52.2 years); 31% had a mucosal (m) and submucosal cancer (sm); 16.8% had intramuscular cancer (pm); a curative operation was performed in 62.0% of cases. The five and ten year survival rates of the advanced cancer group are 52.5% and 42.3%, whereas in the early cancer cases they are 95.0% and 85.4% respectively. These five and ten-year survival rates are significantly lower in patients with lymph node metastasis (43.3% and 35.4%). Thirty five per cent of the patients who underwent resection from 1957 to 1963 required an enlarged total gastrectomy, compared with 15% in the present series.

[Metastasising squamous-cell carcinoma of the skin in a ten-year-old girl]

Because of recurrent paronychia of the right thumb "granulation" tissue was removed from the nail-bed of a ten-year-old girl. Histological examination revealed a cornified squamous-cell carcinoma. About five months later a lymph-node metastasis was found in the right axilla. After radical dissection of the axillary region further lymph-node metastases were found, as well as a lymphangitic carcinosis with tumour infiltration in the veins. Despite telecobalt radiation there were recurrent retastases which could no longer be removed by operation. Two years after the diagnosis the girl died. Necrospy revealed diffuse tumour infiltration of the soft tissue of the axilla, upper arm, shoulder, neck and thoracic wall on the right, including the breast tissue, with thoracic para-aortic-abdominal and left-sided axillary lymph-node metastases, and lung and pleural metastases bilaterally.

Failure of cryosurgical treatment of experimental intradermal tumors to eradicate microscopic lymph node metastases in guinea pigs

Inbred Sewall Wright strain 2 male guinea pigs with established intradermal tumors and microscopic lymph node metastases were treated either by local excision, cryosurgery, or intralesional injection of BCG. Cryosurgery and local excision were effective in eliminating growth of the primary tumor but failed to prevent growth of lymph node metastases. In contrast, intralesional injection of BCG caused regression of primary tumors and prevented growth of lymph node metastases.