Barrier function of lymph node to tumor cells and erythrocytes. II. Effect of x-ray, inflammation, sensitization and tumor growth

A Short History of Bernard Fisher's Contributions to Randomized Clinical Trials

Dr. Bernard Fisher (1918-2019) was an early proponent of evidence-based medicine using the mechanism of prospective, multicenter, randomized clinical trials to test biological and clinical hypotheses. In this article, I trace how his early scientific work in striving to understand the nature of cancer metastasis through animal experiments led to a new, testable, clinical hypothesis: that surgery to remove only the tumor and a small amount of tissue around it was as effective as the more disfiguring operations that were then the standard treatment. Fisher's work with the National Surgical Adjuvant Breast and Bowel Project (NSABP) using large, randomized clinical trials to demonstrate the veracity of this hypothesis led to a new paradigm in which the emphasis was placed on how systemic therapies used at an early stage of disease could effectively eradicate breast cancer for many patients. This new therapeutic approach led to the successful development of new treatments, many of which are widely used today. Ultimately, the new paradigm led to successfully preventing breast cancer in women who were at high risk for the disease but who had not yet been diagnosed with the disease. Throughout his entire career, Fisher championed the use of large prospective, randomized clinical trials despite criticism from many in the medical community who strongly criticized his use of randomization as a mechanism for testing clinical hypotheses. The approach he and the NSABP employed is still considered to be the highest standard of evidence in conducting clinical studies.

Sentinel Node Methods in Penile Cancer - a Historical Perspective on Development of Modern Concepts

Malignant penile tumors are of squamous cell origin in more than 95% of cases and the occurrence of a distant metastasis without prior inguinal lymph node metastatic deposits is very rare. This makes inguinal lymph node staging very reliable and of great prognostic significance since undiscovered and untreated inguinal metastases may lead to a fatal clinical course. In lack of a sufficiently accurate noninvasive lymph node staging modality, penile cancer relies on surgical lymph node removal for regional staging. In this respect sentinel node biopsy offers a favourable minimally invasive alternative to prophylactic inguinal lymph node dissection which is associated with significant surgery-related morbidity. Today sentinel node biopsy is widely used in surgical oncology within high volume cancers such as breast cancer and melanoma. In rare cancers sentinel node biopsy is also emerging as a minimal invasive staging tool in patients with no obvious lymph node involvement. At several specialized units across Europe sentinel node biopsy has been practiced by dedicated specialist within vulva and penile cancer for more than two decades. In fact, the rare disease penile cancer was a model entity for development of the original sentinel node concept as early as the 1970'es due to work by the Paraguayan penile cancer pioneer, Cabañas, the sentinel node concept was subsequently successfully adapted in breast cancer and melanoma. This turned out mutually beneficial since the sequential development of sentinel node biopsy in penile cancer in the 1990s eventually adopted new insights and added conceptual details from the experiences harvested in the broader clinical application possible in these high-volume diseases. The prerequisite to conceptualising the sentinel node approach was the gradual anatomical and functional understanding of the lymphatic system which in western medicine rooted in ancient Greece and gradually increased in details and comprehension with significant contributions from many great notabilities during the last centuries including Hippocrates, Galen, Fallopio, Malpighi, Virchow, Starling, Cabañas, Hodgkin and Horenblas. Sentinel node biopsy in penile cancer is a complex multimodality procedure involving inguinal ultrasonography by radiologists, precise tracer-injection and interpretation of nuclear images by nuclear medicine physicians, radio-tracer- and dye guided open surgical biopsies by urologists and thorough step-sectioning, immunostaining and accurate lymph node specimen analysis by pathologists. This team effort requires well-tested protocols, experience and good collaboration and in rare diseases this calls for centralization of service.

Practice patterns about the role of palliation in veterinary surgical oncology

Whether surgical palliative therapy is appropriate for oncologic veterinary patients is an increasing concern as pet age increases because of improved care. In this study, an online survey (available for 30 days), comprising 100 questions with structured response options, was administered to 492 diplomates of the European College of Veterinary Surgeons (ECVS). The survey queried the technical, ethical, social, medical, and financial aspects of surgical palliative therapy for oncologic veterinary patients. Responses were received from 155 ECVS diplomates (31.5%, n = 155/492). Palliative surgery was a relatively common intervention in veterinary oncology, with 50% of respondents (n = 77.5/155) indicating that 75%-100% of oncological surgeries performed were palliative. The presence of metastasis was judged as a key determinant when deciding to perform palliative oncological surgery by 41% of the respondents (n = 63.5/155). The survey revealed that the most commonly performed procedures in palliative oncological surgery were marginal resection, debulking, and amputation. In contrast to human medicine, palliative limb-sparing surgery, stent placement, and embolization were rarely used in veterinary settings, mainly because of a general lack of expertise among veterinarians, elevated costs, and recourse to euthanasia. Taken together, the survey results highlight the need for appropriate guidelines in the field of oncological surgery. To establish general guidelines and direct veterinarians towards the most appropriate judgement, understanding how and what veterinary surgeons manage palliative oncological surgery and how they perceive the main ethical, social, medical, and financial concerns are essential. Such guidelines will lead to better care for ailing animals and will facilitate the path to healing for owners.

A historical account of breast cancer surgery: beware of local recurrence but be not radical

In the late 19th century, William Halsted proposed the radical mastectomy, which became the standard surgical treatment of breast cancer for nearly 100 years. Later in this period, theories suggesting that breast cancer was a systemic disease at inception were championed by Bernard Fisher. This alternative hypothesis of biological predeterminism was based upon results of randomized clinical trials comparing breast conserving therapy with mastectomy, which showed similar overall survival outcomes. Nonetheless, data from meta-analyses suggest that inadequate local therapy can increase risk of local recurrence, which can subsequently increase mortality. In this review, the authors provide an historical account of how local therapy of breast cancer has evolved in the face of improved adjuvant therapies and better understanding of disease biology.

Clinical comparison of four types of skin incisions for skin-sparing mastectomy and immediate breast reconstruction

PURPOSE

Skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) has become popular as an effective procedure for patients with early breast cancer. We herein report an overview of the four types of skin incisions used for SSM.

METHODS

The records of 111 consecutive breast cancer patients, who received SSM and IBR from 2003 to 2012, were reviewed retrospectively. Four types of skin incisions were used. Type A was the so-called tennis racquet incision, type B was a periareolar incision and mid-axillary incision, type C was the so-called areola-sparing with mid-axillary incision and type D was a small transverse elliptical incision and transverse axillary incision.

RESULTS

Twenty-six type A, 59 type B, 20 type C and six type D incisions were made. The average blood loss and average length of the operation during SSM were not significantly different between the four approaches. The average areolar diameter was 35 mm for type A, B and D incisions, and 45 mm for type C. There was a need for postoperative nipple-areolar complex plasty (NAC-P) in 75 % of the cases following type A, B and D incisions, and 35 % of the cases treated using type C incisions.

CONCLUSION

The type C incision is superior with regard to the cost and cosmetic outcomes, because fewer of these patients request postoperative NAC-P.

Retrospective comparison of non-skin-sparing mastectomy and skin-sparing mastectomy with immediate breast reconstruction

Background. We compared Skin-sparing mastectomy (SSM) with immediate breast reconstruction and Non-skin-sparing mastectomy (NSSM), various types of incision in SSM. Method. Records of 202 consecutive breast cancer patients were reviewed retrospectively. Also in the SSM, three types of skin incision were used. Type A was a periareolar incision with a lateral extension, type B was a periareolar incision and axillary incision, and type C included straight incisions, a small elliptical incision (base line of nipple) within areolar complex and axillary incision. Results. Seventy-three SSMs and 129 NSSMs were performed. The mean follow-up was 30.0 (SSM) and 41.1 (NSSM) months. Respective values for the two groups were: mean age 47.0 and 57; seven-year cumulative local disease-free survival 92.1% and 95.2%; post operative skin necrosis 4.1% and 3.1%. In the SSM, average areolar diameter in type A & B was 35.4 mm, 43.0 mm in type C and postoperative nipple-areolar plasty was performed 61% in type A & B, 17% in type C, respectively. Conclusion. SSM for early breast cancer is associated with low morbidity and oncological safety that are as good as those of NSSM. Also in SSM, Type C is far superior as regards cost and cosmetic outcomes.

The Effect of Radiation Therapy on Normal Tissue Function

As more patients are treated for their primary malignancy with cure or increased disease-free intervals, injury to normal tissues will become more detectable and an important endpoint for study. Future protocols will probably be modified based on toxicity endpoints. In Hodgkin's disease, current protocols use response-based treatment strategies to limit therapy. The objective is to provide the same level of tumor control and follow normal tissue endpoints for outcome analysis. DVH analysis has improved the ability to analyze endpoint data for normal tissues. These image-guided platforms will provide the infrastructure needed to continue efforts in improving the delivery of radiation therapy.

Last-intercalated node and direct lymphatic drainage into the thoracic duct from the thoracoabdominal viscera

OBJECTIVE

We clarified the configuration of the mediastinal lymphatics, focusing on the last intercalated lymph node and the direct drainage vessel to the thoracic duct, based on recent anatomical findings.

METHODS

We macroscopically observed the lymphatics during dissections of 205 cadavers in combination with routine histology. We also review the results of injection by other researchers.

RESULTS

Efferent vessels draining directly into the thoracic duct or venous angle were frequently found in the following node groups: the right paratracheal node group corresponding to the last intercalated node in 98% of cadavers (201); the brachiocephalic angle node group in 85% of cadavers (174); the right recurrent nerve group in 46% (94); the left superior phrenic node group in 73% (150); the node group at the origin of the left common carotid artery (the preaortico-carotid node) in 37% (76); the pretracheal node group in 25% (51) and the left tracheobronchial node group in 36% (74). Last intercalated nodes appeared common for multiple drainage routes or regional lymphatics. These results were mostly consistent with injection studies by Riquet et al. Direct lymphatic drainage from the esophagus to the thoracic duct was observed in 19% of cadavers (39). Direct lymphatic drainage of lung segments to distant mediastinal nodes is also reviewed. The sentinel node concept is discussed in relation to the above observations.

CONCLUSIONS

We hypothesize that the most critical sentinel node, if such usage is allowed, is situated as a guard for a limited specific route and for a common drainage route. We term it the "common terminal node".

Clinical management of the regional lymph node

Appropriate clinical management of the regional lymph node remains controversial. This article briefly reviews the anatomy and physiology of the lymphatic system, pathophysiology of lymphatic metastases, and some guidelines and rationale for clinical management.

Effects of the adjuvant DEAE-dextran and Staphylococcus aureus on the lymph pathways and filtering capacity of popliteal lymph nodes in sheep

The effects of subcutaneous injections of the adjuvant DEAE-dextran and, or killed Staphylococcus aureus on the structure of the lymph pathways of popliteal lymph nodes in sheep were examined using light and electron microscopy and Microfil casts. Dextran with or without killed S aureus caused significant changes in the lymph pathways both within the node and outside it. However, killed S aureus alone did not. The changes included anastomoses among afferent lymph vessels and between afferent and efferent lymph vessels; proliferation of vessels around the node; joining of parts of the capsule and trabeculae to adjacent parenchyma with loss of parts of the subcapsular and trabecular sinuses; enlargement of medullary sinuses; and reduction of the number of reticular processes in sinuses throughout the node. These changes were accompanied by a reduced ability of the node to filter chicken red blood cells labelled with chromium-51 which were injected into an afferent lymph vessel.

The clinical significance of minimal breast cancer: a pathologist's viewpoint

We can draw the following conclusions about minimal breast cancer: The concept of minimal breast cancer as a stage of cancer that is 95% curable is a valid one, if minimal breast cancer is defined by strict parameters. Both 0.5 and 1.0 cm have been defined as the upper limit of size for minimal invasive cancer. Some data indicate that 0.5 cm is the preferable dividing line and that 1-cm cancers are no longer minimal. Other data suggest that the most important factor is axillary lymph node status. One-centimeter cancers are probably 95% curable if axillary lymph nodes are negative. Cancers of 0.5 cm and smaller in size are probably not 95% curable if axillary lymph nodes are involved. Carcinoma in situ appears to be highly curable, even if axillary lymph nodes are involved. Minimal breast cancer should include lobular carcinoma in situ (lobular neoplasia) and ductal carcinoma in situ regardless of nodal status, and (tentatively) invasive carcinoma smaller than 1 cm in total diameter, if axillary lymph nodes are not involved. Many cases of minimal breast cancer are asymptomatic. If special screening is not used, less than 10% of women with breast cancer will be at the minimal stage when diagnosed. Screening programs can increase this ratio to as much as one third of patients, perhaps even more. While serious questions about cost effectiveness of mass screening remain, screening programs appear to represent the best way of detecting minimal breast cancer. Screening programs should include careful history and physical examination, of course. The role of mammography is still controversial. It is probable that at least 50% of all minimal cancers would be missed without mammography. After a period of significant worry about the risk of radiation, opinion seems to be changing now and many authors are willing to accept the fact that mammography is of more benefit than risk for younger women. The HIP study would indicate that the risk/benefit ratio becomes favorable at age 50. Many authorities would now comfortably include mammography in the screening of women age 40 or older. Some authors believe that the benefits of mammography outweight the risks for patients of all ages. This question needs to be tested, and several randomized prospective clinical trials now in progress are doing just that. The legitimate worry over the risks of mammography should not obscure a very important fact.(ABSTRACT TRUNCATED AT 400 WORDS)

The impact of pathology on the biologic, diagnostic, prognostic, and therapeutic considerations in breast cancer

It has become readily appreciated that an understanding of the pathologic aspects of breast cancer is essential to the planning of many clinical trials. The clinical findings obtained from such studies unquestionably served as a stimulus for other relevant pathologic investigations but did not always resolve all of the long-standing pathologic problems associated with the diagnosis of breast diseases. This article addresses some of the pathologic problems that have a bearing on the biologic, diagnostic, prognostic, and therapeutic aspects of breast cancer.

Uveal melanoma: location, size, cell type, and enucleation as risk factors in metastasis

In this series of 3,432 cases of malignant melanoma of the choroid and ciliary body, mortality from metastasis 15 years after enucleation was 46 per cent. This mortality was at least ten times greater than has been observed with tumors of the iris, probably owing to the greater size and more malignant cytology of choroidal and ciliary body tumors. In 56 per cent of the 3,432 cases, the melanomas were composed of a mixture of spindle and epithelioid cells. The 15-year mortality of patients with melanomas of mixed cell type was three times that of patients with tumors of pure spindle cell type. In 30 per cent of the cases in this series, the melanomas of the choroid and ciliary body were larger than 15 mm in diameter. Size was highly correlated with mortality. The distribution of deaths following enucleation in the 3,432 cases was a log-normal function of time from enucleation. This indicated that metastasis occurred in these fatal cases close to the time of enucleation. The authors were also able to infer that many years were usually required for these uveal melanomas to grow from small (7 to 10 mm in diameter) to large (greater than 15 mm in diameter). These observations are consistent with the hypothesis that dissemination of tumor cells at the time of enucleation has been a major cause of metastasis with small and medium-sized uveal melanomas.

Effects of the removal of the regional lymph nodes on the survival of mice bearing B16 melanoma or EAkR lymphosarcoma

This work presents data concerning the effect of tumor excision accompanied or not by the removal of the regional lymph node (RLN) on the survival time of mice bearing the EAkR lymphosarcoma or the B16 melanoma. The operations were performed at various times to study this effect in relation to tumor size. Early tumorectomy, on day 6 for the EAkR lymphosarcoma, on day 10 for the B16 melanoma, significantly prolonged the survival time. The additional removal of the RLN abolished this beneficial effect. In the case of the EAkR lymphosarcoma. a beneficial effect on the survival time was, in contrast, observed after total excision of the tumor accompanied by RLN removal performed on day 8. The two surgical procedures were ineffective in increasing the survival time when they were applied after the 8th day for the EAkR lymphosarcoma and after the 10th day for the B16 melanoma. These results suggest that the preservation of the RLN may be favorable for the host, at least at an early stage of the tumor growth.

The immunologic responsiveness of regional lymphocytes in experimental cancer

This report presents data showing that regional lymph node lymphocytes differ in their immunologic activity from distant lymphocytes and splenic lymphocytes during the initiation and progression of murine mammary adenocarcinoma. Three groups of 100 C3H/He J mice received subcutaneously 10-6 viable tumor cells (I), 10-3 tumor cells (II), or Millipore chambers containing 10-6 viable tumor cells (III). Lymphocytes from different areas in Groups I, II, III, and non-tumor-bearing controls were cultured with PHA-P, autologous tumor, or normal C3H/He J breast tissue. In all groups regional lymph node lymphocytes showed the earliest peak response to PHA-P and autologous tumor, while the splenic lymphocyte and distant lymphocyte responses were delayed, especially in Group III. These studies demonstrate the role of the regional lymph node in the initial processing of tumor antigenic information. The development of central immunity appears to be the result of dissemination of immunogenic tumor products. This may be mediated initially by the regional lymph node.