Surgical resection of pulmonary metastases from colorectal cancer. 10-year follow-up

Pulmonary resection of metastatic lesions from colorectal cancer was performed in 62 patients, and their cumulative 5-year and 10-year survival rates were 42% and 22%, respectively. The overall median survival was 24 months. The survival curve decrease even after 5 years after pulmonary resection; four of 13 patients who survived more than 5 years subsequently died of metastatic disease and only two patients survived more than 10 years. The number and size of the pulmonary metastases were significantly correlated with postthoracotomy survival. Solitary metastases less than 3.0 cm in diameter were good indicators of favorable postthoracotomy survival. There were no significant differences in survival based on Dukes' classification or location of the primary lesion. Sex, age, disease-free interval between the primary tumor and appearance of metastasis, and extent of pulmonary resection had no influence on survival. It is impossible to say from our experience that surgical resection of pulmonary metastases increased the cure rate. Presumably a good 5-year survival rate after thoracotomy would be a reflection of a length bias caused by the biologic behavior of the metastatic pulmonary lesions.

Radiotherapy or surgery for subclinical cervical node metastases

This retrospective study compared elective neck dissection with elective neck radiotherapy for the control of subclinical nodal metastases. Four hundred ninety-eight patients with head and neck primary cancers and no clinically apparent neck metastases on initial presentation comprised the study population. Each patient was followed up for at least 5 years to detect failure to control neck metastases and control of the primary tumor at the time of neck recurrence. Analysis of neck recurrences occurring in patients with control of the primary tumor showed that there was no statistically significant difference between elective radiation therapy to the neck and elective neck dissection for oral cavity, oropharyngeal, and laryngeal cancers. The only statistically significant difference was noted for hypopharyngeal cancers, with radiation therapy being more effective than surgery.

[Malignant fibrous histiocytoma of the breast]

In connection with the mammary tumor of a 41-year-old woman the authors draw attention to the rare occurrence of malignant fibrous histiocytoma in the mamma. The histology of the mammary malignant fibrous histiocytoma, role of immunohistochemical reactions in the diagnosis are described. The literature dealing with the malignant fibrous histiocytoma in the mamma is reviewed. This is the 11th case reported in the literature. The authors discuss the possibilities of the therapy of the malignant fibrous histiocytoma in the mamma.

Strategy for lymphadenectomy of gastric cancer

To determine the extent of lymphadenectomy necessary to cure early gastric cancer, the relationship between the frequency of nodal involvements and the extent of the primary invasion was examined in 274 patients with primary cancer of the stomach. We also evaluated the relationship between the number of metastatic lymph nodes, the pattern of metastases to the nodes, and the histologic type of the primary tumor. In early gastric cancer, lymph node metastasis was more frequent in protruded-type cancer with invasion into the submucosa more than 3 cm in diameter and located in the lower third of the stomach, but was limited to the group 1 lymph nodes, which were defined as being anatomically located nearest to the cancer. In cancer invading into the muscularis propria, metastasis to the group 2 or 3 lymph nodes, which were defined as being anatomically located farther from the cancer than group 1, was found. The number of lymph nodes involved and extent of cancer metastasis in these lymph nodes metastasis, differentiated early gastric cancer had more lymph node involvement and wider extent of metastases than undifferentiated cancers. The cancer cells sometimes replaced most of the node and invaded the perinodal fatty tissue, even in early gastric cancer. In addition, it is occasionally difficult to distinguish macroscopically early gastric cancer with submucosal invasion from cancer invaded into the muscle layer. In conclusion, group 1 and 2 lymph nodes, including perinodal fatty tissue, should be removed completely, even in early gastric cancer, except for carcinoma in situ, particularly when the cancer is of the differentiated type.

[The value and limit of extended surgery in colorectal cancer]

Since the majority of colorectal cancers are well differentiated adenocarcinomas and grow rather slowly and well limited, surgery is the most available and favored treatment. The cancer-related 5-year survival rates of patients having undergone an extended operation versus those undergoing the conventional operation in our hospital (1969-1983) were 86% and 70% for Dukes B stage, and 60% and 38% for Dukes C stage. The survival superiority of the extended operation was confirmed as statistically significant (p less than 0.05). However, this survival advantage not true for patients with lateral lymphnode metastasis. A more extended operation with lateral dissection cutting the iliac internal vessels was performed for patients suspected of having lateral metastasis. Reduction of the incidence of local recurrence is really observed by this procedure. Urine-voiding and sexual dysfunction were observed more frequently in patients with the extended operation than the conventional one. By selectively preserving only 4th pelvic nerve, it becomes possible to preserve the urine voiding function without losing the benefits of the extended operation. In cases of far advanced cancer invading to adjacent organs, value of combined resection was also confirmed. Metastatic lesions to the liver or the lung should be removed by enucleation or partial resection of these organs, unless a multiple case. The 5-year survival of patients were 35% for liver metastasis and 40% for pulmonary metastasis.

Extent of lymph node dissection in melanoma of the trunk or lower extremity

The extent of lymph node dissection necessary to optimize survival and minimize local recurrence in patients with melanoma of the trunk or lower extremity is not well defined. We reviewed the records of 420 patients undergoing superficial or combined superficial and deep groin dissection for melanoma. Prognosis depended on the extent of lymph node involvement rather than the extent of surgery performed. Node-positive patients undergoing elective lymph node dissection had an improved survival over those undergoing therapeutic lymph node dissection. In no subgroup of patients was more extensive lymphadenectomy associated with significant improvement in survival or alteration in pattern of recurrence. Dissection of the deep pelvic nodes in patients with melanoma appears to be of more prognostic than therapeutic value.

[Postoperative lymph node scintigraphy in patients with malignant melanoma]

Completeness of regional lymph node dissection was controlled in 23 patients with melanoma malignum. For that purpose 3--6 weeks after block-dissection lymph node scintigraphy was performed, by administration of intercostal and interdigital radiopharmacutical. Blockdissection was considered as complete, when neither after intercostal, nor after interdigital administration, any lymph nodes were delineated. On the basis of investigations until now, postoperative lymph node scintigraphy proves to be suitable, held to be a non-invasive method for controlling completeness of blockdissection.

Lymph node involvement as the only prognostic factor in curative resected gastric carcinoma: a multivariate analysis

The aim of this study was to evaluate the independent influence of clinical and pathological variables on survival of patients with gastric carcinoma using the Cox regression proportional hazard model. Of 156 patients operated on for gastric carcinoma, 46 (29.5%) underwent palliative operation, 24 (15.5%) had a palliative resection, and 86 (55%) had a curative resection. The overall 5-year survival rate was 25 +/- 4%. After curative resection, the 5-year survival rate was 44 +/- 6%. Univariate analysis applied to these patients showed that poor survival was related (p less than 0.01) to: age (over 80 years), absence of epigastric pain, vomiting and dysphagia, total gastrectomy, tumor size (more than 4 cm), lymph node involvement (LNI), invasion through the muscularis propria, absence of intestinal metaplasia near the tumor, and linitis plastica. In multivariate analysis, lymph node involvement was found to be the only independent prognostic factor. The 5-year survival rate was 75.5 +/- 8% without LNI, 28 +/- 10% with proximal LNI, and 7 +/- 6% with distal LNI. Our results suggest that classification into 3 LNI groups is the best staging system for curative resection in gastric carcinoma.

Recurrence and morbidity in differentiated thyroid carcinoma in children

The management of differentiated thyroid cancer in childhood is controversial. In particular, the role of aggressive surgical treatment has been questioned. This study was performed to identify those factors that are predictive of recurrence and morbidity following treatment through use of a multivariate model. The records of all patients 17 years of age or less admitted in the last 35 years with histologically confirmed differentiated thyroid carcinoma were reviewed. Data were sufficient for multivariate analysis in 93. The mean age at diagnosis was 13.3 years, and the median period of follow-up was 20 years. Seventy-one percent of the patients had nodal metastases. There were no deaths from thyroid carcinoma in this series, and the overall recurrence rate after initial treatment was 34%. Multivariate analysis demonstrated that only age (p less than or equal to 0.07) and histologic subtype (p less than or equal to 0.01) were predictive of time to recurrence. Major morbidity was a function of age (p less than or equal to 0.007) and extent of thyroid surgery (p less than or equal to 0.01). Probability of minor complications was predicted by use of radical neck dissection (p less than or equal to 0.02). Use of total or subtotal thyroidectomy or of radical neck dissection in children does not prevent recurrence and is associated with an increased risk of complications. We conclude that these procedures should be avoided in pediatric patients.

Modified inguinal lymphadenectomy for carcinoma of the penis with preservation of saphenous veins: technique and preliminary results

The controversy surrounding the management of patients with invasive carcinoma of the penis and clinically negative nodes is discussed. The rationale, technique and preliminary results of a modified inguinal lymphadenectomy in which the lateral and caudal extents of nodal excision are reduced, and the saphenous veins are preserved also are presented. This modified lymphadenectomy has been performed in 6 patients with invasive carcinoma of the penis or distal urethra without major or troublesome complications.

Fluorescence of metastasized lymph nodes in esophageal cancer following the administration of intravenous eosin yellow using a laser beam

Fifteen patients with esophageal carcinoma received the photosensitizing dye Eosin Yellow (10 mg/kg) intravenously prior to surgery, and their para-esophageal lymph nodes were then examined for fluorescence using a laser beam at the time of operation. When the time interval between the injection of Eosin Yellow and the operation was 48 hours, 21 out of 22 (95.4 per cent) metastatic lymph nodes exhibited fluorescence and 25 out of 26 (96.2 per cent) non-metastatic lymph nodes did not exhibit fluorescence. This method proved to be invaluable for detecting metastatic lymph nodes macroscopically at the time of surgery for esophageal carcinoma.

5-year results of postoperative extended-field irradiation on 76 patients with nodal metastases from cervical carcinoma stages IB to IIIB

Extended-field irradiation was administered after radical surgery to 76 patients with nodal metastases from cervical carcinoma Stages IB (37 patients), IIA (six patients), IIB (29 patients), and IIIB (four patients). The first recurrent sites of disease were distant organs via hematogenous routes of 12 patients and in the pelvic fields of eight patients. The 5-year disease-free survival rates were 95% for 27 patients with one positive node, 64% for 37 patients with multiple positive nodes, and 44% for 12 patients with unresectable nodes; 72% in total. Poor disease-free survival rates were associated with Stage IIB (60%), more than 30 mm invasion depths (44%), small cell cancer (0%), adenocarcinoma (57%), adenosquamous carcinoma (50%), and premenopause (60%). In 52 patients with nonkeratinizing large cell carcinoma, the disease-free survival rates were significantly different between Stage IB and IIB (87% versus 47%, P less than 0.05). This dissimilarity was caused by significant differences between Stage IB and IIB patients with less than 30 mm invasion depths (90% versus 53%, P less than 0.05), with parametrial extension (100% versus 39%, P less than 0.005), and with unresectable nodes (100% versus 0%, P less than 0.05). These results indicate that postoperative extended-field irradiation can control distant spread via lymphatic routes with significant improvement of patient survival, and that the number of positive nodes, tumor cell types, depth of tumor invasion, and clinical stages are important prognostic factors subsequent to this combined therapy.

Mediastinal nodes in bronchogenic carcinoma: comparison between CT and mediastinoscopy

Computed tomography (CT) and mediastinoscopy were compared in 151 patients with bronchogenic carcinoma. In all patients in whom findings at mediastinoscopy were negative, all accessible nodes were either removed or sampled at thoracotomy. Several size criteria for identifying nodes as enlarged on CT scans were compared. The long axis greater than or equal to 15 mm and short axis greater than 10 mm had very low sensitivity (61%), and the long axis greater than 5 mm had a low specificity (23%). CT (long axis greater than 10 mm) allowed sensitivity equal to that of mediastinoscopy (79%) in the detection of mediastinal metastases, but the specificity with CT was lower (65% vs. 100%). In seven of 44 patients with nodes greater than 10 mm on CT scans and with positive findings at mediastinoscopy, tumor was present not in the enlarged nodes but rather in normal-sized nodes in a different nodal station. The sensitivity of CT for actual nodal stations involved with tumor was only 66%. Eighty-three percent of patients with false-negative findings at mediastinoscopy but only 33% of patients with false-negative findings at CT had surgically resectable stage IIIa disease.

[Cervical lymph node metastases from an unknown primary tumor]

From 1978 through August 1986, 32 patients with lymph node metastases of the neck and unknown primary tumor were treated at the Radiotherapeutic Hospital of the University Erlangen-Nürnberg. Most of the cases were large metastases from squamous cell carcinomas or anaplastic carcinomas. The patients were treated by surgery and postsurgical radiotherapy or radiotherapy alone. In nearly all patients the target volume comprised both sides of the neck including the median structures as well as the base of the tongue and the nasopharynx. A dose of at least 50 Gy was aimed at, which was given within five weeks by individual doses of 2 Gy each. The survival at three years is 70% and at five years 52%. Out of twenty patients irradiated with more than 50 Gy following lymph node extirpation or radical excision of the lymph nodes of the neck, sixteen are tumor-free. The five year survival of this group is 80%. The results of radiotherapy alone are unsatisfactory, because only two out of nine patients are alive with follow-up periods of less than one year. Two primary tumors were found after the end of treatment. Both were situated within the ORL areas beyond the ancient irradiation fields, and both were developed by patients who at first had only been treated by local irradiation. Half of the patients with lymph node metastases of the neck and unknown primary tumors can be cured by complete tumor excision and postsurgical irradiation. The target volume of radiotherapy comprises both sides of the lymph drainage area of the neck as well as the mucous membranes of the ORL region including nasopharynx and base of the tongue. The dose is at least 50 Gy which is given after surgery with conventional fractionation.

Lymphadenectomy for cure in patients with early gastric cancer and lymph node metastasis

The anatomic distribution, size, and histologic mode of involvement of 98 metastatic lymph nodes in 49 of 370 patients were examined to determine to what extent lymphadenectomy should be performed in addition to gastrectomy in patients with early gastric cancer. Nodal involvement in the marginal sinus (30 nodes) and partial medullary sinus (37 nodes) were commonly seen, and the lymph nodes of those types were enlarged compared with 1,086 patients with no metastatic lymph nodes (control group). Lymph nodes of the wide medullary sinus (11 nodes), small nodule (3 nodes), and massive involvement types (17 nodes) did not enlarge compared with those of the other types and those of the control group. Most of the metastatic sites (76.6 percent) were in the perigastric lymph nodes along the lesser and greater curvatures, about a fifth were in the extraperigastric nodes along the left gastric, common hepatic, celiac, and splenic arteries, and the least were in the extraperigastric nodes (3.1 percent) along the hepatoduodenal ligament. Since the rate of macroscopic diagnosis during operation was so poor, regardless of the histologic modes of nodal involvement, and also in cases of metastatic lymph nodes less than 15 mm in widest diameter, for curative operation of patients with early gastric cancer, perigastric and extraperigastric lymph nodes along the main arteries near the stomach should be completely dissected, in addition to resection of the stomach.

Differentiated thyroid cancer: a stage adapted approach to the treatment of regional lymph node metastases

The controversy in the management of regional lymph nodes in patients with differentiated thyroid cancer is discussed on the basis of a review of the literature. Since no prospective studies have yet compared limited dissections ('node picking') with more extensive dissections [(modified) radical neck dissection], a retrospective analysis was performed using two patient groups in which patients were managed differently with regard to the preoperative diagnosis and treatment of regional lymph node metastases. Only patients with proven lymph node metastases were included in the study. Because of selection methods necessary to create comparable patient groups, only 83 patients could be included in the analysis. There was no difference in survival or recurrence rate in either group, although recurrences occurred less frequently in the explored side of the neck after MRND (3.9% vs. 6.3%). More postoperative morbidity was found in the patients who had been subjected to a more extensive search for and treatment of lymph node metastases. Because of the relatively small number of patients only the difference in occurrence of accessory nerve palsies reached statistical significance (P = 0.05). It is advocated that only in the case of papillary carcinoma with limited lymph node involvement node picking is the procedure of choice. In all other cases a modified radical neck dissection should be standard treatment.

Carcinoma of the soft palate treated with irradiation: analysis of results and complications

This is an analysis of 75 patients with squamous cell carcinoma of the soft palate and/or uvula treated with radical radiation therapy alone (64) or in conjunction with planned neck dissection (11) between October 1964 and September 1983. All patients have a minimum follow-up of 2 years and 60 (80%) have a minimum follow-up of 5 years. Patients were excluded from analysis of disease control at the primary site and/or neck if they died within 2 years of treatment with the site(s) continuously disease free. The initial local control rates and ultimate local control rates after surgical salvage of irradiation failures for patients treated with continuous-course irradiation were as follows: T1, 8/8 (100%) and 8/8 (100%); T2, 14/19 (74%) and 16/19 (84%); T3, 5/11 (45%) and 5/11 (45%); and T4, 1/4 (25%) and 1/4 (25%). Overall, 7/55 patients (13%) treated with continuous-course irradiation experienced irradiation-related bone or soft tissue complications; there was only one severe complication. The 5-year determinate survival rates by modified AJCC stage for patients treated with continuous-course irradiation are as follows: I, 83%; II, 78%; III, 38%; IVA, 0/2; and IVB, 25%.

Squamous cell carcinoma of the parotid gland

Squamous cell carcinoma involving the parotid gland is an aggressive and rapidly advancing lesion which if not recognized and treated early will result in a high morbidity and mortality. We reviewed 30 patients with squamous cell carcinoma involving the parotid gland. Twenty-four patients had had previous epidermoid skin lesions in an area known to drain to the parotid gland and three resulted from direct extension into the gland from an overlying skin carcinoma, whereas only three were primary lesions of the gland. Patients who presented with involvement of the gland more than 4 months after excision of the skin lesion had a poor prognosis. Patients with epidermoid skin cancer in areas with a propensity to secondarily involve the parotid gland must be closely followed after treatment of the primary skin lesion.

Favourable response to conservative surgery for extra-pancreatic gastrinoma with lymph node metastases

Five patients with the Zollinger-Ellison syndrome who had extra-pancreatic (duodenal or paraduodenal) gastrinoma with lymph node metastases responded favourably to simple excision or mere shelling out of macroscopic tumour. Acid studies, serum gastrin and the secretin test became normal in all cases in the immediate postoperative period and remained so in three of the five patients when tested at 57, 33 and 8 months. The tests became abnormal in two patients when tested 8 and 53 months after surgery, but both patients are currently well-controlled on ranitidine 150 mg b.d. 22 and 65 months respectively after surgery. These results suggest that in patients with extra-pancreatic gastrinoma who have lymph node metastases simple excision of all macroscopic tumours may offer the prospect of long-term control. The place of total gastrectomy in such patients is questioned.

Metastatic inguinal nodes from an unknown primary neoplasm. A review of 56 cases

Fifty-six cases of this uncommon neoplastic manifestation are presented. These cases represent 0.065% of 86,589 new cases of malignant disease seen at The Princess Margaret Hospital from 1968 to 1982. There were 29 men and 27 women. The median age at presentation was 58 years. Three major groups were identified: inguinal disease, 24 cases; unilateral inguinal plus iliac disease, 16 cases; local plus systemic disease, 16 cases. Pathologic subtypes were anaplastic, 24; squamous, 11; adenocarcinoma, nine; melanoma, nine; and others, three. Survival at 5 years for all patients was 27%. Among 40 patients who presented with inguinal and inguinal plus iliac disease, survival was 37.5% at 5 years. Initial treatment following biopsy was radiation in 35, lymph node dissection in eight, and chemotherapy in four. Excisional biopsy only was performed in nine cases. There were no treatment-related deaths. The findings observed in this study, in which radiation therapy was employed as initial management in the majority of cases, suggests that radiation therapy is a valid alternative to surgery in the management of this disease.

The metastatic potential of prostate carcinomas composed entirely of single malignant glands

Consecutive staging lymphadenectomies on 1046 patients with prostate carcinoma identified 275 patients with metastases in a total of 1115 regional lymph nodes. No prostate carcinomas composed entirely of single malignant glands metastasized and no patient had metastases composed entirely of single malignant glands. All prostate carcinomas that metastasized had cribriform and/or undifferentiated histological patterns in the prostate and in the metastases. These findings suggest that identification of cribriform and/or undifferentiated histological patterns, through rebiopsy or further examination of the surgical specimen, should be considered prior to subjecting patients with prostate carcinomas composed entirely of single malignant glands to therapy or procedures directed against the possibility of metastatic disease.

Postoperative extended-field irradiation in patients with pelvic and/or common iliac node metastases from cervical carcinoma stages IB to IIB

Radical hysterectomy with pelvic and common iliac lymphadenectomy was done for 207 Stage IB (148), IIA (19), and IIB (40) cervical carcinomas. Pelvic nodal involvement was limited in 30 (14.5%) cases, whereas common iliac nodes were involved in 16 (7.7%) cases. Common iliac node metastases were significantly increased, when the number of positive pelvic nodes increased from 2 to 3 or 4 or more (21.4% to 73.3%, P less than 0.05), when the tumor invaded deeper than 20 mm (3.7% to 22.2%, P less than 0.001), and when the tumor extended into parametrial tissues (4.8% to 14.8%, P less than 0.05). Postoperative extended-field irradiation was administered to 40 patients with nodal metastases. The 3-year disease-free rates were 85% in 24 patients with positive pelvic nodes, and 51% in 16 patients with common iliac node metastases; 70% in total. These results indicate that postoperative extended-field irradiation is essential for those patients with nodal metastases from locally resectable cervical carcinomas.

Lymph node metastasis in early gastric cancer

From 1969 through 1984, 304 case of early gastric cancer (EGC) were resected. Nodal status was studied in 272 cases in which lymph node dissection was performed. The lymph nodes were negative for metastasis in 90% of the cases. In 7%, metastasis was noted in the Group 1 lymph nodes alone and in 3%, as far as the Group 2 nodes. But in no case were the Group 3 involved. The 10-year survival rate was poorer in patients with positive nodes than in those with negative nodes (52.8% vs. 94.1%). Cancer recurred more often in patients who had no lymph node dissection than in those with node dissection (9.4% vs. 1.5%). Lymph node metastasis was more frequent in the following EGC types: macroscopically combined type, over 5 cm, and with submucosal invasion. Dissection as far as the Group 2 nodes should be routinely performed even in EGC, especially in cases with the above-mentioned characteristics.

Surgery as palliative treatment for distant metastases of melanoma

Sixty-five patients with distant metastatic melanoma amenable to surgical treatment had excision of 94 metastatic lesions from the brain, lung, abdomen, distant subcutaneous sites, and distant lymph nodes. Relief of symptoms, if present, was obtained after excision of 77% of brain metastases, 100% of lung metastases, 88% of distant lymph node and subcutaneous metastases, and 100% of abdominal metastases. Median survival after excision of brain metastases was 8 months, lung metastases 9 months, abdominal metastases 8 months, and distant subcutaneous and lymph node metastases 15 months. Sixteen per cent of patients lived for 2 years of longer. These results demonstrated that surgery can achieve an effective local disease control in selected patients with distant melanoma metastases and that a few have a relatively long-term survival.

Occult primary adenocarcinoma with axillary metastases

The medical charts of 20 women with occult primary adenocarcinoma with axillary metastases were reviewed. An extensive radiologic workup in search of the primary lesion had a less than 7 percent positivity rate in the 74 studies carried out. Eleven patients were treated with mastectomy, 5 of whom were found to have carcinoma (49 percent). Four of the 11 patients, all with 14 or more positive axillary lymph nodes, died from breast cancer. Seven patients with no evidence of disease had an average of 4.6 positive axillary lymph nodes. Seven patients did not receive mastectomy, and one died from breast cancer. There was no significant difference in survival between the group treated with mastectomy and the group treated with axillary dissection. We conclude that mastectomy is unnecessary for patients with adenocarcinoma in axillary nodes but no apparent primary tumor.

[Adjuvant chemotherapy in addition to radical surgical treatment of regional lymph node metastases in malignant melanoma]

Thirty-three patients with malignant melanoma and regional lymph node metastases who underwent lymph node dissection were additionally given polychemotherapy with carmustine, hydroxycarbamide and dacarbazine immediately before surgery and up to five times postoperatively. Twenty-nine patients were only treated surgically. These two groups were comparable as regards prognostic criteria, in particular tumour size, ulceration and the number of lymph nodes affected, although the individual follow-up periods varied considerably. The group given chemotherapy showed better results than the control group undergoing surgery alone. The log rank test yielded a significant difference (P less than 0.05) with respect to the probability of relapse-free survival but not as regards probability of survival time. Patients with ulcerated primary melanomas and with a large number of affected lymph nodes had a less favourable prognosis. The major side effects of chemotherapy were transient nausea and bone marrow depression.

Studies on hepatobiliary lymph flow with radioactive colloid--for lymph node metastasis resection of carcinoma of the bifurcation of hepatic duct

Hepatobiliary lymphoscintigraphy by Technetium 99m-rhenium colloid (99mTc-Re colloid) using a fine needle guided by ultrasonography was performed on 12 patients who underwent resection of the hepatoduodenal ligament lymph nodes. Histological examination revealed no lymph node metastasis in 8 patients. In 4 patients in whom 99mTc-Re colloid was injected into the left medial inferior hepatic segment, periarterial lymph nodes showed higher isotope uptake count than periductal nodes, and lymph nodes around the common hepatic artery revealed higher values than superior posterior pancreatoduodenal nodes. On the contrary, in 3 patients in whom the isotope was injected into the right anterior inferior segment, periductal lymph nodes had higher values than periarterial nodes, and superior posterior pancreatoduodenal lymph nodes showed higher values than those around the common hepatic artery. In one patient in whom the isotope was injected into both right and left segments, superior posterior pancreatoduodenal lymph nodes showed similar values to those around the common hepatic artery. Periportal lymph nodes tended to have values between those of periarterial and periductal ones. Lymph node metastases were confirmed in 4 patients in whom the relationships mentioned above was not always observed, and periportal lymph nodes showed the highest values among the three.

Metastasis to the lingual lymph node in carcinoma of the tongue

Lingual lymph nodes are occasionally found along the course of some lymph-vessels of the tongue. However, their existence has received little attention and metastasis of carcinoma of the tongue to them has not previously been reported. Three cases of carcinoma of the tongue with metastasis to the lingual lymph node are described and a discussion of the importance of such metastasis in the treatment of carcinoma of the tongue is presented.

Result of treatment of patients with stage D1 prostatic carcinoma

Between 1972 and 1982, 59 patients who had documented pelvic lymph node metastases, proved by pelvic lymphadenectomy, were available for analysis. Radical retropubic prostatectomy was the primary treatment in 33 patients with or without other therapies, while 23 patients received external beam radiation therapy as their primary treatment. Three patients received hormonal therapy alone. Forty-two of 59 patients are alive for a crude survival of 71 per cent. Sixteen patients have died of metastases. Patients with low-grade tumors, small tumor burden, and limited lymph node metastases had excellent short-term survival after radical prostatectomy.

Chylous ascites complicating genitourinary oncological surgery

Chylous ascites is an uncommon complication of retroperitoneal surgery. We report 2 cases of intraperitoneal chyle fistulas, one following retroperitoneal lymphadenectomy for testis cancer and the other after radical nephrectomy with regional lymphadenectomy for renal cell carcinoma. Both patients were treated successfully with medium chain triglyceride diets. We believe that most patients with chylous ascites will respond to simple dietary manipulation, and do not require complex and potentially morbid treatment regimens.

Melanoma metastatic to cervical and parotid nodes from an unknown primary site

The medical records of 96 patients with melanoma metastatic to cervical and parotid nodes from an unknown primary site have been reviewed. The use of various surgical procedures were correlated with local recurrence and survival rates. The size and number of involved nodes and the extent of nodal disease were compared with the type of treatment, and the age and sex of the patients, incidence of above-clavicle recurrence, and the 2, 5, and 10 year survival rates. The only significant correlations were the adverse affects of patient age over 50 years and multiple, large, pathologically positive nodes on local control and survival. Adjunctive chemotherapy and immunotherapy had no therapeutic value.

[New aspects of the reconstruction of large defects of the oral mucosa with microvascularly anastomosed small intestinal grafts]

Our experience in reconstruction of extensive defects in the oral mucosa with free jejunal grafts in 15 patients is reported. The jejunum provides a well vascularised mucosal lining, which is resistant to mechanical stress and being a thin flap contours well in the mouth. Methods of avoiding technical failure are described. The technique permits radical resection of oral tumours.

The surgical approach to primary malignant melanoma

Surgical excision is the only curative treatment for malignant melanoma. Excisional biopsy of the suspected lesion allows for adequate tissue diagnosis and microstaging and does not alter ten year survival periods. Wide local excision with a resection margin of 3 centimeters is recommended for all but the most superficial (less than 0.76 millimeters) lesions. Nodal and systemic metastases and long term survival are unaffected by the size of the resection margin. The role of prophylactic lymphadenectomy for Stage I melanoma remains controversial. The results of both prospective and retrospective studies have demonstrated an improved survival after prophylactic lymphadenectomy for patients with intermediate thickness (0.76 to 3.9 millimeters or Clark's level III to IV, or both) lesions. Patients with ulcerated lesions and lesions in the BANS distribution, even when superficial, might benefit from elective lymphadenectomy. At least quarterly follow-up examination is recommended for those patients who undergo wide excision alone. Therapeutic lymphadenectomy is indicated for the treatment of Stage II melanoma. The results of ongoing prospective randomized studies will clarify the role of fascia removal, resection margins and prophylactic lymphadenectomy in the treatment of malignant melanoma.