Evolution of retroperitoneal lymphadenectomy (RPLND) in the management of non-seminomatous testicular cancer (NSGCT)

The metastatic lymphatic drainage of testis cancer to the retroperitoneum was noted clinically about a century ago. Beginning with extraperitoneal approaches, RPLND was attempted. The first cure after RPLND of node positive disease was in 1905 by Cuneo in Paris. Transperitoneal approaches failed due to infection until post World War II experience at Walter Reed Army Hospital. Thoracoabdominal approaches became popular several decades later. But Improved exposure and vascular management strategies led to increased usage of the transabdominal approach once again. The advent of platinum based combination chemotherapy has had a major impact on both the timing of and the technical requirements of RPLND. Owing to our early involvement in this area, we have accumulated the largest database available on this disease. Our experience with over 2500 RPLNDs in the last 3 decades is divided between low stage (I and II) and high stage (III, postchemotherapy) disease. The former has been "down-regulated" to modified templates and prospective nerve sparing techniques to preserve ejaculation. The latter has been "up-regulated" to include a spectrum of surgical needs including hepatic, vascular, gut and mediastinal resections. Despite these extended requirements, outcomes are good (> 80% survival) postchemotherapy. The evolutionary change of RPLND reflects an optimal paradigm of surgical-medical oncologic interaction.

Dr. Herbert Lumley Snow, MD, MRCS (1847?1930): The Original Champion of Elective Lymph Node Dissection in Melanoma

Herbert Snow (1847-1930), a London surgeon with a particular interest in melanoma, was a controversial proponent of anticipatory gland excision well before acceptance of elective lymph node dissections. This article describes the work of Snow within a wider historical context.

Gastric equivalent of the 'Holy Plane' to standardize the surgical concept of stomach cancer to mesogastric excision: updating Jamieson and Dobson's historic schema

BACKGROUND

Surgery for curable gastric cancer has historically involved dissection of lymph nodes, depending on the risk of metastasis. By establishing the concept of mesogastric excision (MGE), we aim to make this approach compatible with that for colorectal cancer, where the standard is excision of the mesentery.

METHODS

Current advances in molecular embryology, visceral anatomy, and surgical techniques were integrated to update Jamieson and Dobson's schema, a historical reference for the mesogastrium.

RESULTS

The mesogastrium develops with a three-dimensional movement, involving multiple fusions with surrounding structures (retroperitoneum or other mesenteries) and imbedding parenchymal organs (pancreas, liver, and spleen) that grow within the mesentery. Meanwhile, the fusion fascia and the investing fascia interface with adjacent structures of different embryological origin, which we consider to be equivalent to the 'Holy Plane' in rectal surgery emphasized by Heald in the concept of total mesorectal excision. Dissecting these fasciae allows for oncologic MGE, consisting of removing lymph node-containing mesenteric adipose tissue with an intact fascial package. MGE is theoretically compatible with its colorectal counterpart, although complete removal of the mesogastrium is not possible due to the need to spare imbedded vital organs. The celiac axis is treated as the central artery of the mesogastrium, but is peripherally ligated by tributaries flowing into the stomach to feed the spared organs.

CONCLUSION

The obscure contour of the mesogastrium can be clarified by thinking of it as the gastric equivalent of the 'Holy Plane'. MGE could be a standard concept for surgical treatment of stomach cancer.

[Historical outline on the nomenclature of neck lymph nodes as a basis of neck dissection classification]

BACKGROUND

The neck dissection classification is based considerably on the organization of the lymph nodes of the neck. Terminology and anatomical allocation of nearly 300 cervicofacial lymph nodes repeatedly changed since the beginning of the 20th century.

METHODS

Analysis of the literature on neck lymph node organization with reference to the development of the neck dissection classification.

RESULTS

The first fundamental nomenclature of the neck lymph nodes is founded on the work of Rouviére (1932). Suárez (1963) described the functional neck dissection on the basis of the fascial compartmentalization of the neck. Lindberg (1972) left the predominantly anatomically correlated grouping of the cervical lymph nodes as described by Rouviére and divided the lymphatic system of the neck on basis of pathophysiological mechanisms. The attention regarding the location of occult metastases led to the description of the selective neck dissection. Since the fundamental work of Shah et al. (1981) there was a multiplicity of more or less slight changes of the neck node regions. These changes were again basis for new neck dissection terminologies. A new classification was introduced in the year 2000 as the revised version of the American Head and Neck Society.

CONCLUSIONS

The revised version of the neck dissection classification can reduce former controversies, particularly regarding an optimized intraoperative allocation of the lymph nodes and a simplified terminology of the selective neck dissection. With the goal of a standardization of the neck dissection forms it remains to be seen if the proponents of the functional neck dissection after Suárez consider the extent of the neck dissection in patients with N0 neck in favor of the selective neck dissection.

Cutaneous melanoma: therapeutic lymph node and elective lymph node dissections, lymphatic mapping, and sentinel lymph node biopsy

Early clinical observation in cancer patients suggested that tumors spread in a methodical, stepwise fashion from the primary site, to the regional lymphatics, and only then to distant locations. Based on these observations, the regional lymphatics were believed to be mechanical barriers, at least temporarily preventing the widespread dissemination of tumor. Despite evidence now available disputing its validity, this barrier theory has guided the surgical management of the regional lymphatics in cancer patients for more than a century, influencing the use of such surgical modalities as therapeutic lymph node dissection, elective lymph node dissection, and most recently lymphatic mapping and sentinel lymph node biopsy. No published randomized controlled trial exists that demonstrates improved overall patient survival for cancer of any type, including melanoma, after surgical excision of regional lymphatics. This article will review the biology of lymphatics as it relates to regional tumor metastasis, and based on available information, offer practical recommendations for the clinical dermatologist and their patients who have cutaneous melanoma.

[History and advances in the surgical treatment of lung cancer]

In 1933, Graham successfully performed one-stage pneumonectomy for lung cancer. Four years later, Ozawa (Japan) also performed pneumoenctomy for lung cancer. Unfortunately, progress in the surgical treatment of lung cancer in our country was interrupted by World War II. After the war, the first report of resection in 3 cases of lung cancer was published by Ishikawa in 1949. In the 1950s, poorer surgical outcomes were reported from Japan in terms of resection rate or long-term survival compared with those in Western countries. However, since the 1960s, there has been great progress in Japan in the treatment of lung cancer, due to the marked increase in the number of lung cancer patients, developments in endoscopy and imaging devices, and also in surgical procedures such as anatomical lung resection, lymph node dissection, combined resection of adjacent organs, and bronchoplastic surgery. Surgical mortality was over 20% in the early years. However, it has currently decreased to a few percent. The long-term survival rate for resected lung cancer patients has improved remarkably in recent years. Among stage IIIA cases, the optimal surgical outcome is achieved in the group undergoing chest wall resection for T3 N0 M0 disease. However, patients with IIIA-N2 disease generally have a poor surgical outcome. Therefore, trials of induction therapy are being carried out at many institutions.

The surgical management of lymphedema

The treatment of lymphedema remains a formidable task for the patient and physician. However, most patients with both primary and secondary lymphedema can be managed satisfactorily by conservative means. Surgical intervention for lymphedema should be considered only after a serious trial of medical management. Although no present surgical technique offers cure, significant improvement is possible by a variety of methods. The staged excision of skin and subcutaneous tissue, the Charles procedure and the dermal flap by Thompson are still the most popular techniques in the United States. Axial and myocutaneous flaps and microsurgical bypass procedures are currently under investigation and may hold promise after additional study. Future experimental and clinical studies should concentrate on long term follow-up study with objective clinical and roentgenographic documentation of improvement.

[The historical perspective of the sentinel lymph node concept]

The sentinel lymph node procedure is currently standard care in the treatment of breast cancer. The introduction of this procedure in 1992 would not have been possible without the pioneering discoveries regarding lymph nodes and cancer. The Italian surgeon Gaspar Asellius (1581-1626) visualized the lymphatic vessels of a dog after it had been fed and shortly before dissection. At the end of the 17th century, the French anatomists Lauth and Sappey visualized the lymphatics by injecting deceased criminals with mercury. In 1858, the German pathologist Virchow (1821-1902) launched the theory that lymph nodes act as defensive barriers. He also made the first microscopical illustration ofa sentinel lymph node. Gould et al. and Cabaãs independently launched the precursors of the current modern sentinel lymph node concept in 1959 and 1977 respectively. Gould et al. were the first people to use the term "sentinel node'. Cabañas used lymphangiography for the visualisation of the sentinel lymph node. Controversies about the barrier function of the lymph nodes, the fear of skip metastasis and the difficulties of performing the Cabañas procedure, prevented a breakthrough of this concept. In 1992 Morton et al. rediscovered the valuable sentinel node biopsy concept and introduced blue dye for the investigation of patients with melanoma. The combination of lymphoscintigraphy, intra-operative gamma probe guidance and patent blue further increased the reliability of the sentinel lymph node biopsy procedure. Unnecessary lymph gland dissection procedures with considerable morbidity can be prevented by this procedure.

[History of breast cancer surgery and its perspectives]

At the end of the 19th century, surgical treatment of breast cancer was revolutionized by the introduction of the Halsted radical mastectomy. Haagensen, who studied under one of Halsted's students, further strengthened the foundations of the technique, and the Halsted operation became the standard radical breast cancer surgery worldwide. This may have been responsible for the persistence of this operation, particularly in Japan. Some Halstedian surgeons espoused the extended radical mastectomy or super-radical mastectomy. However, breast-conserving surgery is now becoming the most common technique. In the early 1970s breakthroughs in the understanding of the biology of breast cancer led to a new era of adjuvant therapy. Consequently current surgical management of breast cancer is no longer possible without considering other therapeutic modalities. Consistent with this change, it should be realized that the disease is no longer diagnosed at the same stage as it was at the time of Halsted. Although the ultimate patient outcome is not likely to be influenced solely by locoregional treatment, surgery will continue to be employed as the most effective treatment modality, and every effort should be made to prevent locoregional tumor spread.

Surgical treatment of gastric cancer in Japan, trend from standardization to individualization

Japan has a huge number of patients with gastric cancer and has developed various surgical treatments for this disease.This paper intends to introduce our strategies against gastric cancer. The Japanese Gastric Cancer Association was established in 1962. Its major purposes are promotion of basic and clinical researches and popularization of the latest knowledge and technologies. For the purposes, the association organized the annual scientific meeting and the nationwide registry by member hospitals, and published the Japanese Classification of Gastric Cancer (1) and the Treatment Guide Line (2). The nationwide registry reported that proportion of Stage-I cancer was 22.5% in 1963-66,which increased to 59.3% in 2008 (3,4,5). 11,261 patients with gastric resection were registered by 187 hospitals in 2008. 63 patients were died within 30 postoperative days and the direct death rate was 0.55%. 5 year survival rate (5YSR) was 37.5% for resected cases in 1963-66, which was improved to 70.1% in 2008. 5YSR was improved from 55.1% to 74.1% for Stage-II, and from 39.1% to 48.8% for Stage-III in the period. According to remarkable increase of early stage cancer, principle of surgical treatments was shifted from "€œextended and standardized surgery for radicality" €to "€œreasonable and individual surgery considering safety and quality of life"€. This trend produced a large variation in surgical treatments; namely 1) minimally invasive surgeries,2) function preserving surgeries, 3) optimal extent of lymph node dissection, and 4) aggressive but safe surgeries.Intention of this paper is to explain these procedures, the intentions, the indications, and the treatment results.