División ganglionar posquirúrgica y su efecto en el recuento ganglionar y la estadificación en pacientes con cáncer gástrico / Postoperative lymph node division and its effect on lymph node count and staging in patients with gastric cancer

Introducción. La gastrectomía y disección ganglionar es el estándar de manejo para los pacientes con cáncer gástrico. Factores como la identificación de ganglios por el patólogo, pueden tener un impacto negativo en la estadificación y el tratamiento. El objetivo de este estudio fue comparar el recuento ganglionar de un espécimen quirúrgico después de una gastrectomía completa (grupo A) y de un espécimen con un fraccionamiento por grupos ganglionares (grupo B). Métodos. Estudio de una base de datos retrospectiva de pacientes sometidos a gastrectomía D2 en el Servicio de Cirugía gastrointestinal de la Liga Contra el Cáncer seccional Risaralda, Pereira, Colombia. Se comparó el recuento ganglionar en especímenes quirúrgicos con y sin división ganglionar por regiones anatómicas previo a su envío a patología. Resultados. De los 94 pacientes intervenidos, 65 pertenecían al grupo A y 29 pacientes al grupo B. El promedio de ganglios fue de 24,4±8,6 y 32,4±14,4 respectivamente (p=0,004). El porcentaje de pacientes con más de 15 y de 25 ganglios fue menor en el grupo A que en el grupo B (27 vs 57, p=0,432 y 19 vs 24, p=0,014). El promedio de pacientes con una relación ganglionar menor 0,2 fue mayor en el grupo B (72,4 % vs 55,4 %, p=0,119). Conclusiones. Los resultados de nuestro estudio mostraron que una división por grupos ganglionares previo a la valoración del espécimen por el servicio de patología incrementa el recuento ganglionar y permite establecer de manera certera el pronóstico de los pacientes, teniendo un impacto positivo en su estadificación, para evitar el sobretratamiento

Introduction. A gastrectomy and lymph node dissection is the standard of management for patients with gastric cancer. Factors such as the identification of nodes by the pathologist can have a negative impact on staging and treatment. The objective of this study was to compare the lymph node count of a surgical specimen after a complete gastrectomy (group A) and of a specimen with lymph node by groups (group B). Methods. Study of a retrospective database of patients undergoing D2 gastrectomy in the Risaralda section of the Liga Contra el Cancer Gastrointestinal surgical service, Pereira, Colombia. The lymph node count was compared in surgical specimens with and without lymph node division by anatomical regions, prior to sending them to pathology. Results. Of the 94 patients who underwent surgery, 65 were from group A and 29 patients were from group B. The average number of nodes was 24.4±8.6 and 32.4±14.4, respectively (p=0.004). The percentage of patients with more than 15 and 25 nodes was lower in group A than in group B (27 vs 57, p=0.432 and 19 vs 24, p=0.014). The average number of patients with a nodal ratio less than 0.2 was higher in group B (72.4% vs 55.4%, p=0.119). Conclusions. The results of our study showed that a division by lymph node groups prior to the evaluation of the specimen by the pathology service increases the lymph node count and allows the prognosis of patients to be accurately established, having a positive impact on their staging, to avoid overtreatment.

From left to right. para-aortic lymph nodes sampling during pancreatoduodenectomy for pancreatic cancer / Da esquerda para a direita. ressecção de linfonodos para-aórticos durante duodenopancreatectomia para câncer pancreático

ABSTRACT BACKGROUND: Para-aortic lymph nodes involvement in pancreatic head cancer has been described as an independent adverse prognostic factor. To avoid futile pancreatic resection, we systematically perform para-aortic lymphadenectomy as a first step. AIMS: To describe our technique for para-aortic lymphadenectomy. METHODS: A 77-year-old female patient, with jaundice and resectable pancreatic head adenocarcinoma, underwent pancreaticoduodenectomy associated with infracolic lymphadenectomy. RESULTS: The infracolic anterior technique has two main advantages. It is faster and prevents the formation of postoperative adhesions, which can make subsequent surgical interventions more difficult. CONCLUSIONS: We recommend systematic para-aortic lymphadenectomy as the first step of pancreaticoduodenectomy for pancreatic head adenocarcinoma by this approach.

RESUMO RACIONAL: O envolvimento dos gânglios linfáticos para-aórticos no câncer da cabeça do pâncreas tem sido descrito como um fator prognóstico adverso independente. Para evitar a ressecção pancreática inútil, realizamos sistematicamente linfadenectomia para-aórtica. OBJETIVOS: Descrever a técnica de linfadenectomia para-aórtica. MÉTODOS: Paciente do sexo feminino, 77 anos, com quadro de icterícia e adenocarcinoma da cabeça do pâncreas ressecável, submetida à duodenopancreatectomia associada à linfadenectomia infracólica. RESULTADOS: Esta técnica anterior infracólica tem duas vantagens principais: é mais rápida e evita a formação de aderências pós-operatórias, o que pode dificultar as intervenções cirúrgicas subsequentes. CONCLUSÕES: Recomendamos a linfadenectomia para-aórtica sistemática como o primeiro passo da duodenopancreatectomia para o adenocarcinoma da cabeça do pâncreas por esta abordagem.

Pelvic lymph node dissection in high-risk prostate cancer

ABSTRACT Introduction: The therapeutic role of pelvic lymph node dissection (PLND) in prostate cancer (PCa) is unknown due to absence of randomized trials. Objective: to present a critical review on the therapeutic benefits of PLND in high risk localized PCa patients. Materials and Methods: A search of the literature on PLND was performed using PubMed, Cochrane, and Medline database. Articles obtained regarding diagnostic imaging and sentinel lymph node dissection, PLND extension, impact of PLND on survival, PLND in node positive "only" disease and PLND surgical risks were critically reviewed. Results: High-risk PCa commonly develops metastases. In these patients, the possibility of presenting lymph node disease is high. Thus, extended PLND during radical prostatectomy may be recommended in selected patients with localized high-risk PCa for both accurate staging and therapeutic intent. Although recent advances in detecting patients with lymph node involvement (LNI) with novel imaging and sentinel node dissection, extended PLND continues to be the most accurate method to stage lymph node disease, which may be related to the number of nodes removed. However, extended PLND increases surgical time, with potential impact on perioperative complications, hospital length of stay, rehospitalization and healthcare costs. Controversy persists on its therapeutic benefit, particularly in patients with high node burden. Conclusion: The impact of PLND on biochemical recurrence and PCa survival is unclear yet. Selection of patients may benefit from extended PLND but the challenge remains to identify them accurately. Only prospective randomized study would answer the precise role of PLND in high-risk pelvis confined PCa patients.

Axillary surgical approach in T1-T2N0M0 clinical breast cancer staging: Survival in a women's hospital cohort in Rio de Janeiro

The concerns regarding the prognosis and quality of life of patients with early breast cancer staging without lymph node involvement have increased, especially with regard to the axillary surgical approach. The aim of the present study was to determine overall survival and disease-free survival according to the axillary surgical approach. Methods: Retrospective cohort study of 827 women with clinical T1-T2N0M0 diagnosis attended at the Cancer Hospital III of the Brazilian National Cancer Institute, from January 2007 to December 2009, with a follow-up period of 60 months. Data were obtained from the Hospital Registry of Cancer through the medical records. Results: 683 women underwent sentinel lymph node biopsy and 144 underwent sentinel lymph node biopsy followed by axillary lymphadenectomy. After 5 years of follow-up, considering adjustment, it was observed overall survival (96.2% vs 93.6%; HR 0.98; 95%CI 0.42­2.29) and disease-free survival (93.7% vs 91.2%; HR 0.78; 95%CI 0.39­1.48) similar among patients undergoing either one or the other approach. In patients with micrometastasis, both overall (93.3%) and diseasefree survival (100%) were higher in women who underwent only sentinel lymph node biopsy compared to those who underwent this procedure followed by axillary lymphadenectomy (OS: 87.5%; DFS: 90,7%), albeit not statistically significant.

Tumor limítrofe del ovario: revisión de un viejo conocido con nuevas propuestas terapéuticas / Ovarian borderline tumor: Review of an old acquaintance with new therapeutic proposals

Resumen ANTECEDENTES: Las pacientes con un tumor limítrofe del ovario pueden tratarse conservadoramente en etapas tempranas y con ello conseguir una supervivencia considerable. Las etapas avanzadas tienen un periodo libre de enfermedad prolongado, algunas con crecimiento de implantes peritoneales y recaída posterior a 10 años del tratamiento. OBJETIVO: Conocer cuál es el pronóstico de las pacientes con un tumor limítrofe del ovario, y su tratamiento en México y otros países. MÉTODOLOGÍA: Revisión sistemática de ensayos clínicos recientes registrados en las bases de datos de PubMed, Embase y Cochrane de artículos publicados en inglés y en español entre los años 2006 y 2021. Además, una revisión analítica de la experiencia acumulada en 10 años en la atención de pacientes con tumor limítrofe del ovario atendidas en la Unidad Médica de Alta Especialidad de Oncología del Centro Médico Nacional siglo XXI del Instituto Mexicano del Seguro Social, en la Ciudad de México y otros centros médicos de la República Mexicana. RESULTADOS: Se encontraron 62 artículos relacionados con los términos de búsqueda; de éstos, se descartaron 11 porque no eran artículos originales solo de tumores limítrofes del ovario y 4 porque el texto completo estaba escrito en idiomas diferentes al inglés y español. Uno más se eliminó porque sus conclusiones diferían del objetivo planteado y su sustento se consideró endeble. Al final se analizaron 41 artículos. CONCLUSIONES: Las posibilidades de atención quirúrgica de pacientes con tumor limítrofe del ovario, con preservación de la fertilidad, son altas pues su recurrencia es baja. Los tumores microinvasores mucinosos, con permeación vascular y linfática, tendrán mayor posibilidad de recaída a largo plazo. En general, su pronóstico de supervivencia, en cada etapa, es alto. La linfadenectomía retroperitoneal no está indicada en etapas tempranas de la enfermedad.

Abstract BACKGROUND: Patients with borderline ovarian tumor can be treated conservatively in early stages and thereby achieve considerable survival. Advanced stages have a prolonged disease-free period, some with peritoneal implant growth and relapse after 10 years of treatment. OBJECTIVE: To know the prognosis of patients with borderline ovarian tumor and its treatment in Mexico and other countries. METHODOLOGY: Systematic review of recent clinical trials registered in PubMed, Embase and Cochrane databases of articles published in English and Spanish between 2006 and 2021. In addition, an analytical review of the experience accumulated in 10 years in the care of patients with borderline ovarian tumor attended at the Oncology High Specialty Medical Unit of the XXI Century National Medical Center of the Mexican Social Security Institute, in Mexico City and other medical centers in the Mexican Republic. RESULTS: We found 62 articles related to the search terms; of these, 11 were discarded because they were not original articles only on ovarian borderline tumors and 4 because the full text was written in languages other than English and Spanish. One more was eliminated because its conclusions differed from the stated objective and its support was considered weak. In the end, 41 articles were analyzed. CONCLUSIONS: The chances of surgical care of patients with ovarian borderline tumor, with fertility preservation, are high because its recurrence is low. Mucinous microinvasive tumors, with vascular and lymphatic permeation, will have a higher chance of long-term relapse. In general, their prognosis for survival, at each stage, is high. Retroperitoneal lymphadenectomy is not indicated in early stages of the disease.

Cáncer de endometrio: tratamiento quirúrgico en un hospital comunitario de España / Endometrial cancer: surgical treatment in a community hospital in Spain

Resumen OBJETIVO: Exponer los desenlaces quirúrgicos de las pacientes intervenidas por cáncer de endometrio, analizar si existen puntos de mejora en nuestra práctica clínica y aportar más datos a la evidencia publicada, para ayudar al avance en el tratamiento quirúrgico de las pacientes con esta enfermedad MATERIALES Y MÉTODOS: Estudio observacional, descriptivo y retrospectivo llevado a cabo en la Unidad de Oncología Ginecológica del Hospital Regional Virgen Macarena de Sevilla, España, entre junio de 2013 y febrero de 2020. Se reunieron los reportes quirúrgicos de pacientes intervenidas por alguna afección endometrial premaligna o maligna. Variables de estudio: edad, IMC, cirugías previas, diagnóstico histopatológico y estadio, vía de acceso quirúrgico y terapia coadyuvante. Se exponen los desenlaces relacionados con complicaciones quirúrgicas y tasa de curación, así como el tiempo de intervención, vía de acceso quirúrgico y estancia hospitalaria. RESULTADOS: Se estudiaron 250 pacientes, la mayoría (76%) con diagnóstico de adenocarcinoma endometrioide de endometrio. La vía de acceso quirúrgico más utilizada fue la laparoscopia (51.6%), con un porcentaje de complicaciones intraoperatorias del 10% y posoperatorias del 9.2%. El 88.4% de las pacientes permanece viva y libre de enfermedad después del tratamiento, con recaídas solo en el 11.6% y 8% de fallecimientos. CONCLUSIONES: El tratamiento inicial de elección, en pacientes con hiperplasia con atipias o cáncer de endometrio en estadios tempranos, es la cirugía, mediante histerectomía, doble anexectomía y en algunos casos linfadenectomía asociada. La elección de la vía quirúrgica de acceso debe individualizarse a las condiciones particulares de cada paciente. La laparoscopia ofrece múltiples ventajas, es una técnica en auge y cada día más practicada.

Abstract OBJECTIVE: To expose the surgical outcomes of patients operated on for endometrial cancer, to analyze if there are points of improvement in our clinical practice and to contribute more data to the published evidence, to help advance the surgical treatment of patients with this disease. MATERIALS AND METHODS: Observational, descriptive, and retrospective study carried out in the Gynecologic Oncology Unit of the Virgen Macarena Regional Hospital of Seville, Spain, between June 2013 and February 2020. Surgical reports of patients operated on for any premalignant or malignant endometrial condition were collected. Study variables: age, BMI, previous surgeries, histopathological diagnosis and stage, surgical access route and adjuvant therapy. Outcomes related to surgical complications and cure rate are presented, as well as operation time, surgical access route and hospital stay. RESULTS: 250 patients were studied, the majority (76%) with a diagnosis of endometrioid endometrial adenocarcinoma. The most used surgical access route was laparoscopy (51.6%), with a percentage of intraoperative complications of 10% and postoperative complications of 9.2%. 88.4% of patients remain alive free of disease after treatment, with relapses in only 11.6% and 8% deaths. CONCLUSIONS: The initial treatment of choice in patients with hyperplasia with atypia or early-stage endometrial cancer is surgery, by hysterectomy, double adnexectomy and in some cases associated lymphadenectomy. The choice of surgical approach must be individualized to the conditions of each patient. Laparoscopy offers multiple advantages; it is a technique that is on the rise and is being used more and more frequently.

Impact of number and location of metastatic lymph nodes on prognosis in patients after resection for intrahepatic cholangiocarcinoma / 中华肝胆外科杂志

Objective:To study the impact of number and location of metastatic lymph nodes on prognosis of patients after radical resection for intrahepatic cholangiocarcinoma (ICC).Methods:A retrospective study was conducted on 105 patients who underwent radical resection and lymphadenectomy for ICC at the First Affiliated Hospital of Xi’an Jiaotong University from January 2010 to December 2020. There were 49 males and 56 females, with age of (58±10) years old. These patients were divided into 2 groups using the TNM staging (8th edition) into the N0 stage group ( n=62) and N1 stage group ( n=43). Using the NMLN staging, those with 0, 1-2, and >3 number of metastatic lymph nodes (NMLN) were divided into 3 groups: the stage 0 group ( n=62), stage 1 group ( n=24), and stage 2 group ( n=19). Of the 43 patients with lymph node metastasis, they were divided into 2 groups according to whether the lymph node metastasis was limited to the first lymph node station: the first station metastasis group ( n=11) and the non-first station metastasis group ( n=32). The general data, extent of lymph node dissection, pathological examinations, and postoperative survival outcomes of these patients were collected. Determination of risk factors for prognosis of ICC after radical resection was carried out. Results:The median number of lymph node harvested, or the detection of N0 and N1 staging were 6 (3, 8) and 6 (3, 10), respectively. There were no significant differences between the two groups ( Z=-1.10, P>0.05). Overall survival of patients in the N0 stage group was better than the N1 stage group (32.0 vs. 9.0 months, χ 2=23.99, P<0.001). The median survival times of patients in the stage 0, stage 1 and stage 2 groups were 32.0, 14.0 and 6.0 months, respectively. There was a significant difference in overall survival among the 3 groups (χ 2=32.18, P<0.001). The time-dependent receiver operating characteristic curves showed that NMLN staging had better prognostic predictive ability than the N staging. The median survival times of the first station metastasis group and the non-first station metastasis group were 18.0 and 7.0 months, respectively. There was no significant difference between the two groups (χ 2=2.21, P>0.05). Multivariate analysis showed that tumor carbohydrate antigen 125>35.0 U/ml ( HR=4.297, 95% CI:2.418-7.634), hepatolithiasis ( HR=2.713, 95% CI:1.499-4.911), T4 staging ( HR=2.934, 95% CI:1.478-5.825), NMLN stage 1 ( HR=2.759, 95% CI:1.500-5.077) and NMLN stage 2 ( HR=7.376, 95% CI:3.553-15.312) were independent risk factors affecting prognosis of ICC after radical resection ( P<0.05). Conclusion:Lymph node metastasis was an important poor prognostic risk factor after radical resection of intrahepatic cholangiocarcinoma. The prognosis of ICC patients was related to the NMLN, but it was not related to the location of metastatic lymph nodes.

Outcomes and prognosis of radical surgery in patients with stageⅠb2 and Ⅱa2 cervical squamous cell carcinoma / 中华妇产科杂志

Objective:To evaluate the survival, complications and prognostic factors in patients with stageⅠb2 and Ⅱa2 cervical squamous cell carcinoma treated by primarily radical surgery with or without postoperative adjuvant therapy.Methods:The clinical and pathological data of patients with stageⅠb2 and Ⅱa2 cervical squamous cell carcinoma treated in the Cancer Hospital of the University of Chinese Academy of Sciences from January 2015 to January 2018 were retrospectively analyzed. All patients underwent Querleu-Morrow classification (Q-M classification) C2 radical surgery, including extensive hysterectomy+pelvic lymphadenectomy with or without adjuvant therapy based on postoperative risk factors. Survival rate was calculated by Kaplan-Meier method and survival curve was drawn. Univariate analysis was performed by using the log-rank test to analyze the clinicopathological factors related to the prognosis of patients. Multivariate analysis was performed by using Cox regression method to analyze independent risk factors affecting survival prognosis.Results:(1) The median age of 643 patients with cervical squamous cell carcinoma was 50 years old (45-58 years old). Clinical stage: 260 cases (40.4%, 260/643) of stage Ⅰb2, 383 cases (59.6%, 383/643) of stage Ⅱa2. (2) Among 643 cases underwent Q-M classification C2 surgery, 574 cases (89.3%, 574/643) of them received adjuvant therapy and 184 cases (28.6%, 184/643) of them had grade 3-4 complications after treatment, including 134 cases (20.8%, 134/643) early complications and 66 cases (10.3%, 66/643) late complications. The incidence of grade 3-4 complications in 574 patients received postoperative adjuvant therapy was 30.1% (173/574), which was significantly different from that in 69 patients who received surgery alone (15.9%, 11/69; χ2=6.08, P=0.014). (3) All 643 cases were followed up, and the median follow-up time was 40 months (3-76 months). During the follow-up period, 117 cases (18.2%, 117/643) recurred, including 45 cases (7.0%, 45/643) of local recurrence, 54 cases (8.4%, 54/643) of distant metastasis, and 18 cases (2.8%, 18/643) of local recurrence and distant metastasis. The 5-year progression-free survival (PFS) and 5-year overall survival (OS) rates of patients with stage Ⅰb2 and Ⅱa2 cervical squamous cell carcinoma were 79.9% and 85.5%, respectively. Univariate analysis showed that pelvic lymph node metastasis, para-aortic lymph node metastasis, deep stromal infiltration, and lymph-vascular space invasion were significantly associated with 5-year PFS in patients with stage Ⅰb2 and Ⅱa2 cervical squamous cell carcinoma (all P<0.05). The maximum diameter of tumor, pelvic lymph node metastasis and para-aortic lymph node metastasis were significantly associated with the 5-year OS of cervical squamous cell carcinoma in stages Ⅰb2 and Ⅱa2 (all P<0.05). Multivariate analysis showed that pelvic lymph node metastasis and para-aortic lymph node metastasis were independent factors affecting 5-year PFS and 5-year OS in patients with stage Ⅰb2 and Ⅱa2 cervical squamous cell carcinoma (all P<0.01). Conclusion:Radical surgery is a feasible and effective primary treatment for stagesⅠb2 and Ⅱa2 cervical squamous cell carcinoma, with a high 5-year survival rate and an acceptable complication rate.

Simultaneous resection for colon cancer and synchronous liver metastases: case series with follow-up / Resección simultánea por cáncer de colon y metástasis hepáticas sincrónicas: serie de casos con seguimiento

SUMMARY: Treatment of colonic cancer (CC) and synchronic liver metastasis (SLM) is still controversial in relation to how to act. The aim of this study was to analyze initial single center experience in simultaneous surgical approach of patients with CC and SLM, in terms of overall survival (OS) and disease-free survival (DFS). Retrospective case series of patients with CC and SLM undergoing simultaneous surgery, consecutively, at Clínica RedSalud Mayor Temuco, between 2007 and 2021. Outcome variables were OS and DFS. Other variables of interest were postoperative morbidity (POM), surgical time, hospital stay and mortality. Descriptive statistics was used (measures of central tendency and dispersion), and survival analysis was estimated applying Kaplan Meier curves. Sixteen patients (10 female and 6 male) were operated, with a median age of 61 years. The most frequent localization was cecum and right colon (37.5 %). In all patients some type of liver resection was added (parenchymal-sparing hepatectomy or anatomical resection). Median surgical time and hospital stay were 150 min and 5 days respectively. POM was 31.2 % (5 cases), mainly Clavien & Dindo I and II (12.5 % of patients required a re-intervention). With a median follow-up of 52 months 1, 3 and 5-year OS were 100 %, 62.5 %, and 50.0 % respectively. On the other hand, DFS rates of 1, 3 and 5-year were 75.0 %, 43.8 %, and 25.0 % respectively. The series had no mortality. OS, DFS, POM and mortality, were like other series. Simultaneous resection of CC and SLM is an aggressive approach, but not compromise oncological outcomes.

RESUMEN: El tratamiento del cáncer de colon (CC) con metástasis hepática sincrónica (MHS), tiene un tratamiento controvertido aún. El objetivo de este estudio fue analizar la experiencia unicéntrica en el tratamiento de pacientes con CC y MHS simultáneo, en términos de supervivencia global (SG) y supervivencia libre de enfermedad (SLE). Serie de casos retrospectiva consecutiva, de pacientes con CC y MHS sometidos a cirugía simultánea, en Clínica RedSalud Mayor Temuco, entre 2007 y 2021. Las variables de resultado fueron SG y SLE. Otras variables de interés fueron la morbilidad postoperatoria (MPO), tiempo quirúrgico, estancia hospitalaria y mortalidad. Se utilizó estadística descriptiva (medidas de tendencia central y dispersión) y se estimó supervivencia aplicando curvas de Kaplan Meier. Se operaron 16 pacientes (10 mujeres y 6 hombres), con mediana de edad de 61 años. La localización más frecuente fue ciego-colon derecho (37,5 %). En todos los casos se practicó algún tipo de resección hepática (hepatectomía conservadora o resección anatómica). La mediana del tiempo quirúrgico y la estancia hospitalaria fueron de 150 min y 5 días respectivamente. La MPO fue del 31,2 % (5 casos), principalmente Clavien & Dindo I y II (hubo 12,5 % de reintervenciones). Con una mediana de seguimiento de 52 meses. La SG a 1, 3 y 5 años fue 100 %, 62,5 % y 50,0 %, respectivamente. Por otro lado, la SLE a 1, 3 y 5 años fue 75,0 %, 43,8 % y 25,0 %, respectivamente. La serie no tuvo mortalidad. La SG, SLE, MPO y la mortalidad fueron similares a otras series. La resección simultánea de CC y SLM es agresiva, pero no compromete los resultados oncológicos.

Use of flaps in inguinal lymphadenectomy in metastatic penile cancer

ABSTRACT Purpose: Reviewing surgical procedures using fasciocutaneous and myocutaneous flaps for inguinal reconstruction after lymphadenectomy in metastatic penile cancer. Material and Methods: We reviewed the current literature of the Pubmed database according to PRISMA guidelines. The search terms used were "advanced penile cancer", "groin reconstruction", and "inguinal reconstruction", both alone and in combination. The bibliographic references used in the selected articles were also analyzed to include recent articles into our research. Results: A total of 54 studies were included in this review. About one third of penile cancers are diagnosed with locally advanced disease, often presenting with large lymph node involvement. Defects in the inguinal region resulting from the treatment of metastatic penile cancer are challenging for the surgeon and cause high patient morbidity, rendering primary closure unfeasible. Several fasciocutaneous and myocutaneous flaps of the abdomen and thigh can be used for the reconstruction of the inguinal region, transferring tissue to the affected area, and enabling tensionless closure. Conclusions: The reconstruction of defects in the inguinal region with the aid of flaps allows for faster postoperative recovery and reduces the risk of complications. Thus, the patient will be able to undergo potential necessary adjuvant treatments sooner.

Estadificación nodular linfática y supervivencia en pacientes operados por carcinoma pulmonar no microcítico / Lymphatic nodular staging and survival in patients operated due to non-small cell lung cancer

Introducción: En los pacientes con cáncer de pulmón resulta vital el tratamiento quirúrgico, pues posibilita una estadificación patológica minuciosa, así como un pronóstico y tratamiento acordes con la carga tumoral de cada paciente. Objetivo: Determinar la influencia del tipo de linfadenectomía mediastinal en la supervivencia de pacientes operados por cáncer pulmonar de células no pequeñas. Métodos: Se realizó un estudio descriptivo y longitudinal en el Servicio de Cirugía General del Hospital Provincial Clínico-Quirúrgico Docente Saturnino Lora de Santiago de Cuba, durante un período de 10 años (de 2009 a 2019), en 55 pacientes seleccionados aleatoriamente, quienes recibieron algún tipo de linfadenectomía del mediastino además de resección pulmonar. En el procesamiento estadístico, se utilizaron el número absoluto, el porcentaje y la media como medidas de resumen; también la prueba de independencia de la Χ2, para identificar la posible asociación entre variables, y el método de Kaplan-Meier, para precisar la supervivencia. Resultados: La técnica de linfadenectomía mediastínica más utilizada fue el muestreo ganglionar (47,3 %), con la cual también se obtuvo un mayor porcentaje (84,6) de resultados negativos en cuanto a invasión neoplásica, a diferencia de lo observado con la disección ganglionar sistemática, que reveló positividad de infiltración tumoral en un elevado número de pacientes (52,9 %). Asimismo, los pacientes operados mediante disección ganglionar sistemática mostraron mejor supervivencia a los 6 meses (100 %) y al año (87,5 %); a los 5 años las cifras de supervivencia con esta técnica fueron superiores a las obtenidas con todos los tipos de escisiones ganglionares practicadas. Conclusiones: Existió mayor probabilidad del diagnóstico de invasión linfática del mediastino y una mejor supervivencia en los pacientes tratados con disección ganglionar sistemática. Por ello, se recomienda protocolizar dicho tratamiento quirúrgico, lo cual pudiera estar avalado por un ensayo clínico que permita comparar grupos homogéneos que reciban cada tipo de linfadenectomía, respectivamente, a fin de recoger una evidencia científica relevante y concluyente.

Introduction: In the patients with lung cancer it is vital the surgical treatment, because it facilitates a meticulous pathological staging, as well as a prognosis and treatment according to each patient tumoral charge. Objective: To determine the influence of the mediastinal limphadenectomy type in the survival of patients operated due to non-small cells lung cancer. Methods: A descriptive and longitudinal study was carried out in the General Surgery Service of Saturnino Lora Teaching Clinical-Surgical Provincial Hospital in Santiago de Cuba, during 10 years (from 2009 to 2019), in 55 patients selected at random who received some type of mediastinum lymphadenectomy besides lung resection. In the statistical processing, the absolute number, percentage and the mean were used, as summary measures; also the chi-squared test to identify the possible association among variables, and the Kaplan-Meier method, to specify survival. Results: The most used medistinic lymphadenectomy technique was the ganglionar sampling (47.3 %), with which a higher percentage of negative results was also obtained (84.6) as regards neoplastic invasion, contrary to that is observed with the systematic ganglionar dissection that revealed metastasis positivity in a high number of the patients that received it (52.9 %). Likewise, patients operated by means of systematic ganglionar dissection showed a better survival 6 months later (100 %) and a year later (87.5 %); after 5 years the survival number with this technique was superior to all the types of ganglionar excisions practiced. Conclusions: There was a higher probability of the mediastinic lymphatic infiltration diagnosis and better survival in the patients treated with systematic ganglionar dissection. Reason why, it is recommended to protocolize this surgical treatment, which could be endorsed by a clinical trial that allows to compare homogeneous groups that receive each type of lymphadenectomy, respectively, in order to obtain an outstanding and conclusive scientific evidence.

Results of surgical treatment of uncomplicated colon cancer: case series with follow-up / Resultados del tratamiento quirúrgico del cáncer de colon no complicado: serie de casos con seguimiento

SUMMARY: The standard treatment of colonic cancer (CC) continues to be the radical resection of the intestinal segment compromised with free margins, associated or not with adjuvant therapies. The aim of this study was to determine postoperative morbidity (POM) and 5-year overall survival (OS) in patients with uncomplicated colon cancer surgically treated. Retrospective case series of patients with uncomplicated CC undergoing colectomy and lymphadenectomy, consecutively, at Clínica Red Salud Mayor Temuco, between 2007 and 2019. The outcomes variable were POM and 5-years OS. Other variables of interest were surgical time, number of resected lymph nodes, hospital stay and recurrence. Descriptive statistics was used (measures of central tendency and dispersion), and OS analysis was applying Kaplan Meier curves. In this study, 52 patients (53.8 % men) were intervened, with a median age of 68 years. The most frequent localization and stages were right colon (42.3 %); IIIA and IIIB respectively (78.9 %). Median surgical time, number of resected lymph nodes and hospital stay were 98 min, 34 and 4.5 days respectively. POM was 17.3 % (9 cases). With a median follow- up of 58 months, a recurrence of 19.2 % was verified, and the 5-year OS for stages IIA, IIIA, IIIB and IVA was 83.3 %, 73.6 %, 68.2 % and 40.0 % respectively. The results, in terms of POM, mortality and 5-year OS, were similar to national and international series.

RESUMEN: El tratamiento estándar del cáncer de colon (CC), continua siendo la resección radical del segmento intestinal comprometido con márgenes libres (al menos 5 cm por encima y debajo del tumor), pudiendo asociarse o no a terapias complementarias. El objetivo de este estudio fue determinar morbilidad postoperatoria (MPO) y supervivencia actuarial global (SVAG) a 5 años en pacientes resecados por CC no complicado. Serie de casos con seguimiento, de pacientes con CC no complicado, sometidos a colectomía subtotal y linfadenectomía, de forma consecutiva, en Clínica Red Salud Mayor Temuco, entre 2007 y 2019. Las variables resultado fueron MPO y SV actuarial global (SVAG) a 5 años. Otras variables de interés fueron: tiempo quirúrgico, número de linfonodos resecados, estancia hospitalaria y recurrencia. Se utilizó estadística descriptiva, con medidas de tendencia central y dispersión; y análisis de SV con curvas de Kaplan Meier. Se intervinieron 52 pacientes (53,8 % hombres), con una mediana de edad de 68 años. La localización y estadios más frecuentes fueron colon derecho (42,3 %); IIIA y IIIB respectivamente (78,9 %). La resecabilidad de la serie fue 100 %. La medianas del tiempo quirúrgico, del número de linfonodos resecados y de estancia hospitalaria; fueron de 98 min, 34 y 4.5 días respectivamente. La MPO fue 17,3 % (9 casos). Con una mediana de seguimiento de 58 meses, se verificó una recurrencia de 19,2 %; y una SVAG a 5 años para los estadios IIA, IIIA, IIIB y IVA; de 83,3 %; 73,6 %; 68,2 % y 40,0 % respectivamente. Los resultados obtenidos, en términos de MPO, mortalidad y SVAG a 5 años, fueron similares a series de nacionales e internacionales.

Impacto del fenómeno de migración de estadio ganglionar en la supervivencia y la recurrencia de pacientes con cáncer papilar de tiroides sometidos a vaciamiento ganglionar profiláctico / Impact of the node-stage migration phenomenon on survival and recurrence of patients with papillary thyroid cancer who underwent prophylactic lymphnode dissection

Introducción. Dado que un ensayo clínico aleatorio es irrealizable, el rol del vaciamiento ganglionar profiláctico en pacientes con cáncer papilar de tiroides sin comprobación clínica de compromiso ganglionar metastásico (cN0) es controversial. El vaciamiento ganglionar profiláctico acarrea un proceso de reclasificación de pacientes, al hacer evidente la positividad ganglionar micrometastásica antes ignorada, lo que genera una aparente pero falsa mejoría en los desenlaces de los grupos de estadificación, mientras el pronóstico individual y total de la población no cambia, fenómeno conocido como migración de estadio o fenómeno de Will Rogers. Métodos. Se ejecutaron simulaciones de poblaciones con cáncer papilar de tiroides con compromiso ganglionar metastásico clínicamente evidente (cN+) y cN0, para determinar el impacto del fenómeno de migración de estadio en los pacientes sometidos a vaciamiento ganglionar profiláctico. Resultados. Con la simulación de las poblaciones y sus estadios ganglionares, se observa cómo la migración de estadio ganglionar genera una aparente mejoría en los desenlaces de recurrencia loco regional y supervivencia, sin cambiar los desenlaces de la población total ni individuales. Discusión. El fenómeno de migración de estadio es uno de los sesgos más importantes que limitan el uso de grupos históricos de control en ensayos de tratamiento experimental. De acuerdo con nuestros resultados, este fenómeno podría explicar los beneficios observados con el vaciamiento ganglionar profiláctico en algunos de los estudios agregativos publicados hasta el momento, hallazgos que no han sido documentados para el cáncer papilar de tiroides

Introduction. The role of prophylactic central lymph node dissection at the time of total thyroidectomy remains controversial in clinically node-negative (cN0) papillary thyroid carcinoma. Moreover, a prospective randomized controlled trial of prophylactic central lymph node dissection in cN0 RCT is not readily feasible. Methods. In this study we simulated cN0 and clinically node-positive (cN+) populations, to evaluate impact of nodal stage migration in papillary thyroid carcinoma patients that undergo prophylactic central neck dissection. We use simulations of population and nodal stages .Results. Nodal stage migration phenomenon seems to have an improvement in locoregional recurrence and overall survival of cN0 and cN+ populations, without changes in overall population and individual outcomes.Discussion. Nodal stage migration is recognized as an important bias that precludes the use of historical controls groups in experimental treatment trials. In accordance to our findings, this phenomenon could explain the improvements observed in outcomes in patients that undergo prophylactic central neck dissection

Localización intraoperatoria de las recurrencias en cáncer de tiroides mediante la inyección de azul de metileno guiada por ecografía / Intraoperative localization of recurrences in thyroid cancer by ultrasound-guided injection of methylene blue

Introducción. La cirugía para extirpación de metástasis en un cuello previamente intervenido afronta un reto para lograr una resección exitosa. El presente estudio pretende demostrar la utilidad de la técnica de inyección de azul de metileno, guiada por ecografía, para la localización intraoperatoria de lesiones recurrentes en cáncer de tiroides, para facilitar su resección. Métodos. Se realizó un estudio observacional, descriptivo y retrospectivo, en pacientes reintervenidos por recurrencia de carcinoma diferenciado de tiroides, durante un periodo de dos años y medio. Se utilizó la inyección intratumoral de azul de metileno guiada por ecografía para su identificación intraoperatoria de recurrencia. Se hizo análisis de variables demográficas y clínicas. Resultados. Este estudio incluyó 10 procedimientos en 9 pacientes, 77,8 % mujeres, con una media de edad de 54 años. Todos tenían un nivel de tiroglobulina detectable y elevado antes de la intervención; posteriormente, el 89 %presentó un descenso y el 33 % una adecuada respuesta bioquímica. La técnica agregó 10 minutos al tiempo quirúrgico. En el 100 % se identificaron de manera intraoperatoria los ganglios marcados; el promedio de ganglios resecados fue de 12, de los cuales, 6 fueron positivos, todos con carcinoma papilar de tiroides. Esta técnica se consideró de gran utilidad y de bajo costo en todos los casos. Discusión. Esta técnica se muestra como una estrategia efectiva para la identificación intraoperatoria de las recurrencias corregionales en carcinoma de tiroides, permitiendo una disección ganglionar exitosa, disminuyendo complicaciones, tiempo quirúrgico y, especialmente, costos frente a otras intervenciones

Introduction. The approach of a previously operated neck for metastasis resection faces a challenge to achieve a successful resection. The present study aims to demonstrate the usefulness of the ultrasound-guided injection of methylene blue technique for the intraoperative localization of recurrent lesions in thyroid cancer to facilitate their resection. Methods. An observational, descriptive and retrospective study was conducted in patients reoperated for recurrences of differentiated thyroid carcinoma over a period of two and a half years, using ultrasound-guided intratumoral injection of methylene blue for its intraoperative identification. An analysis of demographic and clinical variables was carried out and its advantages over other methods were identified. Results. This study included 10 procedures in nine patients, 77.8% women and 22.2% men, with a mean age of 54 years. All had a detectable and elevated thyroglobulin level before the intervention, 89% had a decrease in its level and 33% had an adequate biochemical response. The technique added 10 minutes to the surgical time. All marked lymph nodes were identified intraoperatively. The average number of lymph nodes resected was 12, of which six were positive, all with papillary thyroid carcinoma. It was considered of great utility and low cost in all cases. Discussion. This technique shows to be an effective strategy for the intraoperative identification of locoregional recurrences in thyroid carcinoma, allowing a successful lymph node dissection, reducing complications, surgical time and especially costs compared to other interventions

Linfadenectomía inguinal por video endoscopia (VEIL) para el manejo de cáncer vulvar en el Instituto Nacional de Cancerología (Bogotá, Colombia) / Video endoscopic inguinal lymphadenectomy (VEIL) for the management of vulvar cancer at the Instituto Nacional de Cancerología (Bogotá, Colombia)

Resumen El cáncer de vulva representa el 2% al 5% de todos los cánceres ginecológicos a nivel mundial, dentro de los cuales, el más frecuente es el carcinoma escamocelular seguido por el melanoma. La cirugía es la piedra angular en el tratamiento de la neoplasia vulvar, y la evaluación del estado ganglionar es un poderoso predictor de supervivencia. La linfadenectomía inguinofemoral hace parte de las estrategias de tratamiento. La aproximación quirúrgica mínimamente invasiva por video endoscopia (VEIL) es una alternativa a la vía abierta que disminuye la morbilidad postoperatoria como dehiscencia de la herida quirúrgica, linfocele, linfedema, infección y deterioro psicosexual. A continuación, se describe la técnica quirúrgica VEIL como abordaje novedoso en Colombia para el manejo de la neoplasia vulvar.

Abstract Vulvar cancer represents 2% to 5% of all gynecological cancers worldwide, of which the most common is squamous cell carcinoma followed by melanoma. Surgery is the cornerstone in the treatment of vulvar neoplasia, and evaluation of lymph node status is a powerful predictor of survival. Inguinofemoral lymphadenectomy is part of the treatment strategies. The minimally invasive surgical approach by video endoscopy (VEIL) is an alternative to the open approach that reduces postoperative morbidity such as dehiscence of the surgical wound, lymphocele, lymphedema, infection, and psychosexual deterioration. The following describes the surgical technique of VEIL, as a novel approach in Colombia for the management of this cancer.

Arco axilar de Langer: serie de casos y revisión de la literatura / Langer's axillary arch: case series and literature review

Introducción. El arco de Langer es una entidad infrecuente, cuya prevalencia depende de la técnica quirúrgica utilizada y usualmente no se asocia con síntomas de compresión vascular o neuronal. El objetivo de este estudio fue describir las características clínicas y morfológicas, y la proporción de síntomas de compresión neurovascular del arco de Langer, en mujeres con cáncer de mama llevadas a cirugía axilar. Métodos. Estudio descriptivo del arco de Langer en mujeres con cáncer de mama, llevadas a cirugía axilar en el registro personal de un cirujano, en Medellín, Colombia, entre el 1 enero de 2017 y el 15 agosto de 2020. Se evaluaron características clínicas, morfológicas y síntomas de compresión neurovascular. Las variables categóricas se agruparon según su frecuencia como porcentajes, y para las variables continuas se calculó la mediana y su rango intercuartílico. Resultados. Entre el 1 enero de 2017 y el 15 agosto de 2020 se realizaron 725 cirugías axilares, 479 biopsias de ganglio centinela y 246 linfadenectomías, encontrando 17 casos de arco de Langer, para una frecuencia de 2,3 %. Fue más frecuente encontrarlo en el curso de una linfadenectomía (n=11, 64,7 %). En 15 (88,2 %) casos se presentó riesgo de ocultamiento ganglionar y en 14 (82,3 %) generó dificultad quirúrgica. No hubo casos con síntomas de compresión vascular o neuronal. En ningún caso se realizó el diagnostico imagenológico prequirúrgico. La conducta quirúrgica predominante fue sección, en 88,2 %, sin presentar complicaciones quirúrgicas asociadas. Discusión. Es importante para el cirujano el conocimiento del arco axilar como una variante anatómica de la axila, que puede ocultar los ganglios o dificultar la disección axilar, por lo que la conducta más usada es la sección

Introduction. Langer's arch is an infrequent entity, the prevalence of which depends on the surgical technique used and is usually not associated with symptoms of vascular or neuronal compression. The objective of this study was to describe the clinical and morphological characteristics, and the proportion of symptoms of neurovascular compression of Langer's arch, in women with breast cancer who underwent axillary surgery.Methods. Descriptive study of Langer's arch in women with breast cancer, who underwent axillary surgery in the personal registry of a surgeon, in Medellín, Colombia, between January 1, 2017 and August 15, 2020. Clinical, morphological and clinical characteristics were evaluated for symptoms of neurovascular compression. Categorical variables were grouped according to their frequency as percentages, and the median and interquartile range were calculated for continuous variables.Results. Between January 1, 2017 and August 15, 2020, 725 axillary surgeries, 479 sentinel node biopsies, and 246 lymphadenectomies were performed, finding 17 cases of Langer's arch, for a frequency of 2.3%. It was more frequently found in the course of lymphadenectomy (n= 11; 64.7%). In 15 (88.2%) cases there was a risk of lymph node concealment and in 14 (82.3%) it generated surgical difficulty. There were no cases with symptoms of vas-cular or neuronal compression. In no case was the pre-surgical imaging diagnosis made. The predominant surgical approach was section, in 88.2%, without presenting associated surgical complications.Discussion. Knowledge of the axillary arch as an anatomical variant of the axilla is important for the surgeon, which can hide the lymph nodes or make axillary dissection difficult, so the most commonly used approach is to cut it

Sentinel lymph node biopsy using single-agent mapping tracer (blue dye) after neoadjuvant chemotherapy in a Brazilian cohort of breast cancer patients. Real world evidence

ABSTRACT Purpose To reduce false-negative rates (FNR) in sentinel lymph node biopsy (SLNB) of clinically positive (cN+) axilla in patients undergoing neoadjuvant chemotherapy (NAC). The removal of three or more lymph nodes with dual-tracer mapping including a radioisotope was used. However, in the Brazilian Unified Health System, the radioisotope tracer is not feasible in some hospitals. We conducted a cross-sectional study to evaluate the detection rate of sentinel lymph node (SLN) in patients who converted from cN+ to ycN0 after NAC using blue dye as a single-agent mapping tracer. Methods During the period of March 2018 to September 2019, 34 patients who underwent NAC with cN+ who converted to ycN0 were enrolled in the study. The SLNB was performed using blue dye as a single-agent mapping followed by axillary lymph node dissection (ALND). Results The detection rate of sentinel lymph node was of 85.3%, being SLNB not possible for five patients (14.7%), due to fibrosis. The mean number of removed SLN was 2.5. Conclusions The use of blue dye as a single-agent mapping tracer demonstrated an acceptable detection rate of 85.3%. Although the FNR was possible to be determined, the small sample size might overestimate this rate. The removal of three or more lymph nodes with single-agent mapping tracer might be indicated for breast cancer patients who converted to ycN0 after NAC in the Brazilian health public services, in which radioisotope tracer is not suitable.

Clinical analysis of testicular rhabdomyosarcoma / 北京大学学报(医学版)

Testicular rhabdomyosarcoma is relatively rare in testicular tumors, but the age of patient is relatively young and the degree of malignancy is high. Therefore, this article introduces 4 cases of testicular rhabdomyosarcoma who were admitted to Peking University Third Hospital from May 1994 to February 2019, and reviews the literature to improve the diagnosis and treatment of this disease. The average age of the 4 patients was 17.5 years (14-21 years), the average hospital stay was 22.0 d (17-31 d), and the average body mass index was 19.6 kg/m2 (14.7-25.8 kg/m2). All the patients underwent routine preoperative blood and urine routine, biochemical tests, as well as serum tumor markers. Preoperative examinations also included chest radiograph, electrocardiogram, ultrasound of the scrotum and groin, and abdominal enhanced CT. Lung CT or other examinations were performed if necessary. The median serum human chorionic gonadotropin (HCG) of the 4 patients was 0.20 IU/L (0.06-0.86 IU/L) (all normal), and the median serum alpha-fetoprotein (AFP) was 1.03 g/L (0.65-1.66 g/L) (all normal). The average maximum diameter of the tumor was 10.0 cm (4.5-15.0 cm). Testicular rhabdomyosarcoma was mainly diagnosed by pathology. The main treatment was radical orchiectomy combined with retroperitoneal lymph node dissection, with or without postoperative adjuvant chemotherapy. The clinical manifestations of the patients with testicular rhabdomyosarcoma had no specific characteristics, but most patients were young at onset with mainly painless masses in the testicles, which were already large when they were found. Patients with testicular rhabdomyosarcoma have a poor prognosis, most of whom recur within two years. Because of the small number of cases of testicular rhabdomyosarcoma, there is no standard treatment currently. It is recommended that patients with testicular rhabdomyosarcoma undergo radical testicular resection combined with retroperitoneal lymph node dissection. Retroperitoneal lymph node metastasis is an important prognostic factor, and patients with postoperative adjuvant chemotherapy can still survive for a longer time. If local recurrence or limited metastasis is found after operation, local resection and salvage radiotherapy are feasible.

IgG4-related Disease: a diagnostic challenge

Immunoglobulin IgG4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition with a characteristic histopathological appearance that can affect almost any organ. The clinical features result from a focal or diffuse appearance of a tumor-like swelling of the affected organs, identified by physical and/or imaging examination. Herein, we report the case of a 38-year-old male complaining of a worsening chronic right lumbar pain associated with legs and scrotum edema. He also had itchy and erythematous cutaneous lesions on the abdominal wall over the last 8 months, and complained of a diffuse and mild to moderate abdominal discomfort. On examination, the liver was firmly enlarged and tender. His legs had 2+ symmetrical pitting edema extending from his feet to just above the knees. An abdominal computed tomography scan showed a large mass (10 x 8 x 4cm) involving the abdominal infrarenal aorta and the iliac arteries, and compressing the inferior vena cava, with dilated iliac veins, raising the possibility of lymphoproliferative disease. During the initial investigation, the laboratory workup revealed anemia, without other marked changes. A laparoscopic-guided biopsy of the peri-aortic mass was undertaken. The histological report associated with IgG4 immunoglobulin measurement rendered the diagnosis of IgG4-RD. The patient had a favorable outcome after the use of glucocorticoids with the abdominal mass remission.

Laparoscopic selective lateral lymph node dissection for radical resection of rectal cancer / 中华普通外科杂志

Objective:To evaluate the safety and feasibility of laparoscopic selective lateral lymph node dissection (LLND) for radical resection of rectal cancer.Methods:From Dec 2018 to Jul 2020, at the Department of Gastrointestinal Surgery of Northern Jiangsu People's Hospital laparoscopic radical resection of rectal cancer was performed in 32 cases and radical resection plus selective LLND in 26 cases.Results:The operation time in the LLND group was significantly longer than that in the simple radical resection group [247(179-405) min vs. 146(118-258) min, Z=-5.169, P<0.001], but there was no significant difference in intraoperative bleeding [68(45-500) ml vs. 56(25-500) ml, Z=-1.598, P=0.110], postoperative ventilation time [2.5(1-6) d vs. 3.0(1-6) d, Z=-0.120, P=0.905], postoperative hospital stay [9.0(7-17) d vs. 9.5(6-14) d, Z=-1.050, P=0.294] and hospitalization costs [(49 000±3 000) RMB vs. (48 000±3 000) RMB, t=-1.072, P=0.289] between the two groups. The incidence of postoperative complications in the two groups was 19% and 27% respectively (χ 2=0.551, P=0.458). The number of lateral lymph node dissection in LLND group was 8(6-16), 5 of 26 patients had lateral lymph node metastasis, with a metastasis rate of 19%. Conclusion:Laparoscopic radical resectim plus selective LLND for rectal cancer harvests more lateral lymph node metastasis without causing higher complications .