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embryology, visceral anatomy, and surgical techniques were integrated to update Jamieson and Dobson's schema, a historical reference for the mesogastrium.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

Axillary surgery for breast cancer: past, present, and future.

In breast cancer surgery, there has been a major shift toward less invasive local treatment. Although axillary lymph node dissection (ALND) was an integral part of surgical treatment for breast cancer, sentinel lymph node (SLN) biopsy was developed as an accurate method for axillary staging. ALND can be avoided not only in patients with negative SLNs but also in those with one or two positive SLNs receiving breast and/or axillary radiation. On the other hand, ALND has remained the standard treatment for patients with clinically positive nodes. However, axillary reverse mapping (ARM) was developed to map and preserve arm lymphatic drainage during ALND and/or SLN biopsy. This procedure allowed reduction of the rate of arm lymphedema without increasing axillary recurrence, although patients receive postoperative chemotherapy and high-risk patients undergo axillary radiation. Standard ALND may not be necessary even for patients with clinically positive nodes who receive axillary radiation and systemic therapy. Thus, the extent of axillary surgery in breast cancer has been decreased with increased use of systemic and radiation therapy.

Axillary surgery in breast cancer: An updated historical perspective.

This historical surgical retrospection focuses on the temporal de-escalation axillary surgery, focusing on the unceasing efforts of researchers toward new challenges, as documented by extensive studies and trials. Axillary surgery has evolved, aiming to offer the best oncologic treatment and improve the quality of life of women. Axillary lymph-node dissection (ALND) has been replaced by sentinel lymph-node biopsy (SLNB) in women with early clinically node-negative breast cancer, providing adequate axillary nodal staging information with minimal morbidity, and becoming the standard of care in the management of breast cancer. However, this is only the beginning. Strategies in defining systemic and radiotherapeutic treatments have gradually been optimized, offering increasingly refined and targeted breast cancer treatment tools. In recent years, the paradigm of completion ALND after a positive SLNB has been questioned, and several studies have led to revolutionary changes in clinical practice. Moreover, the increasingly pivotal role played by neoadjuvant chemotherapy (NAC) has had a profound effect on the extent of axillary surgery, paving the way to a more finite "targeted" procedure in women with node-positive breast cancer who convert to negative nodes clinically after NAC. The utility of SLNB itself and its subsequent omission in women with negative nodes clinically and breast conservative surgery is also under scientific evaluation. The changes over time in the surgical approach to breast cancer have been numerous and significant. The novel emerging perspective characterized by recent advances in biology and genetics, in dedicated axillary ultrasound imaging and chemotherapy regimens, is the present reality that points to the future of axillary node treatment in breast cancer.

Considering the role of radical prostatectomy in 21st century prostate cancer care.

The practice of radical prostatectomy for treating prostate cancer has evolved remarkably since its general introduction around 1900. Initially described using a perineal approach, the procedure was later popularized using a retropubic one, after it was first described as such in 1948. The open surgical method has now largely been abandoned in favour of the minimally invasive robot-assisted method, which was first described in 2000. Until 1980, the procedure was hazardous, often accompanied by massive blood loss and poor outcomes. For patients in whom surgery is indicated, prostatectomy is increasingly being used as the first step in a multitherapeutic approach in advanced local, and even early metastatic, disease. However, contemporary molecular insights have enabled many men to safely avoid surgical intervention when the disease is phenotypically indolent and use of active surveillance programmes continues to expand worldwide. In 2020, surgery is not recommended in those men with low-grade, low-volume Gleason 6 prostate cancer; previously these men - a large cohort of ~40% of men with newly diagnosed prostate cancer - were offered surgery in large numbers, with little clinical benefit and considerable adverse effects. Radical prostatectomy is appropriate for men with intermediate-risk and high-risk disease (Gleason score 7-9 or Grade Groups 2-5) in whom radical prostatectomy prevents further metastatic seeding of potentially lethal clones of prostate cancer cells. Small series have suggested that it might be appropriate to offer radical prostatectomy to men presenting with small metastatic burden (nodal and or bone) as part of a multimodal therapeutic approach. Furthermore, surgical treatment of prostate cancer has been reported in cohorts of octogenarian men in good health with minimal comorbidities, when 20 years ago such men were rarely treated surgically even when diagnosed with localized high-risk disease. As medical therapies for prostate cancer continue to increase, the use of surgery might seem to be less relevant; however, the changing demographics of prostate cancer means that radical prostatectomy remains an important and useful option in many men, with a changing indication.

The Wertheim hysterectomy: Development, modifications, and impact in the present day.

Ernst Wertheim was a pioneer in the history of the surgical treatment of cervical cancer. His English-language manuscript "The extended abdominal operation for carcinoma uteri (based on 500 operative cases)," which was published in 1912, detailed his standardization of the radical hysterectomy and formed the basis of the current treatment for early stage cervical cancer. We contextualize the Wertheim hysterectomy, emphasizing medical advances that allowed for its development and subsequent modification. We then discuss modifications to the originally proposed procedure, including a maximally extended parametrical resection pioneered by Takayama, and the addition of the Taussig en bloc lymph node dissection by Meigs, both of which afforded an improved mortality profile due to decreased disease recurrence. Finally, we discuss progress that has been made in the present day, such as the development of nerve-sparing and fertility-sparing surgeries, as well as the introduction of the robotic platform. In this way, we hope to provide a historical background for the Wertheim hysterectomy-a cornerstone of gynecologic oncology.

Sentinel node biopsy and improved patient care.

Sentinel lymph node biopsy (SLNB) is based on the hypothesis that the sentinel lymph node (SLN) reflects the lymph-node status and a negative SLN might allow complete axillary lymph node dissection (ALND) to be avoided. Past and current sentinel lymph node clinical trials for breast carcinoma have addressed the prognostic and therapeutic benefits of this technique and as such, SLNB has become a standard of care for select breast cancer patients. This article reviews the history of SLNB as well as current guidelines and recent controversies.

History of lymphadenectomy for esophageal cancer and the future prospects for esophageal cancer surgery.

I would herein like to look back upon surgery for esophageal cancer, particularly on lymphadenectomy, and to speculate a little on the future prospects for esophageal surgery. There are two schools of thought on lymphadenectomy in esophageal cancer: one believes in en bloc esophagectomy, which is commonly performed in Western countries; the other believes in three-field lymphadenectomy, which is commonly performed in Japan. We esophageal surgeons at Kurume University have contributed to some advances in three-field lymphadenectomy. For example, we initiated functional mediastinal dissection to ensure patient safety, and we proposed the lymph node compartment theory to assess the clinical importance of regional nodes. Oncological surgery has progressed in terms of its safety, radicality and functional preservation, leading to improved quality-of-life for patients after surgery. This then evolved to the current development of multimodal and individualized tailor-made treatments. I believe that surgery for esophageal cancer will become bipolarized in the future. One strand will evolve as salvage surgery for residual or recurrent tumors, which non-surgical therapies have failed to cure, and the other strand will evolve as less invasive surgery, adjuvant surgery, for cancers at the relatively early stage, for which micro-metastasis can be cured by non-surgical therapies.

Lymph node dissection for lung cancer: past, present, and future.

In 1978, Naruke et al. proposed an anatomical map that included numbered lymph node stations, which then became widely used for nodal dissection. In 1997, Mountain and Dresler published a new map, which is now favored by the American Thoracic Society and the European Respiratory Society. Using these maps, regional nodal dissection has been universally performed in lung cancer surgery. Clear evidence regarding the survival benefit of lymph node dissection for lung cancer is lacking. However, lobectomy with lymph node dissection continues to be a standard surgical procedure for lung cancer because lymph node dissection is an important investigative process in staging patients. Over the last decade, the extent of nodal dissection for lung cancer has changed due to the increasing number of early detected lung cancers made possible by the recent development of the CT scanner. This manuscript describes the history, present strategy, and future perspectives of lymph node dissection for lung cancer.

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.

Robotic-assisted laparoscopic radical cystectomy: history, techniques and outcomes.

OBJECTIVE: Robotic-assisted radical cystectomy (RARC) is a less invasive means of performing the radical cystectomy operation, which holds promise for improved patient morbidity. We review the history, technique and current literature pertaining to RARC and place the current results in context with the open procedure. METHODS: All articles regarding RARC found in PubMed after January 2000 were examined. We selected articles that appeared in high-impact journals, had large patient population size (>80 patients), or were novel in technique or findings. We chose key laparoscopic articles to give reference to the history in transition to robotic radical cystectomy. In addition, we chose classic articles from open radical cystectomy to give reference regarding the newer robotic perioperative outcomes. RESULTS: Studies suggest that a 20-patient learning curve is needed to reach an operative time of 6.5 h, with 30 surgeries performed to reach lymph node counts in excess of 20 (International Robotic Cystectomy Consortium). The only randomized surgical trial comparing open and robotic techniques showed equivalent lymph node yield, which may be surgeon and volume dependent. Literature demonstrates lower estimated blood loss, transfusion rates, early return of bowel function and decreased complications in early small series. CONCLUSION: RARC and urinary diversion are still early in development and limited to centers with extensive robotic experience and volume, although adoption of the robotic approach is becoming more common. Early studies have shown promise to reduce complications with equivalent oncologic results.

President's address of the 65th annual scientific meeting of the Japanese Association for Thoracic Surgery: challenges for advanced esophageal cancer.

Advanced esophageal tumors have been a challenge for surgery since the very beginning, and these challenges continue still today. In the early period of three-field lymphadenectomy (late 1980s), there was no special attention paid to tracheal necrosis after such an extended operation. In 1988, we reported functional mediastinal dissection preserving the right bronchial artery to prevent such complications. In 1993, we reported that the survival after three-field lymphadenectomy was better than that after en-bloc esophagectomy, and then the lymph node compartment classification based on the metastatic rate and the survival rate. This concept was introduced into the 9th edition of the Guidelines for Clinical and Pathologic Studies on Carcinoma of the Esophagus published in 1999. In early 1980s, combined resection of the neighboring organs was initiated for a locally advanced esophageal cancer. Almost all patients who underwent such an operation, however, died of metastasis in the short-term after surgery without any additional treatment. In 1987, we reported several types of tracheal repair using the latissimus dorsi muscle flap, as a less-invasive surgery that enabled adjuvant or additive therapy, after resection of the trachea involved by cancer. Then in 2004, we demonstrated that the canine aorta could be resected even immediately after aortic stenting. This suggests that an esophageal cancer involving the aorta can be resected using a new technique. To meet the challenges posed by advanced esophageal cancer, the help of other specialized fields besides esophageal surgery is needed: "The specialist must know everything of something, something of everything."

Advances in surgical care.

The numerous advances in the surgical care of gynecologic oncology patients are allowing clinicians to offer improved quality of life while maintaining excellent cancer outcomes. Advances in technology and disease understanding will only enhance our surgical abilities beyond what can be imagined today. Surgeons have a responsibility to evaluate new technology critically and incorporate the technology into patient care safely and efficiently.

The history and anatomy of urologic lymphadenectomy.

The history of urologic lymphadenectomy is rich and diverse. Our current understanding of its use and benefits is a product of the hard work of numerous physicians and scientists from many nations. Standard dissection templates for the various urologic malignancies are based on a complete understanding of the anatomy of the lymphatic system, which has developed immensely since Hippocrates first described the white blood of the lymphatic system while performing an axillary dissection. It is hoped that the next 100 years will bring even greater comprehension of its value and utility.

The origins of radical mastectomy.

William halsted is the 19th century surgeon whose name is most frequently associated with the radical mastectomy procedure; however, this type of surgery actually has been performed since the 16th century. The development of radical mastectomy was a long process, and many surgeons over time have contributed valuable insights and alterations to this fundamental treatment for breast cancer. This procedure may be most commonly associated with Halsted because he promoted a meticulous operative technique, synthesized the best points in the techniques suggested by the most famous surgeons of the 19th century, and provided a scientific basis for the performance of radical mastectomy.