Lipiodol embolization for chylous leak complication post robotic-assisted para-aortic lymph node resection.

Thoracic or abdominal chylous leakage, a rare complication of lymph node removal procedures, can lead to the accumulation of lymph fluid within the abdominal cavity, resulting in chylous ascites, abdominal distension, discomfort, and an increased risk of infection. Lipiodol lymphangiography, a diagnostic procedure utilizing a unique contrast agent, serves to identify the site and cause of chylous leaks. Furthermore, it functions as a therapeutic tool by injecting Lipiodol into the affected lymphatic vessel. By employing this diagnostic procedure, successful closure of the leak can be achieved. We present a case where a chylous leak was effectively treated with Lipiodol injection following the robotic-assisted removal of metastatic lymph nodes surgery.

The absence of lymph nodes removed (pNx status) impacts survival in patients with lung cancer treated surgically.

OBJECTIVES: We aimed to study the clinical significance of the lack of lymph node assessment (pNx status) and its impact on survival in non-small-cell lung cancer patients. METHODS: We retrospectively analysed the Polish Lung Cancer Study Group database. pNx status was defined as 0 lymph nodes removed. We included 17,192 patients. RESULTS: A total of 1080 patients (6%) had pNx status. pNx patients were more likely to be younger, be female, have a different pT distribution, have squamous cell carcinoma, undergo open thoracotomy, be operated on in non-academic hospitals, and have a lower rate of some comorbidities. pNx was more likely to be cN0 than pN1 and pN2 but less likely than pN0 (p < 0.001). pNx patients were less likely to undergo preoperative invasive mediastinal diagnostics than pN1 and pN2 patients but more likely than pN0 patients (p < 0.001). Overall, the five-year overall survival rates were 64%, 45%, 32% and 50% for pN0, pN1, pN2 and pNx, respectively. In pairwise comparisons, all pN descriptors differed significantly from each other (all p < 0.0001 but pNx vs. pN1 p = 0.016). The placement of the pNx survival curve and survival rate depended on histopathology, surgical approach and pT status. In multivariable analysis, pNx was an independent prognostic risk factor (HR = 1.37, 95%CI: 1.23-1.51, p < 0.01). CONCLUSION: The resection of lymph nodes in lung cancer remains a crucial step in the surgical treatment of this disease. The survival of pNx patients is similar to that of pN1 patients. pNx survival curve placement depends on the other variables which could be useful in clinical decisions.

[Laparoscopic proximal gastrectomy and lymph node resection in adenocarcinoma of the esophagogastric junction].

The proportion of adenocarcinoma of the esophagogastric junction (AEG) in gastric cancer is gradually increasing. Due to the unique anatomical structure and biological characteristics of the tumor at this site, AEG has a certain degree of complexity in many aspects of diagnosis and treatment, which brings difficulties to the operation method, the selection of the resection range, the lymph node dissection and the treatment decision-making. Therefore, AEG has always been the focus of academic debate. With the development of minimally invasive surgery in recent years, laparoscopic technology has been increasingly mature and widely used in the treatment of gastrointestinal tumors. Compared with distal gastric cancer, the minimally invasive treatment of AEG is in a lagging state, and there are also a series of problems that have not yet reached a consensus. This article reviews and summarizes the recent research progress in two aspects: proximal gastrectomy for AEG and lymph node dissection. Laparoscopic-assisted proximal gastrectomy is safe for early proximal gastric cancer and has a long-term survival outcome not inferior to total gastrectomy, but the surgical indications must be strictly selected. Abdominal lymph node metastasis of AEG is mainly in group 1, 2, 3, and 7, and mediastinal lymph node metastasis is closely related to the length of the infiltrated esophagus. The abdominal transhiatal (TH) approach can obtain a sufficient number of harvested lymph node, and has good safety and efficacy, which is the first-choice of surgical approach for early AEG. The results of the CLASS-10 clinical trial can provide a higher level of evidence for laparoscopic mediastinal lymph node dissection. Laparoscopic surgery for AEG should be carried out in experienced medical center based on clinical research.

Laparoscopic proximal gastrectomy and lymph node resection in adenocarcinoma of the esophagogastric junction / 中华胃肠外科杂志

The proportion of adenocarcinoma of the esophagogastric junction (AEG) in gastric cancer is gradually increasing. Due to the unique anatomical structure and biological characteristics of the tumor at this site, AEG has a certain degree of complexity in many aspects of diagnosis and treatment, which brings difficulties to the operation method, the selection of the resection range, the lymph node dissection and the treatment decision-making. Therefore, AEG has always been the focus of academic debate. With the development of minimally invasive surgery in recent years, laparoscopic technology has been increasingly mature and widely used in the treatment of gastrointestinal tumors. Compared with distal gastric cancer, the minimally invasive treatment of AEG is in a lagging state, and there are also a series of problems that have not yet reached a consensus. This article reviews and summarizes the recent research progress in two aspects: proximal gastrectomy for AEG and lymph node dissection. Laparoscopic-assisted proximal gastrectomy is safe for early proximal gastric cancer and has a long-term survival outcome not inferior to total gastrectomy, but the surgical indications must be strictly selected. Abdominal lymph node metastasis of AEG is mainly in group 1, 2, 3, and 7, and mediastinal lymph node metastasis is closely related to the length of the infiltrated esophagus. The abdominal transhiatal (TH) approach can obtain a sufficient number of harvested lymph node, and has good safety and efficacy, which is the first-choice of surgical approach for early AEG. The results of the CLASS-10 clinical trial can provide a higher level of evidence for laparoscopic mediastinal lymph node dissection. Laparoscopic surgery for AEG should be carried out in experienced medical center based on clinical research.

Association of sonographic features and clinicopathologic factors of papillary thyroid microcarcinoma for prevalence of lymph node metastasis: a retrospective analysis.

OBJECTIVE: The objective of the study was to develop an association between clinicopathologic and sonographic features of patients with papillary thyroid microcarcinoma and the prevalence of lymph node metastasis. METHODS: Clinicopathologic and sonographic features of 415 patients of papillary thyroid microcarcinoma with (n = 102) or without (n = 313) lymph node metastasis were retrospectively reviewed. The thickness of the lymph node ≥ 6 mm with intra-lymph nodal occupying lesions considered lymph node metastasis. Also, it was considered metastasis if lymph node perfusion or blood flow defect was found with any thickness size. Univariate following multivariate analysis was performed for the prediction of sonographic features and clinicopathologic factors for the prevalence of lymph node metastasis. RESULTS: Male gender (p = 0.041), age < 45 years (p = 0.042), preoperative calcitonin > 65 pg/ mL (p = 0.039), nodule size > 5 mm in diameter (p = 0.038), bilaterality (p = 0.038), tumor capsular invasion (p = 0.048), cystic change (p = 0.047), and hyper vascularity (p = 0.049) of thyroid nodules were associated with lymph node metastasis. Also, thyroid nodules 5 mm and more in diameter may have high aggressiveness. CONCLUSION: These data helped the surgeon for individualized treatment in thyroid carcinoma and avoid unnecessary prophylactic surgery of the lymph node.

Association of sonographic features and clinicopathologic factors of papillary thyroid microcarcinoma for prevalence of lymph node metastasis: a retrospective analysis

ABSTRACT Objective: The objective of the study was to develop an association between clinicopathologic and sonographic features of patients with papillary thyroid microcarcinoma and the prevalence of lymph node metastasis. Subjects and methods: Clinicopathologic and sonographic features of 415 patients of papillary thyroid microcarcinoma with (n = 102) or without (n = 313) lymph node metastasis were retrospectively reviewed. The thickness of the lymph node ≥ 6 mm with intra-lymph nodal occupying lesions considered lymph node metastasis. Also, it was considered metastasis if lymph node perfusion or blood flow defect was found with any thickness size. Univariate following multivariate analysis was performed for the prediction of sonographic features and clinicopathologic factors for the prevalence of lymph node metastasis. Results: Male gender ( p = 0.041), age < 45 years ( p = 0.042), preoperative calcitonin > 65 pg/ mL ( p = 0.039), nodule size > 5 mm in diameter ( p = 0.038), bilaterality ( p = 0.038), tumor capsular invasion ( p = 0.048), cystic change ( p = 0.047), and hyper vascularity ( p = 0.049) of thyroid nodules were associated with lymph node metastasis. Also, thyroid nodules 5 mm and more in diameter may have high aggressiveness. Conclusion: These data helped the surgeon for individualized treatment in thyroid carcinoma and avoid unnecessary prophylactic surgery of the lymph node.

Lymph node resection induces the activation of tumor cells in the lungs.

Lymph node (LN) dissection is a crucial procedure for cancer staging, diagnosis and treatment, and for predicting patient survival. Activation of lung metastatic lesions after LN dissection has been described for head and neck cancer and breast cancer. Preclinical studies have reported that dissection of a tumor-bearing LN is involved in the activation and rapid growth of latent tumor metastases in distant organs, but it is also important to understand how normal (non-tumor-bearing) LN resection influences secondary cancer formation. Here, we describe how the resection of tumor-bearing and non-tumor-bearing LN affects distant metastases in MXH10/Mo-lpr/lpr mice. Tumor cells were administered intravenously and/or intranodally into the right subiliac lymph node (SiLN) to create a mouse model of lung metastasis. Luciferase imaging revealed that tumor cells in the lung were activated after resection of the SiLN, irrespective of whether it contained tumor cells. No luciferase activity was detected in the lungs of mice that did not undergo LN resection (excluding the intravenous inoculation group). Our results indicate that resection of an LN can activate distant metastases regardless of whether the LN contains tumor cells. Hence, lung metastatic lesions are suppressed while metastatic LN are present but activated after LN resection. If this phenomenon occurs in patients with cancer, it is likely that lung metastatic lesions may be activated by elective LN dissection in clinical N0 cases. The development of minimally invasive cancer therapy without surgery would help to minimize the risk of activation of distant metastatic lesions by LN resection.

Clinical significance of laparoscopic extraperitoneal abdominal para-aortic lymphadenectomy / 中国实用妇科与产科杂志

OBJECTIVE: To evaluate the clinical significance of laparoscopic extraperitoneal para-aortic lmphadenectomy(PAL)in high para-aortic lymphadenectomy.METHODS: A non-randomized controlled method was used to analyze the clinical data of laparoscopic extraperitoneal PAL in 35 patients(extraperitoneal group)and laparoscopic transabdominal PAL in 40 patients(transabdominal group)in the Gynecological Department of the First Affiliated Hospital of Xiamen University from March 2018 to April 2019.RESULTS: All the 35 cases of laparoscopic extraperitoneal PAL reached the level of renal vein.Endometrial cancer accounted for the largest proportion,with an average age of 47.57 years and an average body mass index of 23.77.The average operation time was 109 minutes in the first 6 cases and 74.73 minutes in the other 29 cases.The amount of hemorrhage was 15.19 mL,and the average number of para-aortic lymph nodes(PALN)resected was 17.87.There were 5 cases of positive PALN metastasis,and the average gastrointestinal recovery time was13.43 hours.The average postoperative pelvic drainage was 76.57 hours and the average postoperative hospital stay was8.24 days.Intraoperative and postoperative complications included 1 case of inferior vena cava rupture,1 case of chyle leakage,and 1 case of vulvar edema.None of the 40 cases of laparoscopic transabdominal PAL reached the level of renal vein,and endometrial cancer accounted for the largest proportion,with the average age of 46.78 years and the average body mass index of 24.03.The average operation time was 90.55 min;the average intraoperative blood loss was 67.40 mL The average number of para-aortic lymph nodes was 3.30.There was one case of PALN metastasis.The average gastrointestinal recovery time was 22.35 hours,and the average postoperative pelvic drainage time was 75.75 hours.The average length of hospital stay was 8.90 days.There were 2 cases of rupture of the inferior mesenteric artery,3 cases of chyle leakage,and 2 cases of vulvar edema.The number of PALN resection,intraoperative blood loss,and operation time in the extraperitoneal group were not related to the body mass index,but the number of PALN in obese patients in the laparoscopic transabdominal group was significantly reduced,the operation time was longer,the intraoperative blood loss was more,and postoperative gastrointestinal recovery time is longer(P<0.05).CONCLUSION: Laparoscopic extraperitoneal PAL can solve the problems of laparoscopic transabdominal PAL lymph node resection,which is difficult to reach the level of renal vein,intraoperative intestinal tube interference,and the number of lymph nodes resected.It is especially suitable for obese patients.Laparoscopic extra-peritoneal high-grade PAL is safe,feasible,and recommended.

Appropriateness of Surgical Approach in Black Patients with Lung Cancer-15 Years Later, Little Has Changed.

INTRODUCTION: Black patients with lung cancer receive an operation less often and have worse survival than white patients. Over the past several decades limited resection has become an acceptable alternative to lobectomy in selected cases, and mediastinal lymph node staging is recommended. The Surveillance, Epidemiology, and End Results database was explored to assess whether the type of surgical approach is similar in black and white patients with lung cancer. METHODS: All cases of pathologically proven lung cancers within the site code International Classification of Diseases for Oncology, Third Edition, C340 to C349 (67,191 whites and 13,387 blacks), age 64 years or younger, diagnosed between 2007 and 2012 were identified. The odds of treatment (operation or radiation) in blacks versus whites were calculated using multivariable logistic regression, with race as the dependent variable, overall and by disease stage. RESULTS: Surgical treatment was significantly less likely to be administered to black patients than to white patients overall (ORadjusted [ORadj] = 0.69, 95% confidence interval [CI]: 0.65-0.74) and according to stage. Opposite results were observed when radiation was analyzed (ORadj = 1.1, 95% CI: 1.04-1.12). Stratification by age groups (≤50 years versus >50 years) or insurance status did not influence the results. Among those who underwent a surgical procedure, black patients were less likely to have their lymph nodes resected overall (ORadj = 0.79, 95% CI: 0.7-0.89) and according to stage. CONCLUSIONS: Racial disparities in appropriate lung cancer treatment are still observed independently from insurance status.

[Mesocolic excision for colonic adenocarcinoma]. / L'exérèse totale du mésocôlon pour adénocarcinome colique.

On the same principle than total mesorectal excision in rectal cancer, the effect of complete mesocolic excision on short and long-term outcomes is actually evaluated for colonic adenocarcinoma. This method, usually performed for left colectomy, offers a surgical specimen of higher quality, with a larger number of lymph nodes harvested. For right colectomy, surgical specifications make it less common complete mesocolic excision and conventional surgery offer comparable outcomes, as regards to postoperative morbidity and mortality rates. No differences are identified between laparoscopic and open surgery. On oncologic outcomes, only two studies report a higher free-disease survival after complete mesocolic excision. Then, there is evidence that complete mesocolic excision offers a higher rate of specimen with extensive lymph node resection, without increased morbidity rate. However, there is limited evidence that it leads to improve long-term oncological outcomes.

Single-port Robotic Pelvic Bulky Lymph Node Resection: A Case Report.

STUDY OBJECTIVE: To report the feasibility of bulky pelvic lymph node resection with robotic-assisted single-port laparoscopy in a patient with cervical cancer before chemoradiation therapy. DESIGN: Resection of pelvic bulky lymph nodes with a narrated video of da Vinci single-port platform surgery (Intuitive Surgical, Sunnyvale, CA) (Canadian Task Force classification III). SETTING: Although not enough evidence exists to reveal that single-site surgery is better than traditional endoscopic surgery, several studies have suggested that single-site robotic surgery has certain advantages such as less postoperative analgesic use, shorter hospital stay, and quicker recovery. Furthermore, robotic single-site surgery has evolved single-site procedures. Compared with the single-port laparoendoscopic procedure, the robotic-assisted single-port laparoscopic procedure offers some advantages to minimally invasive surgery such as greater dexterity, 3-dimensional visualization, and fewer instrument clashes. These advantages make robotic single-port surgery more preferable; nevertheless, the lack of articulating instruments and the low quality of optical exposure are still challenges. Robotic single-port pelvic lymphadenectomy was first described by Tateo et al [1] in an endometrial carcinoma patient. We present a robotic single-port pelvic bulky lymph node resection in an advanced cervical cancer patient. Even though current data are controversial about removing bulky lymph nodes in patients with advanced cervical cancer, some studies have recommended that debulking of tumor-involved lymph nodes before chemoradiation may be benefical for these patients (Leblanc et al [2], Marnitz et al [3]). In our case, the patient underwent robotic-assisted single-port laparoscopy using the da Vinci Single-Site platform. The abdominal cavity was insufflated from a 3-cm umblical incision, and a 5-lumen single port was inserted. Then, an 8.5-mm 3-dimensional camera was inserted through the port, and for dissection and resection 5-mm bipolar fenestrated forceps and a monopolar hook were used. After resection, the bulky lymph nodes were taken out with an endoscopic bag through the assistant port lumen. Additionally, it is important to remember that single-site procedures are not approved by the Food and Drug Administration for lymphadenectomy. PATIENTS: A 46-year-old patient diagnosed with advanced-stage cervical cancer (Fédération Internationale de Gynécologie et d'Obstétrique stage IIIB) presented with bilateral pelvic lymph node metastasis revealed by pelvic magnetic resonance imaging. The patient had no history of prior surgery or comorbidity. We decided to perform resection of the pelvic lymph nodes with a robotic-assisted single-site laparoscopic procedure before chemoradiation threapy. INTERVENTIONS: Excision of pelvic bulky lymph nodes using robotic-assisted single-port laparoscopy. MEASUREMENTS AND MAIN RESULTS: The total operating time was 170 minutes (from docking to the end of the extubation), the estimated blood loss was 30 mL, and no complications occurred. The patient was discharged the day after surgery. The histopathologic examination revealed squamous cell carcinoma metastasis. CONCLUSION: Robotic-assisted single-port surgery seems to be an applicable and alternative technique to perform the resection of bulky pelvic lymph nodes in patients with advanced cervical cancer before chemoradiation therapy.

Multifunctional MRI/PET Nanobeacons Derived from the in Situ Self-Assembly of Translational Polymers and Clinical Cargo through Coalescent Intermolecular Forces.

Novel multifunctional platforms are needed for oncology in order to assist physicians during surgery and chemotherapy. In the present study, we show that polymeric nanobeacons, consisting of the glucose-based polymer dextran, can be used to guide surgery and improve drug delivery. For imaging, the nanobeacons stably retained the positron emitter 89-zirconium and the MRI contrast agent gadolinium, without the need of a chelator. In addition to using them for PET imaging, the (89)Zr-nanobeacons guided the surgical resection of sentinel lymph nodes, utilizing their inherent Cerenkov luminescence. Through weak electrostatic interactions, the nanoparticles carried combinations of chemotherapeutics for the simultaneous inhibition of oncogenic pathways, resulting in enhanced tumor regression. The nanobeacons also allowed monitoring of drug release via MRI, through the quenching of the gadolinium signal by the coloaded drug, making them a new multifunctional theranostic nanotechnology platform for the clinic.

The impact of tumor size on the association of the extent of lymph node resection and survival in clinical stage I non-small cell lung cancer.

INTRODUCTION: Lymph node evaluation for node-negative non-small cell lung cancer (NSCLC) is associated with long-term survival but it is not clear if smaller tumors require as extensive a pathologic nodal assessment as larger tumors. This study evaluated the relationship of tumor size and optimal extent of lymph node resection using the National Cancer Data Base (NCDB). MATERIALS AND METHODS: The incremental survival benefit of each additional lymph node that was evaluated for patients in the NCDB who underwent lobectomy for clinical Stage I NSCLC from 2003 to 2006 was evaluated using Cox multivariable proportional hazards regression modeling. The impact of tumor size was assessed by repeating the Cox analysis with patients stratified by tumor size ≥2 cm vs <2 cm. RESULTS: A median of 7 [interquartile range: 4,11] lymph nodes were examined in 13,827 patients who met study criteria. Following adjustment, the evaluation of each additional lymph node demonstrated a significant survival benefit through 11 lymph nodes. After grouping patients by tumor size, patients with tumors <2 cm demonstrated a significant survival benefit for the incremental resection of each additional lymph node through 4 lymph nodes while patients with tumors ≥2 cm had a significant survival benefit through 14 lymph nodes. CONCLUSION: Pathologic lymph node evaluation is associated with improved survival for clinically node-negative NSCLC, but the extent of the necessary evaluation varies by tumor size. These results have implications for guidelines for lymph node assessment as well as the choice of surgery vs other ablative techniques for clinical stage I NSCLC.

Activation of latent metastases in the lung after resection of a metastatic lymph node in a lymph node metastasis mouse model.

Iatrogenic induction of regional and distant cancer metastases is a risk associated with clinical resection of tumor-positive sentinel lymph nodes. However, there have been no studies of this risk in a mouse model of cancer metastasis. Here, we report that resection of a tumor-bearing subiliac lymph node (SiLN) enhanced lung metastasis in a mouse model of lymph node metastasis. Bioluminescence imaging revealed that metastatic tumor cells in the secondary lymph node continued to grow after resection of the SiLN, and that the probability of metastasis to the lungs was increased when the interval between SiLN inoculation and resection was reduced. Futhermore, histological analysis demonstrated that latents in the lung were stimulated to grow after resection of the SiLN. Fluorescence imaging indicated that the route of tumor cell dissemination from SiLN to the lung was the venous system located over the SiLN. We speculate that our mouse model will be useful for studying the mechanisms of tumor cell latency, with a view to improving the detection and treatment of latent metastases.

Diagnosis and surgical treatment of bilateral thyroid carcinoma / 中国普通外科杂志

0.05).Seventy patients were followed up from 3 months to 8 years post-operatively,with tumor-free survival in 67 cases,and cervical lymph nodes metastasis in 3 cases.No permanent hypo-parathyroidism or paralysis of recurrent laryngeal nerves occurred.Conclusions Total thyroidectomy is advised for bilateral thyroid carcinoma.It is necessary to emphasize the importance of resection of the central region lymph nodes.

The value of predicting the axillary lymph node(ALN) metastases status by sentinel lymph node biopsy(SLNB) with methylene blue subcantaneous injection in the breast cancer / 中国癌症杂志

Purpose:To explore the value of predicting the axillary lymph node(ALN) metastases statu s by sentinel lymph node biopsy(SLNB) with methylene blue subcantaneously inject ion in the breast cancer patient and to provide the scientific basis for selecti ve axillary lymph node dissection(ALND) in breast cancer.Methods :1% methylene blue 2ml was subcantaneously injected at 4 sites of the skin over the tumor in each of 64 patients with breast cancer. Most of these were staged as T 1-2 N 0M 0, and a few were T 3N 0M 0. All patients underwent a S LNB 5 minutes after injection, followed by various ways of radical operation. Pa thohistological examination was assessed in all of SLN which included a frozen s ection intra-operation and a paraffin section after operation, and all other no n-SLN had a paraffin section.Results:The successful detection rate of SLN was 85.9%(55/64), and the accuracy of predi cting ALN metastases was 96.4%(53/55). The sensitivity was 90.9%(20/22), the sp ecificity was 100%(33/33), and the false-negative rate was 9.1%(2/22). The pred ictive value of a positive test and of a negative test were respectively 100%(22 /22) and 94.3%(33/35). In the resected SLN and non-SLN the metastases rates wer e respectively 29.4% and 8.3%(? 2=41.493, P