LYMPHADENECTOMY IN SURGICAL ONCOLOGY: STAGING AND THERAPEUTIC ROLE

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1 LYMPHADENECTOMY IN SURGICAL ONCOLOGY: STAGING AND THERAPEUTIC ROLE Foreword Nicholas J. Petrelli xv Preface Vijay P. Khatri xvii Basic Overview Anatomy of the Lymphatics 1 John E. Skandalakis, Lee J. Skandalakis, and Panagiotis N. Skandalakis The lymphatic system is perhaps the most complicated system of Homo sapiens. An introduction to the anatomy, embryology, and anomalies of the lymphatics is presented. The overall anatomy and drainage of the lymphatic vessels in outlined. The topographic anatomy, relations, and variations of the principle vessels of the lymphatic system (the right lymphatic duct, the thoracic duct, and the cisterna chyli) are presented in detail. Pathological Evaluation of Sentinel Lymph Nodes 17 Gábor Cserni The sentinel lymph nodes are the most likely site of nodal metastasis. Their focused analysis results in upstaging cancers, although the extra yield from a more intensive work-up is generally dominated by micrometastases and isolated tumor cells. Nodal staging is generally done to reflect systemic spread of solid tumors and guide treatment accordingly. However, in general, the two processes of haematogenous and lymphogenic spread are not causally interrelated, and the extrapolation from low-volume nodal involvement to systemic involvement and therapeutic consequences of this extrapolation are still under investigation. VOLUME 16 Æ NUMBER 1 Æ JANUARY 2007 vii

2 Sentinel Node for Staging Sentinel Node Mapping for Melanoma: Results of Trials and Current Applications 35 John F. Thompson and Helen M. Shaw The value of sentinel node (SN) biopsy as a staging procedure and as a guide to prognosis with patients who have melanoma is now clearly established. As well, there is recent clinical trial evidence suggesting a survival benefit for patients found to be SN positive who have an immediate complete lymph node dissection (CLND), compared with those with nodal disease not treated by CLND until it becomes clinically apparent. Clinical trials are ongoing to determine whether CLND is necessary in all patients who are found to be SN positive. Sentinel Node Mapping for Breast Cancer: Progress to Date and Prospects for the Future 55 Helen Mabry and Armando E. Giuliano Sentinel node biopsy (SNB) is indicated for women with small invasive breast cancers and clinically negative nodes. SNB indications are being expanded to larger breast tumors, some cases of ductal carcinoma in situ and selected clinically suspicious nodes. Because SNB has fewer and less severe complications than axillary lymph node dissection, physicians are exploring more ways it can be used to improve breast cancer treatment. The future of SNB includes resolution of the optimal timing of SNB in relation to neoadjuvant chemotherapy and the results of NSABP B-32 and ACOSOG Z10 and Z11. SNB has become the new standard of care for the treatment of early breast cancer. Sentinel Node for Gastrointestinal Malignancies 71 Yuko Kitagawa, Sukamal Saha, Atsushi Kubo, and Masaki Kitajima Sentinel node (SN) concept is valid in gastrointestinal (GI) malignancies. The dual tracer method with radio-guided and dyeguided SN mapping is feasible in GI malignancies and is useful in detecting unexpected aberrant drainage routes from GI cancers. SN mapping enabled us to perform individualized and step-wise lymphadenectomy in patients with GI cancer. A combination of SN mapping and endoscopic surgery will contribute to the improvement in quality of life after surgical treatment of GI cancer. viii

3 Head and Neck Squamous Cell Carcinoma: Sentinel Node or Selective Neck Dissection 81 Adorján F. Kovács Improved knowledge about the metastatic behavior of mucosal squamous cell cancer of the head and neck made it possible to reduce the extension of elective and even therapeutic neck dissections by sparing selected levels, thereby reducing morbidity. The diagnostic question of when to treat a clinically negative neck to avoid unnecessary overtreatment, even through selective neck dissections, might be answered with sentinel lymph node biopsy. A thorough and sophisticated evaluation of this technique is necessary when defining suited patients. Safe Introduction of New Procedures and Emerging Technologies in Surgery: Education, Credentialing, and Privileging 101 Ajit K. Sachdeva and Thomas R. Russell Ongoing horizon scanning is needed to identify new procedures and emerging technologies that should be evaluated for introduction into surgical practice. Following evidence-based evaluation, if a new modality is found ready for adoption in practice, surgeons need education in the safe and effective use of the new modality. The educational experience should include structured teaching and learning, verification of new knowledge and skills, preceptoring or proctoring, and monitoring of outcomes. Credentialing and privileging to perform a new procedure or use an emerging technology should be based on evaluation of knowledge and skills and outcomes of surgical care, and not merely on the numbers of procedures performed. Education of the entire surgical team is also essential. The entire process involving education, verification of knowledge and skills, credentialing, and privileging must be transparent. Patients need to play a central role in making informed decisions regarding their care that involves use of a new procedure or an emerging technology, and they should participate actively in their perioperative care. Therapeutic Lymph Node Dissection Lymph Node Dissection in Surgical Treatment of Esophageal Neoplasms 115 Simon Law and John Wong The optimal lymphadenectomy for esophageal cancer remains controversial. The choice of surgical access determines to a great extent the type of lymphadenectomy possible. En bloc resections and ix

4 three-field lymphadenectomy are concepts pioneered in the West and East, respectively; both should be performed in specialized centers because such extended lymph node dissection has substantial morbidity rates. Recent focus in research is on refining the indications for these procedures. Patient management strategies should be individualized. Gastric Cancer: D2 Dissection or Low Maruyama Index-Based Surgery a Debate 133 Harold O. Douglass, Jr, Scott A. Hundahl, John S. Macdonald, and Vijay P. Khatri This article provides perspectives on the surgical approaches required optimally to manage patients with respectable gastric adenocarcinoma. The status of techniques of surgical resection in the management of gastric cancer is reviewed. The premise of this approach is that extended gastrectomy with D2 lymph node dissection is good. Also addressed are prognostic and predictive factors in the surgical treatment of stomach cancer. Pancreaticoduodenectomy with Extended Retroperitoneal Lymphadenectomy for Periampullary Adenocarcinoma 157 Eugene P. Kennedy and Charles J. Yeo Surgical resection provides the only chance for long-term survival for patients diagnosed with pancreatic and other associated periampullary adenocarcinomas. In the past, it had been suggested that the performance of an extended lymphadenectomy in association with a pancreaticoduodenal resection might have improved long-term survival for some patients. In response, six prospective trials have been performed and reported addressing this issue. These studies, including a large randomized trial of 280 patients from Johns Hopkins University, indicate that there is no demonstrable survival benefit to extended lymphadenectomy for periampullary cancer. Total Mesorectal Excision and Pelvic Node Dissection for Rectal Cancer: An Appraisal 177 Melinda M. Mortenson, Vijay P. Khatri, Joseph J. Bennett, and Nicholas J. Petrelli Total mesorectal excision has revolutionized the surgical treatment of rectal cancer since its introduction in the 1980s. The rationale, technique, and outcomes of total mesorectal excision in rectal cancer are explored. Lateral pelvic lymph node dissection is used by the Japanese in selected patients and has remained a controversial approach in the management of rectal cancer. The technique, controversies, and outcomes are summarized. x

5 Retroperitoneal Lymph Node Dissection in Testicular Cancer 199 Niels-Erik B. Jacobsen, Richard S. Foster, and John P. Donohue With long-term survival in excess of 90 across all stages, testicular cancer has come to represent the model for successful multidisciplinary cancer care. Retroperitoneal lymph node dissection (RPLND) remains an integral component of testis cancer management strategies for both early- and advanced-stage disease. Commensurate with improvements made in clinical staging and in our understanding of the natural history of testis cancer, lymphatic spread, and neuroanatomy, considerable modifications in the technique and template of RPLND have taken place. The morbidity of primary RPLND and postchemotherapy RPLND is low when performed by experienced surgeons. This article reviews the evolution, role, and technique of RPLND in contemporary practice. Radical Lymph Node Dissection for Gallbladder Cancer: Indications and Limitations 221 Yoshio Shirai, Toshifumi Wakai, and Katsuyoshi Hatakeyama Radical lymph node dissection provides survival benefit for patients with pt2 or more advanced gallbladder carcinoma tumors only if potentially curative resection is feasible; it must always be considered when planning a resection or re-resection for robust patients with pt2 or more advanced gallbladder carcinoma tumors. The degree of radical lymphadenectomy depends on clinically assessed nodal status: portal lymph node dissection is limited to cn0 disease; extended portal nodal dissection is indicated for cn0 and a modest degree of cn1 disease; peripancreatic lymph node dissection with pancreaticoduodenectomy is indicated for selected cases of evident peripancreatic nodal disease and/or direct organ involvement. Extended resection with extensive lymphadenectomy should be limited to expert surgeons because it may cause serious morbidity and mortality. Radical Cystectomy with an Extended Pelvic Lymphadenectomy: Rationale and Results 233 Robert D. Mills, Achim Fleischmann, and Urs E. Studer Lymphadenectomy at the time of cystectomy for muscle invasive bladder cancer offers, at worst, staging and prognostic information, and, at best, improved survival or cure. This article assesses both the evidence to support performing a lymphadenectomy at the time of cystectomy and the extent of lymphadenectomy that should be performed. The minimum lymph node dissection that should be performed at the time of cystectomy for muscle invasive bladder cancer should include meticulous removal of all tissue in the internal iliac, external iliac, and obturator areas, extending to include the xi

6 distal common iliac nodes and nodes medial to the internal iliac vessels. Whether more extensive dissections than this improve survival is not yet clear. Regional Node Dissection for Melanoma: Techniques and Indication 247 James W. Jakub, Douglas S. Reintgen, Steven Shivers, and Solange Pendas Because virtually all microscopic nodal disease left untreated in melanoma patients will progress to clinically apparent macroscopic nodal disease, there is worse prognosis with macroscopic nodal disease, and ineffective systemic treatment currently exists, one must be cautious in favoring an observation approach to the regional basin in patients with a positive sentinel lymph node (SLN) in the hopes of avoiding the potential morbidity of a therapeutic node dissection. In the few patients with untreated microscopic nodal disease, the prognosis will be significantly worsened. Until further data are available, melanoma patients with a positive SLN by H&E analysis should proceed to a complete lymph node dissection. Index 263 xii