Accurate Surgical Staging Research Articles

Feasibility and Diagnostic Accuracy of Ultrastaging in the Detection of Micrometastases in Sentinel and Non-sentinel Lymph Nodes in Cervical Cancer: A Single-Center Retrospective Study With a Five-Year Follow-Up Period.

Cervical cancer is the fourth most common cause of malignant tumor-related deaths among women in developing nations. Cervical cancer has been estimated to cause 527.600 new cases and 265.700 deaths globally per year. This study aimed to evaluate patients with cervical cancer by ultrastaging all the lymph nodes (LN), sentinel LN (SLN) and non-SLN, to increase the sensitivity of the detection of LN metastases and the diagnostic accuracy in cervical cancer with a five-year follow-up. Thisis a retrospective study of 14 cervical cancer cases from 2017 to 2019 at the Municipal Emergency Clinical Hospital of Timisoara, Romania. The cases were selected based on their high risk of LN involvement but negative intraoperative pathologic LN. After re-evaluating all paraffin block biopsy samples from 29 cases, 14 cases were included in the study, which met all criteria for ultrastaging on surgical biopsy samples. Patients' ages included in the study ranged from 43 to 70 years (median: 57.14 years). According to the International Federation of Gynecology and Obstetrics (FIGO) staging, the majority of the patients were in stage IB: seven cases (50%). The study revealed a positive correlation between patient age and FIGO staging, with Pearson's correlation coefficient of 0.707 and a p-value of less than 0.05, indicating that older patients were more likely to be diagnosed with a higher FIGO stage. The mean follow-up was 34.5 months, and the median follow-up was 36 months (range: 6-60 months). We obtained 167 nodes, with a mean of 11.92 nodes/case. Twenty-one LN were found to be positive with the ultrastaging method. We detected 11 LN with macrometastases (MAC) (52.38%), seven with micrometastasis (MIC) (33.3%), and three with tumor cell islets (14.4%). That would be 13% of newly diagnosed ultrastaging cases as positive nodes.This ultrastaging method detected nodal MIC in eight (57.1%) out of the 14 patients, who initially tested negative for LN involvement using the routine Hematoxylin and Eosin (HE) method. The detection of micrometastases in these patients underscored the superior sensitivity of ultrastaging, which was further highlighted by the subsequent relapse of four (28.57%) out of these eight patients. The study also found no correlation between the FIGO standardization and the number of MIC found in these patients. Predicting cervical LN metastasis (LNM) is crucial for improving survival rates and reducing recurrence. Very few small cohort studies used an ultrastaging method to assess non-SLNs; most of them only assessed SLNs. We showed in our study that the ultrastaging method, both in the case of SLN and non-SLN, is superior compared with H&E analysis, with a 13% rate of new positive nodule diagnosis. Metastatic involvement of non-SLN was found in over 50% of all cases (8/14) according to the ultrastaging method. Additionally, our study confirms that the sensitivity of SLN ultrastaging is high for the presence of both MIC and MAC in SLN pelvic LN. As a result, we feel that ultrastaging is the most effective method for SLN analysis in patients with early-stage cervical cancer, and bilateral detection is preferable, significantly reducing false-negative results. The routine use of SLN along with ultrastaging would lead to more accurate surgical staging and better oncological follow-up of cases.

Critical elements of radical nephroureterectomy for pediatric unilateral renal tumor

Children with renal masses require surgical management to provide accurate surgical staging and skilled resection of the tumor. This document includes evidence-based recommendations for pediatric surgeons regarding the resection, staging, and proper nodal basin evaluation.

NIR-II Fluorescence Imaging for the Detection and Resection of Cancerous Foci and Lymph Nodes in Early-Stage Orthotopic and Advanced-Stage Metastatic Ovarian Cancer Models.

The high mortality rate of ovarian cancer can be primarily attributed to late diagnosis and early lymph node (LN) metastasis. The anatomically deep-located ovaries own intricate anatomical structures and lymphatic drainages that compromise the resolution and sensitivity of near-infrared first-window (NIR-I) fluorescence imaging. Reported NIR-II imaging studies of ovarian cancer focused on late-stage metastasis detection via the intraperitoneal xenograft model. However, given the significant improvement in patient survival associated with early-stage cancer detection, locating tumors that are restricted within the ovary is equally crucial. We obtained the polymer nanoparticles with bright near-infrared-II fluorescence (NIR-II NPs) by nanoprecipitation of DSPE-PEG, one of the ingredients of FDA-approved nanoparticle products, and benzobisthiadiazole, an organic NIR-II dye. The one-step synthesis and safe component lay the groundwork for its clinical translation. Benefiting from the NIR-II emission (∼1060 nm), NIR-II NPs enabled a high signal-to-noise (S/N) ratio (13.4) visualization of early-stage orthotopic ovarian tumors with NIR-II fluorescence imaging for the first time. Imaging with orthotopic xenograft allows a more accurate mimic of human ovarian cancer origin, thereby addressing the dilemma of translating existing nanoprobe preclinical research by providing the nano-bio interactions with early local tumor environments. After PEGylation, the desirable-sized probe (∼80 nm) exhibited high lymphophilicity and relatively extended circulation. NIR-II NPs maintained their accurate detection of orthotopic tumors, tumor-regional LNs, and minuscule (<1 mm) disseminated peritoneal metastases simultaneously (with S/N ratios all above 5) in mice with advanced-stage cancer in real time ∼36 h after systematic delivery. With NIR-II fluorescence guidance, we achieved accurate surgical staging in tumor-bearing mice and complete tumor removal comparable to clinical practice, which provides preclinical data for translating NIR-II fluorescence image-guided surgery.

A Comparative Study of Transvaginal Sonography and Pelvic MRI in Patients with Endometrial Cancer

Background: The most prevalent type of gynecological cancer is endometrial cancer. Accurate surgical staging is the most important aspect in the management of endometrial cancer. Preoperative evaluation of myometrial invasion and appropriate management could be achieved by transvaginal sonography and pelvic MRI. Methods: A total of 53 patients with endometrial cancer, who were referred to a gynecology oncology department of an academic hospital in Mashhad University of Medical Sciences from 2018 to 2020, were evaluated in this study. Data were collected using a questionnaire on endometrial cancer. All the patients underwent preoperative transvaginal sonography and pelvic MRI to evaluate myometrial invasion. The involvement of myometrium thickness and histological findings were compared between two imaging modalities, and SPSS 23.0 was used to analyze the data. Results: Junctional irregularity was the most prevalent finding on transvaginal sonography. Based on transvaginal sonography, myometrial invasion of less than 50% was found in 73% of patients, while invasion of more than 50% was observed in 26.31%. In 57.44% of MRIs, there was less than 50% myometrial invasion, while in 42.55% of MRIs, there was more than 50% myometrial invasion. In both modalities, the most common finding was myometrial invasion of less than 50%. The accuracy, sensitivity, and specificity of transvaginal sonography were 0.47, 0.27, and 0.75, respectively, whereas the accuracy, sensitivity, and specificity of MRI were 0.54, 0.45, and 0.61, respectively. Conclusion: MRI can be the modality of choice for evaluating myometrial invasion and optimizing endometrial cancer treatment planning, as well as reducing the complications of non-indicated lymphadenectomy.

Feasibility of Sentinel Lymph Node Sampling in Early-Stage Carcinoma Endometrium: Single-Institution Experience.

Accurate surgical staging is an essential component in the management of carcinoma endometrium to assess the stage of disease and to tailor adjuvant treatment. Sentinel node technique was introduced as an alternative for extensive lymphadenectomy in early stages to avoid complications associated with lymphadenectomy. To assess the detection rate and diagnostic accuracy of SLN mapping in patients with early-stage carcinoma endometrium. Prospective validation study involving 30 patients diagnosed to have early-stage carcinoma endometrium. Sentinel nodes were detected by combined methods of radio colloid dye and isosulphan blue dye injection. Sentinel lymph node was detected in 19 patients (63.4%). 11 patients had no sentinel nodes. Total number of sentinel nodes isolated was 68 with a mean of 2.26 per patient (range 0-4). Ten (33.33%) patients had single sentinel node location, while 9 (30%) had more than 1 sentinel lymph nodes. Twelve patients had bilateral sentinel nodes, and the most frequent location of sentinel node was obturator, 19 (63.3%) especially on right hemi-pelvis. One patient had a hot para-aortic node, while none had blue para-aortic sentinel node. Average number of lymph nodes obtained by lymphadenectomy was 13 per patient (range 7-22). All patients with sentinel node had negative frozen report as well as in histopathology. Two patients in whom no sentinel nodes were detected by either techniques had metastatic nodes in histopathology report. Detection rate was maximum with radiocolloid dye, and it is better to utilize the technique for less graded tumours and endometrioid variants.

Spectrum of ovarian tumors in a tertiary care hospital

Ovarian tumors are heterogeneous group of neoplasms with wide range of histopathological patterns. It is one of the leading causes of mortality in females. Often difficult to detect until they are advanced in stage or increased in size as symptoms are vague and insidious. Treatment and prognosis is based upon accurate surgical staging and thorough pathological evaluation. A total 150 cases were studied from June 2014 to May 2017. Their age, clinical presentation and histopathological findings were reviewed and analyzed. Out of 150 cases of ovarian tumors studied 119(79.3%) were benign, 9 (6.0%) borderline and 22 (14.6%) malignant. Age ranged from 9 to 80 years. The commonest presenting complaint in malignant and benign cases was pain in abdomen and in borderline cases abdominal distension. CA125, CEA and LDH were most commonly raised in 53.8%, 23% and 100% malignant cases respectively. Surface epithelial tumors were 68% followed by germ cell tumors 28% and sex cord stromal tumors 4%.

Pelvic Lymphadenectomy and Pelvic and Para-Aortic Lymphadenectomy Versus No Lymphadenectomy for Endometrial Cancer

Background: Although lymphadenectomy is advised for accurate surgical endometrial-carcinoma staging, the procedure is not performed regularly worldwide. Most studies on it include few patients and mainly compare pelvic with pelvic/para-aortic lymphadenectomy. Comparing lymphadenectomy with non-lymphadenectomy is rare. The current study examined prognostic significance and survival advantages of pelvic and pelvic/para-aortic lymphadenectomy compared to no lymphadenectomy. Materials and Methods: This was a retrospective cohort analysis of 75 patients with endometrial carcinomas. The patients were divided into 3 treatment groups based on whether or not lymph-node dissection was performed and the extent of the dissections: (1) pelvic lymphadenectomy; (2) pelvic/para-aortic lymphadenectomy; and (3) no lymphadenectomy. Correlations were analyzed among the surgical techniques used for the 3 groups with respect to the need for adjuvant radiotherapy or chemotherapy, recurrences, and survival outcomes. Results: Pelvic and pelvic/para-aortic lymphadenectomy produced more-favorable overall survival (OS) and progression-free survival (PFS) rates than no lymphadenectomy (p = 0.047). A significant difference was noted among the 3 treatment groups for OS rate and disease-free survival rates (p = 0.015 and 0.017, respectively). The recurrence rates were 47.1%, 35.7%, and 68.8% in the pelvic lymphadenectomy, and pelvic/para-aortic lymphadenectomy, and no lymphadenectomy groups, respectively (p = 0.037). Conclusions: This study showed that pelvic and para-aortic lymphadenectomy improved the OS and PFS rates of patients with endometrial cancer.

Abstract OT3-01-01: Feasibility of carbon tattooing for targeted lymph node biopsy in breast cancer patients treated by primary systemic therapy (TATTOO trial)

Abstract Background: Selective removal of initially suspicious axillary lymph nodes in breast cancer patients downstaged by primary systemic therapy (PST) improves the accuracy of surgical staging and provides the opportunity for less extensive axillary surgery. Different techniques for this targeted lymph node biopsy (TLNB) have been evaluated. These are either prohibited for radiation safety reasons (radioactive seeds) in some countries, or revealed low identification rates for the target lymph node (TLN) in prospective feasibility trials (wire localization of clip-marked TLN). Therefore, an alternative TLN marking procedure avoiding radiation exposure, specialized intraoperative equipment, high costs and preoperative localization procedures is urgently needed. Tattooing TLNs with highly purified carbon suspension prior to PST and identifying the TLN intraoperatively by visual examination, is a method combining low costs with high patient comfort. Because of the data scarcity on the feasibility of TLNB by carbon tattooing, the TATTOO trial was initiated. Trial design: The Tattoo trial is a single-arm, multicentric, prospective feasibility trial. Before initiation of PST, ultrasound-guided fine needle aspiration or core needle biopsy of the most suspicious ipsilateral axillary lymph node (TLN) is performed and a highly purified carbon suspension then injected into the cortex of the sampled lymph node and the adjacent soft tissue. After completion of PST, TLNB and axillary lymph node dissection Level I/II is performed in all patients. In those with clinical and sonographical axillary down-staging, sentinel lymph node (SLN) biopsy is additionally performed. Eligibility criteria: Prior to tattooing, written informed consent is obtained. Female patients aged at least 18 years, with histologically confirmed invasive uni- or bilateral breast cancer with clinically or sonographically suspicious axillary lymph nodes and planned PST without signs of distant metastases are eligible. Specific aims: The primary outcome of the trial is the intraoperative identification rate (IR) of the carbon-labeled TLN after PST. Secondary outcomes are the concordance rate (CR) of sentinel lymph nodes (SLN) and TLN, the false negative rate (FNR) of targeted axillary dissection (TAD, i.e. SLNB biopsy + TLNB) and complications associated with the procedure. Statistical methods: IR is defined as the proportion of patients with intraoperatively visually detectable TLNs of all patients. CR is expressed as the proportion of patients in whom TLNB and SLN biopsy reveal the same lymph nodes. The proportion of patients with negative TLN and/or SLN but with metastatic axillary lymph nodes on ALND out of all patients with positive lymph nodes will be reported as FNR. Complications associated with tattooing (i.e. bleeding, pain, adverse tattoo effects) are reported. Statistical analyses will be carried out using IBM SPSS statistics version 25. Present and target accrual: Patient accrual was initiated in November 2017. Until now, 84 patients have been included by three sites in Germany and Sweden. The target enrollment of 100 patients is estimated to be reached by August 2019 and the final trial report is planned for 2020. Contact information Steffi Hartmann, MD (steffi.hartmann@kliniksued-rostock.de) Citation Format: Steffi Hartmann, Angrit Stachs, Thorsten Kühn, Antje Winckelmann, Jana de Boniface, Bernd Gerber, Toralf Reimer. Feasibility of carbon tattooing for targeted lymph node biopsy in breast cancer patients treated by primary systemic therapy (TATTOO trial) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr OT3-01-01.

Pelvic Lymphadenectomy, and Pelvic and Para-Aortic Lymphadenectomy Versus No Lymphadenectomy for Endometrial Cancer

Background: Although lymphadenectomy is advised for accurate surgical endometrial-carcinoma staging, the procedure is not performed regularly worldwide. Most studies on it include few patients and ...

Para-aortic lymphadenectomy in advanced stage cervical cancer, a protocol for comparing safety, feasibility and diagnostic accuracy of surgical staging versus PET-CT; PALDISC trial

BackgroundCurrently, a PET-CT is used to assess the need for extended field radiotherapy of para-aortic lymph nodes (PALN) in International Federation of Gynaecology and Obstetrics (FIGO) stage IB2, IIA2–IVA (locally advanced stage) cervical cancer. A small study established a sensitivity and specificity estimate for PALN metastases of 50% (95% CI; 7–93%) and 83% (95% CI; 52–98%), respectively. Surgical staging of PALN may lead to a higher diagnostic accuracy. However, surgical staging of para-aortic lymph nodes in locally advanced stage cervical cancer is not common practice. Therefore, a phase 2 randomised controlled trial is needed to assess its safety and feasibility.Methods/designIn addition to standard imaging (MRI or CT scan) with PET-CT, 30 adult women with FIGO stage IB2, IIA2–IVA cervical cancer will be randomised to receive either surgical staging or usual PET-CT staging. Administering extended field radiotherapy will be based on lymphadenectomy results for the intervention group and on the PET-CT results for the control group. Follow-up visits at 0, 3, 6, 9 and 12 months will assess health-related quality of life and progression-free survival.Primary safety and feasibility outcomes of surgical staging will be assessed by calculating means with 95% confidence intervals for duration of surgery, number of complications, blood loss, nodal yield after para-aortic lymphadenectomy and treatment delay due to surgical staging. Secondary patient-centred outcomes on quality of life and first year survival will be documented and compared between the two groups. Estimates of sensitivity, specificity and negative and positive predictive values of MRI, PET-CT and surgical staging will be presented with 95% CI.. All analysis will be performed according to the intention to treat principle.DiscussionThis study will assess safety and feasibility, expressed as the number and severity of complications, effect on quality of life and the treatment delay due to surgically staging para-aortic lymph nodes in locally advanced cervical cancer. It will provide insight in the diagnostic accuracy of the PET-CT and detection rate of missed (micro)metastases due to surgical staging. This information will be used to assess the necessity for a phase 3 study on the diagnostic accuracy of the PET-CT and surgical staging. If a phase 3 study is deemed necessary, current data can be used for sample size calculation of such a phase 3 study.Trial registrationNederlands Trial Register/Dutch Trial Registry (www.trialregister.nl), NTR4922. Registered on 24 November 2014.

Performance of sentinel lymph node (SLN) mapping in high-risk endometrial cancer.

While the accuracy of the SLN procedure has been validated in patients with low risk EC, its relevance for high-risk EC remains debated. The aim of this study was to evaluate the accuracy of SLN mapping in patients with high-risk EC. We reviewed all patients with high risk EC (grade 3 endometrioid, serous, carcinosarcoma, clear cell and undifferentiated) who underwent primary surgery with SLN mapping followed by pelvic +/- paraaortic lymphadenectomy, between November 2010 and November 2016. Among 128 patients who underwent SLN mapping followed by a pelvic lymph node dissection, 41 (32%) had a positive pelvic lymph node. Overall, 48.8% of patients underwent paraaortic node sampling (62/128). Paraaortic lymph node metastasis was identified in 17.7% of patients in whom a para-aortic lymph node dissection was performed (11/62), and all had positive pelvic lymph nodes as well. Successful SLN mapping occurred in 115/128 (89,8%) patients, with a bilateral detection rate at 63.2% (81/128). Positive SLNs were identified in 30.4% of patients (39/128) including 7 isolated tumor cells (ITC), 4 micrometastasis and 28 macrometastasis. When the SLNs were detected bilaterally, only one false negative case occurred, providing a sensitivity and negative predictive value of 95.8% and 98.2% respectively. Accurate surgical staging is an important prognostic predictor of survival in patients with endometrial cancer. Given the high sensitivity and high negative predictive value found in our study, we believe that the use of SLN mapping appears to be an appropriate staging procedure in high-risk endometrial cancer.

Techniques of video-assisted thoracoscopic surgery lobectomy and critical review of published data.

Lung cancer resection techniques have gone through many changes and adaptations. Traditional thoracotomy provided sufficient visualization to fully resect the lobe as well as adequate lymph node dissection. Many thought that this allowed for the most accurate surgical staging of a lung cancer, but subjected the patient to longer hospital stays and increased morbidity and mortality. As with many major surgical operations there has been a culture shift toward minimally invasive techniques, but the adoption has been slow. We present the technique of video-assisted thoracoscopic surgery lobectomy and the literature supporting its use in the treatment of early-stage lung cancer.

Granulosa Cell Tumor of the Ovary in a Benign-looking Adnexal Mass: A Rare Occurrence and its Management

Introduction Granulosa cell tumors (GCT) are rare tumors which account for 1–2 % of all ovarian malignancies and juvenile type of GCT affecting young women are even rarer comprising only 5 % of all GCT’S. Laparoscopy despite increasingly being adopted for the management of all gynecological diseases, still has a controversial role in surgical staging and management of early stage ovarian cancer, major concerns being accuracy of surgical staging, tumor spillage and port site metastasis.

Pelvic sentinel lymph node status and risk of aortic nodal metastasis in patients with endometrial cancer.

5597 Background: Pelvic sentinel lymph node (SLN) mapping is hypothesized to improve the accuracy of surgical staging. The clinical relevance of isolated tumor cell (ITC) metastasis compared to H&E...

Sentinel Lymph Node Mapping for Endometrial Cancer: A Modern Approach to Surgical Staging

Most patients with endometrial cancer will present with early-stage disease. Although the rate of metastasis in these patients is low, proffering excellent prognoses, the standard of treatment in many practices still includes a complete or selective pelvic and para-aortic lymphadenectomy for staging; and accurate surgical staging is the most important prognostic factor. Many patients will undergo a comprehensive lymphadenectomy despite having disease confined to the uterus, resulting in prolonged operating time, additional cost, and potential side effects, such as lower extremity lymphedema. However, recent studies show that a complete lymphadenectomy may have no therapeutic benefit in patients with early-stage endometrial cancer. Sentinel lymph node (SLN) mapping, which has been used in other cancer types, may be an acceptable surgical strategy between a complete lymphadenectomy and no nodal evaluation in patients with endometrial cancer. SLN mapping is based on the concept that lymph node metastasis is the result of an orderly process; that is, lymph drains in a specific pattern away from the tumor, and therefore, if the SLN, or first node, is negative for metastasis, then the nodes after the SLN should also be negative. This approach can help patients avoid the side effects associated with a complete lymphadenectomy, although disease must be thoroughly staged for accurate prognosis and determination of appropriate treatment approach. Surgeon experience, adherence to an SLN algorithm, and the use of pathologic "ultrastaging" are key factors for successful SLN mapping.

Ovarian cancer biomarkers as diagnostic triage tests

Correspondence: Sara Jordan Division of Gynecologic Oncology, UC Irvine Medical Center, 101 The City Drive, Building 56, Room 260, Orange, CA 92868, USA Tel +1 714 456 8020 Fax +1 714 456 6622 Email sara.jordan@uci.edu Abstract: Ovarian cancer survival improves with accurate surgical staging, maximal tumor removal, and appropriate adjuvant chemotherapy. Therefore, survival is higher among patients managed by a gynecologic oncologist trained in these surgical techniques. Unfortunately, identifying patients preoperatively for referral to a gynecologic oncologist is often challenging, given that there are no definitive noninvasive diagnostic tests to triage patients with an adnexal mass to a surgical subspecialist. Inaccurate preoperative diagnosis of an adnexal mass frequently results in either unnecessary surgery for a benign mass or inadequate surgical staging for a malignant mass, with a subsequent negative effect on overall survival. Several recent tests have been investigated to improve the preoperative diagnosis of women presenting with adnexal masses. Cancer antigen 125 is the most commonly used serum marker for screening and monitoring of ovarian cancer, but is elevated in many benign conditions and falsely normal in 50% of early-stage epithelial ovarian cancers. The relatively low sensitivity and specificity of CA125 has driven researchers to identify new biomarkers and algorithms to assist with triaging adnexal masses. A promising new biomarker, human epididymis protein 4, has been developed to monitor for recurrence of ovarian cancer. Three algorithms have also been developed, ie, risk of malignancy index, risk of ovarian malignancy algorithm, and OVA-1, which is the first diagnostic algorithm that combines multiple biomarkers for the purpose of triaging adnexal masses to be approved by the US Food and Drug Administration.

Clinical impact of systematic pelvic and para-aortic lymphadenectomy for pT1 and pT2 ovarian cancer: a retrospective survey by the Sankai Gynecology Study Group

The therapeutic value of systematic lymphadenectomy for early-stage epithelial ovarian cancer (EOC) is controversial. This study evaluates the survival impact and adverse events of systematic pelvic and para-aortic lymphadenectomy in patients with pT1 and pT2 EOC. A retrospective investigation was performed using data from patients with pT1 and pT2 EOC at multi-institutions belonging to the Sankai Gynecologic Study Group (SGSG). We selected patients who had undergone systematic pelvic and para-aortic lymphadenectomy (Group LA) (n=284) and patients who had not undergone lymph node resection (Group no-LA) (n=138). Outcomes for patients and peri-operative adverse events were compared between the two groups. The median operation time was significantly longer in Group LA (288min) than in Group no-LA (128min) (P<0.0001). Total blood loss was significantly higher in Group LA, 43.7% of patients receiving blood transfusions. There were no significant differences between the treatment groups for progression-free survival (PFS) or overall survival (OS). However, for patients with pT2, PFS was significantly longer in Group LA than in Group no-LA (P=0.0150). Lymph node metastases were detected in 23 cases (8.1%) and these patients had significantly shorter PFS than those without metastasis (P=0.0409). The outcome for patients who underwent chemotherapy after surgery was significantly improved in the Group no-LA, but no improvement was observed in Group LA. Systematic lymphadenectomy may improve outcomes only in pT2 EOC patients with acceptable peri-operative events. Furthermore, accurate surgical staging may avoid unnecessary adjuvant chemotherapy in selected early-stage cases.

Should be para-aortic lymphadenectomy up to the level of the renal vein mandatory in ovarian cancer patients presenting ovarian cancer presumed to be confined to the ovary?

Original Article pISSN 2005-0380 eISSN 2005-0399 J Gynecol Oncol Vol. 24, No. 1:29-36 http://dx.doi.org/10.3802/jgo.2013.24.1.29 Analysis of para-aortic lymphadenectomy up to the level of the renal vessels in apparent early-stage ovarian cancer Suk-Joon Chang 1 , Robert E. Bristow 2 , Hee-Sug Ryu 1 Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea; 2 Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine School of Medicine, Orange, CA, USA Objective: The aim of this study was to evaluate the impact of para-aortic lymphadenectomy up to the renal vessels on the accurate staging in ovarian cancer patients presumed preoperatively to be confined to the ovary. Methods: We retrospectively analyzed data on 124 patients with primary epithelial ovarian cancer who were preoperatively thought to have tumor confined to the ovary and underwent primary staging surgery. The distribution of lymph node meta­ stasis and various risk factors for nodal involvement were investigated. Results: Surgical staging yielded: 87 (70.2%) patients had International Federation of Gynecology and Obstetrics (FIGO) stage I disease and 37 (29.8%) patients had stage II-III disease: 4 IIA, 6 IIB, 9 IIC, 1 IIIA, and 17 IIIC. Eighty-six patients had pelvic lymphadenectomy only and 69 had pelvic and para-aortic lymphadenectomy. Lymph node metastases were found in 17 (24.6%) of 69 patients; 5 (7.2%) patients had lymph node metastasis in the pelvic lymph nodes only, 8 (11.6%) in the para-aortic lymph nodes only, and 4 (5.8%) in both pelvic and para-aortic lymph nodes. Six (8.7%) patients had lymph node metastasis in the para- aortic lymph node above the level of the inferior mesenteric artery. On multivariate analysis, grade 3 tumor (p=0.01) and positive cytology (p=0.03) were independent predictors for lymph node metastasis. Conclusion: A substantial number of patients with apparently early ovarian cancer had upstaged disease. Of patients who underwent lymphadenectomy, some patients had lymph node metastasis above the level of the inferior mesenteric artery. Para- aortic lymphadenectomy up to the renal vessels may detect occult metastasis and be of help in tailoring appropriate adjuvant treatment as well as giving useful information about the prognosis. Keywords: Early-stage ovarian cancer, Lymph node metastasis, Para-aortic lymphadenectomy INTRODUCTION Ovarian cancer remains one of the major causes of death from the female genital tract malignancy worldwide, and in Received May 23, 2012, Revised Jun 3, 2012, Accepted Jun 5, 2012 Correspondence to Suk-Joon Chang Department of Obstetrics and Gynecology, Ajou University School of Medicine, 206 World cup-ro, Yeongtong-gu, Suwon 443-721, Korea. Tel: +82-31-219-5251, Fax: +82-31-219-5245, E-mail: drchang@ajou.ac.kr Correspondence to Robert E. Bristow Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine School of Medicine, 101 The City Drive, Building 56, Room 260, Orange, CA 92868, USA. Tel: +1-714-456-8000, Fax: +1-714-456- 7754, E-mail: rbristow@uci.edu the United States, 21,990 new cases and 15,460 deaths were estimated in 2011 [1]. Approximately 25% of ovarian cancer patients are diagnosed with early-stage disease at the time of initial treatment [2]. Surgical staging is a critical aspect of early ovarian cancer as well as advanced ovarian cancer because the International Federation of Gynecology and Obstetrics (FIGO) staging based on surgical and pathologic findings is one of the most important prognostic factors [3]. Accurate surgical staging for early-stage ovarian cancer patients has great significance, permitting accurate estimation of the true extent of disease with detection of occult disease, and providing patients with appropriate information about the prognosis and adjuvant treatment. Up to 30% of patients with apparent early-stage ovarian cancer are found to have extra- Copyright © 2013. Asian Society of Gynecologic Oncology, Korean Society of Gynecologic Oncology This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.ejgo.org

Pediatric germ cell tumors

Pediatric germ cell tumors represent a diverse group of tumors that present from in utero through adolescence at many nongonadal locations, from the neck to the sacrococcygeal region. Surgical resection remains the central element of management, and accurate surgical staging is essential to properly ascertain the correct risk-based treatment. The management for all benign tumors (mature and immature teratomas) and select completely resectable malignant tumors is surgery alone. Modern-day chemotherapy is extremely effective in infants and children with unresectable and metastatic disease and these children have a very high survival rate. The use of neoadjuvant chemotherapy allows vital organ preservation and there is no role for resection of vital structures at the time of initial presentation.

A Retrospective Review of the Effect of Surgeon Specialty on the Management of 190 Benign and Malignant Pediatric and Adolescent Adnexal Masses

Study Objective To investigate the impact of operating surgeon specialty on rates of ovarian preservation, and to explore differences in surgical management when malignant lesions are identified. Design Retrospective study. Setting Education and research hospitals. Participants Between January 1, 2003 and January 1, 2009, all female patients ≤ 20 years of age undergoing surgery with pathologically confirmed ovarian or fallopian tube tissues removed were evaluated. Interventions Demographic, operative, and pathologic data were abstracted. Main Outcome Measures Rates of ovarian preservation with benign lesions, and rates of appropriate surgical staging when malignant lesions were identified. Results The mean age was 11.9 ± 4.4 years. Malignant lesions were larger than benign masses, 17.3 ± 7.1 cm versus 8.8 ± 7.1 cm respectively ( P < .001). Torsion was associated with oophorectomy with a relative risk (RR) of 1.86 and 95% confidence interval (CI) of 1.35-2.57 ( P = 0.033). Postmenarchal patients were less likely to undergo ovarian sacrificing procedures (RR 0.62, 95% CI 0.45-0.84, P < .001). The relative risk of incomplete surgical staging with malignant lesions was reduced in the presence of a gynecologic oncologist (RR 0.14, 95% CI 0.02-0.89, P = .003). Conclusion Ovarian conservation should be prioritized in cases with benign lesions, whereas complete and accurate surgical staging is imperative when malignancy is identified.