Aortic Lymphadenectomy Research Articles

Lymph-vascular Space Involvement and/or p53 Overexpression Correlated With the Clinical Outcome of Early-stage Endometrial Cancer Patients Treated With Adjuvant Vaginal Brachytherapy.

The majority of patients with endometrial cancer (EC) are diagnosed at an early stage and undergo primary surgery, followed by observation or adjuvant therapy according to risk factors on surgical samples. The objective of this study was to assess the correlation between a risk profile represented by the presence of substantial lymph-vascular space involvement (LVSI) and/or p53 overexpression and the clinical outcome of patients with early-stage endometrial cancer (EC) who received adjuvant vaginal brachytherapy (BT). This investigation assessed 79 patients who underwent hysterectomy, bilateral salpingo-oophorectomy, and pelvic and/o aortic lymphadenectomy or sentinel lymph node biopsy followed by hypofractionated (HDR)-vaginal BT, using 192Ir source, for stage I-II endometrioid (n=70) or non-endometrioid (n=9) EC. Thirty-four patients (43.0%) were considered to have an unfavorable risk profile defined by the presence of substantial LVSI and /or p53 overexpression. Five-year disease-free survival (DFS) and five-year overall survival (OS) were 93.7% and 95%, respectively. There was a significant correlation between unfavorable risk-profile and pelvic recurrence rate (p=0.002) and distant recurrence rate (p=0.017). Patients with abnormal p53 had a higher risk of local relapse (p=0.041). Substantial LVSI was strongly associated with pelvic recurrence (p=0.001) and distant metastasis (p<0.001). The presence of substantial LVSI and/or p53 overexpression strictly correlated with poor outcome of patients with early-stage EC and should be taken into consideration for better planning adjuvant treatment in this clinical setting.

Same-day dismissal for endometrial cancer robotic surgery: feasibility factors.

The aim of this study was to investigate the factors in feasibility and safety of same-day dismissal (SDD) of endometrial cancer patients undergoing robotic hysterectomy and staging. A single-institution retrospective chart review of endometrial cancer patients who underwent robotic hysterectomy and staging between 2012 and 2021 was performed. Patient demographics, medical and surgical history, intra- and postoperative events were examined as possible factors related to non-SDD. These factors were analyzed using univariate (chi-square test) and multivariate logistic regression analysis. Of the 292 patients, 117 (40%) had SDD, and 175 (60%) had non-SDD. The SDD rate increased from 13.8% to 88% over the 10-year study period. The factors significantly associated with non-SDD (p < 0.05) were surgery in the first 5years after the introduction of the SDD and ERAS protocols (2012-2016), age > 75years, and comorbidities such as cardiovascular diseases, anemia (Hb < 11g/dl), and anticoagulant therapy. Extensive adhesiolysis, the performance of complete pelvic and/or aortic lymphadenectomy, operating time > 180min, and PACU discharge after 2:00 p.m. were significant factors for non-SDD. Sentinel lymph node sampling was significantly associated with SDD (OR 0.050; CI 0.273-0.934, p = 0.029). We reported no significant difference in the number, setting and timing of any unscheduled postoperative contacts, complications, and readmissions between SDD and non-SDD groups. SDD after robotic hysterectomy and staging for endometrial cancer is feasible and safe. There are patient and surgery factors for the failure of SDD. The sentinel lymph node sampling was significantly associated with achieving SDD. Trial registration: Institutional Review Board approved the study protocol (#: 1764-05).

Transperitoneal vs extraperitoneal approach for aortic sentinel node detection in endometrial cancer

Although the sentinel lymph node technique in endometrial cancer is currently replacing pelvic and aortic lymphadenectomy for the evaluation of lymph node status in endometrial cancer, its performance is not yet standardized. This study aimed to describe the detection rates and locations of aortic sentinel lymph node detection after dual cervical and fundal indocyanine green injection in patients with endometrial cancer, using the transperitoneal and extraperitoneal approaches. Between June 26, 2014 and December 31, 2019, 278 patients underwent laparoscopic surgery for endometrial cancer at our institution. In all cases, we performed sentinel lymph node biopsy with dual cervical and fundal indocyanine green injection, and back-up lymphadenectomy in high-risk cases. A post hoc analysis was performed to evaluate differences between the transperitoneal and extraperitoneal approach to aortic sentinel lymph nodes. The detection rates were as follows: overall detection rate: 93.2% (259/278); pelvic detection rate: 90.3% (251/278); bilateral pelvic detection rate: 68.0% (189/278); aortic detection rate: 66.9% (186/278); and isolated aortic detection rate: 2.88% (8/278). Transperitoneal and extraperitoneal aortic detection rates were similar (65.0% and 69.6%, respectively), with no significant differences (P=.441). Isolated aortic metastases were similar in both groups (2% vs 4.7%, respectively; P=.185). The laterality of aortic sentinel lymph node detection was influenced by the surgical approach (P=.002), but not its location above or below the inferior mesenteric artery (P=.166 and P=.556, respectively). The detection rates at the aortic level were similar between the transperitoneal and extraperitoneal approaches, with no impact on subsequent pelvic detection. The transperitoneal approach detected more laterocaval, precaval, and interaortocaval nodes, whereas the extraperitoneal approach detected more preaortic and left lateroaortic nodes.

Less is more in endometrial cancer (SLN, conservative treatment, radical hysterectomy, molecular classification).

The management of endometrial cancer has known many evolutions within the last decades. In this review, we aim to summarize recent evolutions (mainly toward less aggressive management) that have occurred in the management of endometrial cancer. Enhanced by molecular classification, the determination of lymph node status, in young women, in case of cervical invasion, the treatment is evolving toward a less aggressive strategy. The predictive value and the safety of sentinel lymph node biopsy explain why most societies propose to abandon systematic pelvic and para aortic lymphadenectomy. For young women, the safety of fertility preservation is now well established and efficient protocols have been validated. In stage II endometrial cancer (stromal cervical invasion), radical hysterectomy appears excessive. The Cancer Genome Atlas classification increases prognostic evaluation in association with the traditional pathological classification and permits to tailor adjuvant treatment more accurately.

Same day dismissal for endometrial cancer robotic surgery: Feasibility factors (005)

<b>Objectives:</b> To investigate factors determining the feasibility and safety of same-day dismissal (SDD) of patients after robotic hysterectomy and associated lymph node procedures for endometrial cancer. <b>Methods:</b> A single-institution retrospective chart review was performed of patients with pathologic diagnosis of endometrial cancer who underwent robotic hysterectomy and associated lymph nodes procedures between 2012 and 2021. Outcomes were analyzed by discharge to home, which was categorized as SDD or hospitalization at least for one night (not-SDD). Patient demographics, past medical and surgical history, intra and postoperative events were examined as possible factors related to not-SDD. These factors were analyzed using multivariate logistic regression and univariate analysis (Chi-square test). <b>Results:</b> Of the 292 patients, 117 (40%) had SDD, and 175 (60%) had not-SDD. The rate of SDD has been increasing over time, with up to 88% of patients annually avoiding overnight stay (Figure 1). The factors significantly associated with not-SDD (p<0.05) included surgery in the first five years after the introduction of the SDD protocol (2012-2016), patient age >75 years, presence of comorbid conditions such as cardiovascular disease, anemia (Hb< 11 g/dl) and those on anticoagulant therapy. Additionally, factors including extensive adhesiolysis, the performance of full pelvic and/or aortic lymphadenectomy, operating time >180 minutes, and surgery start time after 2:00 pm were significantly more associated with not-SDD. Interestingly, the use of the sentinel lymph node sampling was significantly associated with achieving SDD (OR: 0.050; 95% CI: 0.273-0.934, p=0.029). No significant difference in complications or re-admissions was found. <b>Conclusions:</b> In this tertiary referral center for minimally invasive treatment of endometrial cancers, SDD hysterectomy with related oncologic procedures is feasible and safe with similar complications and re-admission rates even in the complex clinical scenario of obese patients with comorbid conditions. Multiple risk factors for the failure of the SDD protocol were recognized. Care must be taken for the selection of patients, application of enhanced recovery after surgery (ERAS) protocol, and proper surgical planning to achieve SDD after robotic endometrial cancer surgery.

Neoadjuvant Chemoradiotherapy With Simultaneous Integrated Boost in Locally Advanced Cervical Cancer: Long Term Results of a Single-Center Experience.

Aim of this study was to analyze the efficacy and tolerability of simultaneous integrated boost volumetric modulated arc therapy (SIB-VMAT) associated with cisplatin-based chemotherapy in preoperative setting of patients with locally advanced cervical cancer (LACC). From June 2013 to September 2019, we analyzed patients with LACC who had undergone neoadjuvant chemoradiation (CRT). A radiation dose of 39.6 Gy, 1.8 Gy/fraction was delivered to the pelvis plus a radiation dose to the primary tumor delivered with SIB-VMAT strategy for a total of 50.6Gy, 2.3Gy/fraction in 25 fractions. Cisplatin-based chemotherapy was delivered combined with radiotherapy. Radical hysterectomy plus pelvic with or without aortic lymphadenectomy was performed within 7 to 8 weeks from CRT. One hundred forty-eight patients (median age: 49.5 years; FIGO stage IB2: 7, IIA: 8, IIB: 106, IIIA: 5; IIIB: 16; IVA: 5, IVB: 1; N0: 56, N1: 92) were analyzed. The treatment was well tolerated with good compliance: no grade 3/4 gastrointestinal or genitourinary toxicity was reported; grade 3 neutropenia was described in five cases. Pathological complete response (pCR) was documented in 68 cases (46%) and 32 patients (21.6%) had microscopic residual disease. Pathological nodal involvement was observed in 23 patients (15.5%). At median follow-up of 59 months (range: 27-100), the 3-year local control was 78.5%, whereas the 3-year metastasis-free survival was 70.5%. The 3-year overall survival rate was 89.0%. Neoadjuvant CRT with SIB-VMAT followed by radical surgery results in a high rate of pathologically assessed complete response and a very encouraging local control rate, with acceptable toxicity.

Surgical Outcomes of Laparoscopic Pelvic Lymph Node Debulking during Staging Aortic Lymphadenectomy in Locally Advanced Cervical Cancer: A Multicenter Study.

Simple SummaryLymph node metastasis is an important prognostic factor in locally advanced cervical cancer (LACC), which makes correct staging crucial. In contrast to existing studies evaluating pelvic lymphadenectomy after aortic lymphadenectomy, this study focuses on the pelvic node (PLN) debulking technique which has the dual objective of staging and cytoreduction. This is a multicenter retrospective study of patients with LACC and positive pelvic nodes on imaging tests. Feasibility, morbidity and delay in the initiation of chemoradiotherapy (CRT) were evaluated for the PLN debulking by comparing it with a control group of aortic lymphadenectomy alone. Excision of the bulky nodes was possible in 99.4% of patients. There were no differences in complications between the groups and a shorter time from diagnosis and from surgery to the start of CRT was observed in the study group.Background: Few studies have evaluated laparoscopic pelvic lymph node (PLN) debulking during staging aortic lymphadenectomy in locally advanced cervical cancer (LACC). It allows us to know the lymph node status and facilitates the action of chemoradiotherapy (CRT) by reducing tumor burden. We evaluated its feasibility and compared the perioperative morbidity and the time to CRT with a control group. Methods: This was a multicenter retrospective study of patients with LACC FIGO stage IIIC1r who were recipients of CRT. We compared two cohorts: group 1, which consisted of 164 patients with surgical staging by laparoscopic aortic lymphadenectomy and PLN debulking, and group 2, which consisted of 111 patients with aortic lymphadenectomy alone. Results: Excision of the bulky nodes was possible in all patients in group 1 except for one. Surgery lasted a median of 82 min longer in group 1 but there was no greater intraoperative bleeding or increased hospital stay. There were no significant differences in intraoperative or postoperative complications between the groups. A significantly shorter time from surgery to the start of RT was observed in group 1. Conclusions: It is feasible to perform laparoscopic PLN debulking in the same procedure as the staging aortic lymphadenectomy in LACC without increasing surgical or postoperative complications and without delaying the start of CRT compared to single aortic lymphadenectomy.

Status of the Sentinel Lymph Node in Patients with Endometrial Cancer Stage I-II.

Endometrial cancer (EC) is the most common gynecological cancer in developed countries. In literature, there are discordant data regarding the therapeutic value of systematic lymphadenectomy whereas the importance of lymph node status for determining prognosis and the need for adjuvant treatment is undoubted. Given the low risk of lymph node metastases in stage I-II of EC and the significant surgical and postoperative risks when performing a complete pelvic lymphadenectomy, the surgical approach in these patients is controversial, ranging from no nodal evaluation to comprehensive pelvic and aortic lymphadenectomy. The recent introduction of sentinel node detection represents the mid-way between the execution and omission of node dissection in EC patients. Indeed, the sentinel node mapping has rapidly emerged as an alternative to complete lymphadenectomy to reduce morbidity. In the present research, we discuss the role of sentinel node mapping in the surgical management of EC in early stage. Results of study on SLN in EC in early stages seem to be promising, but only a small series have been published so far.

Laparoscopic Debulking of Enlarged Pelvic Nodes during Surgical Para-aortic Staging in Locally Advanced Cervical Cancer: A Retrospective Comparative Cohort Study

To evaluate laparoscopic pelvic lymph node debulking during extraperitoneal aortic lymphadenectomy in diagnosis, therapeutic planning, and prognosis of patients with locally advanced cervical cancer and enlarged lymph nodes on imaging before chemoradiotherapy. Retrospective, multicenter, comparative cohort study. The study was carried out at 11 hospitals with specialized gynecologic oncology units in Spain. Total of 381 women with locally advanced cervical cancer and International Federation of Gynecology and Obstetrics 2018 stage IIIC 1r (radiologic) and higher who received primary treatment with chemoradiotherapy. Patients underwent pelvic lymph node debulking and para-aortic lymphadenectomy (group 1), only para-aortic lymphadenectomy (group 2), or no lymph node surgical staging (group 3). On the basis of pelvic node histology, group 1 was subdivided as negative (group 1A) or positive (group 1B). False positives and negatives of imaging tests, disease-free survival, overall survival, and postoperative complications were evaluated. In group 1, pelvic lymph node involvement was 43.3% (71 of 164), and aortic involvement was 24.4% (40 of 164). In group 2, aortic nodes were positive in 29.7% (33 of 111). Disease-free survival and overall survival were similar in the 3 groups (p = .95) and in groups 1A and 1B (p = .25). No differences were found between groups 1 and 2 in intraoperative (3.7% vs 2.7%, p = .744), early postoperative (8.0% vs 6.3%, p = .776), or late postoperative complications (6.1% vs 2.7%, p = .252). Fewer early and late complications were attributed to radiotherapy in group 1A than in the others (p = .022). Laparoscopic pelvic lymph node debulking during para-aortic staging surgery in patients with locally advanced cervical cancer with suspicious nodes allows for the confirmation of metastatic lymph nodes without affecting survival or increasing surgical complications. This information improves the selection of patients requiring boost irradiation, thus avoiding overtreatment of patients with negative nodes.

Endometrial Carcinoma Presenting with an Isolated Osseous Metastasis: A Case Report

Patients with advanced endometrial cancer had generally a poor prognostic with a median survival often less than one year. Isolated bone metastases as the first sign of the disease of endometrial cancer was a very exceptional situation rarely described in the literature. The goal of this report is to describe the management of this rare site of metastases and to reviewed Clinic pathological features and prognosis of isolated bone metastases. We present a case of a 56-year-old woman treated for endometrial cancer with isolated ribs bone metastases. She was complaining about progressive right rib pain as a first sign of the disease of endometrial cancer. She had a biopsy of the lesion in the last right thoracic rib. This has proved a metastatic adenocarcinoma compatible with an endometrial primary cancer. An endometrial biopsy showed moderately differentiated endometrioid adenocarcinoma. Imagery did not reveal any other sites of metastatic disease. The patient underwent bilateral salpingo-oophorectomy and hysterectomy, peritoneal washing, omentectomy, bilateral pelvic and par aortic lymphadenectomy. In addition, a right thoracotomy was carried out and complete surgical excision of the rib mass was successfully performed. Adjuvant chemotherapy was administrated. The patient is clinically free of disease 10 months following diagnosis. Single-bone extrauterine metastatic site and local disease limited to the uterus had better survival outcomes than Stage IVb endometrial cancer with multiple metastatic sites. Therefore, the patient treated with surgery with a clear margin continued to behave as early-stage endometrial cancer.

Role of systematic pelvic and para-aortic lymphadenectomy in delayed debulking surgery after six neoadjuvant chemotherapy cycles for high-grade serous ovarian carcinoma.

We analyzed the role of systematic pelvic and para-aortic lymphadenectomy in delayed debulking surgery after six neoadjuvant chemotherapy (NACT) cycles for advanced high-grade serous ovarian carcinoma. We retrospectively reviewed patients with advanced ovarian carcinoma who underwent NACT with carboplatin-paclitaxel between 2008 and 2016. Patients were included only if they had FIGO IIIC-IVB high-grade serous carcinoma with clinically negative lymph nodes after six NACT cycles (carboplatin-paclitaxel) and underwent complete or near complete cytoreduction. Patients with partial lymphadenectomy or bulky nodes were excluded. Patients who underwent systematic pelvic and aortic lymphadenectomy and those who did not undergo lymph node dissection were compared. Progression-free and overall survivals were analyzed using the Kaplan-Meier method. Totally, 132 patients with FIGO IIIC-IVB epithelial ovarian carcinoma were surgically treated after NACT. Sixty patients were included (39 and 21 in the lymphadenectomy and nonlymphadenectomy group, respectively); 40% had suspicious lymph nodes before NACT. Patient characteristics, blood transfusion numbers, and complication incidence were similar between the groups. In the lymphadenectomy group, 12 patients (30.8%) had histologically positive lymph nodes and the surgical time was longer (229 vs. 164 min). The median overall survival in the lymphadenectomy and nonlymphadenectomy groups, respectively, was 56.7 (95% CI 43.4-70.1) and 61.2 (21.4-101.0) months (p=0.934); the corresponding disease-free survival was 8.1 (6.2-10.1) and 8.3 (5.1-11.6) months (p=0.878). Six patients exclusively presented with lymph node recurrence. Systematic lymphadenectomy after six NACT cycles may have no influence on survival.

The extent of aortic lymphadenectomy in locally advanced cervical cancer impacts on survival.

ObjectiveThe prognostic impact of surgical paraaortic staging remains unclear in patients with locally advanced cervical cancer (LACC). The objective of our study was to evaluate the results of the surgical technique of preoperative aortic lymphadenectomy in LACC related to tumor burden and disease spread to assess its influence on survival.MethodsData of 1,072 patients with cervical cancer were taken from 11 Spanish hospitals (Spain-Gynecologic Oncology Group [GOG] working group). Complete aortic lymphadenectomy surgery (CALS) was considered when the lymph nodes (LNs) were excised up to the left renal vein. The extent of the disease was performed evaluating the LNs by calculating the geometric means and quantifying the log odds between positive LNs and negative LNs. The Kaplan-Meier method was used to estimate the survival distribution. A Cox proportional hazards model was used to account for the influence of multiple variables.ResultsA total of 394 patients were included. Pathological analysis revealed positive aortic LNs in 119 patients (30%). LODDS cut-off value of −2 was established as a prognostic indicator. CALS and LODDS <−2 were associated with better disease free survival and overall survival than suboptimal aortic lymphadenectomy surgery and LODDS ≥−2. In a multivariate model analysis, CALS is revealed as an independent prognostic factor in LACC.ConclusionWhen performing preoperative surgical staging in LACC, it is not advisable to take simple samples from the regional nodes. Radical dissection of the aortic and pelvic regions offers a more reliable staging of the LNs and has a favorable influence on survival.

Sentinel lymph node biopsy in endometrial cancer: state of the art.

Endometrial cancer (EC) is the most common gynecological neoplasm in developed countries. In literature, there are discordant data regarding the therapeutic value of systematic lymphadenectomy whereas the importance of lymph node status for determining prognosis and the need for adjuvant treatment is undoubted. Given the low risk of lymph-node metastases in the apparent early-stage disease and the significant surgical and postoperative risks when performing a complete pelvic lymphadenectomy, the surgical approach in these patients is controversial, ranging from no nodal evaluation to comprehensive pelvic and aortic lymphadenectomy. The recent introduction of sentinel node mapping represents the mid-way between the execution and omission of node dissection in EC patients. Indeed, the sentinel node mapping has rapidly emerged as an alternative to complete lymphadenectomy to reduce morbidity. In the present review, we discuss the role of sentinel node mapping in the surgical management of EC evaluating all aspects of this procedure.

Implications of extraperitoneal paraaortic lymphadenectomy to the left renal vein in locally advanced cervical cancer. A Spanish multicenter study

ObjectiveParaaortic lymph node involvement is an important prognostic factor in locally advanced cervical cancer (LACC), but the anatomic limit of aortic lymphadenectomy is controversial. We assessed the impact of extraperitoneal paraaortic lymphadenectomy up to the left renal vein in patients with LACC undergoing pretherapeutic staging. MethodsA retrospective, multicenter study of patients with LACC stages FIGO 2009 IB2 and IIA2-IVA treated in 10 Spanish reference hospitals in gynecological oncology between 2000 and 2016. Sites of metastatic paraaortic lymph nodes above or below the inferior mesenteric artery were evaluated. Procedural-related intraoperative and early and late complications were assessed. ResultsWe included 634 patients undergoing paraaortic lymphadenectomy, in 616 (97.2%) of which the left renal vein was the upper limit of dissection (laparoscopy 592, robotic-assisted 24). The median surgical time was 150 min (interquartile range (IQR) 120–180), blood loss was 50 mL (range 20–80), and the length of stay was 2 days (range 2–3).Metastatic paraaortic involvement was found in 114 patients (18.5%), with infrarenal metastases in 73 (64%) of them. There were 11 patients (9.6%) with infrarenal metastases only, whereas in the remaining 62 (54.4%) patients concomitant infrarenal and inframesenteric metastases were observed. Intraoperative, early, and late postoperative complications occurred in 3.6%, 7.0%, and 4.5% of patients, respectively. ConclusionsIn this study of patients with LACC undergoing surgical staging, paraaortic lymphadenectomy up to the left renal vein detected skip or isolated infrarenal metastasis in 9.6% of patients, with an acceptable surgical morbidity.

Technetium-99m-indocyanine green versus technetium-99m-methylene blue for sentinel lymph node biopsy in early-stage endometrial cancer

IntroductionThe low accuracy of pre-operative imaging techniques for prediction of nodal status strengthens the relevance of sentinel lymph node (SLN) biopsy in endometrial cancer, although the optimal method for its...

Surgical or imaging lymph node assessment in locally advanced cervical cancer: a systematic review and meta-analysis.

ObjectiveTo evaluate the survival impact of imaging vs surgical nodal assessment in patients with cervical cancer stage IB2–IVA prior to definitive chemoradiotherapy (CRT).MethodsPubMed, MEDLINE, Cochrane Library, and ClinicalTrials.gov were used to search for publications in English and Chinese over a 50-year period. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols was used to conduct this review. Inclusion criteria were studies that compared survival outcomes in International Federation of Gynecology and Obstetrics 2009 stage IB2–IVA cervical cancer patients with pre-therapy pelvic and/or aortic lymphadenectomy (LND) or imaging. One or more of the following modalities were used for nodal assessment: computed tomography (CT), magnetic resonance imaging, or positron emission tomography-CT. The National Institutes of Health Quality Assessment Tool was utilized to assess study quality.ResultsThe initial search identified 65 studies, and five met the inclusion criteria. There were a total of 1,112 patients. Seven hundred and fifty-four underwent pelvic and/or aortic LND and 358 had imaging. When compared to LND, imaging had a sensitivity and specificity of 88.9% and 22.2% for pelvic lymph node (LN), and 33%–62.5% and 92%–95.5% for para-aortic LN. There were no differences in progression-free survival (PFS) (hazard ratio [HR]=1.13; 95% confidence interval [CI]=0.73–1.74; I2=75%; p<0.01) and overall survival (OS) (HR=1.06; 95% CI=0.66–1.69; I2=75%; p<0.01) between surgical and imaging nodal assessment.ConclusionsImaging and surgical nodal assessment has comparable PFS and OS in patients with cervical cancer stage IB2–IVA.Trial RegistrationPROSPERO Identifier: CRD42020155486

Robotic sentinel lymph node (SLN) mapping in endometrial cancer: SLN symmetry and implications of mapping failure

PurposeTo establish the bilateral pelvic concordance rate of the sentinel lymph node (SLN) and determine the likelihood of lymph node metastasis in cases of mapping failure.MethodsA database analysis was performed...

Prospective clinical trial of robotic sentinel lymph node assessment with isosulfane blue (ISB) and indocyanine green (ICG) in endometrial cancer and the impact of ultrastaging (NCT01818739)

ObjectivesTo assess the performance sentinel lymph node (SLN) biopsy and effect of ultrastaging in clinically early stage endometrial cancer. MethodsPatients with endometrial cancer prospectively enrolled after informed consent was obtained. The cervix was injected superficially with 1 mL of ISB and 1 mL of ICG (diluted 1:25) at 3 and 9 o'clock each. SLN biopsy was followed by complete pelvic lymphadenectomy (aortic lymphadenectomy at the discretion of the surgeon). Lymph nodes (LNs) were analyzed by standard sectioning with H&E; ultrastaging of SLN was done retrospectively and blinded to treating physicians. Results204 patients received dye injections. In 184 (90.2%) patients at least one SLN was identified. Of all patients, 138 (68%) had bilateral mapping. In the patients with successful mapping of a hemipelvis, ICG detected SLNs in 83% and ISB in 64% of cases (p < 0.0001). Median BMI (kg/m2) for patients with successful mapping was 35.7 compared to 40.1 for those who did not map (p = 0.01). Twenty-three (11.3%) patients had positive LNs. Applying the SLN algorithm, positive nodes were detected in 21/23 (91.3%). The negative predictive value (NPV) was 98.9% (95% CI: 96.01% to 99.71%). Eleven patients had positive SLN with isolated tumor cells (ITCs) or micrometastases detected on ultrastaging. Including these patients, 34 (17%) had positive LNs, increasing the NPV to 99% and sensitivity to 94%. There were no recurrences in patients with ITCs only. ConclusionsSLN assessment in endometrial cancer is feasible and safe with high NPV (99%). ICG was more effective in detecting SLN compared to ISB. Although ultrastaging detected additional positive LNs, treatment based on standard sectioning appears reasonable but further research is needed.

Prevention of lymphorrhea in aortic lymphadenectomy.

The objective of this video 1 is to describe the technique to avoid postoperative lymphorrhea after a lumboaortic lymphadenectomy. All procedures were performed at Donostia University Hospital, a tertiary referral and educational center in San Sebastián, Spain. Lumboaortic extra-peritoneal lymphadenectomy was performed for several gynecological malignancies (endometrial and cervical cancer). During the procedure, afferent lymphatic capillaries were identified at the infra-renal aortic level and clipped to avoid retrograde lymphorrhea at this level. Numerous strategies have been described to reduce the likelihood of lymphorea and lymphocele formation.1 Harmonic scalpel and other sealing advanced devices are not useful to secure lymphatic leakage at this level, although some authors have published a clinical benefit in their use,2 while clips have been found useful to prevent leakage in other lymphatic locations.3 The use of harmonic scalpel, biological agents or surgical patch has been ineffective in our experience, but sealing clips and peritonization (marsupialization),4 once the procedure is concluded, could be an effective approach. Performing simple gestures during lumboaortic lymphadenectomy can help to reduce the appearance of posterior lymphorrhea.

Preliminary study of sequential multi-modality adjuvant chemotherapy and radiation for advanced endometrial cancer

Objective: To evaluate the clinical outcomes and feasibility of multi-modality adjuvant chemotherapy and radiation, which was conducted as postoperative chemotherapy, radiation, and consolidation chemotherapy (CRC) mode for the treatment of advanced endometrial cancer. Methods: A retrospective analysis of 124 patients with International Federation of Gynecology and Obstetrics (FIGO) stages Ⅲ and Ⅳ endometrial cancer from Jan. 2004 to Oct. 2012 was conducted in Peking University People's Hospital and Beijing Obstetrics and Gynecology Hospital. Inclusion criteria were comprehensive staging procedure including hysterectomy, bilateral salpingo-oophorectomy, and (or) selective pelvic aortic lymphadenectomy, and treatment with adjuvant chemotherapy and (or) radiation. The average age of these patients was (55.9±8.4) years old (range from 23 to 79 years old). According to different postoperative adjuvant treatment modes, the patients were divided into CRC group, chemotherapy-radiotherapy (CR) group and single chemotherapy (C) group. The survival and side effects of the three groups were compared. Results: (1) One hundred and twenty-four patients with advanced stage endometrial cancer were identified and received postoperative adjuvant therapies.Sixty-one (49.2%, 61/124) cases of them received postoperative CRC fashion, 19 (15.3%, 19/124) received postoperative CR and 44 (35.5%, 44/124) cases received C. The age, stage, grade and type of surgery of the three groups were not significantly different (all P>0.05); while, the pathology, chemotherapy cycles and chemotherapy regimens differed significantly (all P<0.05). (2) The progression-free survivals (PFS) of the patients with CRC, CR, and C group were (121±7), (68±15), and (100±11) months, respectively. The 3-year PFS rates were 87.9%, 43.7%, and 61.4%, respectively. The 5-year PFS rates were 82.2%, 36.4%, and 61.4%, respectively. The above indicators were significantly higher in the CRC group than in the CR group (all P<0.01), and there was no difference between the CRC group and the C group (P=0.037). The overall survival (OS) of patients with CRC, CR, and C group were (128±6), (80±12), and (99±10) months, respectively. The 3-year OS rates were 87.8%, 72.4%, and 67.1%, the 5-year OS rate were 84.2%, 54.3%, and 64.1%, respectively. The above indicators were significantly higher in the CRC group than those in the CR group and C group (all P<0.01). (3) There was no difference in the frequency of adverse effects either chemotherapy, such as severe bone suppression or radiotherapy; hepatotoxicity,blood transfusion, dose modifications; or cycle delays between the CRC, CR and C group (all P>0.05). (4) In the univariate analysis shown that, stage, the fashion of postoperative adjuvant therapy and type of surgery were risk factors for tumor progression in patients with advanced endometrial cancer (P<0.05). After adjusted for FIGO stage and type of surgery, the tumor progression hazard ratio (HR) was 3.931 (95%CI: 1.734-8.914, P=0.001) for the CR group and 2.188 (95%CI: 1.010-4.741, P=0.047) for the C group, compared to the CRC group. Conclusion: Sequential CRC delivered in a "sandwich" fashion for the treatment in advanced endometrial cancer could significantly improve the 3-year and 5-year OS rates and have a similar adverse effect profile compared with other sequencing modalities.