Aortic Nodes Research Articles

Laparoscopic Extraperitoneal Pelvic Lymph Node Debulking in Locally Advanced Cervical Cancer

To show the feasibility of the laparoscopic extraperitoneal approach for pelvic metastatic lymph node debulking in locally advanced cervical cancer. A surgical video article (Canadian Task Force classification III). A university hospital. A 52-year-old patient presented with stage IIA2 cervical adenocarcinoma according to Fédération Internationale de Gynécologie et d'Obstétrique classification. During the physical examination, a 45-mm tumor was discovered. Positron emission tomographic imaging was positive for hypermetabolic enlarged lymph nodes in the left external iliac region of 1.4-cm size and an standardized uptake value of 21 and in the right obturator region of 1.3-cm size and an standardized uptake value of 7.1; no aortic nodes were found using the imaging procedures. Before chemoradiation therapy, she underwent extraperitoneal aortic lymph node dissection for surgical staging at Vall d'Hebron University Hospital, Barcelona, Spain. Pelvic lymph node debulking was proposed to confirm positivity and, if so, to adjust the radiotherapy field and reduce lymph node radioresistance [1,2]. After a complete extraperitoneal aortic infrarenal lymph node dissection as described by Querleu et al [3], the presacral space is created to expose the iliac vessels. The enlarged lymph nodes are identified and dissected using blunt dissection, monopolar energy, and a vessel sealing device. There were no intraoperative or postoperative complications. The anatomopathologic study confirmed positivity for adenocarcinoma metastasis in 3 pelvic nodes and 2 of 29 aortic nodes. Laparoscopic debulking of enlarged pelvic lymph nodes via the extraperitoneal approach is a feasible procedure. It can be performed as an extension of extraperitoneal aortic lymphadenectomy in selected patients with locally advanced cervical cancer.

Surgically Treated Unsuspected N2-Positive NSCLC: Role of Extent and Location of Lymph Node Metastasis

BackgroundThe role of surgery in the treatment of non–small-cell lung cancer that has spread to ipsilateral mediastinal or hilar lymph nodes (LNs) is controversial. We examined whether the location of LNs positive for non–small-cell lung cancer in mediastinum or hilum influences the survival of these patients. Patients and MethodsWe reviewed data from 881 patients and analyzed those with unsuspected N2 disease or hilar (station 10) LNs. The patients were stratified into the following groups: group A, positive hilar Naruke 10; group B, superior mediastinal and aortic nodes (Naruke 1, 2, 3, 4, 5, and 6); group C, inferior mediastinal nodes (Naruke 7, 8, and 9), and multilevel group D (2 or more positive N2 levels). ResultsA total of 69 pN2 and 19 pN1 patients were included. Progression-free survival (PFS) was statistically significant better in group B versus group C (P = .044) and group B versus group D (P = .0086). The overall survival (OS) of group A did not differ from that of group C. A statistically significant better OS was found between groups B and D (P = .051). ConclusionInferior positive mediastinal N2 node patients seem to have an OS and PFS as poor as multilevel N2 disease patients. The OS and PFS of patients with positive hilar disease are similar to those in the inferior mediastinal positive N2 group. Superior positive mediastinal N2 node patients have better OS and PFS than the inferior mediastinal positive N2 group.

Prognostic analysis of extended field intensity-modulated radiation therapy for cervical cancer

In recent decades, accurate radiotherapy has developed rapidly, and the application of intensity-modulated radiation therapy (IMRT) in gynecologic malignancies has increased gradually in the past ten years. Many studies have shown a high rate of occult abdominal aortic lymph node metastasis in patients with advanced cervical cancer, while pelvic and abdominal aortic lymph node status are important prognostic factors in cervical cancer patients. Conventional prophylactic extended field radiotherapy has the characteristics of severe gastrointestinal side effects, and synchronic chemotherapy is also controversial. The optimal dose of radiation therapy for metastatic pelvic and abdominal aortic lymph nodes is still controversial. This paper mainly analyzed the effect of prophylactic extended conformal radiotherapy with concurrent chemotherapy on the prognosis of cervical cancer and the dose-effect relationship of lymph node positive region. Key words: Cervical neoplasm/intensity modulated radiation therapy; Extended field radiotherapy; Concurrent chemotherapy; Lymph node; Survival rate

Melanoma of Vulva with Multiple Metastases: A Case Report and Review of the Literature

Malignant melanomas of the vulva and vagina are rare tumors located in areas of the body not exposed to ultraviolet radiation. Vulval melanoma is the second most common vulval malignancy after squamous cell carcinoma but represents less than 1% of all melanomas. Because of the overall poor prognosis, it represents a significant issue in women’s health. We present a case of a 40-year-old woman with malignant melanoma of vulva with spread to the inguinal lymph nodes, aortic lymph nodes, and secondaries in the lung.

Prognostic role of mesenteric lymph nodes involvement in patients undergoing posterior pelvic exenteration during radical or supra-radical surgery for advanced ovarian cancer.

The aim of this retrospective study is to analyze the prognostic role and the practical implication of mesenteric lymph nodes (MLN) involvements in advanced ovarian cancer (AOC). A total of 429 patients with AOC underwent surgery between December 2007 and May 2017. We included in the study 83 patients who had primary (PDS) or interval debulking surgery (IDS) for AOC with bowel resection. Numbers, characteristics and surgical implication of MLN involvement were considered. Eighty-three patients were submitted to bowel resection during cytoreduction for AOC. Sixty-seven patients (80.7%) underwent primary debulking surgery (PDS). Sixteen patients (19.3%) experienced interval debulking surgery (IDS). 43 cases (51.8%) showed MLN involvement. A statistic correlation between positive MLN and pelvic lymph nodes (PLN) (p=0.084), aortic lymph nodes (ALN) (p=0.008) and bowel infiltration deeper than serosa (p=0.043) was found. A longer overall survival (OS) and disease-free survival was observed in case of negative MLN in the first 20months of follow-up. No statistical differences between positive and negative MLN in terms of operative complication, morbidity, Ca-125, type of surgery (radical vs supra-radical), length and site of bowel resection, residual disease and site of recurrence were observed. An important correlation between positive MLN, ALN and PLN was detected; these results suggest a lymphatic spread of epithelial AOC similar to that of primary bowel cancer. The absence of residual disease after surgery is an independent prognostic factor; to achieve this result should be recommended a radical bowel resection during debulking surgery for AOC with bowel involvement.

Prognostic value of peritoneal cancer index in primary advanced ovarian cancer

BackgroundEffective tumor debulking is a major factor associated with a favorable prognosis in patients with advanced ovarian cancer (AOC). However, FIGO staging fails to take full account of the extent of the disease in the peritoneum, making it difficult to plan appropriate surgical treatment. In contrast, the peritoneal cancer index (PCI) can provide more detailed information about peritoneal spread. MethodWe evaluated the prognostic value of PCI and its association with clinicopathological features in patients with AOC. Data for 80 patients with AOC who underwent primary debulking surgery were analyzed retrospectively. PCI scores of 0–39 were calculated based on the sizes of lesions in 13 abdominopelvic regions, and patients were classified into three categories with scores of 1–10, 11–20, and >20, respectively. Clinicopathological features, including the presence of residual tumor after surgery and the incidence of postoperative complications, were assessed in relation to PCI score. ResultsPCI was significantly associated with suboptimal surgery and postoperative complications, as well as with preoperative CA125, ascites, prolonged surgery, FIGO stage, positive aortic lymph nodes, prolonged hospitalization, and number of visceral resections. Overall and disease-free survival was also associated with PCI, with an optimal cut-off value of 15. Multivariate analysis identified age, residual tumor, and PCI as independent prognostic factors for survival. A PCI >10 is positively associated with a poor prognosis in patients with AOC. ConclusionGiven the importance of effective tumor debulking, PCI may provide important information for surgical planning in patients with AOC.

Patrón MELF de infiltración miometrial en el adenocarcinoma endometrioide del endometrio. Revisión de 70 casos

IntroductionEndometrioid adenocarcinoma of the endometrium (EAE) usually has a favorable prognosis. Recently, the MELF (microcystic, elongated and fragmented) pattern of myometrial infiltration has been described. It is associated with lymphovascular invasion and lymph node metastasis. Seventy cases of EAE were reviewed to identify the presence of MELF and its correlation with other prognostic factors. Material and methodsHysterectomies performed for EAE during a 5-year period were reviewed, searching for MELF pattern. Its presence was correlated with other variables such as histological grade, depth of myometrial infiltration, pelvic and/or aortic lymph node metastasis, peritoneal implants and evolution. ResultsIn 17 (24%) cases MELF pattern was detected. It was more frequent in low grade tumors; it was present in four grade 3 cases. In 9 (53%) cases there was deep myometrial infiltration. Five cases had lymph node metastasis in the pelvis and three in the para-aortic region. One of the patients died, another presented a vulvar recurrence and another pulmonary metastasis. ConclusionMELF pattern can be seen in high grade EAE and correlates with deep myometrial infiltration and pelvic lymph node metastasis. Its presence does not seem to influence survival.

Technique for precaval and laterocaval nodes excision at extraperitoneal paraaortic lymphadenectomy

Study objectiveTo describe our technique for excision of the pre-caval and laterocaval nodes using an extraperitoneal approach. This technique was developed to make the dissection and excision of the less accessible nodes in an easier and safer way by minimizing the risk of great vessels injury and bleeding. DesignStep-by-step description of the surgical procedure using video (Canadian Task Force classification III). SettingThe procedure was performed at a teaching hospital, Hospital Universitario Donostia (Spain). PatientsA 52-year-old woman with a body mass index of 33 underwent endoscopic extraperitoneal paraaortic lymphadenectomy for advanced high grade cervical adenocarcinoma FIGO IIB. InterventionsThe patient underwent an endoscopic extraperitoneal para-aortic lymphadenectomy. An anatomical dissection is being performed being the upper limit of the dissection the left renal vein. Focus of the video involves the challenging dissection of the right nodes. Measurements and main resultsFirstly we complete a dissection of all the anatomical aortic limits until the renal vein and exeresis of aortic nodes. A plane just above the cava vein is carefully developed by pushing all the lymph nodes to the roof of the dissection. Special care must be taken close to the aortic bifurcation due to the perforating vessels that can be found more frequently in this location. Once all this space is dissected, nodes attached to the roof are easily pushed down. It is useful to use a clip in the upper part, close to the renal vein, to prevent lymphorrhea. Nodes are excised in four blocks, supramesenteric and inframesenteric aortic and precaval nodes. The proximity to the peritoneal roof and the chance for a peritoneal hole and loss of pneumoperitoneum can be less problematic if the right dissection is performed at the end of the procedure. ConclusionA complete para-aortic retroperitoneal dissection can be achieved with this extraperitoneal approach. Benefits of this technique are based on the absence of the bowel or other intraperitoneal structures invading the operative field given the barrier-free nature of the retroperitoneal space. Despite the challenge of the access to the right nodes in a retroperitoneal paraaortic lymphadenectomy they can be successfully excised reaching the renal vein including obese patients.

Computed tomography of the thorax in rabbits: a prospective study in ten clinically healthy New Zealand White rabbits

BackgroundLiterature investigating the normal cross-sectional anatomy of rabbits with computed tomography (CT) is sparse and incomplete. The purpose of the present study was to investigate the normal thoracic structures, in particular the cranial thorax, with CT angiography in 10 clinically healthy New Zealand White (NZW) rabbits.ResultsAbsolute and relative measurements of the trachea, heart, thoracic caudal vena cava and aorta, right and left principal bronchi, right and left caudal lobar bronchi and the accompanying branches of the right and left pulmonary artery and vein, right and left lung volume and lung density were taken. The three lobes of the thymus (right ventral, right dorsal and left thoracic lobes) were identified in all rabbits. Both the right dorsal and left thoracic lobes of the thymus extended between the heart and thoracic wall in all individuals with the left lobe reaching more caudally in seven animals. Consequently, the craniocaudal extension of the left lung was smaller than the right lung in these rabbits. Volume of the left lung was significantly smaller than the right (P = 0.005). The cranial mediastinal, right and left tracheobronchial and the aortic thoracic lymph nodes were very small and identified in four, four, seven and ten rabbits, respectively. The heart took up a median of 4.0 intercostal spaces, and in seven rabbits, it was located in the 2nd–5th intercostal space. Median relative cardiac height and width measured 74 and 88%, respectively. The median angle of the trachea to the spine was 5°. Median density between the right and left lung did not significantly differ (− 549 and − 583 Hounsfield units, respectively). In all but one rabbit, atelectasis was present and classified as mild, moderate or severe in six, two and one individuals, respectively. Mild subclinical bronchopneumonia was diagnosed in seven rabbits.ConclusionsThe present study provides species-specific anatomical CT information and reference values for structures in the thorax of the NZW rabbit. Subclinical bronchopneumonia appears to be a common CT finding.

Sentinel node mapping in endometrial cancer following Hysteroscopic injection of tracers: A single center evaluation over 200 cases

ObjectivesTo analyze detection-rate(DR) and diagnostic-accuracy (A) of sentinel-nodes(SLNs) mapping following hysteroscopic-injection of tracer. To compare DR and A between tracers: ICG and Tc99m. MethodsEvaluation of endometrial-cancer patients who underwent SLNs mapping after hysteroscopic-peritumoral-injection of tracer±lymphadenectomy. Analysis of DR (overall-bilateral-aortic) and A in the entire cohort and comparison between tracers. Results202 procedures were performed from January/2005 to February/2017. Mean age:60years (28–82); mean BMI: 26.8 kg/m2 (15–47). In 133 cases (65.8%) hysterectomy and mapping procedure were performed laparoscopically. The overall-DR of the technique was 93.2% (179/192) (10 cases were excluded: 9 for technical-equipment failure; 1 for vagal reaction). Bilateral pelvic mapping was found in 59.7% of cases (107/179) and was more frequent in the ICG group (72.8% vs 53.3%; p: 0.012). In 50.8% of cases (91/179) SLNs were mapped both in pelvic and aortic nodes, and in 5 cases (2.8%) only in the aortic area. The mean number of detected SLNs was 3.7 (1–8).22 patients (12.3%) had nodal involvement: 10-(45.5%)-macrometastases; 5-(22.7%)-micrometastases; 7-(31.8%)-ITCs. In 6 cases (27.3%) only aortic nodes were positive; in 5 cases (22.7%) both pelvic and aortic nodes and in 11 cases (50%) only pelvic nodes were involved.Three false-negative results were found, all in the Tc99m group. All had isolated aortic metastases with negative pelvic nodes.Overall-sensitivity was 86.4% (95%CI: 68.4–100) and overall-negative-predictive-value (NPV) was 96.4% (95%CI 86.7–100).No differences in terms of overall-DR, overall-sensitivity and overall-NPV were found between the two tracers. ConclusionsHysteroscopic-injection of tracer for SLNs mapping in endometrial cancer is as accurate as cervical injection with a higher DR in the aortic area. ICG improves bilateral-DR. Further investigation is warranted on this topic.

Survival of women with microinvasive adenocarcinoma of the cervix is not improved by radical surgery

Treatment for early-invasive adenocarcinoma of the cervix remains controversial. Although data have shown similar survival rates to those seen with squamous cell carcinoma, conservative options for patients with microinvasive adenocarcinoma have not been as widely accepted. Despite comparable survival outcomes, patients with early-invasive adenocarcinoma are still routinely subjected to more radical surgical techniques than their equivalently staged squamous cell counterparts. The objective of the study was to evaluate how less radical surgery has an impact on 5 year survival in patients with microinvasive adenocarcinoma of the cervix. The Surveillance, Epidemiology, and End Results database was queried from 1988 through 2010 to perform a retrospective analysis of women with International Federation of Gynecology and Obstetrics stage IA1 or IA2 cervical carcinoma. Five year survival by procedure type (local excision, simple hysterectomy, or radical hysterectomy) was determined for each cell type (squamous or adenocarcinoma), as was lymph node status. Among 1567 patients with cervical adenocarcinoma, 5 year survival was 97.3% (confidence interval, 95.8-98.2%) for stage IA1 disease and 98.3% (confidence interval, 96.5%, 99.2%) for stage IA2. For comparison, the 5-year survival rates for 5,749 patients with stage IAI or lA2 squamous cell carcinoma were 96.7% (confidence interval, 96.0-97.3%) and 95.6% (confidence interval, 94.4-96.5%), respectively. For stage IA1 ACA, survival was 96.6%, 98.4% and 96.5% following excision, hysterectomy and radical hysterectomy, respectively. For stage IA2 ACA, survival rates were 100%, 96.9% and 99.4%, respectively. There was no statistical difference in survival between patients having either cell type undergoing local excision (P= .26), simple hysterectomy (P= .08), or radical hysterectomy (P= .87). We also found no statistically significant difference in survival among patients with adenocarcinoma compared by treatment type (local excision compared with simple hysterectomy [P= .64]; local excision compared with radical hysterectomy [P= .82]; or simple hysterectomy compared with radical hysterectomy [P= .70]). Among patients with adenocarcinoma, 0.97% had positive pelvic lymph nodes, none had positive aortic lymph nodes, and 91.85% had confirmed negative lymph nodes. For squamous cell carcinoma, 0.72% of patients had positive pelvic lymph nodes and 0.10% had positive aortic lymph nodes. There was no significant difference in survival when patients were compared by cell type or procedure, suggesting that survival of patients with microinvasive adenocarcinoma is not improved by utilizing more invasive surgical methods. Regardless of histology, the frequency of nodal involvement was very low among both groups, supporting an overall excellent prognosis for all patients with microinvasive disease. We submit these data as evidence that preoperative planning of more conservative techniques is appropriate, not just for those with squamous histology or who desire future fertility, but for all patients with microinvasive cervical disease.

Lymph node involvement in clinically apparent early ovarian cancer: a prospective study.

The objective of this study was to identify the lymph node involvement in apparently early ovarian cancer (OC) Materials and Methods: Patients with clinically apparent early OC who underwent staging surgery between August 2012 and August 2015 were prospectively identified. Patients' characteristics and tumor histopathology were evaluated. Twenty consecutive patients were operated for grossly apparent early ovarian carcinoma. All patients were surgically staged and underwent a systematic pelvic and para- aortic lymphadenectomy. There were eight patients (40%) with lymph node involvement. One of the eight lymph node metastasis was solely in para-aortic node, three patients had both positive-pelvic and aortic nodes, and the other metastasis was in ipsilateral pelvic lymph node. Positive lymph node involvement was significantly higher among patients with poorly differentiated tumor grade (62.5%) (p = 0.02). All patients diagnosed with early OC macroscopically confined to the ovaries should be considered for compre- hensive staging surgery including pelvic and para-aortic lymphadenectomy.

PD53-12 CENTRALIZATION OF CARE PROMOTES TRAINING DISPARITIES WITH REGARD TO THE TEACHING OF RETROPERITONEAL LYMPHADENECTOMY

You have accessJournal of UrologySexual Function/Dysfunction: Penis/Testis/Urethra: Benign Disease & Malignant Disease II1 Apr 2017PD53-12 CENTRALIZATION OF CARE PROMOTES TRAINING DISPARITIES WITH REGARD TO THE TEACHING OF RETROPERITONEAL LYMPHADENECTOMY Ryan Owen, Stephanie Dresner, James Bienvenu, and W. Bedford Waters Ryan OwenRyan Owen More articles by this author , Stephanie DresnerStephanie Dresner More articles by this author , James BienvenuJames Bienvenu More articles by this author , and W. Bedford WatersW. Bedford Waters More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2409AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In 2007, Lowrance et al published a manuscript in the Journal of Urology, which stated that the majority of United States trained urology residents have minimal experience with Retroperitoneal Lymphadenectomy. The purpose of our study is to evaluate if the current trend in retroperitoneal lymphadenectomy training has declined further. METHODS After permission from the American Board of Urology, a retrospective review of operative log reports from 2005-2015 was performed. Using CPT code designation, total cases performed were quantified and further stratified by log year, practice region, practice type and recertification versus primary certification. RESULTS A total of 1227 open retroperitoneal transabdominal lymphadenectomy; extensive, including pelvic, aortic and renal nodes (CPT 38780) were logged by 500 physicians. 247 (49.4%) physicians applying for primary certification logged at least 1 lymphadenectomy compared to 253 (50.6%) applicants for recertification. Of the 500 certifying physicians, 321 (64.2%) reported only 1 lymphadenectomy, 144 (28.8%) reported 2-5 procedures and 35 (7.0%) performed more than 5. When stratified by geographic location, most procedures were recorded in the North Central (27.5%) and Western section (24.4%). There were 793 (64.6%) cases performed in an Academic hospital setting. CONCLUSIONS A significant number of recently trained urologists continue to demonstrate minimal experience with retroperitoneal lymph node dissection. With limited exposure to an operation that was once considered an index case, there is a significant negative impact on the quality of urologic resident education. Additionally, this review demonstrates an already visible trend toward the centralization of care with the majority of procedures performed at major academic institutions. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1045 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Ryan Owen More articles by this author Stephanie Dresner More articles by this author James Bienvenu More articles by this author W. Bedford Waters More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Primary Neuroendocrine Carcinoma of Breast: an uncommon variant.

Neuroendocrine carcinoma of breast ( NECB) is an aggressive variant of invasive mammary carcinoma. Very few cases of Primary NECB have been reported in the literature . Here we report a 50 year female presented with left breast lump measuring 15 x 12 cm. of gradual onset with left axillary lymphadenopathy. On fine needle aspiration cytology of breast and lymphnode were positive for malignant cells. On ultrasonography of abdomino- pelvis showed metastasis to liver, peri pancreatic and para aortic lymph nodes with minimal ascites. On histopathology reported as Primary NECB-Large cell type-left breast. We are presenting this case for its extreme rarity and aggressive clinical behaviour. DOI: 10.21276/APALM.1094

The Effect of Para Aortic Lymph Node Dissection in Staging and Complete Cytoreductive Surgery of Ovarian Cancer

Objective: Lymphatic spread is a common feature of ovarian cancer both in early and advanced stages of the disease. There is also a controversial problem of the impact of para-aortic lymph node dissection between gynecologist oncologist experts. The aim of this study is evaluating the effect of Para aortic Lymph node dissection in ovarian cancer patients. Methods: This descriptive cross-sectional study was performed on 100 ovarian cancer patients admitted in department of gynecology oncology of Ghaem hospital, Mashhad University of Medical Sciences, Iran, from November 2013 - 2014. All patients underwent surgical staging surgery and optimal debulking surgery as possible. In addition, concurrent systematic pelvic and para-aortic lymphadenectomy up to the level of inferior mesenteric artery was performed. Results: A total of 100 patients were studied. The mean age was 47 years (SD = 13). In 73 patients optimal cytoreductive surgery was done with para aortic lymphadenectomy. 53 cases (72.6%) were in primary cytoreductive surgery and 20 cases (27.3%) in interval debulking surgery groups. Positive paraaortic lymph node in the first group was 6 cases (11.3) and in the second group was 2 cases (10%). 27 patients were in apparent stage I and 46 patients were in stage II-III-IV of disease. We found positive paraaortic lymph node in 11% of total patients. We found positive paraaortic lymph node without positive pelvic lymph node in two patients. Conclusions: Lymph node dissection will produce a significant benefit in accurate and complete surgical staging; it will reduce residual disease and then progression-free survival.

Clinical Target Volume in Biliary Carcinoma: A Systematic Review of Pathological Studies.

Radiotherapy is a treatment option for both adjuvant and neo-adjuvant settings for biliary tract cancer. Guidelines on the delineation of the target volume of lymph nodes are lacking; only generic indications are available, without specific recommendations for different primary tumour locations (e.g. intrahepatic, extrahepatic biliary tract or gallbladder cancer). The aim of this study was to systematically review available literature to provide recommendations on lymph node target volume delineation in patients with unresectable biliary tumour. A systematic search of electronic databases was performed up to July 2016. The primary outcome measure was the rate of lymph node involvement according to the location of primary biliary tumour. Sites with ≥5% of nodal metastases were considered in the clinical target volume for radiotherapy planning. Twelve studies (1075 patients) were included. The most frequent site of lymph node metastasis in intrahepatic biliary tree carcinoma was retroportal (61.1%, 95% confidence interval (CI)=50.7-70-6%). Other frequently involved lymph nodes were along the hepatoduodenal ligament [frequency=38.7%, 95% CI=31.0-47.0%], those along the common hepatic artery (17.0%, 95% CI=8.2-31.9%) and the hilar nodes (16.9%, 95% CI=13.2-21.4%). In extrahepatic biliary tree cancer, the most frequently involved lymph nodes were the pericholedochal (42.7%, 95% CI=33.8-52.1%) and those along the hepatoduodenal ligament (40.3%, 95% CI=32.4-48.8%). Other commonly involved nodal regions included retroportal lymph nodes (30.9%, 95% CI=23.0-40.1%), pancreaticoduodenal anterior and posterior nodes (30.1%, 95% CI=12.2-57.1%), those along the common hepatic artery (19.7%, 95% CI=11.8-31.0%) and para_aortic nodes (15.2%, 95% CI=8.0-27.0%). The most common site of metastases in gallbladder cancer were the pericholedochal nodes (25.2%, 95% CI=18.6-33.2%), those along the cystic duct (23%, 95% CI=16.6-30.8%), and retroportal nodes (17.1%, 95% CI=11.6-24.5%). Biliary tract cancer has a high propensity for regional lymphatic metastases. An evidence-based nodal target definition of biliary tract cancer based on primary tumour location was proposed.

Aortic utero-ovarian sentinel nodes and left infrarenal aortic lymph node dissection by ICG supported navigation

•Visualization of paraaortic sentinel compartments in endometrial cancer•Nerve sparing dissection of left paraaortic infrarenal lymph compartment•Educational video may be basis for standardization of paraaortic sentinel node dissection.

SC19.02 Invasive Staging of Lung Cancer: EBUS, EUS and Beyond

Despite the advances in surgical treatment and multimodality treatment, lung cancer is still the leading cause of death from malignant disease worldwide. Accurate staging is important not only to determine the prognosis but also to decide the most suitable treatment plan. During the staging process of non-small cell lung cancer (NSCLC), mediastinal lymph node staging is one of the most important factors that affect the patient outcome. Non-invasive staging such as computed tomography (CT) and positron emission tomography (PET) indicate size and metabolic activity, respectively. However imaging alone is inaccurate and therefore tissue sampling is the preferred and most reliable. Surgical staging by mediastinoscopy has been the gold standard for mediastinal lymph node staging but requires general anesthesia and complications cannot be ignored. Endoscopic ultrasound techniques provide a minimally invasive alternative for surgical staging. The current available endoscopic ultrasound techniques for mediastinal staging include transesophageal endoscopic ultrasound guided fine needle aspiration (EUS-FNA) and endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA). Both procedures can be performed in an outpatient setting under local anesthesia. EUS-FNA is a sensitive and safe method of evaluating the inferior mediastinal nodes (stations 7, 8, and 9) and some parts of the anterior mediastinal nodes if the lymph nodes are accessible from the esophagus. However, in spite of the strength of EUS-FNA for evaluating the inferior mediastinal nodes, its ability to evaluate lesions anterior to the trachea is limited. On the other hand, EBUS-TBNA has reach to the paratracheal and subcarinal (stations 2R, 2L, 4R, 4L, 7), as well as the N1 lymph nodes (stations 10, 11, 12). In experienced hands, EBUS can be used through the esophagus for a EUS-like approach to the inferior mediastinal lymph nodes. Thus, EUS-FNA and EBUS-TBNA are complementary methods for lymph node staging in lung cancer and most of the mediastinum and the hilum can be evaluated with these endoscopic procedures. Aortic nodes (stations 5 and 6) are exceptions and must be evaluated by surgical methods (anterior mediastinotomy, VATS, thoracotomy). Based on the current evidence, EBUS-TBNA and EUS-FNA presents a minimally invasive endoscopic procedure as an alternative to mediastinoscopy for mediastinal staging of NSCLC with discrete N2 or N3 lymph node enlargement, provided negative results are confirmed by surgical staging. EBUS-TBNA can access all lymph nodes accessible by mediastinoscopy as well as hilar (N1) lymph nodes. EUS-FNA has access to the inferior mediastinal lymph nodes not accessible by mediastinoscopy. EBUS-TBNA and/or EUS-FNA have in fact replaced mediastinoscopy in many patients with diffuse mediastinal adenopathy, where a simple tissue diagnosis is required to determine treatment. When combined the techniques offer safe and accurate assessment of mediastinum, with accuracy surpassing that of the pervious gold standard – cervical mediastinoscopy. EBUS-TBNA and/or EUS-FNA can also be repeated with ease and have been used for mediastinal restaging in patients who underwent neoadjuvant therapy in preparation for definitive surgical intervention. Ultrasound image analysis of lymph nodes may assist bronchoscopists during EBUS-TBNA or EUS-FNA. Standard sonographic classification of lymph nodes can help characterize mediastinal and hilar lymph nodes as benign or malignant, which may guide the decision on which lymph nodes to sample. Newer imaging technology such as elastography can potentially enhance US guided image analysis of the lymph nodes.

Secondary cytoreductive surgery: surgical approach to bulky aortic nodes, splenic metastases and mesenteric disease

Secondary cytoreductive surgery: surgical approach to bulky aortic nodes, splenic metastases and mesenteric disease

Robotic Versus Laparoscopic Staging for Early Ovarian Cancer: A Case-Matched Control Study

Study ObjectiveTo evaluate the feasibility, surgical outcome, and oncologic results observed after robotic staging compared with conventional laparoscopic staging for patients with early-stage ovarian cancer patients. DesignA retrospective cohort study (Canadian Task Force classification II-2). SettingCatholic University of the Sacred Heart, Rome, Italy. PatientsNinety-six patients underwent minimally invasive staging for presumed stage I ovarian cancer; 32 underwent the robotic approach (cases), and 64 underwent the laparoscopic approach (controls). Measurements and Main ResultsThere was no statistically significant difference between the 2 approaches with regard to final Fédération Internationale de Gynécologie et d'Obstétrique stage, histology, and grade of tumors. In the whole series, 15 patients (15.6%) were upstaged, with no statistically significant difference between the 2 groups. The median number of pelvic lymph nodes removed was 14 (range, 3–42) and 11 (range, 2–29) in the robotic and laparoscopic groups (p = .235), respectively. The median number of aortic lymph nodes removed was 11 (range, 3–26) and 12 (range, 1–39) in the robotic and laparoscopic groups (p = .263), respectively. The operative time was significantly shorter in the robotic group compared with the laparoscopic group (p = .043), whereas the amount of estimated blood loss was similar (p = .691). No difference was found in terms of early and postoperative complications. Overall, 72 patients were considered as requiring adjuvant treatment. Two patients experienced peritoneal recurrence. ConclusionThe present study suggests that there is no relevant difference between the robotic and laparoscopic approaches in staging early-stage ovarian cancer. Further prospective trials are needed to confirm our results.