Common Iliac Lymphadenectomy Research Articles

Patterns of lymph node involvement and role of common iliac lymphadenectomy in early-stage cervical cancers: A retrospective analysis from tertiary care cancer center in Eastern India

Aims: The aim of the study was to analyze the patterns of lymph node metastasis in early cervical cancer cases operated and to measure the metastatic burden in common iliac nodes and subsequently assess the need for its dissection. Materials and Methods: The study included all the cases of early carcinoma of cervix (Stage IA to IIA) that were operated in our institute. The cases with positive (metastatic) lymph nodes were isolated incorporating the data in tabular form and the patterns of lymph node metastasis analyzed with special reference to common iliac node involvement. Results: A total of 250 patients were operated in our study cohort and 50 cases (20%) had positive lymph node metastasis. External iliac nodes (58%) were most commonly involved, whereas 20% of cases had common iliac nodal involvement and isolated common iliac nodal involvement was seen only in 8% of these cases. Among all the lymph node positive cases, 74% had two or more of the three intermediate-risk factors including deep stromal invasion, lymphovascular space invasion positivity, or large-sized lesion (>4 cm). All the isolated common iliac lymph node positive cases had either positive parametrium or at least two intermediate-risk factors. Conclusion: Isolated common iliac nodal involvement being very low (8%), and this isolated involvement having been demonstrated only in cases with other risk factors; the role of common iliac lymph node dissection in early-stage cancer cervix becomes questionable.

Inguinal polypropylene plug: A cause of unusual testicular tumor pelvic metastasis

We report the case of a patient who had undergone polypropylene plug placement 3 years before and referred to our institution with testicular tumor. CT scan demonstrated an enlargement of pelvic lymph nodes on the tumor side while retroperitoneal nodes were normal. Orchifunicolectomy was performed and histopathological examination showed a mixed germ cell tumor involving the tunica vaginalis, rete testis, epididymis and spermatic cord. After surgery the patient was addressed to adjuvant chemotherapy according to PEB scheme. Clinical re-staging showed a decrease of the pelvic bulk disease whereas retroperitoneal nodes were still normal and tumor markers were negative. Left external, internal and common iliac lymphadenectomy as well as left modified template nervesparing retroperitoneal lymph node dissection was performed. Intraoperatively the node bulk was firmly adherent to the external iliac artery and extended until the common iliac bifurcation. In the deeper part of this enlarged and firm lymphatic chain the polypropylene plug placed at the time of hernioplasty was found. Behind the plug all retroperitoneal nodes appeared normal and resulted negative on histopathologic examination. The patient had an unusual metastatization, probably due to the plug.

Location of aortic node metastases in locally advanced cervical cancer

BackgroundTo assess the location of aortic node metastasis in patients with locally advanced cervical cancer undergoing extraperitoneal aortic lymphadenectomy to define the extent of the aortic lymphadenectomy. Material and methodsBetween August 2001 and December 2010, 100 consecutive patients with primary locally advanced cervical cancer underwent extraperitoneal laparoscopic aortic and common iliac lymphadenectomy. The location of aortic node metastases, inframesenteric or infrarenal was noted. ResultsThe mean number±standard deviation (SD) of aortic nodes removed was 15.9±7.8 (range 4–62). The mean number±SD of inframesenteric (including common iliac) nodes removed was 8.8±4.5 (range 2–41) and the mean number±SD of infrarenal nodes removed was 7.8±4.1 (range 2–21). Positive aortic nodes were observed in 16 patients, and in 5 (31.2%) of them the infrarenal nodes were the only nodes involved, with negative inframesenteric nodes. ConclusionInframesenteric aortic nodes are negative in the presence of positive infrarenal nodes in about one third of patients with locally advanced cervical cancer and aortic metastases.

Intraoperative frozen section is essential for assessment of myometrial invasion but not for histologic grade confirmation in endometrial cancer: a ten-year experience

To evaluate the accuracy of endometrial biopsy (EB), transvaginal ultrasonography (TVS) and intraoperative frozen section (FS) for assessment of myometrial invasion and histologic grade to predict more conservative surgery in endometrial carcinoma. Demographic and clinical data of 220 patients with endometrial carcinoma were retrospectively reviewed. Preoperatively, the subjects were evaluated by EB and TVS. Intraoperatively, FS was also performed to evaluate histological grading and myometrial invasion. All patients underwent surgical-pathological staging after removal of the uterus, adnexa and pelvic lymph nodes. Sensitivity and specificity values were calculated for EB, TVS and FS with regard to detection of histological grading and neoplastic invasion of the myometrium according to the final histopathologic examination. Bilateral pelvic and common iliac lymphadenectomy was performed in 80 patients without performing intraoperative biopsy because of preoperative high risk. Evaluation of the tumor grade by preoperative EB showed a sensitivity, specificity and accuracy of 73, 97 and 91%, respectively. Evaluation of the tumor grade by intraoperative biopsy showed a sensitivity, specificity and accuracy of 73, 96 and 90%, respectively. Evaluation of the depth of myometrial invasion with TVS showed a sensitivity, specificity and accuracy of 52, 91 and 79%, respectively. Evaluation of the depth of myometrial invasion with intraoperative biopsy showed a sensitivity, specificity and accuracy of 86, 94 and 92%, respectively. Evaluation of the histologic grade by EB and of the depth of myometrial invasion by intraoperative biopsy is a good option for deciding the necessity of lymphadenectomy.

Feasibility of extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy

Objective. The aim of this study is to evaluate the feasibility of extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy for cervical and endometrial carcinoma. Methods. Seventy-six patients underwent extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy between February 1999 and September 2005. The lymph nodes dissected with the laparoscopic procedure included the inframesenteric para-aortic lymph nodes, the sacral lymph nodes, and the bilateral common iliac lymph nodes. The extraperitoneal laparoscopic operation was performed with pelvic open surgery using Lap Disc to ensure the safety of patients. Results. The number of patients with cervical and endometrial carcinoma was 36 and 40, respectively. The median age of patients was 51 years (range 24–75 years). Conversion to open surgery was necessary in 8 patients. These include 3 patients who encountered blood loss of 400, 136 and 128 ml; 2 extremely obese women; and 3 patients who had peritoneal tears causing CO 2 gas leakage. Among the remaining 68 patients, the median operating time for extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy was 75 min (range 45–145 min), and the median estimated blood loss was 5 ml (range 5–138 ml). The median total number of resected nodes was 14 (range 2–31), and 4 patients had lymph node metastasis. No patient encountered postoperative complications attributable to extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy. Conclusions. Extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy with pelvic open surgery using Lap Disc is a feasible procedure, particularly in the surgeons learning phase.

The Use of a Pelvic Displacement Prosthesis to Exclude the Small Intestine from the Radiation Field Following Radical Hysterectomy

Objective. The goal of this study was to develop a device which will elevate the small intestine out of the pelvic cavity during radiation after radical surgery.Methods. A prosthetic device of silicone plastic was designed which conforms to the pelvis. This device is filled with saline and renograffin for X-ray visualization. The capacity of the device is between 750 and 1500 cc. A small bowel contrast radiograph is performed prior to radiation to document exclusion from the radiation field. The device remains in place throughout radiation therapy and is then removed through a small incision after draining the contents of the prosthesis.Results. Seven devices have been placed to date. The patients' age ranged from 35 to 65 years. All women had stage Ib1 carcinoma of the cervix and all underwent a type III radical hysterectomy with bilateral pelvic and common iliac lymphadenectomy. The indication for placement of the device was deep invasion of tumor in five patients, close margin in one patient, and positive pelvic lymph nodes in one patient. The amount of fluid instilled in the device ranged from 960 to 1200 cc. All patients had a return to normal bowel function within 3 days of surgery. All had radiologically documented exclusion of the small intestine from the radiation field prior to beginning radiation. In the postoperative period there was one major complication: a pulmonary embolism documented by pulmonary angiogram on postoperative day 2. All seven patients completed planned radiotherapy. The devices have been removed, with no adhesions to the prosthesis.Conclusions. The results of this study determine that the feasibility, safety, and efficacy of a prosthetic device in displacing the small bowel from the radiation field following radical surgery are sufficient to warrant a large-scale study. The device should be applicable to any and all tumors that require high dose pelvic radiation. It is expected that displacement of the small intestine from the radiation field will diminish overall complications and may allow delivery of radiation doses that approach colon and bladder tolerance.

Laparoscopic radical hysterectomy: A preliminary report

The Laparoscopic Assisted Surgery Program began in 1991 at The Graduate Hospital. Initially, traditional laparoscopic gynecologic procedures were performed including laparoscopic oophorectomy, hysterectomy, and adhesiolysis. We then began staging patients with ovarian and endometrial cancer laparoscopically. Next, a series of patients who underwent laparoscopic extrafascial hysterectomy with lymph node sampling for endometrial cancer was attempted. In June of 1992, we performed what we believe to be the first completely laparoscopic radical hysterectomy and bilateral pelvic and common iliac lymphadenectomy for a stage IB squamous carcinoma of the cervix. To date fourteen of these procedures have been performed with few complications. The complications encountered thus far include narrowing of a right ureter detected by an intravenous pyelogram obtained on postoperative day 10 and a small vesicovaginal fistula. The narrowed right ureter had a retrograde stent placed as a precaution. It would appear that laparoscopic radical hysterectomy in selected patients offers significant advantages in terms of hospitalization, incision size, and wound, pulmonary, and intestinal complications. In addition to the clinical advantages, laparoscopic radical hysterectomy appears to be more cost effective than traditional laparotomy.

Postoperative extended-field irradiation in patients with pelvic and/or common iliac node metastases from cervical carcinoma Stages IB to IIB

Radical hysterectomy with pelvic and common iliac lymphadenectomy was done for 207 Stage IB (148), IIA (19), and IIB (40) cervical carcinomas. Pelvic nodal involvement was limited in 30 (14.5%) cases, whereas common iliac nodes were involved in 16 (7.7%) cases. Common iliac node metastases were significantly increased, when the number of positive pelvic nodes increased from 2 to 3 to 4 or more (21.4% to 73.3%, P < 0.05), when the tumor invaded deeper than 20 mm (3.7% to 22.2%, P < 0.001), and when the tumor extended into parametrial tissues (4.8% to 14.8%, P < 0.05). Postoperative extended-field irradiation was administered to 40 patients with nodal metastases. The 3-year disease-free rates were 85% in 24 patients with positive pelvic nodes, and 51% in 16 patients with common iliac node metastases; 70% in total. These results indicate that postoperative extended-field irradiation is essential for those patients with nodal metastases from locally resectable cervical carcinomas.