Complete Pelvic Lymph Node Dissection Research Articles

Assessment of the Diagnostic Value of Sentinel Lymph Node Mapping with Blue Dye (Blue Methylene) with Complete Lymph Node Dissection for Endometrial Cancer Staging Surgery (a Multicenter, Prospective, Cross-Sectional Study)

In gynecological cancers, sentinel lymph node (SLN) mapping has been proposed as an alternative to complete lymph node dissection. The goal of this study was to determine sentinel lymph node mapping's sensitivity, specificity, NPV, and PPV versus gold standard surgery (complete lymph node dissection) in patients with metastatic illness. A total of 26 patients were prospectively enrolled from spring 2021 to winter 2022. Sentinel lymph node mapping with complete pelvic lymph node dissection was done in all of them, and para-aortic lymphadenectomy was detected in 11 (43.33%) patients. At least one sentinel lymph node was successfully mapped in 22 (84.6%) patients. Three patients (11.5%) had positive lymph nodes, with an 85.7% sensitivity (95 percent CI) to detect node positive illness, a specificity of 74.93%, an NPV of 99.6 (99.5 CI), and a PPV of 5.9% calculated. There were no serious adverse effects due to blue dye. The accuracy rate of sentinel lymph node mapping by methylene blue was 75.1%.

Lymph Node Involvement in Early-Stage Cervical Cancer: Is Lymphangiogenesis a Risk Factor? Results from the MICROCOL Study.

Simple SummaryThe prognosis of cervical cancer is significantly influenced by lymph node involvement. The lymphatic system is the primary way of metastasis for cervical carcinoma, and lymph-vascular space invasion (LVSI) is considered the most important risk factor for pelvic lymph node metastasis (PLNM). Previous studies have not clarified the correlation between lymphangiogenesis and an increased risk of metastasis and tumor recurrence. The evaluation and identification of several markers of lymphangiogenesis may identify patients with high risk of PLNM. Our findings suggest that the lymphatic spread does not required the proliferation of new lymphatic endothelial cells. These results emphasize the importance of pre-existing peritumoral lymphatic vessels in the metastatic process in early cervical cancer.Background: In patients with cervical cancer, the presence of tumoral lymph-vascular space invasion (LVSI) is the main risk factor for pelvic lymph node metastasis (PLNM). The objective of this study was to evaluate the presence of several markers of lymphangiogenesis in early-stage cervical cancer and their correlation with PLNM and tumoral recurrence. Materials and Methods: Seventy-five patients with early-stage cervical carcinoma underwent sentinel lymph node (SLN) sampling in association with complete pelvic lymph node dissection. Primary tumors were stained with the following markers: Ki67, D2-40, CD31 and VEGF-C. A 3-year follow-up was performed to evaluate the disease-free survival. Results: Overall, 14 patients (18.6%) had PLNM. Positive LVSI was seen in 29 patients (38.6%). There was a significant correlation between LVSI evidenced by H/E staining and PLNM (p < 0.001). There was no correlation between high Ki67, CD31, D2-40, and VEGF-C staining with PLNM or tumor recurrence. Conclusions: Our data support that lymphatic spread does not require the proliferation of new lymphatic endothelial cells in early-stage cervical cancer. These results emphasize the importance of pre-existing peritumoral lymphatic vessels in the metastatic process in early cervical cancer. None of the markers of lymphangiogenesis and proliferation assessed in this study were predictive of PLNM or recurrence.

Rectal mobilization for laparoscopic pelvic lymphadenectomy of the lower paracervical pathway in patients with uterine cancer.

ObjectiveThe pelvic lymphatic drainage system comprises the upper and lower paracervical pathways (LPPs). Lymph node dissection of the LPP, including the cardinal ligament, internal iliac, internal common iliac, and presacral lymph nodes, requires higher surgical skills because of the anatomical limitations of the pelvic cavity and the dissection of vessels while preserving the nerves in the pelvic floor. In this video, we demonstrate rectal mobilization for laparoscopic complete pelvic lymph node dissection of the LPP in patients with uterine cancer.MethodsRectal mobilization was performed before complete pelvic lymph node dissection of the LPP. The pararectal space was opened widely and the connective tissue between the presacral fascia and prehypogastric nerve fascia was dissected bilaterally, allowing the rectum to be pulled.ResultsThis procedure created a wide-open space in the pelvic floor, allowing clear visualization of the nerves and lymph nodes of the LPP. Laparoscopic complete lymph node dissection of the LPP was performed in the open space while preserving the hypogastric and pelvic splanchnic nerves and isolating the extensive network of blood vessels in the pelvic cavity.ConclusionRectal mobilization enabled the safe execution of laparoscopic complete pelvic lymph node dissection of the LPP in patients with uterine cancer.

Utility of lymphadenectomy in mucinous ovarian carcinoma

Objectives: Mucinous ovarian carcinoma is a rare subtype of epithelial ovarian cancer that, when grossly confined to the ovary, is rarely upstaged after surgical lymph node staging based on relatively small case series. While typically full nodal staging is recommended in all epithelial ovarian cancers, this retrospective data calls into question the risk/benefit ratio of complete surgical staging in mucinous ovarian carcinoma. Given the small numbers of reported fully staged mucinous ovarian cancers, our objective was to report our institution's experience. Methods: Patients at University of Iowa Hospital and Clinics with a histologic diagnosis of mucinous ovarian cancer who underwent complete lymphadenectomy were identified in the Holden Comprehensive Cancer Center Registry between 2000 - 2018. Patient charts were reviewed for demographic, diagnostic, surgical and treatment data. Results: A total of 70 patients were identified with primary mucinous ovarian cancer who underwent surgical nodal staging. All 70 patients underwent complete pelvic lymph node dissection and most (95.7%, n=67) also underwent paraaortic nodal dissection. The median patient age was 54 years and mean tumor size was 20.2 cm. Tumor grades were Grade 1 (40.8%, n=29); Grade 2 (21.1% n=15) and Grade 3 (21.2%, n=15). Most were not categorized as expansile vs. infiltrative type, as this terminology has been more recently adopted. A total of 67 patients had disease confined to the ovary, and 3 had nodal metastases. Of the three patients with nodal involvement, one had obvious metastatic disease at the time of surgery with uterine involvement, omental involvement, and bulky lymphadenopathy. Another had areas of undifferentiated carcinoma within the underlying mucinous carcinoma; the undifferentiated carcinoma was the histologic pattern identified in the lymph nodes. Only one patient with disease intraoperatively confined to the ovary with a purely mucinous histology had nodal involvement. Within 1 month of her staging surgery, this patient was subsequently found to have biopsy proven bony metastases to the iliac, lumbar and sacrum. On retrospective review of her surgical pathology, this was classified as an infiltrative type mucinous carcinoma and pathology would have recommended additional stains to rule out pancreatic or other primary malignancy. Of our 68 patients with intraoperative disease confined to the ovary and pure mucinous histology, only one had nodal metastasis (1.5%) and it did not affect her treatment plan due to short interval development of widely metastatic disease. Download : Download high-res image (234KB) Download : Download full-size image Conclusions: This is the largest case series of fully staged mucinous ovarian cancer patients to date and supports that mucinous ovarian carcinoma grossly confined to the ovary is rarely upstaged by nodal staging and unlikely to change management. It is therefore reasonable to omit lymphadenectomy in early mucinous ovarian carcinoma.

Surgical‐pathologic risk factors of pelvic lymph node metastasis in stage Ib1‐IIb cervical cancer

To study the distribution characteristics and risk factors of cervical cancer lymph node metastasis (LNM). Retrospective study. Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology and Affiliated Hospital to Zunyi Medical College. 404 women diagnosed with cervical cancer FIGO stage Ib1-IIa who underwent primary radical surgery and 104 women with Ib2-IIb tumors treated with neoadjuvant chemotherapy (NACT) before surgery. Clinicopathological data were collected and analyzed. Incidence of infiltration, metastasis and pelvic LNM. In women without NACT, the incidence of infiltration, metastasis and LNM was 7.2, 17.6 and 15.8%, respectively. Metastasis and LNM were significantly associated with advanced FIGO stage and poorer histological grade. The incidence of multiple metastatic lymph nodes (MLNs), bilateral LNM, skip LNM, LNM in primary group and LNM in secondary group was 6.2, 3.0, 6.2%, 11.4 and 4.5%, respectively. Of the 111 MLNs, 13 (11.7%) were common iliac lymph nodes. In the NACT group, infiltration, metastasis and LNM were observed in 10 (9.6%), 24 (23.1%) and 21 (20.1%) of 104 women, respectively. Metastasis and LNM were significantly correlated with moderate cell differentiation. High LNM risk is expected in tumors of IIa stage or higher and in moderately differentiated tumors. Skip metastasis and common iliac LNM are relatively common and therefore should not be neglected. Our results suggest that standardized and complete pelvic lymph node dissection under surgery is an important measure to ensure a therapeutic effect.

Muscle-Invasive Urothelial Carcinoma of the Bladder

Muscle-invasive urothelial (transitional cell) carcinoma is a potentially lethal condition for which an attempt at curative surgery is required. Clinical staging does not allow for accurate determination of eventual pathologic status. Muscle-invasive urothelial carcinoma is a highly progressive disease, and initiation of definitive therapy within 3 months of diagnosis is worthwhile. Age is not a contraindication for aggressive surgical care, and surgical candidates should be evaluated in the context of overall medical comorbidity. In those patients who undergo surgery, clinical pathways may streamline care. Radical cystectomy remains the “gold standard” of therapy, providing 5-year survival rates of 75% to 80% in patients with organ-confined disease, yet organ-sparing procedures demonstrate clinical effectiveness as well. Cystectomy should be undertaken with the intent of performing complete pelvic lymph node dissection and attaining surgically negative margins. In younger female patients, the preservation of reproductive organs may be achieved in many cases. Prostate- and seminal vesicle–preserving cystectomy has been performed, yet the long-term safety and efficacy of such a procedure remains to be determined. Laparoscopic and robotic cystectomy procedures continue to be explored by several investigators. The role of “radical transurethral resection” in muscle-invasive disease is limited to a small cohort of patients, and, when it is performed, cystectomy may be required to consolidate therapy. Postoperative follow-up after cystectomy should occur over short intervals during the first 2 years and can be extended, but not discontinued, beyond that time. Currently, no tumor markers have been prospectively validated to help guide clinical decision making, and prospective trials incorporating marker data should be encouraged.

Detection of Sentinel Lymph Nodes in patients with Early Stage Cervical Cancer

The purpose of this study was to determine the feasibility of identifying the sentinel lymph nodes (SNs) as well as to evaluate factors that might influence the SN detection rate in patients with cervical cancer of the uterus. Eighty nine patients underwent intracervical injection of 1% isosulfan blue dye at the time of planned radical hysterectomy and lymphadenectomy between January 2003 and December 2003. With the visual detection of lymph nodes that stained blue, SNs were identified and removed separately. Then all patients underwent complete pelvic lymph node dissection and/or para-aortic lymph node dissection. SNs were identified in 51 of 89 (57.3%) patients. The most common site for SN detection was the external iliac area. Metastatic nodes were detected in 21 of 89 (23.5%) patients. One false negative SN was obtained. Successful SN detection was more likely in patients younger than 50 yr (p=0.02) and with a history of preoperative conization (p=0.05). However, stage, histological type, surgical procedure and neoadjuvant chemotherapy showed no significant difference for SN detection rate. Therefore, the identification of SNs with isosulfan blue dye is feasible and safe. The SN detection rate was high in patients younger than 50 yr or with a history of preoperative conization.

Advanced clear-cell adenocarcinoma of the bladder successfully treated by radical surgery with adjuvant chemoradiotherapy

A 52-year-old woman was referred to our institute for the evaluation of a tumor in her pelvic cavity. The tumor seemed to have arisen from the bladder or urethra, and bilateral iliac lymphadenopathy was seen. Her urethral mucosa looked intact according to the results of cystourethroscopy. Histopathological examination of the biopsy specimens showed clear-cell adenocarcinoma. She underwent radical cystourethrectomy with complete pelvic lymph node dissection and the construction of a bilateral ureterocutaneostomy. Macroscopically, the tumor had arisen from the trigone of the bladder, and histopathological examination of the tumor revealed adenocarcinoma exhibiting solid clear cells with glandular and papillary patterns. The tumor had infiltrated perivesical structure (pT3a), and metastases in multiple pelvic lymph nodes were recognized (pN3). Postoperatively, three courses of systemic combination chemotherapy with 5-fluouracil (FU) and cisplatin, along with a total of 45 Gy of irradiation during the second course of chemotherapy, were conducted. No evidence of the disease has been seen 28 months after the surgery.

Laparoscopic detection of sentinel lymph nodes followed by lymph node dissection in patients with early stage cervical cancer

Objective The purpose of this study was to investigate the feasibility of sentinel node detection through laparoscopy in patients with early cervical cancer. Furthermore, the results of laparoscopic pelvic lymph node dissection were studied, validated by subsequent laparotomy. Methods Twenty-five patients with early stage cervical cancer who planned to undergo a radical hysterectomy and pelvic lymph node dissection received an intracervical injection of technetium-99m colloidal albumin as well as blue dye. With a laparoscopic gamma probe and with visual detection of blue nodes, the sentinel nodes were identified and separately removed via laparoscopy. If frozen sections of the sentinel nodes were negative, a laparoscopic pelvic lymph node dissection, followed by radical hysterectomy via laparotomy, was performed. If the sentinel nodes showed malignant cells on frozen section, only a laparoscopic lymph node dissection was performed. Results One or more sentinel nodes could be detected via laparoscopy in 25/25 patients (100%). A sentinel node was found bilaterally in 22/25 patients (88%). Histological positive nodes were detected in 10/25 patients (40%). One patient (11%) had two false negative sentinel nodes in the obturator fossa, whereas a positive lymph node was found in the parametrium removed together with the primary tumor. In seven patients (28%), the planned laparotomy and radical hysterectomy were abandoned because of a positive sentinel node. Bulky lymph nodes were removed through laparotomy in one patient, and in six patients only laparoscopic lymph node dissection and transposition of the ovaries were performed. These patients were treated with chemoradiation. In two patients, a micrometastasis in the sentinel node was demonstrated after surgery. Ninety-two percent of all lymph nodes was retrieved via laparoscopy, confirmed by laparotomy. Detection and removal of the sentinel nodes took 55 ± 17 min. Together with the complete pelvic lymph node dissection, the procedure lasted 200 ± 53 min. Conclusion Laparoscopic removal of sentinel nodes in cervical cancer is a feasible technique. If radical hysterectomy is aborted in the case of positive lymph nodes, sentinel node detection via laparoscopy, followed by laparoscopic lymph node dissection, prevents potentially harmful and unnecessary surgery.

MINI‐LAPAROTOMY STAGING PELVIC LYMPH NODE DISSECTION FOR LOCALIZED PROSTATE CANCER

We report our early experience with mini-laparotomy staging pelvic lymph node dissection (PLND) for clinically localized prostate cancer. We have used virtually the same original technique described by Steiner and Marshall. A 5 cm lower midline abdominal incision provides excellent exposure, allowing complete PLND under direct visualization. If radical retropubic prostatectomy is indicated by the state of the pelvic lymph nodes, this can be performed only by extending the same incision. Nine patients with histologically proven prostate cancer underwent mini-laparotomy staging PLND. The average intraoperative time for mini-laparotomy PLND was 33 minutes (range, 25-50 minutes). The intraoperative blood loss was 44 ml (range, 20-90 ml). The mean number of pelvic lymph nodes removed was 6.9 (range, 5-10 nodes) on the right and 10.8 (range, 8-21 nodes) on the left. Eight patients underwent immediate radical retropubic prostatectomy and one had radiation therapy. There were no complications directly related to the mini-laparotomy staging PLND. Mini-laparotomy staging PLND is an attractive alternative to laparoscopic PLND, especially for patients at low risk of lymph node metastasis.

The difficulties of complete pelvic lymph node dissection in radical hysterectomy for carcinoma of the cervix

Three hundred patients with carcinoma of the uterine cervix were treated by radium insertions followed by radical hysterectomy and lymph node dissection. Preoperative lymphography was performed and peroperative radiographs were taken to ensure as complete a dissection as possible. The surgical technique used is described, and a survey is given of the anatomic localization and radiologic appearance of certain lymph nodes which caused particular problems during dissection.