Pelvic Node Involvement Research Articles

External validation of the Memorial Sloan Kettering Cancer Centre and Briganti nomograms for the prediction of lymph node involvement of prostate cancer using clinical stage assessed by magnetic resonance imaging.

To evaluate the impact of using clinical stage assessed by multiparametric magnetic resonance imaging (mpMRI) on the performance of two established nomograms for the prediction of pelvic lymph node involvement (LNI) in patients with prostate cancer. Patients undergoing robot-assisted extended pelvic lymph node dissection (ePLND) from 2015 to 2019 at three teaching hospitals were retrospectively evaluated. Risk of LNI was calculated four times for each patient, using clinical tumour stage (T-stage) assessed by digital rectal examination (DRE) and by mpMRI, in the Memorial Sloan Kettering Cancer Centre (MSKCC; 2018) and Briganti (2012) nomograms. Discrimination (area under the curve [AUC]), calibration, and the net benefit of these four strategies were assessed and compared. A total of 1062 patients were included, of whom 301 (28%) had histologically proven LNI. Using DRE T-stage resulted in AUCs of 0.71 (95% confidence interval [CI] 0.70-0.72) for the MSKCC and 0.73 (95% CI 0.72-0.74) for the Briganti nomogram. Using mpMRI T-stage, the AUCs were 0.72 (95% CI 0.71-0.73) for the MSKCC and 0.75 (95% CI 0.74-0.76) for the Briganti nomogram. mpMRI T-stage resulted in equivalent calibration compared with DRE T-stage. Combined use of mpMRI T-stage and the Briganti 2012 nomogram was shown to be superior in terms of AUC, calibration, and net benefit. Use of mpMRI T-stage led to increased sensitivity for the detection of LNI for all risk thresholds in both models, countered by a decreased specificity, compared with DRE T-stage. T-stage as assessed by mpMRI is an appropriate alternative for T-stage assessed by DRE to determine nomogram-based risk of LNI in patients with prostate cancer, and was associated with improved model performance of both the MSKCC 2018 and Briganti 2012 nomograms.

677 Incidental Diagnosis of Metastatic Prostate Cancer by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration (EBUS-TBNA) In the Absence of Pelvic Lymphadenopathy

Abstract Metastasis pattern of prostate cancer varies widely; however, predominant affinity is towards regional lymph nodes. Mediastinal lymphadenopathy as the initial presentation, in absence of any pelvic lymph node involvement, remains extremely rare. Most patients are incidentally diagnosed and often have widespread metastatic disease on confirmation of diagnosis. A high index of clinical suspicion is necessary and routine clinical examination such as a digital rectal examination (DRE) can aid in earlier diagnosis and prompt clinical intervention can improve disease outcome. We present this case study of a 53-year-old patient who was incidentally diagnosed with metastatic adenocarcinoma of prostatic origin by TBUS-EBNA of hilar lymph nodes in the absence of pelvic lymphadenopathy.

Pretreatment [18F]FDG PET/CT Prognostic Factors in Patients with Squamous Cell Cervical Carcinoma FIGO IIIC1.

Purpose: This study aims to determine whether semiquantitative parameters obtained from both the primary tumor and metastatic pelvic lymph nodes (PLN) diagnosed in fluoro-18-deoxy-glucose positron emission tomography (FDG-PET-CT) are associated with disease-free survival (DFS), local control (LC), distant metastasis-free survival (DMFS) and overall survival (OS) in patients with locally advanced squamous cervical cancer (LACC) and metastatic pelvic lymph nodes. Materials: Retrospective analysis was performed on 93 female patients with FIGO IIIC1. The median age was 53 years (27–75). The PET parameters both in the primary tumor and metastatic pelvic lymph nodes, including SUVmax, SUVmean, TLG, MTV, heterogeneity, along with clinical variables, before radical cisplatin-based radiochemotherapy (RCT) were analyzed. The p-values < 0.05 were considered statistically significant. Results: Median follow-up was 38 months (4.5–92.6). Three years and five years OS were 75% and 70% respectively. Patients with SUVmax above 12.6, SUVmean above 7.6 and with TLG in tumors >245.7 lived longer (p < 0.05). The higher SUVmax or SUVmean reduced increased DMFS (HR 0.3 95%CI 0.56–0.96 and 0.59 95%CI 0.37–0.93). The clinical factors and other FDG PET CT parameters were not found to be statistically relevant in terms of OS, DFS, DM and LC. Conclusions: This study is the first report showing that in LACC patient population with PLN involvement treated with definitive RCT, high SUVmean, SUVmax and TLG of the primary tumor in FDG-PET-CT were linked with longer OS. Lower SUVmean and SUVmax were linked with shorter DMFS. None of the clinical factors and the nodal FDG-PET-CT parameters influenced the outcome.

Role of Pelvic Lymph Node Resection in Vulvar Squamous Cell Cancer: A Subset Analysis of the AGO-CaRE-1 Study

BackgroundAs the population at risk for pelvic nodal involvement remains poorly described, the role of pelvic lymphadenectomy (LAE) in vulvar squamous cell cancer (VSCC) has been a matter of discussion for decades.MethodsIn the AGO-CaRE-1 study, 1618 patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB or higher primary VSCC treated at 29 centers in Germany between 1998 and 2008 were documented. In this analysis, only patients with pelvic LAE (n = 70) were analyzed with regard to prognosis and correlation between inguinal and pelvic lymph node involvement.ResultsThe majority of patients had T1b/T2 tumors (n = 47; 67.1%), with a median diameter of 40 mm (2–240 mm); 54/70 patients (77.1%) who received pelvic LAE had positive groin nodes. For 42 of these 54 patients, the number of affected groin nodes had been documented as a median of 3; 14/42 (33.3%) of these patients had histologically confirmed pelvic nodal metastases (median number of affected pelvic nodes 3 [1–12]). In these 14 patients, the median number of affected groin nodes was 7 (1–30), with a groin metastases median maximum diameter of 42.5 mm (12–50). Receiver operating characteristic analysis showed an area under the curve of 0.85, with 83.3% sensitivity and 92.6% specificity for the prediction of pelvic involvement in cases of six or more positive groin nodes. No cases of pelvic nodal involvement without groin metastases were observed. Prognosis in cases of pelvic metastasis was poor, with a median progression-free survival of only 12.5 months.ConclusionFor the majority of node-positive patients with VSCC, pelvic nodal staging appears unnecessary since a relevant risk for pelvic nodal involvement only seems to be present in highly node-positive disease.

The influence of 68Ga-prostate-specific membrane antigen PET/computed tomography on prostate cancer staging and planning of definitive radiation therapy.

Prostate-specific membrane antigen (PSMA) PET/computed tomography (CT) is a novel imaging tool with an evolving role in the management of prostate cancer. This study aims to retrospectively evaluate the impact of 68Ga-PSMA PET/CT on prostate cancer staging and definitive radiation therapy planning. Between April 2015 and June 2020, 366 men with prostate cancer were evaluated with 68Ga-PSMA PET/CT. Of these, 108 patients had PSMA PET/CT before radiation therapy. Radiation was given as primary treatment in 58 (54%) and as salvage radiation therapy for biochemical recurrence after primary surgery in 50 (46%) patients, respectively. Patient and disease characteristics were analyzed, and impact of PSMA PET/CT on disease staging and radiotherapy planning was evaluated in comparison to conventional imaging. Median age at presentation was 69 years, and median prostate-specific antigen was 18 ng/mL (3.6-400) for primary and 0.4 ng/mL (0.1-4.6) for salvage radiation, respectively. The combined change of disease stage rate was 36% (39/108) with 45% (26/58) in the subgroup of primary radiation and 26% (13/50) in the patients intended for salvage radiation. Upstaging was found in 24 (22%) and downstaging in 15 (14%) patients. Radiation planning was changed based on PSMA PET/CT in 34 (31%) patients, including 7 (6.4%) patients in which stereotactic body radiotherapy (SBRT) was added to oligometastatic sites. The radiation field was extended to include pelvic lymph node involvement in 21 patients. 68Ga-PSMA PET/CT changed the prostate cancer stage in around one-third of men. PSMA PET/CT significantly impacted radiation planning. Further prospective studies are still required.

Association between percentage of positive biopsy cores and risk of pelvic lymph node involvement in prostate cancer.

205 Background: Commonly used tools for predicting the risk of pelvic lymph node involvement (LNI) in prostate cancer often do not incorporate information on the percentage of positive biopsy cores (PPB). To better inform the use of elective nodal irradiation in the definitive treatment of prostate cancer, we examined the association between PPB and risk of pathologic pelvic LNI in men with prostate cancer who underwent radical prostatectomy (RP). Methods: We identified 109,577 men from the National Cancer Database who were diagnosed in 2010-2015 with cN0M0 prostate cancer, had 6-24 cores sampled at biopsy, and underwent RP with pathologic nodal evaluation. Multivariable logistic regression was used to examine the association between PPB and the likelihood of having ≥1 positive pelvic lymph node, adjusting for other known clinicopathologic prognostic variables. Results: Overall, 4.0% (4,340) of the cohort was found to have pelvic LNI at the time of RP. Higher PPB was associated with an increased risk of pelvic LNI (adjusted odds ratio [AOR] 1.75 for 25.1-50.0% PPB, 2.63 for 50.1-75.0% PPB, and 4.49 for 75.1-100.0% PPB vs. ≤25.0% PPB, all P&lt;0.001). Notably, men with Gleason 8 disease and ≤25.0% PPB only had a 3.6% risk of pelvic LNI, whereas men with Gleason 9-10 disease and 75.1-100.0% PPB had a 32.6% risk (Table). Other factors associated with the likelihood of pelvic LNI included a higher biopsy Gleason score (AOR 1.43 for Gleason 8 and 2.84 for Gleason 9-10 vs. Gleason 4+3, both P&lt;0.001), more advanced clinical tumor stage (AOR 1.48 for cT2, 1.97 for cT3, and 3.87 for cT4 vs. cT1, all P&lt;0.001), and a higher PSA (AOR 1.90 for 10.0-19.9 ng/mL, 2.40 for 20.0-39.9 ng/mL, and 2.60 for ≥40.0 ng/mL vs. &lt;10.0 ng/mL, all P&lt;0.001), but not more advanced age (AOR 0.98 for &gt;62 years [median] vs. ≤62 years, P=0.59) or black vs. white race (AOR 0.99, P=0.92). Conclusions: There was a statistically significant and clinically relevant association between increasing PPB and a higher risk of pelvic LNI. As the ongoing RTOG 0924 randomized trial matures, clinicians should consider incorporating information on PPB in determining which patients with prostate cancer may benefit from receiving radiation therapy to the pelvic lymph nodes. [Table: see text]

DASL-HiCaP: Darolutamide augments standard therapy for localized very high-risk cancer of the prostate (ANZUP1801)—A randomized phase III double-blind, placebo-controlled trial of adding darolutamide to androgen deprivation therapy and definitive or salvage radiation.

TPS266 Background: Radiation therapy (RT), plus androgen deprivation therapy (ADT) with a luteinizing hormone releasing hormone analogue (LHRHA), is standard of care for men with very high-risk localized prostate cancer (PC), or with very high- risk features and persistent PSA after radical prostatectomy (RP). Despite this, incurable distant metastases develop within 5 years in 15% of men with very high-risk features. Darolutamide is a structurally distinct oral androgen receptor antagonist with low blood-brain-barrier penetration, a demonstrated favorable safety profile and low potential for drug-drug interactions. Our aim is to determine the efficacy of adding darolutamide to ADT and RT in the setting of either primary definitive therapy, or adjuvant therapy for very high-risk PC. Methods: This study is a randomized (1:1) phase III placebo-controlled, double-blind trial for men planned for RT who have very high-risk localized PC; or very high-risk features with PSA persistence or rise within one year following RP. The trial will be stratified by: RP; use of adjuvant docetaxel; pelvic nodal involvement. 1100 participants will be randomized to darolutamide 600 mg or placebo twice daily for 96 weeks. Participants will receive LHRHA for 96 weeks, plus RT starting week 8-24 from randomisation. Participants are allowed nonsteroidal antiandrogen (up to 90 days) in addition to LHRHA up until randomisation. Early treatment with up to 6 cycles of docetaxel completed at least 4 weeks prior to RT is permitted. The primary endpoint is metastasis-free survival (ICECaP-validated), with secondary endpoints overall survival, PC-specific survival, PSA-progression free survival, time to subsequent hormonal therapy, time to castration-resistance, frequency and severity of adverse events, health related quality of life, fear of recurrence. Tertiary endpoints include incremental cost-effectiveness, and identification of prognostic and/or predictive biomarkers of treatment response, safety and resistance to study treatment. Clinical trial information: NCT04136353.

Long-Term Outcomes of Cervical Cancer Patients Treated With Definitive Chemoradiation Following a Complete Metabolic Response

AimsA complete metabolic response (CMR) on early post-treatment 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is a positive prognostic factor for cervical cancer patients treated with definitive chemoradiation, but long-term outcomes of this group of patients are unknown. Patterns of failure and risk subgroups are identified. Materials and methodsPatients who received curative-intent chemoradiation from 1998 to 2018 for International Federation of Gynecology and Obstetrics (FIGO) stage IB1–IVA cervical cancer and had a CMR on post-treatment FDG-PET within 5 months of treatment completion were included. Cox proportional hazards models determined factors associated with locoregional and distant failure. Kaplan–Meier estimates of freedom from any recurrence (FFR) of patient subgroups were compared with Log-rank tests. ResultsThere were 402 patients with a CMR after chemoradiation on FDG-PET. Initial T stage was T1 (38%)/T2 (40%)/T3 (20%)/T4 (2%); initial FDG-avid nodal status was no nodes (50%)/pelvic lymph nodes (40%)/pelvic and para-aortic lymph nodes (10%). After a median follow-up of 6 years, 109 (27%) recurred. The pattern of recurrence was locoregional (27%), distant (61%) or both (12%). No factors were associated with locoregional failure. Distant recurrence was more likely in patients with T3–4 lesions (hazard ratio = 2.4, 95% confidence interval 1.5–3.8) and involvement of pelvic (hazard ratio = 1.6, 95% confidence interval 1.0–2.7) or para-aortic lymph nodes (hazard ratio = 2.7, 95% confidence interval 1.4–5.0) at diagnosis. The 5-year FFR rates for T1–2 patients with no nodes, pelvic nodes alone or para-aortic nodes at diagnosis were 85, 76 and 62%, respectively (P = 0.04, none versus para-aortic nodes). The 5-year FFR for T3–4 patients with no nodes, pelvic nodes alone or para-aortic nodes at diagnosis were 68, 56 and 25%, respectively (P = 0.09, none versus para-aortic nodes). ConclusionsT3–4 tumours and para-aortic nodal involvement at diagnosis are poor prognostic factors, even after a CMR following chemoradiation.

False negative rate at 18F-FDG PET/CT in para-aortic lymphnode involvement in patients with locally advanced cervical cancer: impact of PET technology

BackgroundThe identification of factors responsible for false negative (FN) rate at 18F- Fluorodeoxyglucose (FDG) Positron Emission Tomography /Computed Tomography (PET/CT) in para-aortic (PA) lymph nodes in the presurgical staging of patients with locally advanced cervical cancer (LACC) is challenging. The aim of this study was to evaluate the impact of PET/CT technology.MethodsA total of 240 consecutive patients with LACC (International Federation of Gynecology and Obstetrics, FIGO, stage IB2-IVA) and negative Magnetic Resonance Imaging (MRI) and/or Computed Tomography (CT) and negative 18F-FDG PET/CT in the PA region, undergoing laparoscopic PA lymphadenectomy before chemoradiotherapy were included. The FN rate in patients studied with Time of flight (TOF) PET/CT (TOF PET) or non-Time of flight PET/CT (no-TOF PET) technology was retrospectively compared.ResultsPatients presented with FIGO stage IB (n = 78), stage IIA-B (n = 134), stage III (n = 18) and stage IVa (n = 10), squamous cell carcinoma (n = 191) and adenocarcinoma (n = 49). 141/240 patients were evaluated with no-TOF PET/CT and 99/240 with TOF PET/CT. Twenty-two patients (9%) had PA nodal involvement at histological analysis and considered PET/CT FN findings. The FN rate was 8.5% for no-TOF PET and 10% for TOF PET subgroup respectively (p = 0.98). Ninety patients (38%) presented with pelvic node uptakes at PET/CT. The FN rate in the PA region was 18% (16/90) and 4% (6/150) in patients with and without pelvic node involvement at PET/CT respectively (19 vs 3% for no-TOF PET and 17 vs 5% for TOF PET subgroup).ConclusionsIn LACC, FN rate in PA lymph nodes detection is a clinical issue even for modern PET/CT, especially in patients with pelvic uptake. Surgical lymphadenectomy should be performed in case of negative PET/CT at PA level in these patients, while it could be discussed in the absence of pelvic uptake.

Biochemical control after adjuvant radiation therapy for prostate cancer: a\xa0unicentric, retrospective analysis

PurposeTo retrospectively evaluate the biochemical no evidence of disease (bNED) and late side effects after adjuvant radiotherapy in prostate cancer patients.MethodsPatients (n = 85) treated with external beam radiotherapy between 1997 and 2013 following radical prostatectomy (RPE) with pathological tumour stage pT2c with positive surgical margins or pT3 and pT4 tumours with or without positive margins who presented with a postoperative and a preradiation prostate-specific antigen (PSA) level below 0.1 ng/ml. The mean dose applied was 66 Gy with conventional fractionation (4 field box-technique). No androgen deprivation therapy was administered, and patients with incomplete data (missing Gleason score, pT stage, or PSA values postoperatively and/or prior to radiation at the presentation at our department) have been excluded from the analysis. Biochemical recurrence was defined as reaching a PSA level > 0.2 ng/ml during follow-up and bNED rates were assessed. In addition, patients were divided into two groups according to the Roach formula for predicting the risk of pelvic node involvement at a cut-off value of 15%. Late urogenital and gastrointestinal side effects (EORTC/RTOG) were assessed.ResultsAfter a median follow-up of 60 months the bNED rate was 88% at 5 years and 72% at 10 years for all patients. Patients with low risk of lymph node involvement (group < 15%) had a 5 year and 10 year bNED of 97% and 85%, while patients with high risk of positive lymph node involvement (group > 15%) showed corresponding bNED rates of 77% and 52%, respectively. A significant difference according to the Roach stratification was detected (p ≤ 0.002). Late urogenital (UG) and gastrointestinal (GI) grade ≥ 2 side effects were detected in 10% and 15%, respectively.ConclusionPostoperative radiotherapy with an average dose of 66 Gy to the prostatic fossa following RPE provides excellent tumour control rates with acceptable side effects. Patients with a higher risk of positive lymph nodes (> 15%) according to the Roach formula show significant worse tumour control rates.

Diagnostic efficiency of whole-body 18F-FDG PET/MRI, MRI alone, and SUV and ADC values in staging of primary uterine cervical cancer

BackgroundThe use of PET/MRI for gynecological cancers is emerging. The purpose of this study was to assess the additional diagnostic value of PET over MRI alone in local and whole-body staging of cervical cancer, and to evaluate the benefit of standardized uptake value (SUV) and apparent diffusion coefficient (ADC) in staging.MethodsPatients with histopathologically-proven cervical cancer and whole-body 18F-FDG PET/MRI obtained before definitive treatment were retrospectively registered. Local tumor spread, nodal involvement, and distant metastases were evaluated using PET/MRI or MRI dataset alone. Histopathology or clinical consensus with follow-up imaging were used as reference standard. Tumor SUVmax and ADC were measured and SUVmax/ADC ratio calculated. Area under the curve (AUC) was determined to predict diagnostic performance and Mann-Whitney U test was applied for group comparisons.ResultsIn total, 33 patients who underwent surgery (n = 23) or first-line chemoradiation (n = 10) were included. PET/MRI resulted in higher AUC compared with MRI alone in detecting parametrial (0.89 versus 0.73), vaginal (0.85 versus 0.74), and deep cervical stromal invasion (0.96 versus 0.74), respectively. PET/MRI had higher diagnostic confidence than MRI in identifying patients with radical cone biopsy and no residual at hysterectomy (sensitivity 89% versus 44%). PET/MRI and MRI showed equal AUC for pelvic nodal staging (both 0.73), whereas AUC for distant metastases was higher using PET/MRI (0.80 versus 0.67). Tumor SUVmax/ADC ratio, but not SUVmax or ADC alone, was significantly higher in the presence of metastatic pelvic lymph nodes (P < 0.05).ConclusionsPET/MRI shows higher accuracy than MRI alone for determining local tumor spread and distant metastasis emphasizing the added value of PET over MRI alone in staging of cervical cancer. Tumor SUVmax/ADC ratio may predict pelvic nodal involvement.

CT diagnosis of ilioinguinal lymph node metastases in melanoma using radiological characteristics beyond size and asymmetry.

BackgroundDiagnosis of lymph node (LN) metastasis in melanoma with non-invasive methods is challenging. The aim of this study was to evaluate the diagnostic accuracy of six LN characteristics on CT in detecting melanoma-positive ilioinguinal LN metastases, and to determine whether inguinal LN characteristics can predict pelvic LN involvement.MethodsThis was a single-centre retrospective study of patients with melanoma LN metastases at a tertiary cancer centre between 2008 and 2016. Patients who had preoperative contrast-enhanced CT assessment and ilioinguinal LN dissection were included. CT scans containing significant artefacts obscuring the pelvis were excluded. CT scans were reanalysed for six LN characteristics (extracapsular spread (ECS), minimum axis (MA), absence of fatty hilum (FH), asymmetrical cortical nodule (CAN), abnormal contrast enhancement (ACE) and rounded morphology (RM)) and compared with postoperative histopathological findings.ResultsA total of 90 patients were included. Median age was 58 (range 23–85) years. Eighty-eight patients (98 per cent) had pathology-positive inguinal disease and, of these, 45 (51 per cent) had concurrent pelvic disease. The most common CT characteristics found in pathology-positive inguinal LNs were MA greater than 10 mm (97 per cent), ACE (80 per cent), ECS (38 per cent) and absence of RM (38 per cent). In multivariable analysis, inguinal LN characteristics on CT indicative of pelvic disease were RM (odds ratio (OR) 3.3, 95 per cent c.i. 1.2 to 8.7) and ECS (OR 4.2, 1.6 to 11.3). Cloquet’s node is known to be a poor predictor of pelvic spread. Pelvic LN disease was present in 50 per cent patients, but only 7 per cent had a pathology-positive Cloquet’s node.ConclusionAdditional CT radiological characteristics, especially ECS and RM, may improve diagnostic accuracy and aid clinical decisions regarding the need for inguinal or ilioinguinal dissection.

Prospective Non-randomized Control Trial on Role of Systematic High Para-Aortic Lymphadenectomy in Endometrial Cancer: Indian Study

Endometrial cancer (EC) accounts for approximately 10% of all cancers in females and is the second most common gynecologic cancer. The primary goal of surgical staging in EC is to identify extrauterine disease. Pelvic and para-aortic lymph node dissection (PLND and PaLND) is the gold standard in the detection of lymph node metastases in EC. However, there is still no uniformity worldwide regarding the scope and extent of lymph node dissection in EC. The present prospective non-randomized study was conducted to establish the importance of systematic lymphadenectomy (LND), especially PaLND above the inferior mesenteric artery (IMA), and to identify the risk factors associated with lymph node metastasis. A total of 210 patients with EC were included. All patients underwent comprehensive surgical staging which included simultaneous PLND and PaLND. In addition for non-endometrioid, additional omental and peritoneal biopsies were also performed. PLND consisted of complete removal of common iliac, external iliac, internal iliac and obturator lymph nodes as per standard techniques. The extent of PaLND was up to the renal veins. Pelvic lymph nodes (PLN), para-aortic lymph nodes (PaLN) harvested below the IMA and PaLN dissected above the IMA were labeled separately and submitted for histopathological examination (HPE). Patient’s demographic factors, surgical outcomes and tumor histological findings were tabulated for analysis. Patients diagnosed with EC were most commonly in their seventh decade (59.5%). The mean time for LND was 35 min. In 66% of the cases with positive PLN, the PaLN was also positive. Twenty-nine (13.8%) patients had both PLN and PaLN involvement. In all cases of positive PaLN, the nodes between IMA and renal veins were the only positive nodes. In 15 (7.1%) patients, PaLN were the only positive nodes. The mean PaLN yield was 9.1. Predictors of PaLN positivity were pelvic node positivity, Grade III tumors and lymphovascular space invasion (LVSI). Major complications observed were wound infection, paralytic ileus and subacute intestinal obstruction. In oncology, a good loco-regional control has the greatest impact on survival. Systematic para-aortic lymphadenectomy done with good surgical technique results in minimal morbidity and mortality without any additional blood transfusion requirement. The trend toward greater use of complete surgical staging has been accompanied by a judicious use of adjuvant therapy. This has led to marked decrease in the use of pelvic radiation therapy and its complications and has a significant impact on the cost of treatment.

Herpes zoster infection mimicking pelvic lymph node metastasis on FDG-PET/CT in a patient with cervical cancer.

Although 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) is an established method for the staging of malignancies, benign lesions (e.g, active inflammatory lesions) often show increased metabolic activity. Herpes zoster is the clinical manifestation of the activation and replication of dormant varicella-zoster virus (VZV) in individuals with decreased cell-mediated immunity. Although the diagnosis of herpes zoster is clinical, it is sometimes observed incidentally during imaging for another disease. We describe the case of a 67-year-old Japanese female patient diagnosed with cervical cancer in whom FDG-PET/CT revealed herpes zoster manifestations: hypermetabolic cutaneous lesions in the buttock and pelvic lymph node involvement. The resected lymph nodes showed no malignant lesions but revealed lymphoid follicle formation, probably related to viral infection. There has been no report comparing FDG-PET findings of lymph nodes with histologic findings; the present findings are compatible with a clinically VZV-induced inflammatory reaction in regional lymph nodes, which increased FDG accumulation. Active infection with VZV displays increased FDG uptake in regional lymph nodes and may lead to incorrect malignant disease management in oncology. Misdiagnoses can be avoided by a careful interpretation by experienced nuclear medicine physicians as well as proper clinical evaluation.

Pelvic Exenteration in Patients with Persistent and Recurrent Cervical Cancer: A Case Series from Belarus

ABSTRACT Introduction: The prognosis of patients with persistent or recurrent cervical cancer (CC) is poor, and patient selection for exenterative surgery is challenging. The aim of this study was to determine the outcomes of patients undergoing pelvic exenteration (PE) for persistent or recurrent CC after treatment with radiotherapy in Belarus. Methods: A retrospective study was performed of 22 patients with persistent and recurrent CC who underwent supralevator PE from 2006 to 2012 at NN Alexandrov National Cancer Centre. Anterior PE was performed in 16 (72.7%) patients, posterior PE in 2 (9.1%) and total PE in 4 (18.2%) patients. Results: The mean surgical procedure time was 289.1 minutes. Urinary diversion was performed in 20 patients: 5 (25.0%) underwent ureterostomy and 15 (75.0%) underwent neobladder formation. Fecal diversion with end colostomy (Hartman’s procedure) was performed in 5 patients and in one patient a rectosigmoid resection with anastomosis was performed. The median follow-up time was 87 months (range, 4.4–146.0 months). To date, 16 (72.7%) patients have died of cervical cancer and there were no deaths due to other causes. The median survival was 17 months with a 5-year survival rate of 31.8% (SE 9.9%). Cox regression analysis showed that surgical margin status and pelvic lymph node involvement were independent risk factors for survival. Conclusions: PE was found to be a safe and feasible option for patients with persistent or recurrent cervical cancer who do not have other potentially curative treatment options. Careful patient selection is needed to determine which patients will benefit from this treatment. Highlights:

Evaluation of Total Mesorectal Excision With or Without Lateral Pelvic Lymph Nodes Dissection for Middle and Lower Rectal Cancer

Background: The most important prognostic factor in colorectal cancer is nodal status, and lymph node metastasis is a determining factor for adjuvant chemotherapy and subsequently key to predicting disease free and overall survival. Methods: A descriptive prospective study was conducted on 40 patients presenting with middle and low rectal cancer to the outpatient clinic of Menoufia University Hospitals. All patients in the study will require resection of their tumors by total mesorectal excision by open and laparoscopic techniques. Patients will be divided into 2 groups: Group A: was operated without lateral pelvic lymph nodes dissection. Group B: was operated with lateral pelvic lymph nodes dissection during the period between November 2018 and November 2020. Results: The main presentation of patients was bleeding per rectum 12 (30%), 12 (30%) patients have constipation. 28 patients with adenocarcinoma (70%) and 8 mucinous (20 %) and 4 (10%) with signet ring. Sixteen patients undergo Low ant resection (40%), 16 patients with AP. resection (40 %) and 8 patients with Intersphencteic resection (20%). Regarding intraoperative data, with a mean operative time was (90.00 ± 3.84 min.) for without Lateral pelvic L.N dissection and (122.91±4.89 min.) for with Lateral pelvic L.N dissection. Conclusion: Surgical mortality of LPLD is low, but there is an increase of morbidities in the form of prolonged operative time, intraoperative blood loss and genito-urinary malfunction. For avoiding the drawbacks of LPLD extended lymphadenectomies with sparing of the pelvic nerves is recommended. Lateral pelvic lymph node involvement is a regional disease that is curable. LPLD was effective to control recurrence at lateral nodes sites.

Pelvic Lymphadenectomy in Vulvar Cancer - Does it make sense?

Since the publication of the updated German guideline in 2015, the recommendations for performing pelvic lymphadenectomy (LAE) in patients with vulvar cancer (VSCC) have changed considerably. The guideline recommends surgical lymph node staging in all patients with a higher risk of pelvic lymph node involvement. However, the current data do not allow the population at risk to be clearly defined, therefore, the indication for pelvic lymphadenectomy is still not clear. There are currently two published German patient populations who had pelvic LAE which can be used to investigate both the prognostic effect of histologically verified pelvic lymph node metastasis and the relation between inguinal and pelvic lymph node involvement. A total of 1618 patients with primary FIGO stage ≥ IB VSCC were included in the multicenter AGO CaRE-1 study (1998 – 2008), 70 of whom underwent pelvic LAE. During a retrospective single-center evaluation carried out at the University Medical Center Hamburg-Eppendorf (UKE), a total of 514 patients with primary VSCC treated between 1996 – 2018 were evaluated, 21 of whom underwent pelvic LAE. In both cohorts, around 80% of the patients who underwent pelvic LAE were inguinally node-positive, with a median number of three affected groin lymph nodes. There were no cases of pelvic lymph node metastasis without inguinal lymph node metastasis in either of the two cohorts. Between 33 – 35% of the inguinal node-positive patients also had pelvic lymph node metastasis; the median number of affected groin lymph nodes in these patients was high (> 4), and the maximum median diameter of the largest inguinal metastasis was > 40 mm in both cohorts. Pelvic lymph node staging and pelvic radiotherapy is therefore probably not necessary for the majority of node-positive patients with VSCC, as the relevant risk of pelvic lymph node involvement was primarily found in node-positive patients with high-grade disease. More, ideally prospective data collections are necessary to validate the relation between inguinal and pelvic lymph node involvement.

Adjuvant Chemotherapy After Concurrent Chemoradiotherapy for Pelvic Lymph Node-Positive Cervical Squamous Cell Carcinoma

Distant metastasis predominates the failure pattern of patients with pelvic lymph node (PLN)-positive cervical cancer. This study evaluated whether adjuvant chemotherapy (ACT) yields better treatment outcomes than observation after concurrent chemoradiotherapy (CCRT) for patients with (PLN)-positive cervical squamous cell carcinoma (SCC). The records of 159 patients with PLN-positive cervical SCC treated with CCRT between March 2007 and February 2018 were retrospectively reviewed. Patients with metastatic para-aortic lymph nodes and/or distant metastasis were excluded. The ACT regimens consisted of 5-Fluorouracil plus cisplatin and paclitaxel plus cisplatin. Treatment outcomes were compared according to the use of ACT before and after propensity score matching. Among the 159 eligible patients, 141 patients (88.7%) underwent CCRT and 42 patients underwent a median of 2 ACT cycles (range: 1-6 cycles) using cisplatin-based doublet chemotherapy. The median follow-up period was 33.8 months (range: 2.9-113.0 months). In multivariate analysis, poor overall survival was independently predicted by larger PLN size (≥15mm) and common iliac lymph node involvement. After propensity score matching, none of the patients was over 65 years old. The ACT group had non-significantly better estimated 3-year rates of overall survival (83.0% and 63.7%, p = 0.173), progression-free survival (80.2% and 60.4%, p = 0.071), local control (94.0% and 81.9%, p = 0.123), as well as a significantly better estimated 3-year rate of distant metastasis-free survival (DMFS) (85.9% and 60.1%, p = 0.040). Grades 3-4 neutropenia were significantly more common in the ACT group (38.1% versus 17.9%, p = 0.008). ACT significantly improved DMFS and tended to improve progression-free survival with tolerable toxicities in patients with PLN-positive cervical SCC. Further studies are needed to verify these findings and clarify the relationship between PLN involvement and prognosis in patients with cervical cancer.

Association Between Percentage of Positive Biopsy Cores and Risk of Pelvic Lymph Node Involvement in Prostate Cancer

Association Between Percentage of Positive Biopsy Cores and Risk of Pelvic Lymph Node Involvement in Prostate Cancer

694TiP DASL-HiCaP: Darolutamide augments standard therapy for localised very high-risk cancer of the prostate (ANZUP1801). A randomised phase III double-blind, placebo-controlled trial of adding darolutamide to androgen deprivation therapy and definitive or salvage radiation

Radiation therapy (RT), plus androgen deprivation therapy (ADT) with a luteinising hormone releasing hormone analogue (LHRHA), is standard of care for men with very high-risk localised prostate cancer (PC), or with very high-risk features and persistent PSA after radical prostatectomy (RP). Despite this, incurable distant metastases develop within 5 years in 15% of men with very high-risk features. Darolutamide is a structurally distinct oral androgen receptor antagonist with low blood-brain-barrier penetration, low potential for drug-drug interactions, and a favourable safety profile. Our aim is to determine the efficacy of adding darolutamide to ADT and RT in the setting of either primary definitive therapy, or adjuvant therapy for very high-risk PC. This study is a randomised (1:1) phase III placebo-controlled, double-blind trial for men planned for RT who have very high-risk localised PC; or very high-risk features with PSA persistence or rise within one year following RP. The trial will be stratified by: RP; use of adjuvant docetaxel; pelvic nodal involvement. 1100 participants will be randomised to darolutamide 600 mg or placebo twice daily for 96 weeks. Participants will receive LHRHA for 96 weeks, plus RT starting week 8-24 from randomisation. Participants are allowed nonsteroidal antiandrogen (up to 90 days) in addition to LHRHA up until randomisation. Early treatment with up to 6 cycles of docetaxel completed at least 4 weeks prior to RT is permitted. The primary endpoint is metastasis-free survival, with secondary endpoints overall survival, PC-specific survival, PSA-progression free survival, time to subsequent hormonal therapy, time to castration-resistance, frequency and severity of adverse events, health related quality of life, fear of recurrence. Tertiary endpoints include incremental cost-effectiveness, and identification of prognostic and/or predictive biomarkers of treatment response, safety and resistance to study treatment. ANZUP1801. Australian and New Zealand Urogenital and Prostate Cancer Trials Group (ANZUP) in collaboration with the University of Sydney.