Para-aortic Area Research Articles

Improvements and challenges in intraperitoneal laparoscopic para-aortic lymphadenectomy: The novel "tent-pitching" antegrade approach and vascular anatomical variations in the para-aortic region.

This study introduces and compares a new intraperitoneal laparoscopic para-aortic lymphadenectomy method to reach the level of the renal vein, the "tent-pitching" antegrade approach with the retrograde approach in gynecological malignancy surgeries in terms of success rate, complication incidence, and the number of lymph nodes removed. It focuses on the feasibility, safety, and effectiveness. Meanwhile, this article reports on the vascular anatomical variations discovered in the para-aortic region to enhance surgical safety. This was a retrospective cohort study including patients undergone laparoscopic para-aortic lymphadenectomy at a single center from January 2020 to December 2023 for high-risk endometrial and early-stage ovarian cancer. Patient charts were reviewed for mode of operation, perioperative complications, operative details, and histopathology. The patients were divided into anterograde group and retrograde group according to the operation mode. The two groups were further compared based on the success rate of lymph node clearance at the renal vein level, perioperative complications, and the number of removed lymph nodes. Quantitative data were analyzed using the t-test, non-normally distributed data using the rank-sum test, and categorical data using Fisher's exact test and the chi-square test, with statistical significance defined as P < 0.05. Among 173 patients, the antegrade group showed higher surgery success (97.5% vs 68.82%), more lymph nodes removed (median 14 vs 7), and less median blood loss. The operation time was shorter in the antegrade group. Postoperative complications like lymphocele and venous thrombosis were lower in the antegrade group. Vascular abnormalities were found in 28.9% of patients, with accessory lumbar vein routing anomaly and accessory renal arteries being most common. The antegrade approach is feasible, safe, and effective, improving surgical exposure, reducing difficulty without additional instruments or puncture sites, and minimizing organ damage risk. It is effective in achieving better access to the renal vein and removing more para-aortic lymph nodes than the retrograde method. Recognizing and carefully managing the diverse vascular abnormalities in the para-aortic area, including variations in renal arteries, veins, and the inferior vena cava, is essential to reduce intraoperative bleeding and the likelihood of converting to open surgery.

The preliminary analysis of lymphatic flow around the connective tissues surrounding SMA and SpA elucidates patients’ oncological condition in borderline-resectable pancreatic cancer

BackgroundIn pancreatic ductal adenocarcinoma (PDAC), invasion of connective tissues surrounding major arteries is a crucial prognostic factor after radical resection. However, why the connective tissues invasion is associated with poor prognosis is not well understood.Materials and methodsFrom 2018 to 2020, 25 patients receiving radical surgery for PDAC in our institute were enrolled. HyperEye Medical System (HEMS) was used to examine lymphatic flow from the connective tissues surrounding SMA and SpA and which lymph nodes ICG accumulated in was examined.ResultsHEMS imaging revealed ICG was transported down to the paraaortic area of the abdominal aorta along SMA. In pancreatic head cancer, 9 paraaortic lymph nodes among 14 (64.3%) were ICG positive, higher positivity than LN#15 (25.0%) or LN#18 (50.0%), indicating lymphatic flow around the SMA was leading directly to the paraaortic lymph nodes. Similarly, in pancreatic body and tail cancer, the percentage of ICG-positive LN #16a2 was very high, as was that of #8a, although that of #7 was only 42.9%.ConclusionsOur preliminary result indicated that the lymphatic flow along the connective tissues surrounding major arteries could be helpful in understanding metastasis and improving prognosis in BR-A pancreatic cancer.

Assessment of lymph node area coverage with total marrow irradiation and implementation of total marrow and lymphoid irradiation using automated deep learning-based segmentation.

Total marrow irradiation (TMI) and total marrow and lymphoid irradiation (TMLI) have the advantages. However, delineating target lesions according to TMI and TMLI plans is labor-intensive and time-consuming. In addition, although the delineation of target lesions between TMI and TMLI differs, the clinical distinction is not clear, and the lymph node (LN) area coverage during TMI remains uncertain. Accordingly, this study calculates the LN area coverage according to the TMI plan. Further, a deep learning-based model for delineating LN areas is trained and evaluated. Whole-body regional LN areas were manually contoured in patients treated according to a TMI plan. The dose coverage of the delineated LN areas in the TMI plan was estimated. To train the deep learning model for automatic segmentation, additional whole-body computed tomography data were obtained from other patients. The patients and data were divided into training/validation and test groups and models were developed using the "nnU-NET" framework. The trained models were evaluated using Dice similarity coefficient (DSC), precision, recall, and Hausdorff distance 95 (HD95). The time required to contour and trim predicted results manually using the deep learning model was measured and compared. The dose coverage for LN areas by TMI plan had V100% (the percentage of volume receiving 100% of the prescribed dose), V95%, and V90% median values of 46.0%, 62.1%, and 73.5%, respectively. The lowest V100% values were identified in the inguinal (14.7%), external iliac (21.8%), and para-aortic (42.8%) LNs. The median values of DSC, precision, recall, and HD95 of the trained model were 0.79, 0.83, 0.76, and 2.63, respectively. The time for manual contouring and simply modified predicted contouring were statistically significantly different. The dose coverage in the inguinal, external iliac, and para-aortic LN areas was suboptimal when treatment is administered according to the TMI plan. This research demonstrates that the automatic delineation of LN areas using deep learning can facilitate the implementation of TMLI.

Unusually aggressive primary testicular diffuse large B-cell lymphoma initially presenting as systemic disseminating metastases in older adult men: a case report.

Herein, the authors describe the case of a 64-year-old man with the chief complaint of a painless unilateral scrotal mass. Computed tomography scans of the abdomen and a pelvic examination demonstrated a left testicular tumor with multiple lymphadenopathies partially aggregated in the para-aortic area and disseminated to multiple soft tissues and organs. Subsequently, the patient underwent a left radical orchiectomy. Pathological and immunohistochemical examinations confirmed the diagnosis of left PT-DLBCL with systemic disseminating metastases. PTL often aggressively spreads to other extranodal organs, such as the contralateral testis, central nervous system, lung, pleura, Waldeyer's ring, and soft tissues. In men over 60 years of age, PT-DLBCL is the most common testicular malignancy. However, extensive systemic metastasis as the initial presentation is extremely rare. PT-DLBCL has a dismal prognosis and requires radical orchiectomy followed by multimodal therapy and central nervous system prophylaxis or systemic intervention to improve survival. The diagnosis of PT-DLBCL through preoperative and imaging examinations is often challenging. Thus, histopathology and immunohistochemical markers play a crucial and valuable role in the definite diagnosis and differential diagnosis of PTLs.

Reduced uptake pattern on 68 Ga-DOTATATE-scan may indicate necrosis predicting aggressive behavior in pheochromocytoma and paragangliomas (PPGLs).

Predicting malignancy among pheochromocytoma paragangliomas (PPGLs) remains a challenge, with only limited understanding of the clinical and molecular characteristics. It has been suggested that reduced avidity of a PPGL on 68 Ga-DOTATATE PET/CT could be a sign of not only altered metabolic activity, but also of increased biologic aggressiveness, possibly due to loss of SSTR-expression. Retrospective cohort review. Thirty-seven patients who underwent treatment for PPGL at a tertiary institution over the period 2010-2022, had their biochemical, radiological, and clinicopathological variables collected. Five of 37 (13%) patients (5 males) with a mean age of 42 years were found to have malignant PPGLs. The mean size of the tumors were 5.4 cm, with 4 located in the paraaortic area and 1 in right adrenal. Functional imaging with 68 Ga-DOTATATE PET/CT showed a mean SUVmax of 4.5. Four of 5patients underwent open resection of the tumors under general anesthesia following preoperative alpha blockade with oral phenoxybenzamine. The mean PASS score of the excised tumors was 5.5 in keeping with biologically aggressive tumors, with evidence of necrosis. All but 1 patient had germline SDHB-mutation (Deletion Exon 1). Postintervention after a mean follow-up of 31 months, 2 of 5 (40%) patient developed spinal metastasis and 1 patients (25%) died of cardiac complications. A non-highly avid PPGL on DOTATE scan should be considered as possibly having necrosis of tumors indicating a more aggressive tumor-biology. There might be a subgroup of patients in whom FDG-PET scan should be considered to gain additional information.

Prognostic factors in patients with endometrial cancer with isolated lymphatic recurrence

ObjectiveTo analyze the clinicopathological features and outcomes in patients with endometrial cancer with isolated lymphatic recurrence after lymphadenectomy, stratified by different isolated lymphatic recurrence sites and treatment approaches.MethodsWe retrospectively reviewed...

Applications and Safety of Sentinel Lymph Node Biopsy in Endometrial Cancer.

Lymph node status is important in predicting the prognosis and guiding adjuvant treatment in endometrial cancer. However, previous studies showed that systematic lymphadenectomy conferred no therapeutic values in clinically early-stage endometrial cancer but might lead to substantial morbidity and impact on the quality of life of the patients. The sentinel lymph node is the first lymph node that tumor cells drain to, and sentinel lymph node biopsy has emerged as an acceptable alternative to full lymphadenectomy in both low-risk and high-risk endometrial cancer. Evidence has demonstrated a high detection rate, sensitivity and negative predictive value of sentinel lymph node biopsy. It can also reduce surgical morbidity and improve the detection of lymph node metastases compared with systematic lymphadenectomy. This review summarizes the current techniques of sentinel lymph node mapping, the applications and oncological outcomes of sentinel lymph node biopsy in low-risk and high-risk endometrial cancer, and the management of isolated tumor cells in sentinel lymph nodes. We also illustrate a revised sentinel lymph node biopsy algorithm and advocate to repeat the tracer injection and explore the presacral and paraaortic areas if sentinel lymph nodes are not found in the hemipelvis.

Final Analysis of Diagnostic Endoscopic Resection Followed by Selective Chemoradiotherapy for Stage I Esophageal Cancer: JCOG0508

Final Analysis of Diagnostic Endoscopic Resection Followed by Selective Chemoradiotherapy for Stage I Esophageal Cancer: JCOG0508

Sentinel lymph node detection in early stage ovarian cancer: the primary experience in N. N. Blokhin national medical Research Center of Oncology

Background. Surgical staging including pelvic and para-aortic lymphadenectomy is recommended in patients with clinical early-stage epithelial ovarian cancer. The therapeutic role of pelvic and para-aortic lymphadenectomy is still under debate, this procedure can increase risk of intra- and post-operative complications. using the sentinel lymph node (SLN) detection in early stage ovarian cancer in very promising and decreases the level of surgical damage. But nowadays the data on effectiveness, safety sensitivity and specificity of SLN are limited and the technique has to be standardized.Aim. To determine the feasibility of the SLN detection procedure using indocyanine green in early stage ovarian cancer.Materials and methods. four patients with clinical stage I epithelial ovarian cancer underwent SLN detection using indocyanine green. The tracer was injected into hilum of the ovary or ovarian ligament stumps in the case of previous adnexectomy. SLN were detected in infrared spectrum. Systemic retroperitoneal lymph node dissection of the pelvic and paraaortic areas was performed after SLN being removed. frozen section of was not performed in this study.Results. SLN were detected in paraaortic area in three of four patients. no one of patients had metastatic disease.Conclusion. The primary experience demonstrates SLN mapping of the ovary being feasible. Prospective study is required to evaluate sensitivity and specificity of SLn detection in early stage ovarian cancer.

A para-aortic malignant melanotic nerve sheath tumor mimicking a gastrointestinal stromal tumor: a rare case report and review of literature

BackgroundMalignant melanotic nerve sheath tumor (MMNST), formerly called melanotic schwannoma, is a rare tumor of neural crest derivation which most frequently arises from the region of spinal or autonomic nerves near the midline. Recent studies have reported malignant behavior of MMNST, and there still has no standard management guidelines. Intra-abdominal MMNST, which has never been reviewed as an entity, is even rarer. In this study, we present a rare case of a cystic MMNST arising from the para-aortic region and mimicking an intra-abdominal gastrointestinal stromal tumor (GIST), and review the literature regarding MMNSTs located in the abdominal cavity.Case presentationA 59-year-old female was incidentally found a tumor located in the left para-aortic area by non-contrast computed tomography. A Magnetic Resonance Imaging showed a cystic mass originated from the inferior mesenteric artery (IMA) territory. A GIST was initially diagnosed. The tumor was resected en bloc by laparoscopic surgery and was found between mesocolon and Gerota’s fascia with blood supply of IMA. Grossly, dark brown materials were noted at the inner surface of the cystic wall. Microscopically, the tumor cells were melanin-containing, and no psammomatous bodies were present. Immunohistochemically, the tumor showed positivity for MART1, HMB45, collagen IV, and SOX10, and negativity for AE1/AE3. MMNST was favored over malignant melanoma, since the tumor was located near ganglia and had cells with less atypical cytology and a low mitotic rate, and subsequent adjuvant radiotherapy was performed. The patient was alive with no evidence of recurrent or metastatic disease 11 months after radiotherapy.ConclusionsOur review of abdominal MMNST cases showed a female predominance, with an average age of 54.8 years, and a trend toward being a larger tumor showing cystic or necrotic changes. Local recurrence and metastasis rate were reviewed, and both showed a low rate. Diagnosis of MMNST should combine all the available findings, and complete excision of the tumor should be performed, followed by long-term patient monitoring.

Laparoscopic Ovarian Transposition with Extraperitonealization of the Infundibulopelvic Ligament for Cervical Cancer in Ten Steps

Preservation of ovarian function is important for the physical and psychosexual well-being of young patients with cancer. Patients with pelvic malignancies such as cervical or rectal cancer planned for radiotherapy may benefit from ovarian transposition with the aim of moving the ovaries outside the radiation field.1 Different surgical techniques have been reported previously.2,3 With the present video, we aim to standardize the surgical technique of laparoscopic ovarian transposition in ten steps. We present the case of a 30-year-old nulliparous woman diagnosed with grade 3 squamous cell cervical carcinoma having a largest tumor diameter of 41 mm on magnetic resonance imaging (MRI) scan. The tumor was staged as FIGO 2018 stage IIIC1r with a common iliac lymphadenopathy reported on both MRI and positron emission tomography (PET)/computed tomography (CT) scan. The multidisciplinary team recommended exclusive chemoradiation extended to paraaortic area. The patient underwent laparoscopic bilateral salpingectomy and bilateral ovarian transposition with extraperitonealization of the infundibulopelvic ligament. The procedure was divided into the following ten steps: division of uteroovarian ligament, incision of lateral pelvic peritoneum, identification of ureter, incision of medial pelvic peritoneum, skeletonization of the infundibulopelvic ligament, retroperitoneal tunnel in paracolic gutter, creating the window (as high as possible), mobilization of the ovary without torsion, intraperitonealization of the ovary, and fix ovary with clips (Fig. 1). Surgical time was 30 min, with minimal estimated blood loss. No intra- or postoperative complication was recorded. The patient started radiotherapy 14 days after the procedure. In conclusion, we showed that laparoscopic ovarian transposition in cervical cancer before radiotherapy can be standardized in ten steps with encouraging perioperative results, making it an easily reproducible procedure. Ovarian function is reported to be preserved in 62–65% of cases undergoing ovarian transposition and radiation therapy.4,5Fig. 1Laparoscopic view of right ovary transposed below the liver edge after extraperitonealization of the infudibulopelvic ligament

The best postoperative adjuvant therapy for patients with early stage cervical adenosquamous carcinoma

BackgroundCervical adenosquamous carcinoma (ASC) was previously thought to be a subtype of cervical adenocarcinoma, but recent studies have found that the clinical features of the two diseases are different. Moreover, the pathological characteristics, survival, prognosis, and optimal ASC therapy remain unknown. This study aims to retrospectively analyze the postoperative survival of patients with early-stage ASC and to evaluate their condition after treatment with postoperative concurrent chemoradiotherapy (CCRT) and prophylactic irradiation of the para-aortic lymphatic drainage area.MethodsThis study enrolled 131 patients with pathologically confirmed ASC screened from 3502 patients with confirmed stage I–II cervical cancer diagnosis who had completed surgical treatments in our hospital. Among the 131 enrolled patients, 75 patients received CCRT, 33 patients received chemotherapy (CT), and 23 patients did not receive adjuvant treatment (named surgery alone (S alone). Of the 75 patients CCRT, 43 patients received prophylactic irradiation of the para-aortic lymphatic drainage area. The efficacy of the postoperative treatments of patients among groups (CCRT, CT, and S alone) was compared.ResultsThe median follow-up time, age, and overall survival (OS) were 76 months, 43 years, and 74 months, respectively. The 3- and 5-year survival rates were 82% and 71.4%, respectively. The median disease-free survival (DFS) was 64 months. Cox regression analysis showed that postoperative adjuvant treatment modalities and positive lymph node metastases were associated with OS and DFS. Patients who received CCRT treatment had higher OS and DFS than those with CT and S alone. Prophylactic irradiation of the para-aortic lymphatic drainage area did not improve the OS and DFS of patients with CCRT treatment. However, further subgroup analysis suggested that it might improve survival rates in patients who had positive pelvic lymph nodes as confirmed by postoperative pathology.ConclusionPostoperative CCRT improved the survival rates in patients with early-stage ASC. The value of prophylactic irradiation of the para-aortic lymphatic drainage area remains debatable, but it may benefit patients with pelvic lymph node involvement.

294. Abdominal radical trachelectomy as a fertility-sparing treatment for early-stage cervical cancer; a single institution experience

Introduction and aims of the study: The recommended surgical treatment for FIGO stage IA2–IB1 cervical cancer is radical hysterectomy with bilateral pelvic lymphadenectomy. Unfortunately, this procedure leads to loss of fertility. Abdominal Radical Trachelectomy (ART) is a procedure that preserves the uterus without increasing the risk of recurrence while retaining childbearing potential. We describe the surgical, oncologic, and fertility outcomes of patients treated with ART. Methods: We conducted a retrospective analysis of patients undergoing fertility-sparing ART with pelvic lymphadenectomy for early-stage cervical cancer at our institution from 2002 to 2016. Results: A total of 80 patients who underwent ART with pelvic lymphadenectomy were followed for 2–106 months. Thirty-two patients had undergone conization before surgery. The characteristics of the patients included tumor diameter of 8–32 mm (stage IA2 = 10, stage IB1 [b3.2 cm] = 70), average age of 29.5 years (range, 26–43 years), mean operative time of 185 min (range, 142–245 min), and average blood loss of 350 mL (range, 150– 750 mL). Uterine arteries were identified at their origin from the internal iliac artery and gently preserved in 76 cases. There were two recurrences in the paraaortic area treated with chemoradiation (n = 1) and radical hysterectomy (n = 1). Three patients developed high-grade squamous intraepithelial lesions and were successfully treated by loop excision. Forty-five women attempted to conceive, and 34 successful pregnancies were recorded (75%). All of the pregnancies resulted in live births, with a preterm delivery rate of 17.6% (6/34). Conclusions: Our study is one of the largest series of ART to date. Our results show that radical abdominal trachelectomy is feasible and can be performed safely in well-selected patients with cervical cancer who wish to preserve their fertility.

Whole-body MRI evaluation in neurofibromatosis type 1 patients younger than 3 years old and the genetic contribution to disease progression

BackgroundNeurofibromatosis type 1 (NF1) is a common human genetic disease with age-dependent phenotype progression. The overview of clinical and radiological findings evaluated by whole-body magnetic resonance imaging (WBMRI) in NF1 patients < 3 years old assessed with a genetic contribution to disease progression is presented herein.MethodsThis study included 70 clinically or genetically diagnosed NF1 patients who received WBMRI before 3 years old. Clinical, genetic, and radiologic features were collected by retrospective chart review. In NF1+, widely spread diffuse cutaneous neurofibromas, developmental delay, autism, seizure, cardiac abnormalities, hearing defect, optic pathway glioma, severe plexiform neurofibromas (> 3 cm in diameter, disfigurement, accompanying pain, bony destruction, or located para-aortic area), brain tumors, nerve root tumors, malignant peripheral nerve sheath tumors, moyamoya disease, and bony dysplasia were included.ResultsThe age at WBMRI was 1.6 ± 0.7 years old, and NF1 mutations were found in 66 patients (94.3%). Focal areas of signal intensity (FASI) were the most common WBMRI finding (66.1%), followed by optic pathway glioma (15.7%), spine dural ectasia (12.9%), and plexiform neurofibromas (10.0%). Plexiform neurofibromas and NF1+ were more prevalent in familial case (28.7% vs 5.7%, p = 0.030; 71.4% vs 30.2%, p = 0.011). Follow-up WBMRI was conducted in 42 patients (23 girls and 19 boys) after 1.21 ± 0.50 years. FASI and radiologic progression were more frequent in patients with mutations involving GTPase activating protein-related domain (77.8% vs 52.4%, p = 0.047; 46.2% vs 7.7%, p = 0.029).ConclusionsWBMRI provides important information for the clinical care for young pediatric NF1 patients. As NF1 progresses in even these young patients, and is related to family history and the affected NF1 domains, serial evaluation with WBMRI should be assessed based on the clinical and genetic features for the patients’ best care.

Classic Hodgkin Lymphoma Involving Spleen, Stomach, and Pancreas Without Peripheral Lymphadenopathy

Classic Hodgkin lymphoma (HL) is a lymphoid neoplasm most often affecting the lymph nodes of the cervical region (75%), followed by mediastinal, axillary, and para-aortic areas. Extranodal involvement is much less common in HL. We present an extremely rare case of classic HL (CHL) with involvement of the spleen, stomach, and pancreas and perigastric, mesenteric, and para-aortic lymph nodes without peripheral lymphadenopathy, in a 54-year-old male, which clinicoradiologically mimicked a carcinoma. An extensive English literature search did not reveal any case of CHL involving the spleen, stomach, and pancreas simultaneously.

Growing teratoma syndrome after surgery for ovarian immature teratoma

Growing teratoma syndrome (GTS) is a condition characterized by tumor growth during or after chemotherapy for a germ cell tumor, albeit with normal tumor marker levels in the absence of histopathological evidence of immature teratoma components. We encountered a 10-cm large GTS lesion in the para-aorti nodes after fertility-preserving surgery for a grade 3 ovarian immature teratoma. The patient was a 20 year old woman who presented to the hospital with complaints of abdominal pain and swelling. Imaging examination revealed an ovarian tumor mass measuring 24 cm in the abdominal cavity, suspected to be composed of a mixture of fat and other components. The α-fetoprotein (AFP) levels were elevated at 853 ng/mL. We elected to perform fertility-preserving surgery. The surgical findings included a tumor in the right ovary, which was excised without rupture with adnexectomy. The histopathological diagnosis was grade 3 immature teratoma. Palpation of the pelvic and para-aortic lymph node areas did not reveal significant lymphadenopathy. Subsequently, a para-aortic node metastasis (major axis: 8 cm) was discovered before chemotherapy (19 days after surgery). We confirmed that there was no swelling before surgery and assumed that the immature teratoma had recurred. Chemotherapy was initiated, and the serum AFP levels normalized after 4 courses of bleomycin, etoposide, and cisplatin (BEP) therapy. However, the para-aortic node metastasis had grown further (major axis: 10 cm). Another open surgery was performed. The nodal mass was completely excised and pathology revealed only mature teratoma. Growing teratoma syndrome should be considered in the setting of a recurrent mass with negative tumor markers.

A Case Report on ROS1-positive Recurrent Non-small-cell Lung Cancer Treated with Crizotinib and Korean Medicine

Objectives: This study examined the case of a patient with ROS1-positive recurrent non-small-cell lung cancer treated with crizotinib and traditional Korean medicine.Methods: The patient was treated with crizotinib from January 20 2021 to May 22 2021, together with &lt;i&gt;Haedogyangpye-tang&lt;/i&gt; and &lt;i&gt;Haengso-tang&lt;/i&gt;. The tumor size was measured using computed tomography (CT), and adverse events were evaluated according to the National Cancer Institute’s Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 5.0.Results: After four months of combined treatment, the sizes of the lymph nodes in the porta hepatis, hepatoduodenal, retrocrural, aortocaval, and para-aortic areas had decreased, and no lymph nodes larger than 1 cm in diameter were observed. The side effects of chemotherapy also improved.Conclusions: This case study suggests that traditional Korean medicine may alleviate the side effects of chemotherapy, improve quality of life, and complement chemotherapy itself.

Sentinel Node Mapping in Endometrial Cancer Using Hysteroscopic Injection of Indocyanine Green and Near-Infrared Fluorescence Imaging

<h3>Study Objective</h3> To report on the performance of hysteroscopic injection of indocyanine green (ICG) for sentinel lymph node mapping (SNM) in endometrial cancer. <h3>Design</h3> This is a retrospective cohort study of consecutive patients who had SNM via hysteroscopic injection of IGC. Detection rate, accuracy, and oncologic outcomes were evaluated. <h3>Setting</h3> Cancer center. <h3>Patients or Participants</h3> Consecutive patients with apparent early-stage endometrial cancer. <h3>Interventions</h3> Laparoscopic staging including hysterectomy, bilateral salpingo-oophorectomy, and SNM. SNM was performed using a hysteroscopic injection of IGC and near-infrared fluorescence imaging (Video). <h3>Measurements and Main Results</h3> Chart of 52 patients were evaluated. At least one sentinel node was detected in 95% of patients. Bilateral pelvic mapping was found in 74% of cases. In 45% of cases, SLNs mapped in both pelvic and para-aortic nodes, and four cases (8%) in the para-aortic area, only. In three patients (6%) sentinel nodes were found in aberrant (parametrial/presacral) areas. Seven (13.5%) patients were diagnosed with nodal involvement. Low volume disease was observed in four (8%) patients (2 with isolated tumor cells and 2 with micrometastasis). After a median (range) follow-up of 34.7 (10, 61) months, five (9.6%) patients developed recurrences: two abdominal/distant, one vaginal, and one nodal (in the para-aortic area in a patient diagnosed with endometrioid G1 endometrial cancer and isolated tumor cells in a pelvic node). No patient died of disease. <h3>Conclusion</h3> Hysteroscopic injection of ICG ensures delineation of lymphatic drainage from the tumor area, thus achieving accurate detection of sentinel nodes. Further evidence is warranted to assess the role of hysteroscopic injection in identifying extrapelvic sentinel nodes.

Patterns of Regional Failure after Pancreaticoduodenectomy in Patients with Distal Extrahepatic Cholangiocarcinoma: Suggestion of the Clinical Target Volume for Elective Nodal Irradiation

AimsTo evaluate the pattern of locoregional recurrence (LRR) after pancreaticoduodenectomy in patients with distal extrahepatic cholangiocarcinoma (DEHC) and to identify an optimal target volume for elective nodal irradiation. Materials and methodsWe analysed the medical records of DEHC patients who underwent pancreaticoduodenectomy and had LRR between 1991 and 2015. Among these patients, 30 received adjuvant chemotherapy alone, 14 underwent radiotherapy with or without chemotherapy and 28 received no treatment. After reviewing computed tomography or magnetic resonance imaging scans, the sites of LRR were identified and mapped to the corresponding locations on the representative computed tomography images. ResultsIn total, 136 LRRs were identified in 72 patients from four institutions. Local recurrences were observed at 44 sites (32.4%): tumour bed in 15, choledochojejunostomy in 25 and pancreaticojejunostomy in four. Regional recurrences were observed at 92 sites (67.6%); the most common site was the portal vein area (n = 18), followed by the para-aortic area (n = 17). Based on the mapped plots of regional recurrence, a clinical target volume covering 90% of regional recurrences was generated using the appropriate margin for the vascular structures of the portal vein, celiac axis, superior mesenteric artery, left gastric artery and aorta. ConclusionsGiven the pattern of LRR, we showed that the nodal clinical target volume based on vascular structures could appropriately cover high-risk regions of nodal involvement. These findings may help physicians construct a target volume in postoperative radiotherapy for DEHC patients undergoing pancreaticoduodenectomy.

Sentinel lymph node biopsy in upper tract urothelial cancers: an experience with intraoperative radiotracer injection.

The feasibility of the sentinel node mapping in upper tract urothelial cancers (UTUC) was evaluated, using a radiotracer as the mapping material. To identify the sentinel lymph nodes, 37 MBq of [99mTc] phytate was injected in five patients with the renal pelvis or ureter cancer, who were candidates for ureterectomy and lymphadenectomy. The radiotracer was injected in a peritumoral fashion following the surgical exposure of the tumour. The sentinel lymph nodes were detected using a handheld gamma probe. By intraoperatively injecting the radiotracer immediately after surgical exposure of the tumour, at least one sentinel lymph node could be detected in each patient, and the detection rate was 100%. The location of sentinel nodes was in the paracaval, renal hill, retro-aortic, para-aortic, common iliac, and external iliac areas, which was dependent on the tumour location. No false-negative case was identified. Sentinel node mapping is feasible in UTUC. Injection technique (intra-vesical approach vs peri-tumoral injection after exposure of the tumour) and location of the tumour (proximal vs distal) may affect the technique's feasibility.