Para-aortic Area Research Articles

Risk Factors and Patterns of Locoregional Recurrence after Radical Nephrectomy for Locally Advanced Renal Cell Carcinoma.

PurposeWe aimed to investigate the risk factors and patterns of locoregional recurrence (LRR) after radical nephrectomy (RN) in patients with locally advanced renal cell carcinoma (RCC).Materials and MethodsWe retrospectively analyzed 245 patients who underwent RN for non-metastatic pT3–4 RCC from January 2006 to January 2016. We analyzed the risk factors associated with poor locoregional control using Cox regression. Anatomical mapping was performed on reference computed tomography scans showing intact kidneys.ResultsThe median follow-up duration was 56 months (range, 1 to 128 months). Tumor extension to renal vessels or the inferior vena cava (IVC) and Fuhrman’s nuclear grade IV were identified as independent risk factors of LRR. The 5-year actuarial LRR rates in groups with no risk factor, one risk factor, and two risk factors were 2.3%, 19.8%, and 30.8%, respectively (p < 0.001). The locations of LRR were distributed as follows: aortocaval area (n=2), paraaortic area (n=4), retrocaval area (n=5), and tumor bed (n=11). No LRR was observed above the celiac axis (CA) or under the inferior mesenteric artery (IMA).ConclusionTumor extension to renal vessels or the IVC and Fuhrman’s nuclear grade IV were the independent risk factors associated with LRR after RN for pT3–4 RCC. The locations of LRR after RN for RCC were distributed in the tumor bed and regional lymphatic area from the bifurcation of the CA to that of the IMA.

Sentinel node mapping vs. sentinel node mapping plus back-up lymphadenectomy in high-risk endometrial cancer patients: Results from a multi-institutional study

ObjectiveSentinel node mapping (SLN) has replaced lymphadenectomy for staging surgery in apparent early-stage low and intermediate risk endometrial cancer (EC). Only limited data about the adoption of SNM in high risk EC is still available. Here, we evaluate the outcomes of high-risk EC undergoing SNM (with or without back-up lymphadenectomy). MethodsThis is a multi-institutional international retrospective study, evaluating data of high-risk (FIGO grade 3 endometrioid EC with myometrial invasion >50% and non-endometrioid histology) EC patients undergoing SNM followed by back-up lymphadenectomy and SNM alone. ResultsChart of consecutive 196 patients were evaluated. The study population included 83 and 113 patients with endometrioid and non-endometrioid EC, respectively. SNM alone and SNM followed by back-up lymphadenectomy were performed in 50 and 146 patients, respectively. Among patients having SNM alone, 14 (28%) were diagnosed with nodal disease. In the group of patients undergoing SNM plus back-up lymphadenectomy 34 (23.2%) were diagnosed with nodal disease via SNM. Back-up lymphadenectomy identified 2 (1%) additional patients with nodal disease (in the para-aortic area). Back-up lymphadenectomy allowed to remove adjunctive positive nodes in 16 (11%) patients. After the adoption of propensity-matched algorithm, we observed that patients undergoing SNM plus back-up lymphadenectomy experienced similar disease-free survival (p = 0.416, log-rank test) and overall survival (p = 0.940, log-rank test) than patients undergoing SLN alone. ConclusionsAlthough the small sample size, and the retrospective study design this study highlighted that type of nodal assessment did not impact survival outcomes in high-risk EC. Theoretically, back-up lymphadenectomy would be useful in improving the removal of positive nodes, but its therapeutic value remains controversial. Further prospective evidence is needed.

Sentinel node mapping using indocyanine green and near-infrared fluorescence imaging technology for endometrial cancer: A prospective study using a surgical algorithm in Indian patients.

Background:Indocyanine green (ICG) fluorescence with high-definition, three-dimensional imaging systems is emerging as the latest strategy to reduce trauma and improve surgical outcomes during oncosurgery.Materials and Methods:This is a prospective study involving 100 patients with carcinoma endometrium who underwent robotic-assisted Type 1 pan-hysterectomy, with ICG-directed sentinel lymph node (SLN) biopsy from November 2017 to December 2019. The aim was to assess the feasibility and diagnostic accuracy of SLN algorithm and to evaluate the location and distribution of SLN in pelvic, para-aortic and unusual areas and the role of frozen section.Results:The overall SLN detection rate was 98%. Bilateral detection was possible in 92% of the cases. Right side was detected in 98% of the cases and left side was visualised in 92% of the cases. Complete node dissection was done where SLN mapping failed. The most common location for SLN in our series was obturator on the right hemipelvis and internal iliac on the left hemipelvis. SLN in the para-aortic area was detected in 14% of cases. In six cases, SLN was found in atypical locations, that is pre-sacral area. Eight patients had SLN positivity for metastasis and underwent complete retroperitoneal lymphadenectomy. Comparison of final histopathological report with frozen section reports showed no false negatives.Conclusions:SLN mapping holds a great promise as a modern staging strategy for endometrial cancer. In our experience, cervical injection was an optimal method of mapping the pelvis. ICG showed a high overall detection rate, and bilateral mapping appears to be a feasible alternative to the more traditional methods of SLN mapping in patients with endometrial cancer. The ICG fluorescence imaging system is simple and safe and may become a standard in oncosurgery in view of its staging and anatomical imaging capabilities. This approach can reduce the morbidity, operative times and costs associated with complete lymphadenectomy while maintaining prognostic and predictive information.

Safety and Efficacy of Ultrasound-Guided Percutaneous Core Needle Biopsy of Pancreatic and Peripancreatic Lesions Adjacent to Critical Vessels.

PurposeTo evaluate the safety and efficacy of ultrasound-guided percutaneous core needle biopsy (USPCB) of pancreatic and peripancreatic lesions adjacent to critical vessels.Materials and MethodsData were collected retrospectively from 162 patients who underwent USPCB of the pancreas (n = 98), the peripancreatic area adjacent to the portal vein, the paraaortic area adjacent to pancreatic uncinate (n = 34), and lesions on the third duodenal portion (n = 30) during a 10-year period. An automated biopsy gun with an 18-gauge needle was used for biopsies under US guidance. The USPCB results were compared with those of the final follow- up imaging performed postoperatively. The diagnostic accuracy and major complication rate of the USPCB were calculated. Multiple factors were evaluated for the prediction of successful biopsies using univariate and multivariate analyses.ResultsThe histopathologic diagnosis from USPCB was correct in 149 (92%) patients. The major complication rate was 3%. Four cases of mesenteric hematomas and one intramural hematoma of the duodenum occurred during the study period. The following factors were significantly associated with successful biopsies: a transmesenteric biopsy route rather than a transgastric or transenteric route; good visualization of targets; and evaluation of the entire US pathway. In addition, the number of biopsies required was less when the biopsy was successful.ConclusionUSPCB demonstrated high diagnostic accuracy and a low complication rate for the histopathologic diagnosis of pancreatic and peripancreatic lesions adjacent to critical vessels.

Para-aortic and Right Obturator Lymphadenectomy for Surgical Staging of Advanced Cervical Cancer through the TU-LESS Extraperitoneal Approach

To present an innovative transumbilical laparoendoscopic single-site (TU-LESS) extraperitoneal approach for lymphadenectomy in a patient with advanced cervical carcinoma. Demonstration of the novel technique through video. In advanced cervical cancer, determining the status of the para-aortic lymph nodes is essential because extended-field radiologic therapy is recommended for a patient with positive para-aortic lymph nodes [1]. Nonetheless, the sensitivity and specificity of currently available imaging workup for positive lymph nodes are limited. Surgical staging enables precise evaluation. However, laparotomy has potential wound complications and leads to treatment delay. Multiport laparoscopic transperitoneal and extraperitoneal approaches limit surgeons' ability to reach the para-aortic area or obturator fossa in the same operation [2]. Thus, we take full use of these approaches' advantages and avoid their disadvantages to design a promising minimally invasive surgery approach [3]. Para-aortic and obturator lymphadenectomy through the TU-LESS extraperitoneal approach was successfully performed without complications. The patient recovered quickly and received subsequent concurrent chemoradiation on schedule. TU-LESS extraperitoneal para-aortic lymphadenectomy provides satisfactory exposure and easy access to both the para-aortic area and obturator fossa. In addition, the bowels are uplifted by an extraperitoneal air cushion to achieve excellent exposure and reduce the risk of bowel injury. With quick recovery, the patient could start accurate radiation treatment promptly.

Oncologic Impact of Local Recurrence in Resected Pancreatic Cancer and Topographic Preference in Local Recurrence Patterns According to Tumor Location.

The objective of this study was to investigate the pattern and the oncologic impact of local recurrence after surgical resection of pancreatic cancer. From July 1992 to December 2016, 388 patients who underwent curative-intent surgery for pancreatic ductal adenocarcinoma were retrospectively reviewed. At a median follow-up of 29.0 months, 286 (73.7%) of the 367 patients experienced recurrence, and the 5-year overall survival rate was 31.3%. The first recurrence pattern was local in 83 patients (22.0%), systemic in 152 patients (40.2%), and locosystemic in 51 patients (13.5%). There was no difference in overall survival between the patients who had either local or systemic recurrence (P > 0.05). Remnant pancreas, common hepatic artery, celiac trunk, and para-aortic area were the common local recurrence sites in both head and body/tail cancer. However, the superior mesenteric artery (P = 0.050) and portal vein (P = 0.001) were more frequent local recurrence sites for a head tumor, and the surgical bed was a common recurrence site for body/tail tumor (P < 0.001). Our study shows the importance of local recurrence on overall survival and that preferred sites of local recurrence according to tumor location are predictable.

Distribution of lymphocele following lymphadenectomy in patients with gynecological malignancies.

ObjectiveThis study identified the distribution of lymphocele, as well as the factors associated with lymphocele formation, in patients undergoing pelvic and/or para-aortic lymph node dissection (PLND and/or PALND) for gynecologic malignancies.MethodsThis study was retrospective, and data were collected from patients who underwent surgical procedures including lymphadenectomy due to gynecologic malignancies from March 2013 to May 2016. Lymphocele was defined by postoperative computer tomography within 2 weeks after surgery.ResultsA total of 116 patients underwent lymphadenectomy, of whom, 47 (42.0%) developed lymphocele and 14 (12.1%) had symptomatic lymphocele formation. The affecting factors of lymphocele formation were PLND concomitant with PALND and a large amount of blood loss ≥600 mL (P=0.030 and P=0.006, respectively). All clinical factors were not significantly different between patients with symptomatic and asymptomatic lymphocele. Lymphocele developed more frequently in the left side (67.1%) of the body compared to the right side (48.7%), and in the pelvic area (75.9%) compared to the para-aortic area (24.1%, P<0.001, both).ConclusionLymphocele formation is more prevalent in the left and pelvic area of the body compared to the right and paraaortic side. PLND concurrent with PALND and large amounts of blood loss were significant risk factors for lymphocele formation.

A new score based on biomarker values to predict the prognosis of locally advanced cervical cancer

ObjectiveTo define a prognostic score based on pretreatment values of leucocyte, platelet and hemoglobin in locally advanced cervical cancer (LACC). Material and methodsWe conducted a prospective study of 238 patients for LACC with negative PET imaging in the para-aortic (PA) area and who were undergoing laparoscopic PA lymphadenectomies. All patients were treated with chemo-radiation and brachytherapy. ResultsPatients had clinical International Federation of Gynecology and Obstetrics stages IB2 (n = 76), IIA (n = 13), IIB (n = 122), III (n = 18) or IVA (n = 9). We identified three biological parameters (at the time of diagnosis) with three cut-offs which impacted disease free survival (DFS) and overall survival (OS): <12 g/dL for hemoglobin, >10,000/μL for leucocyte and >300 × 109/L for platelet. A score is calculated, as shown in the table below, by adding the scores of all three biological parameters together (with a maximum score of three).Unlabelled TableScore01Hemoglobin≥12 g/dL<12 g/dLLeucocyte≤10,000/μL>10,000/μLPlatelet<300 × 109/L≥300 × 109/LTotal score/3DFS at 36 months was 87.3% [78.3–97.4], 58% [45–74.6], 79.1% [71.1–88], 58% [45–74.6] and 56.8% [37.8–85.4] for scores of 0, 1, 2 and 3 respectively. OS at 36 months was 92.6% [84.9–100], 84% [76.6–92.1], 62.5% [48.9–79.9] and 67% [46.8–96] for scores of 0, 1, 2 and 3 respectively. ConclusionThis score includes three biomarkers with easily remembered cut-offs that allow us to identify, at the time of diagnosis, those patients with a high risk of relapse (scores of two or three) and those requiring dose escalation.

The mesopancreas and pancreatic head plexus: morphological, developmental, and clinical perspectives.

Total mesopancreas excision has been found to be helpful for increasing no residual tumor resection rate and improving the prognosis of pancreatic cancer. This study analyzed the relationships among the mesopancreas and pancreatic head plexus from the morphological, developmental, and clinical perspectives. Twenty-four cadavers were employed. The upper abdominal viscera were resected en-bloc with the hepatoduodenal ligament, abdominal aorta, and nerve plexuses, and the innervation of the pancreas was dissected. Ten additional cadavers were used for histological examination of the pancreatic head and neck, part of the duodenum, the superior mesenteric artery (SMA) and its surrounding tissues, and the related arteries and veins. As results, cross-sections of the SMA revealed 6-9 layers of membranous structures resembling the layers of an onion, and the nerve fibers of the superior mesenteric plexus ran between the layers. Loose areolar tissue, adipose tissue, and lymphatics existed between the SMA and the pancreatic head/uncinate process, along with abundant thin blood vessels and capillaries, but very few nerves were found approaching the pancreas. Several parallel layers of collagen fibers (so-called Treitz's fusion fascia) existed between the dorsal aspect of the pancreatic head and the aortocaval plane. The mesopancreas was continuous and connected with the para-aortic area. It may be better termed the mesopancreatoduodenum than the mesopancreas, as the duodenum-pancreas-SMA forms a complex morphological, developmental, functional, and pathological structure.

Complementary role of 18F-FDG PET/CT for sentinel lymph node algorithm in endometrial cancer with high-risk factors for lymphatic metastasis.

National Comprehensive Cancer Network (NCCN) sentinel lymph node (SLN) algorithm includes 'mandatory steps' for evaluating pelvic lymph nodes, but assessment of paraaortic area is left to surgeon's discretion. In this study, we aimed to investigate the complementary role of preoperative F-FDG PET/computed tomography (CT) scan in detecting pelvic and especially paraaortic lymphatic metastasis in endometrial cancer patients with high-risk factor(s) according to Mayo Clinic Criteria and underwent SLN algorithm. Patients who underwent preoperative F-FDG PET/CT scan, intraoperative SLN algorithm followed by systematic lymphadenectomy (LND) and had at least one high-risk criterion for lymphatic metastasis were included in this study. F-FDG PET/CT and SLN algorithm were compared with final histopathological results of systematic LND. Thirty-eight patients were eligible for the study. Lymphatic metastasis was seen in 10 patients (26.3%). Four cases had paraaortic lymphatic metastases which were together with pelvic (n:2) or isolated (n:2) metastases. SLN algorithm was able to detect all pelvic lymph node metastases. However, isolated paraaortic metastases were diagnosed only by F-FDG PET/CT. In 76 hemipelvises, sensitivity and negative predictive value of SLN algorithm for diagnosis of pelvic nodal metastasis were 100%, while sensitivity, specificity, positive predictive value and negative predictive value of F-FDG PET/CT were 45.4, 95.3, 62.5 and 91.1%, respectively. Although SLN algorithm has an excellent diagnostic value for pelvic nodal metastasis, paraaortic metastasis might be underdiagnosed. F-FDG PET/CT may be a feasible tool to exclude paraaortic lymphatic metastasis in high-risk patients for lymphatic metastasis who will undergo SLN algorithm.

Gastrointestinal Plasmoblastic Lymphoma Associated with Wiskott-Aldrich Syndrome: A Case Report

Introduction: Plasmablastic lymphoma (PBL) is a rare and aggressive subtype of non-Hodgkin lymphoma that commonly occurs in human immunodeficiency virus (HIV)-positive individuals.1 But also PBL can be seen in patients with other immunodeficiencies as well as in immunocompetent individuals. Wiskott-Aldrich syndrome (WAS) is a primary immunodeficiency disorder with X-linked recessive transmission that being susceptible to infections and also reduced ability to form blood clots.2 We report a case of gastrointestinal PBL in a 28-year-old male patient who had been diagnosed with WAS for 12 years. Case description: He was admitted to our clinic with hematemesis and melena complaints and endoscopy was performed. A 5X4 cm mass was observed in the gastric antrum and biopsy was reported plasma cell dyscrasias with kappa monoclonal. PET/CT was performed: Bilateral paraaortic area, common iliac chain, internal and external iliac chain and bilateral inguinal area were observed in multiple lymph nodes with moderate-dense hypermetabolic activity of 35x25 mm in size, and intense hypermetabolic activity in lung, stomach and spleen were seen. These findings were primarily evaluated as nodal and extranodal involvement of malignant lymphoproliferative processes (lymphoma?). Physical examination revealed ascites, hepatosplenomegaly and hyperpigmentation under both knees. Ascites sampling showed diffuse plasmocytic cells, and flowcytometry showed peritoneal involvement of: CD38 +, CD138 +, CD56-, CD19-. Bronchoscopy was performed and atypical plasma cell proliferation was observed. Anti-HIV was negative. We started Bortezomib, Cyclophosphamide and Dexamethasone treatment. Discussion: PBL is a subtype of diffuse large B-cell lymphoma usually seen in HIV-positive patients. In a review of 590 cases by Castillo et al., 28% of PBL patients were HIV-negative.3 However, in all cases with PBL, as in our patient, there is an immunosuppressed situation. Again in the same review the sex distribution shows a male predominance (75%). In PBL, the most common site of involvement, regardless of whether HIV-positive or negative, is oral (48% and 40%) and gastrointestinal (12% and 21%) respectively.3 However, involvement can be seen almost everywhere. PBL is a high-grade neoplasm with cytomorphologic features such as large immunoblasts or large plasma cells that express plasma cell markers and lack B-cell markers. The diagnosis of PBL is challenging because it has features that overlap with those of myeloma and with lymphomas that have plasmablastic morphology. The immunophenotype is similar to that in plasma cell neoplasms, positive for CD79a, IRF-4/MUM-1, BLIMP-1, CD38, and CD138.4 The neoplastic cells are negative for B-cell markers CD19, CD20, and PAX-5; however, a subset may be dim positive for CD45. Some cases express T-cell markers CD2 or CD4.5 Epstein-Barr virus infection and MYC rearrangements are frequently observed. Treatment of PBL is challenging because of the lack of established treatment and poor outcomes, with median survival times shorter than one year.6 Conclusion: PBL is a very rare disease and it is quite difficult to diagnose because it contains different components. PBL should be considered in immunosuppressive patients that have negative B cell markers and positive plasma cell markers. Disclosures No relevant conflicts of interest to declare.

PP-16 - Gastrointestinal plasmoblastic lymphoma associated with Wiskott-Aldrich syndrome: a case report

Introduction: Plasmablastic lymphoma (PBL) is a rare and aggressive subtype of non-Hodgkin lymphoma that commonly occurs in human immunodeficiency virus (HIV)-positive individuals.1 But also PBL can be seen in patients with other immunodeficiencies as well as in immunocompetent individuals. Wiskott-Aldrich syndrome (WAS) is a primary immunodeficiency disorder with X-linked recessive transmission that being susceptible to infections and also reduced ability to form blood clots.2 We report a case of gastrointestinal PBL in a 28-year-old male patient who had been diagnosed with WAS for 12 years. Case description: He was admitted to our clinic with hematemesis and melena complaints and endoscopy was performed. A 5X4 cm mass was observed in the gastric antrum and biopsy was reported plasma cell dyscrasias with kappa monoclonal. PET/CT was performed: Bilateral paraaortic area, common iliac chain, internal and external iliac chain and bilateral inguinal area were observed in multiple lymph nodes with moderate-dense hypermetabolic activity of 35x25 mm in size, and intense hypermetabolic activity in lung, stomach and spleen were seen. These findings were primarily evaluated as nodal and extranodal involvement of malignant lymphoproliferative processes (lymphoma?). Physical examination revealed ascites, hepatosplenomegaly and hyperpigmentation under both knees. Ascites sampling showed diffuse plasmocytic cells, and flowcytometry showed peritoneal involvement of: CD38 +, CD138 +, CD56-, CD19-. Bronchoscopy was performed and atypical plasma cell proliferation was observed. Anti-HIV was negative. We started Bortezomib, Cyclophosphamide and Dexamethasone treatment. Discussion: PBL is a subtype of diffuse large B-cell lymphoma usually seen in HIV-positive patients. In a review of 590 cases by Castillo et al., 28% of PBL patients were HIV-negative.3 However, in all cases with PBL, as in our patient, there is an immunosuppressed situation. Again in the same review the sex distribution shows a male predominance (75%). In PBL, the most common site of involvement, regardless of whether HIV-positive or negative, is oral (48% and 40%) and gastrointestinal (12% and 21%) respectively.3 However, involvement can be seen almost everywhere. PBL is a high-grade neoplasm with cytomorphologic features such as large immunoblasts or large plasma cells that express plasma cell markers and lack B-cell markers. The diagnosis of PBL is challenging because it has features that overlap with those of myeloma and with lymphomas that have plasmablastic morphology. The immunophenotype is similar to that in plasma cell neoplasms, positive for CD79a, IRF-4/MUM-1, BLIMP-1, CD38, and CD138.4 The neoplastic cells are negative for B-cell markers CD19, CD20, and PAX-5; however, a subset may be dim positive for CD45. Some cases express T-cell markers CD2 or CD4.5 Epstein-Barr virus infection and MYC rearrangements are frequently observed. Treatment of PBL is challenging because of the lack of established treatment and poor outcomes, with median survival times shorter than one year.6 Conclusion: PBL is a very rare disease and it is quite difficult to diagnose because it contains different components. PBL should be considered in immunosuppressive patients that have negative B cell markers and positive plasma cell markers. Disclosures No relevant conflicts of interest to declare.

Mapping of local recurrence after pancreaticoduodenectomy for distal extrahepatic cholangiocarcinoma: implications for adjuvant radiotherapy.

To generate a map of local recurrences after pancreaticoduodenectomy (PD) for patients with distal extrahepatic cholangiocarcinoma (DEHC) and to evaluate the adequate target volume coverage encompassing the majority of local recurrences when the clinical target volume (CTV) for pancreatic cancer was applied. We retrospectively reviewed the records of DEHC patients who underwent pancreaticoduodenectomy and had postoperative CT scans acquired between 1991 and 2015 available. The sites of local recurrence were delineated on individual CT scans, and then, mapping was manually performed onto template CT images. Coverage of each site of local recurrence was evaluated by applying the CTV defined according to Radiation Therapy Oncology Group (RTOG) consensus guidelines (CTVRTOG ) for target delineation in the postoperative treatment of pancreatic head cancer. Of the 99 patients, 36 patients had a total of 62 local relapses identifiable by postoperative CT scans; the relapses were the most frequent in the choledochojejunostomy (CJ) site, 11 sites (17.7%); para-aortic area, 10 sites (16.1%), superior mesenteric artery area, 10 sites (16.1%); and portal vein area, 9 sites (14.5%). 21 sites (33.9%) were not covered by the CTVRTOG, and the most common site of local recurrence outside the CTVRTOG was the CJ site. When mapping of local relapses was evaluated according to the CTVRTOG, the choledochojejunostomy site was identified as a high-risk area of local recurrence but was insufficiently covered within the CTVRTOG. These findings may help construct a target volume for postoperative radiotherapy in DEHC. Mapping local recurrences can aid in defining appropriate target volume for postoperative radiotherapy in DEHC.

Predictive factors of unexpected lymphatic drainage pathways in early-stage cervical cancer

ObjectivesThe purpose of this study was to describe sentinel lymph nodes (SLN) topography in patients with early-stage cervical cancer and to determine factors associated with atypical lymphatic drainage pathway (LDP). MethodsWe analyzed the data of two prospective multicentric trials on SLN biopsy for cervical cancer (SENTICOL I and II) in women undergoing surgery for early-stage cervical cancer. SLN detection was realized with a combined labeling technique (Patent blue and radioactive tracer). Patients having bilateral SLN detection were included. Univariate and Multivariate analysis were performed by patients and by side to assess clinical and pathologic factors that may predict atypical LDP. ResultsBetween January 2005 and July 2012, 326 patients with 1104 intraoperative detected SLNs fulfilled the inclusion criteria. The SLNs were mainly located in the interiliac or external iliac area in 83.2%. The other localizations were: 9.2% in the common iliac area, 3.9% in the parametrium, 1.6% in the promontory area, 1.5% in the paraaortic area and 0.5% in other areas. Thirty-five patients (10.7%) had atypical SLN without SLN in typical area on one or both sides. In multivariate analysis, tumor size ≥20 mm appeared as an independent factor of having at least one exclusive atypical LDP (ORa = 3.95 95%CI = [1.60–9.78], p = 0.003). Multiparity decreased significantly the probability of having at least one exclusive atypical LDP (ORa = 0.16 95%CI = [0.07–0.39], p < 0.0001). ConclusionsTumor size larger than 20 mm and nulliparity increase the risk of having exclusive atypical LDP in early-stage cervical cancer.

Para-aortic plus pelvic lymphadenectomy in locally advanced cervical cancer: A single institutional experience

ObjectiveThe aim of the study is to assess the safety and efficacy of transperitoneal laparoscopic para-aortic and pelvic lymphadenectomy in the setting of surgical staging of patients with locally advanced cervical cancer (LACC), and to analyse the prognostic value and impact of this staging on the survival prognosis of this condition. Study DesignData from 67 patients with LACC who underwent transperitoneal laparoscopic para-aortic and pelvic lymphadenectomy and who received chemo-radiation therapy were retrospectively analysed. ResultsMetastatic lymph nodes (LN) were identified in 32 patients (47.7%), 20 (29.8%) had metastatic LN in the pelvic area and 12 (17.9%) had metastatic LN in the pelvic and para-aortic area. There were no skip metastases in the para-aortic area.After a median follow-up of 54.6 months (5–122.2 months), the 5-year local control and disease-free survival (DFS) rates for the whole group were 91.1% and 60.5% respectively. The five-year DFS for patients without LN metastasis was 86.4%, while for patients with pelvic LN metastases or pelvic and para-aortic metastases was 34.2% and 24.2% respectively (p < 0.001).The five-year overall survival (OS) for the whole group was 67.3%. The mortality rate in patients with para-aortic nodal metastases was increased compared to patients with negative nodes (5-year OS 21.3% vs 81.6% respectively, p = 0.005), but the OS rate was similar in patients with negative nodes and those with only pelvic nodes affected (5-year OS 81.6% vs 70.8% respectively, p = 0.380).This approach allowed the modification of the initial treatment plan in the para-aortic area in 13.4% of patients and in the pelvic area in 28.3%.The overall intraoperative morbidity rate was 5.9%, while the postoperative morbidity rate was 10.4%, with only 3 patients presenting grade 3 morbidity. ConclusionsTransperitoneal para-aortic and pelvic lymphadenectomy provides precise information about nodal state and allows personalized treatment planning in patients with LACC, avoiding false negative (FN) and false positive (FP) imaging results. In 17.9% of patients, the external beam radiotherapy (EBRT) field had to include the aortic area, whilst 47.7% received pelvic boost to the involved nodes.

Exploratory study for the application of photodynamic diagnosis to biliary pancreatic surgery

Introduction: Photodynamic diagnosis (PDD) is one of the candidates for navigation surgery in HPB malignancies. The purpose of this presentation is to show our exploratory study for the application of 5-ALA-PDD and ICG-PDD to biliary pancreatic surgery. Method: Two studies were enrolled. Result: Study 1: 5-ALA-PDD on an animal model. The purpose of this model study was to determine if 5-ALA-PDD could detect lesions in murine models of biliary-pancreatic cancers. Methods: A murine peritoneal disseminated nodule model was established by intraperitoneal injection of TFK-1 and PK-1 cells. Results: In the murine model of peritoneal dissemination, micro-disseminated nodules (< 1 mm) that could not be detected under white light were clearly visible using 5-ALA-PDD. Study 2: ICG-PDD. A) ICG-PDD on the hepatoduodenal ligament to the para-aortic area. The purpose of this study was to investigate whether ICG-PDD could demonstrate LF/lymph nodes (LN) of biliary or pancreatic tumor. Methods: 43 patients with HPB malignancies were enrolled in this study. After 5 mg/ml of ICG (0.5 ml) was injected into the Calot's triangle, LF/LN were observed. Results: LF/LN were detected in 29 out of 43 patients, on the hepatoduodenal ligaments or in the para-aortic area. Fluorescent signals were recorded in the LN along the bile duct and the posterior surface of the head of the pancreas. We also detected PAN fluorescent signals on the right side of the aorta, around the left renal vein. B) PDD for pancreatic neuroendocrine tumor (pNET). Methods: Two cases of pNET (pancreatic body and head) were evaluated. After laparotomy, 5 mg/ml of ICG (0.5 ml) was injected; LF and LN were then observed. Results: ICG accumulated in LN 8a on the pancreatic body pNET, and LN14d were also detected on the pancreatic head tumor. Conclusion: In conclusion, ICG-PDD can be applicable for navigation surgery to identify areas of lymphadenectomy in HPB malignancies.

Extended-field radiotherapy for locally advanced cervical cancer

Extended-field radiotherapy for locally advanced cervical cancer

Diagnostic Value of 18F-FDG PET/CT and MRI in the Preoperative Evaluation of Uterine Carcinosarcoma.

This study aimed to compare the diagnostic value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) and magnetic resonance imaging (MRI) in the preoperative evaluation of uterine carcinosarcoma. Fifty-four women with pathologically confirmed uterine carcinosarcoma who underwent preoperative FDG PET/CT and MRI from June 2006 to November 2016 were included. Pathologic findings from primary tumor lesions, para-aortic and pelvic lymph node (LN) areas, and peritoneal seeding lesions were compared with the FDG PET/CT and MRI findings. The maximum standardized uptake value (SUVmax) of the primary tumor and LN was obtained. The tumor-to-liver ratio (TLR) was calculated by dividing the SUVmax of the primary tumor or LN by the mean SUV of the liver. For detecting primary tumor lesions (n = 54), the sensitivity and accuracy of FDG PET/CT (53/54) and MRI (53/54) were 98.2%. The sensitivity, specificity, and accuracy of FDG PET/CT versus MRI were as follows: 63.2% (12/19) versus 26.3% (5/19), 100% (35/35) versus 100% (35/35), and 87.0% versus 74.0%, respectively, for pelvic LN areas (p = 0.016); 85.7% (12/14) versus 42.9% (6/14), 90% (36/40) versus 97.5% (39/40), and 88.9% versus 83.3%, respectively, for para-aortic LN areas (p = 0.004); and 59.4% (19/32) versus 50% (16/32), 100% (22/22) versus 100% (22/22), and 75.9% versus 70.4%, respectively, for peritoneal seeding lesions (p = 0.250). For distant metastasis, the sensitivity, specificity, and accuracy of FDG PET/CT were 100 (8/8), 97.8 (45/46), and 98.2%, respectively. FDG PET/CT showed superior diagnostic accuracy compared to MRI in detecting pelvic and para-aortic LN metastasis in patients with uterine carcinosarcoma. Moreover, FDG PET/CT facilitated the identification of distant metastasis.

Oncologic impact of local recurrence in resected pancreatic cancer: its topographic preference in local recurrence patterns according to tumor location

Introduction: The role of extended surgery and adjuvant therapy to control local recurrence is still controversial. Little is known about the oncologic impact of local recurrence and the pattern of recurrence according to tumor location. Methods: From July 1992 to December 2016, patients who underwent curative-intent surgery for pancreatic ductal adenocarcinoma were retrospectively reviewed. Results: 76.5% (n = 289) of the 378 patients had recurrence during the follow-up period (median 29.0 month [1.3∼139.2]). There was no recurrence in 92 (24.3%) patients. The first recurrence pattern was local in 83 (22.0%) patients, systemic in 152 (40.2%) patients, and loco-systemic in 51 (13.5%) patients. The 5-year survival rates according to recurrence pattern were 76.6% (no recurrence), 10.3% (local), 16.9% (systemic), and 11.3% (loco-systemic). Neoadjuvant chemoradiation was helpful in lowering local recurrence (24.7% vs. 16.0%, p = 0.038), but not systemic recurrence. Remnant pancreas, common hepatic artery, celiac trunk, and paraaortic area were the common sites of frequent local recurrence. However, the superior mesenteric artery (38 vs. 7, p = 0.005) and portal vein (34 vs. 2, p < 0.001) were more frequent local recurrence sites for the head tumor, and the surgical bed was the one for the body and tail tumor (1 vs. 7, p = 0.002). Conclusion: Local recurrence of pancreatic cancer has an oncologic impact similar to systemic recurrence. Because of anatomical relationship of the pancreas and the surrounding organs, there are frequent sites of local recurrence depending on the location of the tumor. Further investigation is necessary to effectively control local recurrence.

Locally Advanced Cervical Cancer: Is a Trimodality Treatment a Safe and Effective Approach?

Background: Chemoradiotherapy (CRT) is the standard of care for locally advanced cervical cancer (LACC). Pre-treatment lymph nodes (LN) assessment may have an important therapeutic role. CRT followed by adjuvant chemotherapy increased progression free survival (PFS) and overall survival (OS). Our study evaluated the feasibility and the effectiveness of a trimodality strategy in patients with LACC and positive LN. Methods: Consecutive patients with LACC treated at the National Cancer Institute of Milan were enrolled. All patients underwent pelvic and para-aortic extraperitoneal laparoscopic lymphadenectomy to assess the nodal status. After surgery, patients received radiotherapy followed by chemotherapy according to the stage of disease. Results: Between April 2012 and October 2013, 19 cervical cancer patients were enrolled. Overall, 10 (52.6%) patients presented with positive LN: 6 in the pelvic area and 4 both in the pelvic and para-aortic area. No perioperative major complications occurred. The most common surgical-related adverse events were bleeding (26%), respiratory distress (5%), infection (5%) and the development of lymphoceles (25%). Overall, 15 (78.9%) complete responses and 2 (10.5%) partial responses were registered. After a median follow-up of 43.3 months, 89.5% of patients were alive at the last visit, and 3-year PFS was 63%. Conclusions: Trimodality treatment appears feasible, well tolerated and promising in terms of oncologic outcome.