Para-aortic Node Dissection Research Articles

A case of lymphangioleiomyomatosis with endometrial cancer diagnosed by retroperitoneoscopic para-aortic lymph node dissection

A case of lymphangioleiomyomatosis with endometrial cancer diagnosed by retroperitoneoscopic para-aortic lymph node dissection

Evaluation of Inferior Mesenteric Superior Lymph Node Metastasis in Early-Stage Endometrium Cancer and Its Clinical Significance

Endometrial cancer is the fourth most common type of cancer in women cancers. In the light of projections, approximately 11,000 deaths occur annually in the USA alone. Lymph node metastasis is the most important prognostic factor in endometrial cancer. The aim of this study is to investigate the clinical and histopathological risk factors affecting lymph ode involvement. The study included 30 randomly selected women from external centers who applied to our clinic with a preliminary diagnosis of endometrial cancer and were diagnosed with endometrial cancer in our clinic. The study group was divided into two groups as stage I (early stage) and stage II and above (advanced stage) according to the stages. Total abdominal hysterectomy (Type II), bilateral salpingo-oophorectomy, paraaortic lymph node dissection from the pelvic and IMA to the level of the left renal vein, omentectomy, and peritoneal cytology sampling were performed on each of the endometrial cancer participants. The mean number of lymph node involvement in 30 patients in the study group was 45.9±15.1. The mean number of pelvic lymph nodes involved was 32.1±10.1, while the mean number of paraaortic lymph nodes involved was 13.9±6.9. As a result of the examinations, the highest number of Stage Ia was found. The frequency of endometrial adenocarcinoma was 80% and it was seen in 24 people. The mean tumor size, myometrial thickness, and depth of invasion of the patients were 2.97(±1.6), 1.57(±0.6), and 0.7(±0.6), respectively. With positive sub-IMA lymph node involvement, lymph node positivity was also detected in the area extending from the IMA to the level of the renal vein. It has been shown that the non-endomethroid tumor type detected in this group, myometrial invasion of more than 50%, grade 3 tumor and the presence of lymphovascular invasion affect lymph node involvement above the IMA.

Laparoscopic Resection of a High Grade Serous Ovarian Cancer that Recurred at the Vaginal Stump with Extensive Pelvic Adhesions after Complete Surgical Staging

To show laparoscopic resection of a high grade serous ovarian cancer that recurred at the vaginal stump with extensive pelvic adhesions after complete surgical staging. Stepwise demonstration of the procedure with narrated video footage. University hospital. We reported a case of a 62-year-old woman with a history of complete surgical staging of high grade serous ovarian cancer staged IIB, which consisted of hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, and omentectomy, about 18 months before this admission. She received 6 courses of carboplatin/paclitaxel combination therapy after complete surgical staging and achieved complete remission. About 12 months after the last course of chemotherapy, she visited the local clinic because of irregular vaginal bleeding. Physical examination revealed a 3×3×2 cm3 mass at the vaginal vault. Biopsy of the mass was performed under colposcopy, and pathological reports showed recurrent high grade serous cancer. Her serum cancer antigen 125 level was in normal range. Positron emission tomographic/computed tomographic imaging (PET/CT) showed no evidence of disease dissemination. A diagnosis of recurrent high grade serous ovarian cancer was made. After the biopsy of the recurrent mass, there were no visible lesions, which made us believe that laparoscopy management would not contribute to intraperitoneal spread of the tumors. Therefore, laparoscopic resection of the vaginal stump was scheduled. The key steps of the procedure were summarized as follows. First, the bowels were released from the side abdominal wall to expose bilateral external iliac vessels. Second, bilateral ureters were identified and mobilized to avoid incidental ureter injuries. Third, we opened the rectovaginal space and detached the rectum from the posterior vaginal wall. Fourth, the posterior vesical wall was separated from the vaginal stump. After exposure of the key anatomic landmarks, laparoscopic resection of the vaginal stump was performed safely. Final pathologic report showed recurrent high grade serous ovarian cancer. The patient received 6 courses of carboplatin/paclitaxel combination therapy, and maintenance therapy with olaparib was suggested, but the patient refused to accept this suggestion. She is still in complete remission 8 months after surgery. Laparoscopic resection of a high grade serous ovarian cancer that recurred at the vaginal stump with extensive pelvic adhesions after complete surgical staging was achieved successfully in a logical way. The critical point of the procedure is to expose the key anatomic landmarks of the pelvis to avoid incidental injuries [1].

The predictive and prognostic value of CA 125 in endometrial cancer

Endometrial cancer is the most common malignant tumour of the female genital tract. It affects mainly older women, with postmenopausal bleeding as the primary symptom. The diagnosis of endometrial cancer is confirmed by histological evaluation of tissue specimens and described as either type I or type II. Treatment includes surgery (hysterectomy, adnexectomy and dissection of pelvic and paraaortic lymph nodes), radiotherapy, chemotherapy and hormonal therapy. Preoperative serum CA 125 (Cancer Antigen 125 or Carbohydrate Antigen 125) concentrations are correlated with depth of myometrial invasion, lymph node metastases, positive peritoneal cytology and invasion of the lymphovascular space, and can assist in making decisions about the extent of surgery. Preoperative CA 125 levels have prognostic value; postoperative levels serve as a predictor of early recurrence. Elevated serum CA 125 is linked not only with endometrial cancer, but also with several benign and malignant conditions, including ovarian cancer. Other tumour markers (e.g., CA 15–3, CA 19–9) and a promising new marker human epididymis protein 4 (HE4) can also be used for managing patients with endometrial cancer.

Predictive factors of survival of colorectal cancer patients after para-aortic lymph node metastasis.

Para-aortic lymph node (PALN) metastasis is an ominousmanifestation indicating a poorprognosis in colorectal cancer (CRC) patients; however, some treatments prolong survival. In this study, we investigated predictors of prolonged survival in CRC patients after PALN metastasis. We examined 141 patients with CRC that metastasized to the PALNs from CRC with or without extra-PALN metastasis. Among clinicopathological parameters, factors associated with survival after PALN metastasis were identified by multivariate analyses using Cox's proportional hazard models. The mean hemoglobin and albumin values at diagnosis were 12.3g/dL and 3.7g/dL, respectively. Rectal cancer was predominant (n = 81). Mutated RAS was detected in 43%. One hundred and four patients had differentiated adenocarcinoma. Patients underwent PALN dissection (n = 11), radiotherapy (n = 6), and systemic therapy (n = 120). Biologics were administered to 95 patients. The median survival time was 29.1months. On multivariate analysis, independent factors associated with reduced survival after PALN metastasis were low albumin (hazard ratio [HR] 2.33 per -1g/dL), mutated RAS (HR 2.55), other than differentiated adenocarcinoma (HR 2.75), rectal cancer (HR 3.38 against right-sided colon, and 3.48 against left-sided colon), the presence of extra-PALN metastasis (HR 6.56), and no use of biologics (HR 3.04). This study revealed that hypoalbuminemia as well as RAS mutation, undifferentiated histology, rectal cancer, other site metastasis, and no use of biologics contribute to poor prognosis in CRC patients with PALN metastasis. Nutritional management may be important for improving survival of these patients.

Sentinel Lymph Node Sampling in Robot-Assisted Staging of Endometrial Cancer.

Sentinel lymph node (SLN) sampling in endometrial cancer staging has become an acceptable standard. Indocyanine green dye injected into the cervix and detected by near-infrared light is technically simple and sensitive. We aimed to evaluate SLN sampling in robot-assisted surgical staging of endometrial cancer at a university-affiliated teaching hospital. A retrospective chart review, from January 2016 to December 2017, of patients who underwent robot-assisted surgical staging with cervical injection of indocyanine green dye detected by near-infrared light. The map rate, sensitivity, false negatives, and negative predictive value were calculated. A total of 105 charts were reviewed; 79 patients met inclusion criteria. The mean age was 65 (range 38-93) and the mean body mass index was 33.3 (range 16-49). Most patients (72.2%) had stage I disease and grade 1 or 2 histology (77.1%). Eight (10.1%) patients had lymph node metastasis. Seventy-two (91.1%) patients had positive mapping to at least 1 SLN. Sixty-two (78.5%) patients had bilateral mapping. Forty-four patients had concurrent pelvic ± para-aortic lymph node dissection and were included in the sensitivity analysis. Five of 44 cases had LN metastasis. The sensitivity was 80%, and the negative predictive value of SLN sampling was 97.5%. SLN mapping and sampling at a university-affiliated teaching hospital have comparable map rate, sensitivity, and negative predictive value as demonstrated in multiple trials. The technique has the potential to standardize endometrial cancer staging across different practice settings.

Pleural Metastasis of High-Grade Endometrial Stromal Sarcoma With YWHAE Gene (17p13.3) Rearrangement, A Rare Case Report

Abstract Introduction/Objective Endometrial stromal sarcoma (ESS), a rare malignant neoplasm of endometrial stroma, accounts for less than 1% of all uterine tumors. High grade ESS (HGESS) is aggressive and commonly relapses even after surgical and neoadjuvant therapy. Abdominal and pelvic regions are common sites of metastasis, however, distant metastases to the liver, lung, vertebrae, and brain have been reported. Methods/Case Report We encountered a 49-year-old female who presented with shortness of breath, found to have a left pleural effusion and multiple pleural masses. She initially presented three years ago with heavy irregular menses and left pelvic pain for one year. D&C revealed prominent small spindle cells for which a stromal nodule and low-grade or malignant process was probable. CT scan showed an enlarged uterus. Hysterectomy with bilateral salpingo- oophorectomy, bilateral pelvic and para-aortic lymph node dissection, and partial omentectomy were performed. The uterus revealed an intramural 7 cm mass with a serpiginous growth pattern and lymphovascular invasion. Tumor cells were plump to spindled with areas of high cellularity, rounded nuclei, increased atypia and mitosis. Atypical areas were positive for cyclin D1, focally positive for CD10, and negative for ER, PR, SMA, desmin, AE1/3 and CAM5.2. FISH studies showed rearrangement of YWHAE gene (17p13.3) and no rearrangement of JAZF1 or PHF1 gene regions. Findings supported the diagnosis of HGESS. The patient received post-operative chemotherapy. Biopsy of the current pleural lesion revealed a nonspecific malignant spindle cell neoplasm positive for BCL1, CD56, CD117, CD99, TLE1 and INI1, while negative for AE1/3, CAM5.2, EMA, ER, PR, CK5/6, calretinin, SMA, desmin and S100. The CD10 stain was inconclusive. FISH studies showed rearrangement of YWHAE gene (17p13.3) and no rearrangement involving JAZF1 or PHF1 gene regions. No rearrangement of the SS18 gene region was observed and synovial sarcoma was excluded. Overall findings support the diagnosis of metastatic HGESS. Results (if a Case Study enter NA) NA Conclusion HGESS, a rare tumor with a nonspecific immunostain profile, has the ability to metastasize to rare body sites, such as the pleura in our case. Display of spindle cell morphology is a nonspecific finding that raises broad differential diagnoses. In women, with or without a history of uterine neoplasm, HGESS is a clinically worthwhile diagnosis to be mindful of.

Primary Debulking Via Robotic-Assisted Laparoscopy for Stage IIIc Poorly Differentiated Endometrioid Adenocarcinoma of the Ovary.

<h3>Study Objective</h3> It has been demonstrated that minimally invasive surgery (MIS) is feasible and effective for interval cytoreduction after neoadjuvant chemotherapy for advanced ovarian cancer patients. MIS is also widely used to assess resectability in the setting of newly diagnosed advanced ovarian cancer. However, the role of MIS in the primary debulking of advanced ovarian cancer is less clear. Here, we present a case of a patient with stage IIIC high-grade endometrioid ovarian cancer, which was optimally debulked to no gross residual(R0) via robotic-assisted laparoscopy. <h3>Design</h3> This is a presentation of a patient who underwent primary ovarian cancer debulking via robotic-assisted laparoscopy. <h3>Setting</h3> The patient was taken to the operating for a planned robotic left ovarian oophorectomy, myomectomy and resection of endometriosis. Diagnostic laparoscopy revealed peritoneal tumor implants consistent with advanced ovarian cancer. The frozen section confirmed epithelial ovarian cancer. <h3>Patients or Participants</h3> This case involves a 37-yo patient who was found to have advanced ovarian cancer at the time of a planned robotic surgery for a complex left ovarian cyst and resection of fibroids and endometriosis. <h3>Interventions</h3> The patient underwent robotic-assisted total hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, resection of pelvic peritoneal, rectosigmoid, and diaphragmatic tumor nodules, pelvic and paraaortic lymph node dissection as well as pelvic washing. Final pathology showed stage IIIC poorly differentiated endometrioid adenocarcinoma of the ovary. <h3>Measurements and Main Results</h3> Complete gross resection (R0) was achieved. The estimated blood loss was 50 cc. The operative time was 3 hours and 10 mins. She was discharged on postoperative day 1. Her postoperative course was uncomplicated. Adjuvant chemotherapy with IV carboplatin and paclitaxel was initiated three weeks after surgery. <h3>Conclusion</h3> MIS is a feasible option for primary debulking in select cases of advanced ovarian cancer.

New Technique of Laparoscopic Paraaortic Lymph Node Dissection for Colorectal Cancer Using Fluorescence Navigation.

According to limited current reports, therapeutic paraaortic lymph node (PALN) dissection with intensive combined therapy for colorectal cancer improves prognosis in select patients. Laparoscopic PALN dissection is a difficult technique that has not yet been established. We applied this procedure using an intraoperative fluorescence navigation technique with a near-infrared ray catheter (NIRC™) fluorescent ureteral catheter (NIRFUC). We evaluated the utility of laparoscopic fluorescence navigation and the short-term outcomes of 6 patients undergoing laparoscopic PALN dissection. There were 3 surgeries for synchronous metastasis and 3 surgeries for recurrent metastasis. The mean surgical duration, blood loss, and postoperative hospital stay were 677 (range=518-1,090) min, 7.5 (range=3-1,600) ml, and 14 (range=9-33) days, respectively. Postoperative complications (Clavien-Dindo grade >III) occurred in 1 case. Dissection around the ureter was navigated with a NIRFUC. Fluorescence ureteral navigation facilitated completion of the complex laparoscopic PALN dissection procedure.

Is D2 Lymphadenectomy Alone Suitable for Gastric Cancer With Bulky N2 and/or Para-Aortic Lymph Node Metastases After Preoperative Chemotherapy?

BackgroundFor gastric cancer (GC) with extensive lymph node metastasis (bulky N2 and/or para-aortic lymph node metastases), there is no standard therapy worldwide. In Japan, preoperative chemotherapy (PCT) followed by D2 gastrectomy plus para-aortic lymph node dissection (PAND) is considered the standard treatment for these patients. However, in China, the standard operation for GC patients with only bulky N2 metastases was D2 gastrectomy. Besides, after PCT, whether doing PAND improves survival or not is debatable for GC patients with para-aortic lymph node (PAN) metastases. Therefore, we conducted this study to investigate whether D2 lymphadenectomy alone is suitable for these patients after PCT.MethodsWe retrospectively collected data on patients from our electronic medical record system. GC patients with bulky N2 and/or PAN metastases who underwent D2 lymphadenectomy alone after PCT were enrolled. The survival outcomes and chemotherapy responses were analyzed and compared with the results of the JCOG0405 study.ResultsFrom May 2009 to December 2017, a total of 83 patients met all eligibility criteria and were enrolled. The median survival duration for all patients was 40.0 months. The 3-year and 5-year OS rates for all patients were 50.3% and 45.6%, respectively. For patients with only bulky N2 metastasis, the 3-year and 5-year OS rates were 77.1% and 71.6%, respectively, which were similar to the results of the JCOG0405 study (82.7% and 73.4%). For patients with only PAN metastases, the 3-year and 5-year OS rates were 50.0% and 50.0%, respectively, which seemed to be lower than those of the JCOG0405 study (64.3% and 57.1%). For patients with bulky N2 and PAN metastases, the 3-year and 5-year OS rates were 7.4% and 0.0%, respectively, which were lower than those of the JCOG0405 study (20.0% and 20.0%).ConclusionThe results of our study suggest that D2 lymphadenectomy alone is suitable for GC patients with only bulky N2 metastasis after PCT. However, D2 lymphadenectomy alone perhaps is not suitable for patients with bulky N2 and PAN metastases after PCT.

V09-07 ROBOTIC INTRACORPOREAL SINGLE ILEAL INTERPOSITION FOR BILATERAL URETERAL STRICTURE

You have accessJournal of UrologyUpper Tract Reconstruction (V09)1 Sep 2021V09-07 ROBOTIC INTRACORPOREAL SINGLE ILEAL INTERPOSITION FOR BILATERAL URETERAL STRICTURE Sunchin Kim, and Matthew Gretzer Sunchin KimSunchin Kim More articles by this author , and Matthew GretzerMatthew Gretzer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002052.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Bilateral ureteral obstruction is a common complication for patients who have undergone radiation treatment for cervical cancer. Given the effect of radiation to the bladder, the usual reconstructive options are limited and becomes a challenging problem for a urologist to manage. This video aims to offer a robotic, completely intracorporeal urinary diversion using a single ileal loop interposition for bilateral ureteral strictures. METHODS: A 29 year old female with cervical cancer underwent treatment with robotic radical hysterectomy, bilateral salpingectomy, para-aortic lymph node dissection, then radiation treatment. She developed a vesicovaginal fistula and underwent repair with a pudendal thigh flap, then developed bilateral obliterative ureteral strictures at the mid-distal junction managed with bilateral nephrostomy tubes. Discussion of other options included Boari flap, psoas hitch, buccal augment, appendiceal interposition, and autotransplant. Patient was placed in a steep Trendelenburg position with four 8-mm robotic trocars placed subcostally and one assistant 12 mm port. Bilateral ureters were dissected out and transected at the level of their obliteration. The left ureter was tunneled underneath the rectum and brought over to the right side for a spatulated Wallace anastomosis. The distance between the ureter and bladder was measured, and the ileal segment was harvested. RESULTS: The operative time was 5 hours and 30 minutes. Estimated blood loss was 30 ml. Length of stay was 8 days with no complications, had extended stay for pain control given significant prior narcotics use. Bowel function and flatus were present on postoperative day 3. Foley catheter was left in place for 10 days, and bilateral ureteral stents were left in for 6 weeks. Preoperative creatinine was 0.83. Post-stent removal creatinine was 0.55. A flexible cystoscopy after stent removal revealed widely patent vesico-ileal and ileo-ureteral anastomoses. CONCLUSIONS: Complete intracorporeal robotic ileal interposition for bilateral ureters is a safe and feasible option for bilateral ureteral strictures. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e689-e689 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sunchin Kim More articles by this author Matthew Gretzer More articles by this author Expand All Advertisement Loading ...

Omitting lymphadenectomy in obese endometrial cancer patients undergoing sentinel lymph node mapping: when more is less

<h3>Objectives:</h3> Obese patients present unique surgical and technical challenges to their surgeons and anesthesiologists given their multiple comorbidities, difficult anatomy, and excessive weight. Thus, any surgical procedure that prolongs surgical time and potentially increases risk for complications in this population, needs to be carefully evaluated and minimized.The aim of this study is to evaluate the feasibility of sentinel lymph node (SLN) mapping in obese endometrial cancer patients, and to determine whether omitting lymph node dissection (LND) from surgical staging where SLN sampling is performed, impacts oncologic outcomes. <h3>Methods:</h3> Between December 2007 and August 2017, 722 patients with uterine cancer underwent surgical staging in our institution. We excluded patients with sarcomas (n=32), patients with stage 4 disease (n=9), patients who received neoadjuvant therapy (n=5) and patients whose body mass index (BMI) was below 35.0 kg/m² (n=453). The approach for LND at our center changed over the years: all surgeries from January 2008 to August 2014 included bilateral pelvic LND, with para-aortic LND at the surgeon's discretion (LND±SLN cohort). In addition to LND, all consecutive patients from December 2010 to August 2014 underwent SLN mapping with a cervical injection. With the establishment of SLN mapping algorithm feasibility, patients operated from August 2014 to August 2017 went through SLN mapping without LND (SLN cohort). <h3>Results:</h3> Out of 223 patients with a median BMI of 40.6 kg/m², 140 patients underwent LND (± SLN) and 83 patients underwent SLN. The median operative time for surgical staging in SLN only group was shorter in 47.5 minutes than for patients in the LND±SLN group (190.5 minutes (108-393) vs. 238 minutes (131-440), respectively, (p<0.001)), and they had reduced estimated blood loss (EBL) compared to the LND±SLN group (30 ml (0-300) vs. 40 ml (0-800ml), P=0.03). At a 24 months' follow-up cut-off, 98% of the patients were alive and 95.5% were free of disease, without significant differences in OS, DSS and PFS between the two groups (p=0.7, p=0.8 and p=0.4, respectively).Overall, 171 patients underwent SLN biopsy (±LND) and stratified by the tracer used for mapping (ICG versus blue dye). The ICG injected group had higher successful mapping and bilateral detection rates (92.8% vs 71.7%, p<0.001 and 80.2% vs 43.3%, p<0.001, respectfully). <h3>Conclusions:</h3> The obese population is at increased risk for intraoperative and postoperative complications associated with prolonged operative time from secondary to challenges in the surgical and anesthesia process. The advantage of minimizing the surgery towards SLN approach, as reflected in our results by shorter operative time and minimal bleeding is of particular importance in this set of patients. Omitting LND from surgical staging where SLN is performed was not associated with inferior survival outcomes. Given the higher successful detection and metastatic nodes rates with ICG and NIR fluorescence imaging compared to previously reported rates with blue dye based SLN, ICG should be the dye of choice in obese and morbid obese EC patients. Future studies should focus on molecular stratification of obese EC patients into risk groups for nodal disease, selecting patients for LND in cases of failed mapping.

Sentinel lymph node mapping detection and recurrence rates in clinical stage I endometrial cancer

Objectives: The literature suggests that sentinel lymph node biopsy (SLNB) is an acceptable alternative to pelvic and paraaortic lymph node dissection (PPALND) in patients with clinical stage I endometrial cancers. The referenced data is largely published from high-volume specialized institutions and a complete PPALND is still performed by many surgeons at smaller, non-specialized centers. Our aim is to demonstrate that SLNB is feasible, reproducible, and sensitive without affecting cancer-specific outcomes when implemented at a non-specialized center. Methods: A retrospective review of patients with clinical stage I endometrial cancer was performed from September 2016 through February 2020. All patients had undergone either a robot-assisted or laparoscopic hysterectomy with SLNB. Endometrioid, uterine papillary serous (UPSC), malignant mixed mesodermal tumor (MMMT), and clear cell (CC) histologies were included. Indocyanine green was injected into the cervix bilaterally as per a previously described protocol. Paraaortic LND was performed at the discretion of the surgeon. In addition to SLNB, complete PPALND was performed for patients with MMMT, UPSC or CC. Sentinel lymph nodes (SLN) were evaluated using ultra-staging protocols including serial sectioning and cytokeratin staining. The medical record was queried for clinical or radiographic evidence of recurrence. Results: A total of 92 patients were included: 69 stage IA, 12 stage IB, 3 stage II and 8 stage III (2 IIIA, 2 IIIC1, 4 IIIC2). The majority of patients were endometrioid (73%), followed by UPSC (15.0%), MMMT (5.0%) and CC (4%). At least one SLN was detected in 95.4% of cases. The rate of bilateral SLN detection was 74.3% and improved over time from 2017-2019: 70% (2017), 74.4% (2018), 80% (2019). Twenty patients underwent PPALND. Non-SLN were positive in 3 patients, all with high-risk histology. There were no other patients with false-negative SLNB. There have been 3 (3%) recurrences to date; one rectal recurrence, one pelvic side wall and one paraaortic lymph node recurrence. All three patients had detected bilateral SLN which were negative at the time of their initial surgery; all three recurrences were high grade histology. Conclusions: SLNB is a sensitive and specific method for assessing lymph node involvement in patients with clinical stage I endometrial cancers. Our detection and recurrence rates are comparable to the rates reported in the literature and demonstrate that when applied at non-specialized centers this approach is safe and reproducible without affecting cancer-specific outcomes.

Lymphatic mapping and obesity with sentinel lymph node biopsy in endometrial cancer

<h3>Objectives:</h3> Sentinel lymph node biopsy (SLNB) has emerged as an acceptable alternative to complete pelvic and paraaortic lymph node dissection (PPALND) for patients with clinical stage I endometrial cancer. Several factors are associated with high risk of bilateral SLN detection failure. Our aim is to investigate the effect of obesity on bilateral SLN detection rates. <h3>Methods:</h3> Patients with either clinical stage I endometrial cancer or complex atypical hyperplasia were retrospectively reviewed from September 2016 through February 2020. All patients had undergone either a robot-assisted or laparoscopic hysterectomy with SLNB. Endometrioid, uterine papillary serous (UPSC), malignant mixed mesodermal tumor (MMMT), and clear cell (CC) histologies were included. Indocyanine green was injected into the cervix per our protocol. Patients with suboptimal lymph node mapping or nodes suspicious for metastasis underwent a side specific pelvic lymph node dissection (LND). In addition to SLNB, PPALND was performed for patients with UPSC, MMMT, and CC. Sentinel lymph nodes (SLN) were evaluated using ultra-staging protocols including serial sectioning and cytokeratin staining. The medical record was queried for successful bilateral or unilateral sentinel lymph node detection. Patient demographic data was then collected and analyzed with sentinel lymph node detection rate. <h3>Results:</h3> A total of 97 patients were reviewed and included: 92 had diagnosed endometrial cancer while 5 had complex atypical hyperplasia. Stage were as follows: 81 patients had stage I or II disease, and 8 patients had Stage III disease diagnosed at surgery. At least one SLN was detected 95.9% of cases, with an overall bilateral detection rate of 77.7%. In total, 53 patients classified as obese (25 Class I, 15 Class II and 13 Class III), 24 patients were overweight (BMI 25-29.9) and 20 patients had normal BMI. Unilateral and bilateral detection rates were not independently associated with obesity class. Bilateral SLN detection rates were 76% in normal BMI class and 67%, 83% and 73% for Class I, Class II and Class III obesity respectively; while at least one SLN was detected in 94% of normal BMI class and 92%, 96%, 100% and 92% in overweight weight class, Class I, II and II obesity respectively. <h3>Conclusions:</h3> Patient BMI is an important consideration for preoperative planning and success of bilateral sentinel lymph node mapping. Bilateral detection rates among obese patients are comparable to those of non-obese patients in our cohort. Despite previously reported correlation between BMI and successful bilateral mapping, our results do not demonstrate this relationship and obesity does not appear to be a contraindication to SLNB.

Para-aortic lymph node involvement in cervical cancer: Implications for staging, outcome and treatment.

Locally advanced cervical cancer with the involvement of para-aortic lymph nodes (PALN) is a common occurrence in low-income and low-middle-income countries. With the incorporation of PALN in the recent FIGO staging, therapeutic management becomes crucial. There are varied presentations of this group which may range from microscopic involvement to extensive lymphadenopathy. Various imaging modalities have been studied to accurately diagnose PALN metastases without surgical intervention, while some investigators have studied the survival benefit of para-aortic lymph node dissection for accurate staging and guiding extent of radiation. With recent advances in radiation therapy, its application to treat bulky nodal metastases and the role of prophylactic irradiation have been reported. In this review, the available evidence and the scope of further interventions is presented.

Utility of lymphadenectomy in mucinous ovarian carcinoma

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

Effect of lymphadenectomy in colorectal cancer with isolated synchronous para-aortic lymph node metastasis.

There is controversy about the treatment of para-aortic lymph node (PALN) metastasis and usefulness of surgical removal. We investigated the clinical effects of synchronous isolated PALN dissection in patients with this metastasis. Patients with colorectal cancer with isolated PALN metastasis were selected between January 2008 and December 2016 at Samsung Medical Center. Patients who were selected for gross-free PALN dissection were set as the dissection group (DG). Patients who did not undergo PALN dissection or underwent biopsy were set as the non-dissection group (NDG). The oncological and operative outcomes were compared. A total of 73 patients were recruited. The most clinical and pathological characteristics were not significantly different. The incidence of postoperative complications was also similar. The 5-year overall survival of DG patients was 33.9%, that of NDG patients was 10.1%, and the survival curves were significantly different (P=0.044). Multivariate analysis revealed that location of tumour in the left colon rather than in the right colon was a risk factor affecting survival in sub-analysis. PALN dissection did not increase postoperative complications and had a better effect on patient survival. It is suggested that lymphadenectomy be performed more aggressively when PALN metastasis is seen in patients with right colon cancer.

Pathological complete response at the para-aortic nodes as a possible surrogate endpoint in gastric cancer surgery with para-aortic node dissection after neoadjuvant chemotherapy

PurposeGastric cancer with para-aortic node (PAN) metastasis has a chance to be cured with multidisciplinary treatment of D2 and PAN dissection (PAND) following neoadjuvant chemotherapy (NAC), but its prognosis remains unsatisfactory. To establish a better multidisciplinary treatment, a better surrogate endpoint is needed. The present study focused on a pathological complete response at the PANs alone as a new surrogate endpoint and evaluated its prognostic value. MethodsThe study examined patients who received radical gastrectomy with D2 and PAND after NAC for gastric cancer with PAN metastasis from 2004 to 2015. The study compared five methods of evaluating the response to NAC: RECIST, clinical disappearance of PANs (cPAN), histological response of the primary tumor defined by Japanese Classification of Gastric Carcinoma (JCGC histological criteria) and Becker's criteria, and pathological disappearance of PANs (pPAN). The efficacy of these methods was compared using the hazard ratio (HR) for death between responders and non-responders. ResultsThirty-two patients were analyzed. The respective HR and 5-year overall survival rates of responders and non-responders were 1.316 and 49.1% vs. 60.0% by RECIST, 1.106 and 52.9% vs. 52.5% by cPAN, 0.246 and 71.3% vs. 28.6% by JCGC histological criteria, 0.239 and 76.2% vs. 36.8% by Becker's criteria, and 0.074 and 81.0% vs. 0.0% by pPAN. ConclusionsA pathological complete response at the PANs had the lowest HR and clearly differentiated the survival, suggesting it might be a good surrogate endpoint for identifying future candidates for NAC in multidisciplinary treatment for gastric cancer with PAN metastasis.

A Way to Reduce the Occurrence of Intraoperative Capsule Rupture in Presumed Clinically Early-stage Ovarian Cancer with Adhesions to the Abdominal Wall

To present a procedure to reduce the occurrence of intraoperative capsule rupture in presumed clinically early-stage ovarian cancer with adhesions to the abdominal wall. Stepwise presentation of the procedure with narrated video footage. The occurrence of intraoperative capsule rupture exerts a negative effect on the prognosis of early-stage ovarian cancer [1,2]. Thus, it is important to reduce intraoperative capsule rupture to improve the oncologic outcome of such patients. In this video we describe a laparoscopic procedure to minimize the risk of intraoperative capsule rupture in presumed clinically early-stage ovarian cancer with adhesions to the abdominal wall. A 52-year-old woman was referred from a local clinic for a 6×6×4-cm left ovarian mass and a 7×6×6-cm right ovarian mass. Her serum cancer antigen 125 level was 214.4U/mL. Pelvic magnetic resonance imaging and positron emission tomographic/computed tomographic imaging showed no evidence of metastatic diseases or lymph node involvement. A diagnosis of ovarian malignancy was suspected. Laparoscopic evaluation suggested that the right adnexa was adhered to the right abdominal wall and there was no evidence of tumor seeding in the peritoneal cavity. We collected the peritoneal lavage fluid. Since pelvic adhesiolysis between the right adnexa and the abdominal wall may increase the occurrence of intraoperative capsule rupture of the ovarian tumor, leading to a worse clinical outcome, we decided to remove both the right adnexa as well as the adhered peritoneum. The key steps of the procedure are summarized as follows. First, the utero-ovarian ligament and tubal isthmus were coagulated and excised. Second, the pelvic peritoneum was excised, and the infundibulo-pelvic ligament and ureter were identified and mobilized. Third, the infundibulo-pelvic ligament was coagulated and excised. Fourth, the pelvic peritoneum which was adhered to the right adnexa was dissected off the ureter and excised. Then, the resected right adnexa as well as the adhered peritoneum were collected in a disposable pocket and removed to avoid further contamination. Adenocarcinoma was diagnosed by frozen section evaluation. So, surgical staging was performed laparoscopically, and consisted of hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, omentectomy, and random peritoneal biopsies from the pelvis, paracolic gutters, and undersurfaces of the diaphragm. Final pathologic reports showed ovarian clear cell carcinoma with involvement of both ovaries and the adhered peritoneum. Our method is effective for intact removal of the involved adnexa without rupture and the adhered pelvic peritoneum with potential for tumor seeding.

Lymphadenectomy, obesity and open surgery are associated with surgical complications in endometrial cancer

ObjectiveTo investigate surgical complications related to the staging procedure for endometrial cancer (EC) and to explore complication associations towards patient characteristics and survival. MethodsA population-based cohort study of women diagnosed with EC where primary surgery was performed at a tertiary centre between 2012 and 2016. The Swedish Quality Registry for Gynecological Cancer was used for identification, medical records reviewed and surgical outcomes, including complications according to Clavien-Dindo (CD), and comorbidity (Charlson's index) registered. Uni- and multivariable logistic regression analyses were performed with complications as outcome and multivariable Cox regression analysis with overall survival (OS) as endpoint. ResultsIn total 549 women were identified where 108 (19.7%) had CD grade II-V complications. In the multivariable regression analysis; surgical technique, BMI and lymph node dissection, but not comorbidity or age, were found to be risk factors for complications CD grade II-V, with OR of 0.32 (95%CI:0.18–0.56) for minimalinvasive surgery (MIS) compared to open, OR 2.18 (95%CI:1.37–3.49) for BMI ≥30 and OR 2.63 (95%CI:1.32–5.31) for pelvic and paraaortic lymphnode dissection. In Cox regression analysis, a significant lower OS was found within the first 1.5 years for the cohort of complications (CD II-V) compared to no complications. ConclusionSurgical staging with lymphadenectomy was found a risk factor for complications together with high BMI in EC. Using MIS was significantly associated with less complications. Overall survival was found to be negatively affected within the first years after complications. Our results may be taken into consideration when performing updated treatment guidelines including surgical staging.