Para-aortic Lymphadenectomy In Patients Research Articles

Outcomes of minimal access retroperitoneal para-aortic lymphadenectomy in patients with locally advanced cervical cancer

Background To evaluate outcomes of laparoscopic retroperitoneal para-aortic lymphadenectomy for stage 1b3-3b cervical cancer. Methods Pathology databases searched for all para-aortic lymphadenectomy cases 2005–2016. Descriptive statistics were used to analyse baseline characteristics, cox models for treatment affect after accounting for variables, and Kaplan Meier curves for survival (STATA v15). Results 191 patients had 1b3-3b cervical cancer of which 110 patients had Para-aortic lymphadenectomy. 8 (7.3%) patients stage 1b3, 82 (74.6%) stage 2b, and 20 (18.1%) stage 3b cervical cancer. Mean lymph node count 11.7 (SD7.6). The intra-operative and post-operative 30 day complication rates were 8.8% (CI: 4.3%, 15.7%) and 5.3% (CI: 1.9%, 11.2%) respectively. Para-aortic nodes were apparently positive on CT/MRI in 5/110 (5%) cases. Cancer was found in 10 (8.9%, CI: 4.3%, 15.7%) cases on histology, all received extended field radiotherapy. Only 2 were identified on pre-operative CT/MRI imaging. 3 of 10 suspected node-positive cases on CT/MRI had negative histology. Para-aortic lymphadenectomy led to alteration in staging and radiotherapy management in 8 (8%, CI: 3.7%, 14.6%) patients. Mean overall survival 42.81 months (SD = 31.79 months). Survival was significantly higher for women undergoing PAN (50.57 (SD 30.7) months) compared to those who didn’t (31.27 (SD 32.5) months) Conclusion Laparoscopic retroperitoneal para-aortic lymphadenectomy is an acceptable procedure which can guide treatment in women with locally advanced cervical cancer.

Therapeutic role of para-aortic lymphadenectomy in patients with intermediate- and high-risk endometrial cancer: a systematic review and meta-analysis.

Lymph nodal involvement is a prognostic factor in endometrial cancer. The added value of para-aortic lymphadenectomy compared with pelvic nodal evaluation alone remains a matter of debate in the management of patients with intermediate- and high-risk endometrial cancer. A systematic review and meta-analysis was conducted to assess the prognostic value of para-aortic lymphadenectomy in terms of overall survival and disease-free survival in patients with intermediate- and high-risk endometrial cancer. The study adhered to the PRISMA guidelines. PubMed, Google Scholar and ClinicalTrials.gov were searched from January 2000 to April 2023. Studies on intermediate- and high-risk patients who underwent pelvic versus pelvic and para-aortic dissection were included in the analysis. The Methodological Index for Nonrandomized Studies (MINORS) and the Quality Assessment of Diagnostic Accuracy Studies 2 tool (QUADAS-2) were used for quality assessment of the selected articles. Fourteen studies were identified, encompassing 9415 patients with a median age of 62 years (IQR 56.5-66.5). The majority had International Federation of Gynecology and Obstetrics stage I-II disease (76%) and endometrioid histology (89%). The 72% of patients who underwent only pelvic nodal evaluation and the 87% who underwent pelvic and para-aortic lymphadenectomy received adjuvant treatment (p=0.44). Pelvic and para-aortic lymphadenectomy was associated with a significant improvement in 5-year overall survival (RR=0.71, 95% CI 0.57 to 0.88, p<0.01), translating to a 41% reduction in the risk of overall death. However, no significant differences were observed in the 5-year risk of recurrence (RR=1.12, 95% CI 0.94 to 1.34, p=0.15). Additionally, patients undergoing pelvic and para-aortic lymphadenectomy experienced a 26% increased risk of post-operative complications (RR=1.26, 95% CI 1.04 to 1.53, p=0.03) and prolonged operative times (MD=56.27, 95% CI 15.94 to 96.60, p<0.01). Pelvic and para-aortic lymphadenectomy appears to confer a prognostic benefit in patients with intermediate- and high-risk endometrial cancer. Robust prospective studies are needed to further validate these findings and elucidate the precise role of para-aortic lymphadenectomy in the optimal management of these patients.

FloSeal for preventing symptomatic lymphocele after pelvic and/or para-aortic lymphadenectomy in gynecological cancers: a randomized controlled trial

To evaluate the role of FloSeal for preventing symptomatic lymphocele following pelvic and/or para-aortic lymphadenectomy in patients with gynecological cancers. Between October 2014 and April 2015, 40 patients with gynecological cancers planned for surgical management were randomly placed into FloSeal and non-FloSeal groups in a 1:1 ratio. Lymphocele incidence was evaluated using intravenous contrast-enhanced, abdominopelvic computed tomography 3–6 months after surgery. The quality of life questionnaire was completed by patients at 1, 3 and 6 months after surgery. The incidence of symptomatic lymphocele was compared using a chi-square test. All patients underwent bilateral pelvic lymph node dissection, and eight patients in each group (40%vs. 44.4%, p &gt; 0.999) underwent para-aortic lymph node dissection. The mean number of total, right pelvic, left pelvic and para-aortic lymph nodes retrieved was similar between the groups. One patient (1/20, 5%) in the FloSeal group and three (3/18, 16.7%) in the non-FloSeal group developed lymphoceles (p = 0.328). The incidence of symptomatic lymphocele was 0% and 11% (2/18) in the FloSeal and non-FloSeal groups (p = 0.218), respectively. The mean time interval to drain removal (4.8 ± 2.0 days vs. 5.3 ± 2.2 days, p = 0.400) was shorter and the mean drain volume (1656 ± 1362 mL vs. 2022 ± 2301 mL, p = 0.550) was smaller in FloSeal group. The use of FloSeal after pelvic and/or para-aortic lymphadenectomy in patients with gynecological cancers may be effective for preventing symptomatic lymphocele. Clinical Trial registration: NCT01679483.

A pre-operative radiological score to predict lymph node metastasis in advanced epithelial ovarian cancer

BackgroundLymphadenectomy is part of cytoreductive surgery for patients with advanced epithelial ovarian cancer (AEOC) in case of abnormal lymph nodes before and during surgery. The aim of this study was to develop and validate a pre-operative radiological score to predict pelvic and/or para-aortic lymph node metastasis (LNM) in patients with AEOC undergoing cytoreductive surgery. MethodsWe conducted a multicentre retrospective study. The construction sample was composed of 53 patients operated within two referral centers. The validation sample was composed of 39 patients operated in a third referral center. The score was built with a logistic regression model with internal validation by bootstrap. ResultsTwo variables were associated with the prediction of pelvic and/or para-aortic LNM at computerized tomography (CT) and/or positron emission tomography (PET/CT): “para-aortic lymph node involvement” (adjusted diagnostic odds ratio) (aDOR) = 8.77 95CI [1.42–54.09], p = 0.02) and “colon involvement” (aDOR = 7.97 95CI [1.28–49.58], p = 0.03). Bootstrap procedure showed that the model was stable. The 2-points LNM pre-operative radiological score was derived from these 2 radiological variables and a high-risk group was identified for a score ≥ 1: the probability of pelvic and/or para-aortic LNM was 76%, the specificity was 85.7% 95CI [67.3–96.0] and the positive likelihood ratio was 3.6 95CI [1.4–9.7]. In the validation sample, a score ≥ 1 had a specificity of 78.3% and a LR+ of 1.2. ConclusionLNM pre-operative radiological score could help the surgeon's decision to perform pelvic and para-aortic lymphadenectomy in patients with AEOC undergoing cytoreductive surgery. Trial registrationThe research protocol was approved by the Ethics Committee for Research in Obstetrics and Gynecology (CEROG 2016-GYN 1003).

Systematic Lymphadenectomy and Oncological Outcomes of Women With Apparent Early-Stage Clear Cell Carcinoma of the Endometrium: A Multi-Institutional Cohort Study

ObjectiveThe survival value of systematic lymphadenectomy for endometrial cancer is ambiguous and controversial. The current study aimed to evaluate the long-term survival role of combined pelvic and para-aortic lymphadenectomy in patients with presumed early-stage clear cell carcinoma of the endometrium.MethodsPatients in three Chinese teaching hospitals who presented between 2012 and 2017 with apparent early-stage clear cell carcinoma of the endometrium and underwent surgical staging were selected. Patients who did and did not undergo systematic lymphadenectomy were identified and clinicopathological characteristics were compared. Disease-free survival and overall survival were evaluated following the generation of the Kaplan-Meier curves and the comparison using the log-rank test. A Cox proportional hazards model was employed to control for confounders.ResultsA total of 244 patients underwent systematic lymphadenectomy and 89 did not receive lymph node dissection. The demographic and baseline data were comparable between the two groups. The rate of disease-free survival at 5 years was 64.10% in patients who underwent systematic lymphadenectomy and 45.05% in patients who did not undergo lymphadenectomy. Patients who underwent systematic lymphadenectomy had better disease-free survival than those who did not receive lymphadenectomy (HR, 0.54. 95% CI, 0.38-0.76. P=0.000). The rate of 5-year overall survival was 68.87% in the lymphadenectomy group and 53.33% in patients who did not undergo systematic lymphadenectomy. Systematic lymphadenectomy was also associated with improved 5-year overall survival for women with presumed early-stage clear cell carcinoma of the endometrium (HR, 0.58. 95% CI, 0.39-0.85. P=0.005). After adjusting for confounders, systematic lymphadenectomy was still independently associated with improved disease-free survival and overall survival.ConclusionPatients with apparent early-stage clear cell carcinoma of the endometrium who underwent systematic lymphadenectomy had better long-term survival than those who did not undergo systematic lymphadenectomy.

Effectiveness of Laparoscopic Combined Retroperitoneal and Transperitoneal Approach in Para-aortic Lymphadenectomy for Endometrial Cancer.

This study aimed to compare laparoscopy with laparotomy and evaluate the effectiveness of a laparoscopic combined retroperitoneal and transperitoneal approach for para-aortic lymphadenectomy in patients with endometrial cancer. In this single-center retrospective study, patients with endometrial cancer who underwent para-aortic lymphadenectomy between December 2016 and November 2019 were analyzed. The patient's clinical and pathologic data were procured from medical records. Statistical analyses were performed using Fisher's exact and the Mann-Whitney U-tests. A total of 37 and 28 patients were included in the laparoscopic and laparotomy groups, respectively. The laparoscopic group had similar operative time, similar number of resected para-aortic and pelvic lymph nodes, less intraoperative blood loss and complications, lower rate of blood transfusion, and shorter postoperative stay than the laparotomy group. Laparoscopic combined retroperitoneal and transperitoneal approach for endometrial cancer is safe and effective compared to laparotomy.

Endometrial Cancer Lymphadenectomy Trial (ECLAT) (pelvic and para-aortic lymphadenectomy in patients with stage I or II endometrial cancer with high risk of recurrence; AGO-OP.6)

BackgroundThe impact of comprehensive pelvic and para-aortic lymphadenectomy on survival in patients with stage I or II endometrial cancer with a high risk of recurrence is not reliably documented. The...

Para-aortic lymph node surgical staging in locally-advanced cervical cancer: comparison between robotic versus conventional laparoscopy

ObjectiveWith the expansion of the use of minimally invasive surgical techniques within the field of gynecological oncology, a robot assisted procedure seems to be an attractive technique for para-aortic lymph...

Multicenter study comparing oncologic outcomes after lymph node assessment via a sentinel lymph node algorithm versus comprehensive pelvic and paraaortic lymphadenectomy in patients with serous and clear cell endometrial carcinoma

ObjectivesTo compare survival after nodal assessment using a sentinel lymph node (SLN) algorithm versus comprehensive pelvic and paraaortic lymphadenectomy (LND) in serous or clear cell endometrial carcinoma, and to compare survival in node-negative cases. MethodsThree-year recurrence-free survival (RFS) and overall survival were compared between one institution that used comprehensive LND to the renal veins and a second institution that used an SLN algorithm with ultra-staging with inverse-probability of treatment weighting (IPTW) derived from propensity scores to adjust for covariate imbalance between cohorts. Results214 patients were identified (118 SLN cohort, 96 LND cohort). Adjuvant therapy differed between the cohorts; 84% and 40% in the SLN and LND cohorts, respectively, received chemotherapy ± radiation therapy. The IPTW-adjusted 3-year RFS rates were 69% and 80%, respectively. The IPTW-adjusted 3-year OS rates were 88% and 77%, respectively. The IPTW-adjusted hazard ratio (HR) for the association of surgical approach (SLN vs LND) with progression and death was 1.46 (95% CI: 0.70–3.04) and 0.44 (95% CI: 0.19–1.02), respectively. In the 168 node-negative cases, the IPTW-adjusted 3-year RFS rates were 73% and 91%, respectively. The IPTW-adjusted 3-year OS rates were 88% and 86%, respectively. In this subgroup, IPTW-adjusted HR for the association of surgical approach (SLN vs LND) with progression and death was 3.12 (95% CI: 1.02–9.57) and 0.69 (95% CI: 0.24–1.95), respectively. ConclusionOS was not compromised with the SLN algorithm. SLN may be associated with a decreased RFS but similar OS in node-negative cases despite the majority receiving chemotherapy. This may be due to differences in surveillance.

Role of Pelvic and Para-Aortic Lymphadenectomy in Advanced Ovarian Epithelial Cancer

Background: the role of detection and removal of retroperitoneal lymph nodes in patients with advanced ovarian cancer disease is unclear. Aim of the work: this study was aimed to evaluate the therapeutic role of pelvic and paraaortic lymphadenectomy in patients with advanced epithelial ovarian cancer. Patients and Methods: this study was designed as a prospective randomized controlled trial. Thirty patients were divided into two equal groups; 15 patients underwent optimum cytoreduction and in the other 15 patient retroperitoneal lymphadenectomy was added. Results: the mean number of nodes removed was 26, and the mean number of positive nodes was 6. There was significant difference between the two groups of the study when considering operation time (Mean 122 min. Vs. 192 min.). Also there is significant difference between the two groups of the study when considering hospital stay in days (Mean 8 days Vs. 13 days). There was significant difference between the two group of the study when considering the blood loos and need for blood transfusion (26% Vs. 80%). There was no significant difference between the two groups of the study when considering recurrence (73.3% Vs. 60%). Conclusion: Our results show improvement towards decrease the recurrence in the lymphadenectomy group but with non-significant results.

Role of Pelvic and Para-Aortic Lymphadenectomy in Advanced Ovarian Epithelial Cancer

Background: the role of detection and removal of retroperitoneal lymph nodes in patients with advanced ovarian cancer disease is unclear. Aim of the work: this study was aimed to evaluate the therapeutic role of pelvic and paraaortic lymphadenectomy in patients with advanced epithelial ovarian cancer. Patients and Methods: this study was designed as a prospective randomized controlled trial. Thirty patients were divided into two equal groups; 15 patients underwent optimum cytoreduction and in the other 15 patient retroperitoneal lymphadenectomy was added. Results: the mean number of nodes removed was 26, and the mean number of positive nodes was 6. There was significant difference between the two groups of the study when considering operation time (Mean 122 min. Vs. 192 min.). Also there is significant difference between the two groups of the study when considering hospital stay in days (Mean 8 days Vs. 13 days). There was significant difference between the two group of the study when considering the blood loos and need for blood transfusion (26% Vs. 80%). There was no significant difference between the two groups of the study when considering recurrence (73.3% Vs. 60%). Conclusion: Our results show improvement towards decrease the recurrence in the lymphadenectomy group but with non-significant results.

Lack of Survival Benefit of Para-Aortic Lymphadenectomy in Advanced Cervical Cancer

Introduction: The presence of positive para-aortic lymph nodes in advanced cervical cancer remains the most important prognostic factor for survival and also defines the treatment. Our aim was to define the influence of staging para-aortic lymphadenectomy in patients’ survival. Material and Methods: The medical records of 74 patients with advanced cervical cancer (FIGO IIB-IVA) were reviewed. In 31 patients (41.9%), the assessment of lymph nodes was performed with imaging test (group 1) and in 43 (58.1%) within a surgical staging para-aortic lymphadenectomy (group 2). We compared both groups according to stage of disease, treatment, progression-free survival (PFS), and overall survival (OS). Results: The extended-field radiotherapy was performed in 44.2 and 19.4% of patients in surgical and imaging staging group, respectively (p = 0.045). The disease-free survival rate was 17.4 ± 17.4 months in group 1 and 14.4 ± 12.6 months in group 2 (p = 0.456). No differences in OS were found between these 2 groups (p = 0.676). Conclusions: Despite the higher diagnostic accuracy of surgical staging and the higher number of patient who received extended field radiotherapy, we did not find differences between the overall and PFS rates in both the studied groups. Further prospective study on a higher number of patients would be necessary.

A Randomized Trial of Lymphadenectomy in Patients with Advanced Ovarian Neoplasms

BackgroundSystematic pelvic and paraaortic lymphadenectomy has been widely used in the surgical treatment of patients with advanced ovarian cancer, although supporting evidence from randomized clinical trials has been limited.MethodsWe intraoperatively randomly assigned patients with newly diagnosed advanced ovarian cancer (International Federation of Gynecology and Obstetrics stage IIB through IV) who had undergone macroscopically complete resection and had normal lymph nodes both before and during surgery to either undergo or not undergo lymphadenectomy. All centers had to qualify with regard to surgical skills before participation in the trial. The primary end point was overall survival.ResultsA total of 647 patients underwent randomization from December 2008 through January 2012, were assigned to undergo lymphadenectomy (323 patients) or not undergo lymphadenectomy (324), and were included in the analysis. Among patients who underwent lymphadenectomy, the median number of removed nodes was 57 (35 pelvic and 22 paraaortic nodes). The median overall survival was 69.2 months in the no-lymphadenectomy group and 65.5 months in the lymphadenectomy group (hazard ratio for death in the lymphadenectomy group, 1.06; 95% confidence interval [CI], 0.83 to 1.34; P=0.65), and median progression-free survival was 25.5 months in both groups (hazard ratio for progression or death in the lymphadenectomy group, 1.11; 95% CI, 0.92 to 1.34; P=0.29). Serious postoperative complications occurred more frequently in the lymphadenectomy group (e.g., incidence of repeat laparotomy, 12.4% vs. 6.5% [P=0.01]; mortality within 60 days after surgery, 3.1% vs. 0.9% [P=0.049]).ConclusionsSystematic pelvic and paraaortic lymphadenectomy in patients with advanced ovarian cancer who had undergone intraabdominal macroscopically complete resection and had normal lymph nodes both before and during surgery was not associated with longer overall or progression-free survival than no lymphadenectomy and was associated with a higher incidence of postoperative complications. (Funded by Deutsche Forschungsgemeinschaft and the Austrian Science Fund; LION ClinicalTrials.gov number, NCT00712218.)

Laparoscopic para-aortic lymphadenectomy for colorectal cancer with clinically suspected lymph node metastasis.

The optimal surgical management strategy for isolated para-aortic lymph node (PALN) metastases from colorectal cancer (CRC) remains unclear. However, the complication rates for open approaches remain high. In this study, the outcomes of laparoscopic para-aortic lymphadenectomy in patients with clinically suspected PALN metastasis were evaluated. Between April 2013 and April 2018, we performed laparoscopic primary resection and para-aortic lymphadenectomy in 11 patients with advanced colorectal cancer and clinically suspected PALN metastasis. This study was a single-center, retrospective, case series analysis, and the surgical outcomes were reviewed. There were no cases of perioperative mortality, and conversion to open surgery was necessary in only one patient (9%) because of invasion into a rib. One patient (9%) required a blood transfusion. Postoperative complications occurred in three patients, and the morbidity rate was 27% (3/11). Pathologically, PALN metastasis was confirmed in five patients (45%), all of whom received postoperative chemotherapy. The median survival time for all patients was 25 months, and one patient died of recurrence at 25 months after the initial surgery. Two other patients were alive with recurrence after 47 and 36 months, and two patients were alive without recurrence after 17 and 2 months. Laparoscopic para-aortic lymphadenectomy for advanced colorectal cancer with clinically suspected PALN is technically feasible and may be beneficial in selected patients. It is necessary to investigate the feasibility of this procedure in a future case series, and information regarding true oncologic outcome will require long-term follow-up.

Compromiso ganglionar para-aórtico en estadios tempranos de cáncer de endometrio de acuerdo con el algoritmo de kumay y col.

Introducción: La linfadenectomía para-aórtica en pacientes con estadios tempranos de cáncer de endometrio continúa siendo controversial, debido a que algunos estudios sugieren mayor morbilidad y costo sin claro beneficio en la sobrevida global. Objetivo: determinar el compromiso ganglionar para-aórtico en pacientes con cáncer de endometrio en estadios tempranos de acuerdo con él algoritmo de Kumar y col. Método: estudio descriptivo retrospectivo tipo serie de casos que incluyó pacientes llevadas a cirugía clasificatoria por vía abierta o laparoscópica (histerectomía total, salpingo-oforectomía bilateral más linfadenectomía pélvica y para-aórtica) con diagnóstico de adenocarcinoma de endometrio tipo endometriode, aplicación del algoritmo y evaluación de las diferencias que resultaran. Resultados: se incluyeron 15 pacientes, de las 9 clasificadas por el algoritmo de Kumar y col. como de alto riesgo en 2 (28.5%) hubo compromiso ganglionar para-aórtico (GPA) y en ninguna en el grupo de bajo riesgo. Cuatro (26,6%) pacientes presentaron complicaciones derivadas del procedimiento, 75% fueron tempranas, una ingresó a la unidad de cuidado intensivo (UCI) y no hubo muertes asociadas con los procedimientos quirúrgicos. Conclusión: las pacientes de bajo riesgo según el algoritmo de Kumar y col. fueron negativas para compromiso GPA, sin embargo, no ocurrió lo mismo para las de alto riesgo, por lo cual no podemos recomendar el uso rutinario de la realización de la linfadenectomía para-aórtica. Tendrán que realizarse estudios prospectivos para validar este algoritmo con el número de pacientes con el que fue planteado.

LION: Lymphadenectomy in ovarian neoplasms—A prospective randomized AGO study group led gynecologic cancer intergroup trial.

5500 Background: So far, there is no level-1 evidence regarding the role of systematic pelvic and para-aortic lymphadenectomy (LNE) in patients with advanced ovarian cancer (AOC) with macroscopic complete resection und clinically negative lymph nodes (LN). Therefore, surgical management regarding LNE worldwide is very heterogeneous. Methods: Prospective randomized trial including patients with newly diagnosed AOC FIGO IIB-IV with macroscopic complete resection and pre- and intra-operatively clinical negative LN were randomized intra-operatively to LNE versus no-LNE. All centers had to qualify regarding surgical skills before participation in this trial. The primary endpoint was overall survival. Results: 647 patients were randomized between 12/08 and 1/12 to LNE (n=323) or no-LNE (n=324). The median number of removed LN in patients randomized to LNE was 57 (pelvic 35 and para-aortic22). Post-op platinum-taxane based chemotherapy was applied in 85% of the patients in the no-LNE arm and 80% in the LNE arm. Microscopic metastases were diagnosed in 56% of the pts in the LNE arm. Median OS in the no-LNE arm was 69 months and 66 months in the LNE arm (HR 1.06, 95%CI 0.83-1.34, p=0.65) and the median PFS was 26 months in both arms (HR 1.11, 95%CI 0.92-1.34 p=0.30). Surgery in the LNE arm was 64 minutes longer (means: 352 vs 288 min), resulted in a higher median blood loss (650 vs 500 ml), and a higher transfusion rate (67% vs 59%). Furthermore, serious post-operative complications occurred more frequently in the LNE arm (e.g. rate of re-laparotomies 12.1% vs 5.9% [p=0.006], hospital re-admittance rate 8.0% vs 3.1% [p=0.006] and deaths within 60 days after surgery 3.1 vs 0.9% [p=0.049]). Conclusions: Systematic pelvic and para-aortic LNE in patients with AOC with both intra-abdominal complete resection and clinically negative LN neither improve overall nor progression-free survival despite detecting (and removing) sub-clinical retroperitoneal lymph node metastases in 56% of the patients. Our data indicate that systematic LNE of clinical negative LN in patients with AOC and complete resection should be omitted to reduce post-operative morbidity and mortality. Clinical trial information: NCT00712218.

The role of para-aortic lymphadenectomy in stage IIIC endometrial cancer: A single-institute study

The therapeutic value of para-aortic lymphadenectomy (PAL) in women with endometrial cancer (EC) remains uncertain. We retrospectively analysed 25 patients with stage IIIc EC (17 stage IIIC1; 8 IIIC2) who were treated in our institution. All subjects had undergone pelvic lymphadenectomies in which para-aortic nodes were sampled, or removed only when these nodes were enlarged. Sampling of para-aortic nodes or PAL was performed in all patients with stage IIIC2 disease and one of 17 with stage IIIC1 disease. Para-aortic lymph nodes were the most frequent site of recurrence in stage IIIC1 patients, but no such recurrences occurred in stage IIIC2 patients. Overall survival tended to be shorter in stage IIIC1 patients than stage IIIC2 patients. Our findings indicate that PAL improves the outcomes of patients with EC and high risk of para-aortic lymph node metastasis, such as those with positive pelvic lymph nodes or enlargement of para-aortic lymph nodes.Impact statementPara-aortic lymph node (PALN) metastases are important prognostic factors in endometrial cancer.Overall survival of patients with stage IIIC1 disease is generally longer than for those with stage IIIC2 disease.Retrospective studies – but no prospective studies – have suggested that para-aortic lymphadenectomy (PAL) provides a survival benefit.In our institution, we had performed PAL or para-aortic sampling for patients with enlarged PALNs; therefore, as most IIIC1 patients had no enlarged PALNs, they underwent pelvic lymphadenectomy only, whereas all IIIC2 patients had enlarged PALNs and underwent pelvic lymphadenectomy and PAL or PALN sampling in addition to pelvic lymphadenectomy. However, under this policy, survival of stage IIIC1 patients was not better than for stage IIIC2 patients. Our retrospective study indicates a survival benefit for PAL in patients with pelvic node-positive or enlarged PALN. PAL warrants a prospective randomised trial to see whether it should be a standard treatment in these patients.

Radical hysterectomy with or without para-aortic lymphadenectomy for patients with stage IB2, IIA2, and IIB cervical cancer: outcomes for a series of 308 patients

Although many studies have already shown that lymph node metastasis is one of the major prognostic factors for cervical cancer, the therapeutic significance of para-aortic lymphadenectomy for the surgical treatment of cervical cancer remains controversial. A total of 308 patients diagnosed with stage IB2, IIA2, or IIB cervical cancer and treated with radical hysterectomy were retrospectively investigated to assess the incidence of para-aortic lymph node metastasis and the clinicopathological factors linked to cervical cancer prognosis. Para-aortic lymph node metastases were pathologically confirmed in 13 of the 136 patients (9.6 %) who underwent para-aortic lymphadenectomy. The incidence of para-aortic lymph node metastasis was significantly higher in the patients who had common iliac lymph node metastases (odds ratio 31.5, p < 0.001) according to logistic regression analysis. Common iliac lymph node metastasis was related to risk of recurrence (hazard ratio 2.43, p = 0.003) and death (hazard ratio 2.62, p = 0.007) in Cox regression analysis. Kaplan-Meier analysis and Cox regression analysis showed that para-aortic lymphadenectomy did not have a positive impact on survival in 308 patients or 140 pN1 patients, but para-aortic lymphadenectomy was related to better overall survival with a marginal trend toward significance (p = 0.053) in 30 patients with common iliac lymph node metastasis. Indication for para-aortic lymphadenectomy in the surgical treatment of stage IB2, IIA2, or IIB cervical cancer needs to be individualized. Patients with common iliac lymph node metastasis are possible candidates, and a prospective study is needed to clarify this issue.

Present and Future in Endometrial Cancer Treatment

It should be mentioned that pelvic and para-aortic lymphadenectomy, are absolutely necessary in EC patients for the diagnosis of stage IIIc disease [3-5,8,9,11-13,20,21]. Moreover the application of pelvic and para-aortic lymphadenectomy in patients with advanced stage type I EC and in all patients with type II EC, associated with improved survival [2-5,11,22-26]. However the application of pelvic and para-aortic lymphadenectomy in patients with early stage type I EC, do not improve survival [25,11,12,27,28].

Does ultrasonic advanced energy reduce lymphocele incidence in laparoscopic para-aortic lymphadenectomy?

ObjectiveTo evaluate the use of ultrasonic advanced energy in reducing the occurrence of symptomatic lymphocele and its related complications in laparoscopic extra-peritoneal para-aortic lymphadenectomy in patients with gynecological cancer. Study designA retrospective cohort study of consecutive patients in a tertiary referral center identified 2 groups of patients, undergoing laparoscopic extra-peritoneal para-aortic lymphadenectomy with or without the use of ultrasonic advanced energy. Surgery time, hospital stay, number of retrieved nodes and lymphocele requiring treatment were studied. Results were also compared between trained and trainee surgeons. Results163 patients were scheduled for laparoscopic extra-peritoneal para-aortic lymphadenectomy: 81 treated using bipolar energy (control group: group 1) between August 1999 and January 2005, and 82 treated using ultrasonic advanced energy (study group: group 2) between July 2010 and March 2014. The main indication (90% in group 1, 61% in group 2) was advanced cervical carcinoma (stage IB2 and above). Ultrasonic advanced energy significantly decreased operative time (p=0.001) and intra-operative bleeding (p=0.01) and increased the number of para-aortic nodes retrieved (p=0.02). There was no significant difference in hospital stay or lymphocele requiring treatment (8.6% in group 1, 8.5% in group 2: p=0.98). For senior than for junior surgeons, surgery time was shorter but not significantly (p=0.80) and postoperative lymphocele rates were identical. ConclusionUltrasonic advanced energy may provide benefit in laparoscopic para-aortic lymphadenectomy, facilitating surgical ergonomics, but did not decrease post-surgery lymphocele.