Para-aortic Lymphadenectomy Research Articles

Assessment of Lymph Node Involvement with PET-CT in Advanced Epithelial Ovarian Cancer. A FRANCOGYN Group Study.

The objective of our study is to evaluate the diagnostic performance of positron emission tomography/computed tomography (PET-CT) for the assessment of lymph node involvement in advanced epithelial ovarian, fallopian tubal or peritoneal cancer (EOC). This was a retrospective, bicentric study. We included all patients over 18 years of age with a histological diagnosis of advanced EOC who had undergone PET-CT at the time of diagnosis or prior to cytoreduction surgery with pelvic or para-aortic lymphadenectomy. We included 145 patients with primary advanced EOC. The performance of PET-CT was calculated from the data of 63 patients. The sensitivity of PET-CT for preoperative lymph node evaluation was 26.7%, specificity was 90.9%, PPV was 72.7%, and NPV was 57.7%. The accuracy rate was 60.3%, and the false-negative rate was 34.9%. In the case of primary cytoreduction (n = 16), the sensitivity of PET-CT was 50%, specificity was 87.5%, PPV was 80%, and NPV was 63.6%. The accuracy rate was 68.8%, and the false negative rate was 25%. After neoadjuvant chemotherapy (n = 47), the sensitivity of PET-CT was 18.2%, specificity was 92%, PPV was 66.7%, and NPV was 56.1%. The accuracy rate was 57.5%, and the false negative rate was 38.3%. Due to its high specificity, the performance of a preoperative PET-CT scan could contribute to the de-escalation and reduction of lymphadenectomy in the surgical management of advanced EOC in a significant number of patients free of lymph node metastases.

Stadification ganglionnaire lombo-aortique dans les cancers du col de stade supérieur ou égal à IB2: comparaison des performances du PETscan au 18FDG et du curage lombo-aortique à partir des données du registre des cancers gynécologiques de Côte d’Or de 2003 à 2016

IntroductionCurrent guidelines (ASCO, ESTRO, and ESGO) recommend para-aortic lymphadenectomy (PAL) for lymph node staging in patients with a negative initial PET-CT in locally advanced cervical cancer (LACC), with the aim to determine the radiation fields for radiochemotherapy. The main goal of this study was to compare overall survival (OS) in two groups, which differed according to the para-aortic lymph node staging technique used: imaging alone versus imaging and PAL. Secondary objectives were to determine recurrence-free survival (RFS), the proportion of false negatives on PET-CT, and surgery-related complications. MethodsWe conducted a retrospective, observational study on data from the Côte d’Or gynaecological cancer registry collected from 2003 to 2016, and compared two groups of LACC with different techniques for staging para-aortic lymph nodes: PET-CT alone (iN group) (n=99) and PET-CT associated with PAL (pN group) (n=35) for a total of 134 patients. ResultsOS (HR=1.04 (95% CI: 0.53-2.03); P=0.9) and RFS (HR=0.65 (95% CI: 0.29-1.45); P=0.29) were similar in both groups. There were 11.4% of false negatives in PET-CT, and 2.9% of patients who underwent PAL experienced complications. The staging method, iN or pN, had no impact on the time to the implementation of concomitant radiochemotherapy. ConclusionFor lymph node staging in LACC, PAL after a PET-CT as compared with PET-CT staging alone, had no significant impact on OS or RFS.

A retrospective study of internal small bowel herniation following pelvic lymphadenectomy for gynecologic carcinomas

After pelvic lymphadenectomy (PLA), pelvic vessels, nerve, and ureter are skeletonized. Internal hernias beneath the skeletonized pelvic structure following pelvic lymphadenectomy (IBSPP) are a rare complication following PLA. To the best of our knowledge, only 12 IBSPP cases have been reported and clinical details on such hernias remain unknown. The aim of the study was to investigate the incident and etiology of IBSPP. 1313 patients who underwent open or laparoscopic pelvic lymphadenectomy were identified from our database. A retrospective review was performed. Mean follow-up period was 33.9 months. A total of 12 patients had IBSPP. Multivariate analysis of laparoscopic surgeries group as compared to open surgeries group, para-aortic lymphadenectomy rate, number of dissected lymph nodes by PLA, antiadhesive material use rate, and blood loss were lower in laparoscopic surgeries group: odd ratio (OR) = 0.13 [95% confidence interval (CI) 0.08–0.19], and OR = 0.70 [95% CI 0.50–0.99], OR = 0.17 [95% CI 0.10–0.28], OR = 0.93 [95% CI 0.92–0.94]. However, no significant difference was observed in the incidence of IBSPP between laparoscopic surgery (1.0%) and open surgery (0.8%). All IBSPP occurred in the right pelvic space. These findings may contribute to the development of prevention methods for this disease.

Day-case robot-assisted laparoscopic surgery: Feasibility and safety.

The delivery of surgical services has undergone a shift in the past decade with increasing numbers of surgeries being performed in the daycare setting. Implementing a minimally invasive surgical approach with a robot with an enhanced recovery protocol permits robot-assisted laparoscopic surgeries (RALS) to be performed as a day-case (DC) procedure. This study aimed to assess the feasibility and safety of DC surgery according to our experience. In this prospective observational study, 43 patients underwent DC RALS performed by a single surgeon over 18 months [simple nephrectomy (n=7), radical nephrectomy (n=15), radical nephrectomy with para-aortic lymphadenectomy (n=5), and adrenalectomy (n=5)]. In addition, reconstructive urological procedures that included pyeloplasty (n=9), ureteroureterostomy (n=1), and bladder diverticulectomy with ureteric re-implantation (n=1) were performed as DC surgeries during this study period. RALS was performed in the standard way with an enhanced recovery pathway of care for DC. We collected data regarding the demographic information, medical comorbidities, preoperative outcomes, intraoperative outcomes, complications, length of stay, and readmission rates. The data were analyzed and evaluated. All the patients (100%) were successfully discharged on the same day with no major complications (Clavien-Dindo grade>I). The readmission rates were 0%. DC RALS are safe and feasible with an enhanced recovery protocol. With adequate protocols in place, these surgeries might prove to be better than the available minimally invasive techniques and can become the standard of care in the future.

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

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

Prediction of lymph node involvement in epithelial ovarian cancer by PET/CT, CT and MRI imaging

Objective: The aim of this study is to detect retroperitoneal metastatic lymph nodes in epithelial ovarian cancer with preoperative imaging methods (MRI, CT, 18F-FDG PET/CT). Material and method: Patients with epithelial ovarian cancer followed by the Akdeniz University Faculty of Medicine Gynecologic Oncology Surgery Department registered in the hospital’s electronic file system, who had undergone pelvic and/or paraaortic lymphadenectomy, and having undergone at least one imaging method (MRI, CT, PET/CT), were included in the study. Based on the data available, 89 patients were included in the study. Lymph node metastasis in the histopathology reports of these patients was accepted as the gold standard. The presence of lymph nodes on the imaging modalities (MRI, CT, PET/CT) was regarded as positive and was compared with the gold standard pathological lymph node metastasis. By doing so, the accuracy, specificity, sensitivity, PPV and the NPV of the imaging methods in predicting lymph node metastasis were calculated. Findings: Thirty-eight (42.7%) of 89 patients included in our study were at stage 3C. Based on the data, while 85 of the 89 patients included in the study obtained had undergone pelvic and paraaortic lymphadenectomy, four patients had undergone only pelvic lymphadenectomy. Of the patients, 73 had undergone a CT, 20 had undergone a PET/CT and 12 had undergone an MRI. The sensitivity, specificity, PPV, NPV and the accuracy of CT regarding all nodal involvement was 62%, 52%, 57%, 57%, and 57%, respectively. The PET/CT’s values were 63%, 66%, 70%, 60% and 65%, respectively. The sensitivity, specificity, PPV, NPV and the accuracy of PET regarding paraaortic nodal involvement alone were 50%, 91%, 80%, 73% and 75%, respectively. Conclusion: According to the data we obtained, it is challenging to decide whether to perform systemic pelvic and paraaortic lymphadenectomy based on imaging modalities (MRI, CT, PET/CT), and hence, further investigation is needed for more accurate imaging techniques.

Lymphadenectomy issues in endometrial cancer.

ObjectivesThis review aims to introduce preoperative scoring systems to predict lymph node metastasis (LNM) and ongoing clinical trials to investigate the therapeutic role of lymphadenectomy for endometrial cancer.MethodsWe summarized previous reports on the preoperative prediction models for LNM and evaluated their validity to omit lymphadenectomy in our recent cohorts. Next, we compared characteristics of two ongoing lymphadenectomy trials (JCOG1412, ECLAT) to examine the survival benefit of lymphadenectomy in endometrial cancer, and described the details of JCOG1412.ResultsLymphadenectomy has been omitted for 64 endometrial cancer patients who met low-risk criteria to omit lymphadenectomy using our scoring system (LNM score) and no lymphatic failure has been observed. Other two models also produced comparable results. Two randomized phase III trials to evaluate survival benefit of lymphadenectomy are ongoing for endometrial cancer. JCOG1412 compares pelvic lymphadenectomy alone with pelvic and para-aortic lymphadenectomy to evaluate the therapeutic role of para-aortic lymphadenectomy for patients at risk of LNM. For quality assurance of lymphadenectomy, we defined several regulations, including lower limit of the number of resected nodes, and submission of photos of dissected area to evaluate thoroughness of lymphadenectomy in the protocol. The latest monitoring report showed that the quality of lymphadenectomy has been well-controlled in JCOG1412.ConclusionOur strategy seems reasonable to omit lymphadenectomy and could be generalized in clinical practice. JCOG1412 is a high-quality lymphadenectomy trial in terms of the quality of surgical procedures, which would draw the bona-fide conclusions regarding the therapeutic role of lymphadenectomy for endometrial cancer.

Paraaortic sentinel lymph node detection in intermediate and high-risk endometrial cancer by transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR).

ObjectiveWe aimed to evaluate the accuracy of sentinel lymph node (SLN) mapping with transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR) to detect lymph node (LN) metastases, in patients with intermediate and high-risk endometrial cancer (EC), focusing on its performance to detect paraaortic involvement.MethodsProspective study including women with preoperative intermediate or high-risk EC, according to ESMO-ESGO-ESTRO consensus, who underwent SLN mapping using the TUMIR approach. SLNs were preoperatively localized by planar and single photon emission computed tomography/computed tomography images, and intraoperatively by gamma-probe. Immediately after SLN excision, all women underwent systematic pelvic and paraaortic lymphadenectomy by laparoscopy.ResultsThe study included 102 patients. The intraoperative SLN detection rate was 79.4% (81/102). Pelvic and paraaortic drainage was observed in 92.6% (75/81) and 45.7% (37/81) women, respectively, being exclusively paraaortic in 7.4% (6/81). After systematic lymphadenectomy, LN metastases were identified in 19.6% (20/102) patients, with 45.0% (9/20) showing paraaortic involvement, which was exclusive in 15.0% (3/20). The overall sensitivity and negative predictive value (NPV) of SLNs by the TUMIR approach to detect lymphatic involvement were 87.5% and 97.0%, respectively; and 83.3% and 96.9%, for paraaortic metastases. After applying the MSKCC SLN mapping algorithm, the sensitivity and NPV were 93.8% and 98.5%, respectively.ConclusionThe TUMIR method provides valuable information of endometrial drainage in patients at higher risk of paraaortic LN involvement. The TUMIR approach showed a detection rate of paraaortic SLNs greater than 45% and a high sensitivity and NPV for paraaortic metastases in women with intermediate and high-risk EC.

Assessment of myometrial invasion of endometrial carcinoma with preoperative transvaginal sonography

Objective: Routine pelvic and para-aortic lymphadenectomy up to the level of the renal veins is controversial in endometrial cancer as the complication rate and prolonging the operation time is considerable. Intraoperative frozen section analysis of the uterus is the mainstay for the decision of performing a staging lymphadenectomy. Preoperative estimation of myometrial invasion may be useful for surgical planning. Our objective is to assess the accuracy of preoperative transvaginal ultrasound for identifying myometrial invasion. Methods: 80 consecutive patients operated between August 2017 and December 2019 with a histologically confirmed diagnosis of endometrial carcinoma evaluated within two weeks before surgery by transvaginal ultrasound are the subject of this study. Myometrial invasion estimation is documented and intraoperative frozen section analysis and final pathologic diagnosis as the reference standard was recorded. Results: Preoperative TVUS had 76.5% sensitivity, 91.3% specificity, whereas frozen section analysis had 85.3% sensitivity and 93.5% specificity, and they correlate well with each other (P < 0.01). Agreement between these two methods was substantial according to Cohen’s kappa index (κ) = 0.74 (P < 0.01) and percentage of agreement was 88%. Increasing tumor diameter decreased the prediction accuracy of preoperative ultrasound (P < 0.01). Conclusion: There is good correlation of preoperative transvaginal ultrasound with intraoperative frozen section analysis and final pathology results. The subjective assessment of transvaginal ultrasound can guide surgeons as a useful preoperative tool for preparing surgery

WITHDRAWN: Transumbilical laparoendoscopic single-site surgery (TU-LESS) extraperitoneal approach for lymphadenectomy: an innovative method.

Ahead of Print article withdrawn by publisher.

A new technique of laparoscopic para-aortic lymphadenectomy optimizes perioperative outcome.

ObjectiveThe aim of the present study was to introduce a new technique for laparoscopic para-aortic lymphadenectomy (PAL): an invented retroperitoneum suspension needle combined with modified trocar placement.MethodsThis prospective pilot study randomly categorized women with cervical cancer of stage I–II into 2 groups. The patients in the study group would have laparoscopic PAL with our new technique, while those in the control group with control method. Patients' characteristics and perioperative outcomes were compared between the 2 groups.ResultsA total of 37 patients were included in our study, of which 20 cases in the study group and 17 cases in the control group. As a result, the mean number of para-aortic lymph nodes (PALNs) resected in the study group was significantly more than that in the control group (p<0.001). The time for resecting PALNs (p<0.001) and total operative time (p<0.001) in the study group decreased significantly than those in the control group.ConclusionsFor laparoscopic PAL, this new technique was effective and practical.

Total laparoscopic vs. conventional open abdominal nerve-sparing radical hysterectomy: clinical, surgical, oncological and functional outcomes in 301 patients with cervical cancer.

ObjectiveTotal laparoscopic nerve-sparing radical hysterectomy (TL-NSRH) has been considered a promising approach, however, surgical, clinical, oncological and functional outcomes have not been systematically addressed. We present a large retrospective multi-center experience comparing TL-NSRH vs. open abdominal NSRH (OA-NSRH) for early and locally-advanced cervical cancer, with particular emphasis on post-surgical pelvic function.MethodsAll consecutive patients who underwent class C1-NSRH plus bilateral pelvic + para-aortic lymphadenectomy for stage IA2–IIB cervical cancer at 4 Italian gynecologic oncologic centers (Negrar, Varese, Bologna, Avellino) were enrolled. Patients were divided into TL-NSRH and OA-NSRH groups and were investigated with preoperative questionnaires on urinary, rectal and sexual function. Postoperatively, patients filled a questionnaire assessing quality of life, taking into account sexual function and psychological status. Oncological outcomes were analyzed using Kaplan-Meyer method.Results301 consecutive patients were included in this study: 170 in the TL-NSRH group and 131 in the OA-NSRH group. Patients in the OA-NSRH group were more likely to experience urinary incontinence and (after 12-months follow-up) urinary retention. No patient in the TL-NSRH group vs. 5 (5.5%) in the OA-NSRH group had complete urinary retention (at the >24-month follow-up [p=0.02]). A total of 20 (11.8%) in the TL-NSRH and 11 (8.4%) patients in the OA-NSRH had recurrence of disease (p=0.44) and 14 (8.2%) and 9 (6.9%) died of disease during follow-up, respectively (p=0.83).ConclusionOur study shows that TL-NSRH is feasible, safe and effective and conjugates adequate radicality and improvement in post-operative functional outcomes. Oncological outcomes of laparoscopic procedures deserve further investigation.

Effect of using magnifying loupe glasses on lymphocele formation and surgical outcomes in gynecologic oncology.

Objective:To investigate the effect of using magnifying loupes during surgery on surgical outcomes and lymphocele formation.Materials and Methods:We prospectively enrolled 36 patients with gynecologic cancer who underwent pelvic and para-aortic lymphadenectomy. Age, body mass index, menopausal status, type of cancer, comorbid diseases, preoperative albumin and albumin replacement therapy, performance status, serum CA125, hemoglobin, platelets and white blood cells, surgical procedure, blood loss, blood transfusion, the count of removed lymph nodes, presence of metastatic lymph nodes, total amount of drainage, postoperative complications, operation length, and count of used hemoclips were recorded. Patients were randomized into two groups: group 1 operated using loupe glasses, and group 2, without loupes.Results:In the loupe-negative group, total drainage volume was 6698 mL, whereas in the loupe-positive group, it was only 1049 mL (p<0.01). Postoperatively, the mean drainage duration was 10.6±5.1 days in loupe-negative group and 4.8±2.4 days in the loupe-positive group (p=0.0001). There were no differences between the two groups in terms of surgical site infections, fascial defects, and pulmonary thromboembolism (p=0.39, 0.33, 0.59, respectively). There was no significant difference in the number of harvested lymph nodes in patients who underwent surgery with or without loupes being used. The count of used hemoclips were 50.22±8.05 and 41.38±9.7 for the loupe-negative and positive groups, respectively (p<0.01). There was no lymphocele in the loupe-positive group, but we detected 5 (27.8%) lymphocele in the loupe-negative group (p=0.05).Conclusion:Gynecologic oncologic surgeons can add magnifying loupe glasses to their armament and benefit from this technical device; lymphocele development, total drainage volume, length of drainage time, and clip counts can be decreased by using loupe glasses in gynecologic cancer surgery.

Bone recurrence after radical hysterectomy and lymphadenectomy in early-stage cervical cancer.

Objective:To present the clinical, surgical, and pathologic features of bone recurrence in patients who underwent radical hysterectomy for early-stage uterine cervical cancer.Materials and Methods:Data of 412 patients who underwent type III radical hysterectomy and pelvic ± paraaortic lymphadenectomy for stage 1B-2A epithelial cervical cancer were reviewed. Seven (1.7%) patients with bone recurrence in the first recurrence were included in the study.Results:The median follow-up of the main cohort (n=412) was 46 (range=1-300) months. In this period, recurrence developed in 53 (12.9%) patients and recurrence was observed in bone in 13.2% (7 of 53) of these recurrences. Time to recurrence ranged from 9 to 45 months. Of the recurrences, five were in the axial skeleton and two were in the appendicular skeleton. Recurrence was observed in lumbar vertebrae in three patients, thoracic vertebrae in one patient, sacral vertebrae in one patient, lumbosacral vertebrae in one patient, and the left femur in two patients. Four patients had multiple recurrence in 3 patients despite isolated bone recurrence. Patients with multiple recurrences died within 6-25 months. All isolated bone recurrences were in the axial skeleton. Complete clinical response with salvage therapy was achieved in two patients with isolated bone recurrence.Conclusion:Complete clinical response and long postoperative survival can be achieved with salvage treatment when bone recurrence is solitary in cervical cancers.

Diagnosis, treatment and prognosis of uterine serous carcinoma

Objective: To investigate the diagnosis, treatment and prognosis of uterine serous carcinoma (USC), and further analyze the prognostic factors. Methods: USC patients who underwent surgery with complete follow-up at Cancer Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences between January 1, 2004 and December 31, 2014 were retrospectively reviewed. The Kaplan-Meier method and Cox regression analysis were used for survival analysis. Results: (1) Diagnosis and treatment: the study included 71 USC patients. Only 32 patients (45%, 32/71) were diagnosed preoperatively with USC, and 25 cases of them (35%, 25/71) underwent USC standard comprehensive staging surgery. Of the 25 patients, 10 cases (40%, 10/25) had up-staged after operation. (2) Prognosis: the 5-year disease free survival (DFS) rate and overall survival (OS) rate for all patients were 76.5% and 80.6%, respectively. (3) The results of prognostic factors analysis: univariate analysis on age, range of lymphadenectomy, peritoneal cytology, the depth of myometrial invasion, adnexal and (or) serosa involvement and omentum metastasis were significantly associated with 5-year DFS rate (all P<0.05); range of lymphadenectomy, range of surgical staging, peritoneal cytology, adnexal and (or) serosa involvement and postoperative adjuvant treatment were significantly associated with 5-year OS rate (all P<0.05). Multivariate analysis on range of surgical staging (HR=5.18, 95%CI: 1.04-25.70, P=0.044) and adnexal and (or) serosa involvement (HR=8.41, 95%CI: 2.28-31.05, P=0.001) were independent prognostic factors for 5-year DFS rate; range of lymphadenectomy [no lymphadenectomy vs pelvic lymphadenectomy (PLN)+para-aortic lymphadenectomy (PALN), HR=27.76, 95%CI: 1.76-437.78, P=0.018;PLN vs PLN+PALN, HR=5.98, 95%CI: 1.11-32.27, P=0.038] and peritoneal cytology (HR=5.47, 95%CI: 1.18-25.39, P=0.030) were independent prognostic factors for 5-year OS rate. Conclusions: The preoperative pathological diagnosis of USC is difficult, resulting in incomplete surgical staging and inaccurate staging. Range of surgical staging, adnexal and (or) serosa involvement, peritoneal cytology and range of lymphadenectomy are independent prognostic factors, which deserve much attention in clinical practice.

Impact of restaging lymphadenectomy after sentinel node biopsy on endometrial cancer

IntroductionApproximately 10 % of patients with an intra-operative diagnosis of low-risk endometrial cancer (EC) will be upstaged after a definitive histological evaluation of hysterectomy and bilateral adnexectomy samples. This study aimed to explore the results associated with the performance of pelvic and para-aortic lymphadenectomy for restaging after upstaging/upgrading these patients, and to compare those who underwent sentinel lymph node biopsy (SNB) in the first procedure with those who did not. Materials and methodsThis retrospective cohort study included 27 patients diagnosed with low-risk EC (based on the criteria of the European Society of Medical Oncology/European Society of Gynecological Oncology/European Society for Radiotherapy and Oncology), who underwent surgical laparoscopic restaging due to upstaging based on the final histological result at Hospital Universitario Donostia from April 2013 to September 2018. Surgical and oncological results were compared between patients who underwent hysterectomy and double adnexectomy without any additional procedures (SNB-; n = 17) and patients who also underwent pelvic&aortic sentinel node biopsysen (SNB+; n = 10). The main outcome evaluated in the study was intra-operative complications. Secondary outcomes were mean operative time, length of hospital stay, number of nodes obtained, progression-free survival (PFS) and overall survival (OS). ResultsThe median duration of restaging surgery was 240 [interquartile range (IQR) 180–300) min in the SNB(−) group and 300 (IQR 247.5–330) min in the SNB(+) group; this difference was significant (one-sided Student’s t-test, p = 0.0295). With regard to intra-operative complications, there were 17.65 % and 40 % in the SNB(−) and SNB(+) groups, respectively, all of which were vascular; this difference was not significant. There were no significant difference in the length of hospital stay, number of pelvic nodes obtained, PFS or OS between the groups. ConclusionWomen with EC who require lymph node restaging due to upstaging, and have previously undergone SNB, experience more surgical complications and a longer operative time. The authors advise against performing second restaging surgery in these patients.

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.

Does complete-staging lymphadenectomy improve survival outcomes in stage I endometrioid epithelial ovarian carcinoma? A multi-institutional retrospective study with propensity score-weighted analysis.

We investigated the prognostic impact of complete-staging lymphadenectomy on patients with clinically apparent Stage I endometrioid epithelial ovarian carcinoma. We conducted a regional multi-institutional retrospective study between 1986 and 2018. Amongst 4897 patients with malignant ovarian tumours diagnosed under central pathological review, 259 women with Stage I endometrioid epithelial ovarian carcinoma were eligible. We evaluated differences in survival of patients with both pelvic and para-aortic lymphadenectomy (Group A) and those with only pelvic lymphadenectomy and/or clinical lymph node evaluation (Group B). To analyse the therapeutic effects, the baseline imbalance between patients with both pelvic and para-aortic lymphadenectomy and others was adjusted with an inverse probability of treatment weighting using propensity score involving independent clinical variables. In total, 145 patients (56.0%) received both pelvic and para-aortic lymphadenectomy. With propensity score-based adjustment, estimated survival was better in Group A compared with that in Group B but not significant. Pelvic and para-aortic lymphadenectomy also led to no significant improvement of overall survival in most of the subgroups. However, point estimations of the hazard ratio for lymphadenectomy in patients with an age of 45 or younger (hazard ratio, 0.304; 95% confidence interval, 0.094-0.982), a Grade 1-2 (hazard ratio, 0.441; 95% confidence interval, 0.204-0.954) and T1c2-3 tumour (hazard ratio, 0.449; 95% confidence interval, 0.164-1.231) were better compared with those with the opposite characteristics. Complete-staging lymphadenectomy was not a significant prognostic factor in patients with Stage I endometrioid epithelial ovarian carcinoma, where we still need to explore appropriate candidate for the procedure.

Primary endometrioid carcinoma of the uterosacral ligament arising from deep infiltrating endometriosis 6\u2009years after bilateral salpingo-oophorectomy due to atypical proliferative endometrioid tumor of the ovary: a rare case report

BackgroundEndometriosis can potentially lead to the development of a malignant tumor. Most malignant tumors arising from the endometriosis originate from the ovarian endometrioma, whereas those arising from extragonadal lesions are rare. We report a rare case of endometrioid carcinoma that developed from deep infiltrating endometriosis in the uterosacral ligament 6 years after treatment for atypical proliferative endometrioid tumor of the ovary in a 48-year-old woman.Case presentationSix years ago, the patient underwent laparoscopic bilateral salpingo-oophorectomy for her right ovarian tumor with atypical proliferative (borderline) endometrioid tumor accompanied by ovarian endometrioma. The solid tumor in the cul-de-sac was detected during follow-up using magnetic resonance imaging. Positron emission tomography/computed tomography revealed an abnormal accumulation of 18F-fluorodeoxyglucose at the tumor site. Thus, tumor recurrence with borderline malignancy was suspected. The patient underwent diagnostic laparoscopy followed by hysterectomy and partial omentectomy. Retroperitoneal pelvic lymphadenectomy and para-aortic lymphadenectomy were also performed. The cul-de-sac tumor at the left uterosacral ligament was microscopically diagnosed as invasive endometrioid carcinoma arising from deep infiltrating endometriosis. The final diagnosis was primary stage IIB peritoneal carcinoma. The patient received six courses of monthly paclitaxel and carboplatin as adjuvant chemotherapy. The patient showed no evidence of recurrence for 2 years after the treatments.ConclusionThis study reports a rare case of metachronous endometriosis-related malignancy that developed 6 years after treatment for borderline ovarian tumor. If endometriosis lesions remain after bilateral salpingo-oophorectomy, the physician should keep the malignant nature of endometriosis in mind.

Preoperative assessment of endometrial cancer.

Endometrial cancer (EC), the most common among gynaecological malignancies occurs predominantly after the menopause. The diagnosis is most commonly (in about 75–80%) set up at early stage when surgical therapy and if necessary postoperative radiotherapy results in an excellent prognosis, with a 90–95% 5-year overall survival (OS) and a locoregional recurrence rates of 4–8%. Accurate preoperative assessment of the lymph nodes would ideally identify those patients with advanced stage disease, who might benefit from more extensive surgical procedures and adjuvant therapies. magnetic resonance imaging (MRI), hysteroscopic excisional biopsy (HEB) and high resolution 2D or 3D ultrasound performed by expert operator are considered to add valuable information for preoperative staging of EC. The use of biomarkers could be beneficial in decreasing inter-observer variability between the histology of the diagnostic specimen and the final operative sample, as well as to avoid overtreatment in a part of the high-grade tumors with excellent prognosis. The goal of surgical management of EC is to remove the primary tumor and to identify definite prognostic factors to determine whether adjuvant therapy is required. Extended surgery, including para-aortic lymphadenectomy has a significant morbidity, and with the future selection of cases it can be safely avoided, we can decrease complications without compromising oncological safety. In the future, the importance of hysteroscopy guided sampling may increase to gain a representative sample for biomarker detection.