Para-aortic Lymph Node Recurrence Research Articles

Salvage laparoscopic lymphadenectomy combined to chemotherapy and/or radiation therapy for isolated para-aortic nodal recurrence of cervical cancer: Morbidity and outcomes of a case series

Salvage laparoscopic lymphadenectomy combined to chemotherapy and/or radiation therapy for isolated para-aortic nodal recurrence of cervical cancer: Morbidity and outcomes of a case series

Secondary debulking surgery for isolated para-aortic nodal recurrence in ovarian cancer involving the division of the left renal vein

ObjectiveTo present a case that involved para-aortic lymphadenectomy in the aortocaval and retrocaval region involving the division of the left renal vein (LRV). MethodsA 36-year-old woman presented with ovarian cancer and isolated nodal recurrence located in the aortocaval and retrocaval region above and below the renal vein. Cytoreduction of para-aortic lymph nodes involving the division of the LRV was performed. Results and conclusionDivision of the LRV facilitates the separation of the lymph nodes from the renal artery or inferior vena cava under direct vision. No intra- or early postoperative complications, including renal dysfunction, occurred. Further analyses with long-term follow-up are warranted to evaluate this surgical method.

Chemotherapy reduces para-aortic node recurrences in endometrial cancer with positive pelvic and unknown para-aortic nodes.

The objective of this study was to evaluate how the administration of different adjuvant therapies influences the risk for developing recurrences in the para-aortic area in endometrial cancer (EC) with positive pelvic and unknown para-aortic nodes. We retrospectively evaluated the data of 58 patients with EC affected by stage IIIC1 who had undergone pelvic but not para-aortic lymphadenectomy from January 1, 1990 to December 31, 2011. Survival outcomes within the first 5 years after surgery were assessed using the Kaplan-Meier model. Chemotherapy plus radiotherapy, chemotherapy only, and external radiotherapy only were administered in 12 (23%), 18 (34%), and 23 (43%) patients, respectively. Five (9%) patients, who were selected to forego adjuvant therapy due to poor performance status, were excluded from the analysis. Disease-free and overall survivals assessed at 5 years were 54%, and 61%, respectively. All para-aortic recurrences were observed among the patients with endometrioid EC, whereas no cases of para-aortic recurrences were found in patients with nonendometrioid histology (5/36 (14%) vs 0/17 (0%); P = 0.16); the latter were more likely to develop distant (hematogenous, peritoneal, and distant lymphatic) recurrences (P = 0.09). Type of adjuvant therapy was the only factor influencing para-aortic failure: chemotherapy (± radiotherapy) reduced the rate of para-aortic node recurrence in comparison with pelvic radiotherapy as a sole modality (P = 0.01). However, adjuvant therapy did not influence the 5-year survival outcomes (P > 0.05). In the absence of local treatment (ie, para-aortic lymphadenectomy and radiotherapy), the administration of chemotherapy seems effective in reducing recurrences in the para-aortic area among patients with stage IIIC1 endometrioid EC.

Lymphovascular space invasion and positive pelvic lymph nodes are independent risk factors for para-aortic nodal metastasis in endometrioid endometrial cancer

ObjectivePara-aortic lymph node dissemination in endometrioid endometrial cancer is uncommon, and systematic para-aortic lymph node dissection increases morbidity. The purpose of this study was to identify a subgroup of endometrioid endometrial cancer patients who did not require para-aortic lymphadenectomy. Study designAll patients who had undergone surgery for endometrioid endometrial cancer between 1 January 1995 and 31 December 2012 were retrospectively reviewed. Patients with higher risk factors for nodal metastasis and inadequate lymphadenectomy were excluded. Para-aortic lymph node dissemination was defined as nodal metastasis when pelvic and para-aortic lymph node dissection was performed, when para-aortic lymph node recurrence occurred after negative para-aortic lymph node dissection or when para-aortic lymph node dissection was not performed. Multivariate logistic regression models were used to identify the pathological features as predictors for para-aortic lymphatic dissemination. ResultsA total of 827 patients were assessed, 516 (62.4%) of whom underwent pelvic and para-aortic lymph node dissection. Sixty-seven (13%) patients (37 with only pelvic, 26 with pelvic and para-aortic, and 4 with only para-aortic metastasis) had positive lymph nodes in the pelvic and para-aortic lymph node dissection group. Multivariate analysis confirmed positive pelvic nodes (odds ratio 20.58; p<0.001) and lymphovascular space invasion (odds ratio 8.10; p=0.022) as independent predictors of para-aortic lymphatic dissemination. When these two factors were absent (in 83% of patients), the predicted probability of para-aortic lymph node metastasis was 0.1%. ConclusionPositive pelvic nodes and lymphovascular space invasion are highly associated with para-aortic lymph node metastasis. These markers may be useful for identifying those patients who require para-aortic lymph node dissection.

Clinical Outcome of Isolated Para-Aortic Lymph Node Recurrence Treated With Salvage Chemoradiation Therapy for Uterine Cervical Cancer

Clinical Outcome of Isolated Para-Aortic Lymph Node Recurrence Treated With Salvage Chemoradiation Therapy for Uterine Cervical Cancer

Successful salvage lymphadenectomy after stent grafting for aortic lymph node recurrence of thoracic esophageal carcinoma: a first case report

In advanced esophageal carcinoma, aortic complications can be fatal. Here, we report our experience with a patient undergoing salvage lymphadenectomy after preoperative aortic stent grafting for paraaortic lymph node recurrence for esophageal carcinoma. The patient was a 54-year-old man, who underwent subtotal esophagectomy for thoracic esophageal carcinoma. Computed tomography performed 12 months after the initial surgery revealed lymphadenopathy on the left side of the thoracic aorta and radiotherapy was performed for lymph node recurrence. FDG-PET performed after radiotherapy revealed slight growth of the lymph node involvement and an accumulation of FDG. We decided to insert a stent graft into the aorta at the site of tumor invasion before surgery to ensure safety. The tumor was sharply dissected and excised with Cooper’s scissors after the aorta had been taped at the levels upstream and downstream from the tumor. After surgery, chylothorax was observed, but resolved with conservative treatment. The patient was discharged 30 days after surgery.

繰り返す局所治療で長期生存した腹部大動脈・頸部リンパ節再発胃癌の1例

繰り返す局所治療で長期生存した腹部大動脈・頸部リンパ節再発胃癌の1例

直腸癌根治術後12年目に切除しえた，大動脈周囲リンパ節再発の1例

直腸癌根治術後12年目に切除しえた，大動脈周囲リンパ節再発の1例

The importance of adjuvant chemotherapy and pelvic radiotherapy in high-risk early stage endometrial carcinoma

ObjectiveTo determine the impact of a policy change in which women with high-risk early stage endometrioid endometrial cancer (EEC) received adjuvant chemoradiotherapy. MethodsThis is a population-based retrospective cohort study of British Columbia Cancer Registry patients diagnosed from 2008 to 2012 with high-risk early stage EEC, who received adjuvant chemoradiotherapy after primary surgery. High-risk early stage was defined as the presence of two or more high-risk uterine factors: grade 3 tumor, more than 50% myometrial invasion, and/or cervical stromal involvement. Adjuvant therapy consisted of 3 or 4cycles of carboplatin and paclitaxel chemotherapy, followed by pelvic radiotherapy. Sites and rate of recurrence were compared to a historical cohort diagnosed from 2005 to 2008 in which none of the patients received adjuvant chemoradiotherapy. Five-year progression-free and overall survival rates were calculated. ResultsThe study includes 55 patients. All patients except for 2 received at least 3cycles of chemotherapy. All patients received pelvic radiotherapy except for 2 who received brachytherapy only. Median follow-up was 27months (7–56months). Four patients (7.3%) recurred, including three with distant recurrence only and one with both a pelvic and paraaortic nodal recurrence. The historical cohort had a 29.4% recurrence rate, and therefore the hazard ratio for recurrence was 0.27 (95% CI 0.02–4.11). Five-year progression-free and overall survival rates were 88.6% and 97.3%, respectively. ConclusionPatients with high-risk early stage endometrial carcinoma treated with adjuvant chemoradiotherapy have a low rate of recurrence compared to those not receiving such therapy.

Achievement of 10-year survival: A case of pubic bone recurrence as the primary failure site of chemo-refractory ovarian clear cell carcinoma

Clear cell carcinoma of the ovary tends to have a poor response to conventional platinum-based chemotherapy. Bone recurrence from ovarian cancer is rare and prognosis of patients with such a condition is poor. We report a patient with chemo-refractory ovarian clear cell carcinoma who developed pubic bone recurrence and subsequent para-aortic node recurrence. The patient achieved long-term survival after salvage surgery twice in spite of these inauspicious conditions. Surgical treatment should be taken into consideration for skeletal recurrence from ovarian clear cell carcinoma.

Comparison of the outcome between cervical adenocarcinoma and squamous cell carcinoma patients with adjuvant radiotherapy following radical surgery: SGSG/TGCU Intergroup Surveillance

The efficacy of radiotherapy (RT) for adenocarcinoma (AC) is controversial, although patients with AC of the uterine cervix are treated in a similar manner to those with squamous cell carcinoma (SCC). This retrospective study was conducted to evaluate the efficacy of adjuvant RT for patients with AC compared to those with SCC following radical hysterectomy. A total of 820 patients with stage IB-IIB cervical cancer, who underwent type III radical hysterectomy between 1997 and 2003, were retrospectively examined; the sample included 280 patients with AC and 540 with SCC. A total of 139 patients with AC and 327 with SCC underwent adjuvant treatment. The histological type did not affect the outcome for patients with stage I disease; however, stage II patients with AC exhibited a significantly worse 5-year overall survival (OS) rate compared to those with SCC. Patients with SCC exhibited significantly higher lymph node involvement compared to those with AC in stage IB1; however, there were no differences between stages IB2 and II. Among patients with lymph node involvement, patients with AC exhibited a significantly worse 5-year survival rate compared to those with SCC (46.4 vs. 72.3%, respectively; P=0.0005). Among patients receiving adjuvant RT, those with AC recurred more frequently compared to those with SCC, particularly in the pelvic cavity, including the vaginal stump and/or pelvis (24.6 vs. 10.5%, respectively; P= 0.0022). By contrast, the histological type did not affect the incidence of recurrence in paraaortic lymph nodes and/or distant recurrence. In conclusion, RT may not suffice as an adjuvant treatment for patients with cervical AC following radical hysterectomy.

Cancer of the pelvis: definitive three-dimensional conformal radiotherapy for patients with isolated recurrence in the para-aortic lymph nodes

The purpose of this study was to evaluate the outcome of definitive three-dimensional conformal radiotherapy (RT) for isolated para-aortic lymph node (LN) recurrence in patients with controlled primary cancer of the pelvis. Twenty-four consecutive patients with isolated para-aortic LN recurrence were retrospectively analyzed. The patients were included in this study if they were eligible to receive definitive RT for abdominal para-aortic LN recurrence with controlled primary cancer of the pelvis without other distant/recurrent diseases. The median time between the front-line therapy and RT for isolated para-aortic LN metastases was 21 months. Nineteen (79%) patients had an objective tumor response. In-field failure occurred in four patients (17%), while failure outside of the irradiated field was recognized in 12 patients (50%). The overall survival, progression-free survival and local control rates at 5 years were 56%, 29% and 72%, respectively. Statistically significant prognostic factors of the overall survival rate in the univariate analyses were an objective tumor response (P = 0.0098) and the time between front-line therapy and RT (P = 0.033). The maximum tumor size was a significant prognostic factor of the overall survival rates in the multivariate analyses (P = 0.046). The toxicities were mild; leukopenia of Grade 3 was detected in one patient, and no Grade 3 or higher non-hematological toxicity was observed. In conclusion, definitive three-dimensional RT for isolated abdominal para-aortic LN recurrence in patients with controlled primary cancer of the pelvis may be feasible, and can provide a relatively longer-term survival. The results justify further investigation of higher dose RT using modern RT planning techniques.

Pretreatment carcinoembryonic antigen level is a risk factor for para-aortic lymph node recurrence in addition to squamous cell carcinoma antigen following definitive concurrent chemoradiotherapy for squamous cell carcinoma of the uterine cervix

BackgroundTo identify pretreatment carcinoembryonic antigen (CEA) levels as a risk factor for para-aortic lymph node (PALN) recurrence following concurrent chemoradiotherapy (CCRT) for cervical cancer.MethodsFrom March 1995 to January 2008, 188 patients with squamous cell carcinoma (SCC) of the uterine cervix were analyzed retrospectively. No patient received PALN irradiation as the initial treatment. CEA and squamous cell carcinoma antigen (SCC-Ag) were measured before and after radiotherapy. PALN recurrence was detected by computer tomography (CT) scans. We analyzed the actuarial rates of PALN recurrence by using Kaplan-Meier curves. Multivariate analyses were carried out with Cox regression models. We stratified the risk groups based on the hazard ratios (HR).ResultsBoth pretreatment CEA levels ≥ 10 ng/mL and SCC-Ag levels < 10 ng/mL (p < 0.001, HR = 8.838), SCC-Ag levels ≥ 40 ng/mL (p < 0.001, HR = 12.551), and SCC-Ag levels of 10-40 ng/mL (p < 0.001, HR = 4.2464) were significant factors for PALN recurrence. The corresponding 5-year PALN recurrence rates were 51.5%, 84.8%, and 27.5%, respectively. The 5-year PALN recurrence rate for patients with both low (< 10 ng/mL) SCC and CEA was only 9.6%. CEA levels ≥ 10 ng/mL or SCC-Ag levels ≥ 10 ng/mL at PALN recurrence were associated with overall survival after an isolated PALN recurrence. Pretreatment CEA levels ≥ 10 ng/mL were also associated with survival after an isolated PALN recurrence.ConclusionsPretreatment CEA ≥ 10 ng/mL is an additional risk factor of PALN relapse following definitive CCRT for SCC of the uterine cervix in patients with pretreatment SCC-Ag levels < 10 ng/mL. More comprehensive examinations before CCRT and intensive follow-up schedules are suggested for early detection and salvage in patients with SCC-Ag or CEA levels ≥ 10 ng/mL.

The significance of abdominal para-aortic lymph node metastasis in patients with lower thoracic esophageal cancer

Para-aortic lymph node (PALN) recurrence is often seen in patients with lower thoracic esophageal cancer treated by esophagectomy with extended lymph node dissection. However, the clinicopathological characteristics of patients with PALN metastasis and the significance of PALN dissection are unknown. A total of 283 patients with lower thoracic esophageal cancer underwent esophagectomy with lymphadenectomy at our hospital between April 1984 and March 2007. Among these 283 patients, 60 patients were enrolled in this retrospective study according to following criteria: (i) clinical T2 to T4 tumor, (ii) no clinical PALN metastasis, and (iii) received PALN dissection. PALN dissection was indicated by a tumor depth of at least T2 and no severe complications. The clinicopathological data, recurrence pattern, and overall survival were compared between patients with PALN and without PALN metastasis. The mean length of surgery was 587 min and the mean blood loss was 1383 mL. The morbidity was 33.3% and mortality was 5% in this series. Sixteen patients (26.7%) had PALN metastasis; these showed significantly more lymph node metastases (15.8 ± 13.2 vs. 3.0 ± 3.2, P < 0.0001) and significantly worse survival rates (53.3% vs. 79.9% at 1 year, 6.7% vs. 62.0% at 3 years, P < 0.0001) than patients without PALN metastasis. The incidence of lymph node recurrence (P < 0.0001) and hematogenous recurrence (P= 0.0487) was also higher in patients with PALN metastasis than in patients without PALN metastasis. Among the 16 patients with PALN metastasis, a univariate analysis revealed total number of metastatic nodes < 8 (P= 0.0325) to be a significant prognostic factor. A multivariate logistic regression analysis of the regional lymph nodes identified the invasion of the lower mediastinal nodes (hazard ratio = 6.120) and retroperitoneal nodes (hazard ratio = 15.167) to be significantly correlated with PALN metastasis. PALN metastasis is suggested to be related to the systemic spread of lymphatic metastasis even in lower thoracic esophageal cancer. PALN dissection for pathological PALN(+) patients should not be performed. It remains to be determined in future prospective studies whether patients without pathological PALN metastasis, but showing PALN micrometastasis, could achieve improved survival with PALN dissection.

Initial failure site according to primary treatment with or without para-aortic lymphadenectomy in endometrial cancer

ObjectiveThe objective of this study was to compare the initial failure sites in patients with endometrial cancer who underwent surgical treatment including pelvic lymphadenectomy with or without para-aortic lymphadenectomy. MethodsA retrospective chart review was carried out for 657 endometrial cancer patients with no residual disease after initial treatments including lymphadenectomy at two tertiary centers between 1987 and 2004. Surgical treatment at one institute included pelvic lymphadenectomy (PLX) without para-aortic lymphadenectomy (PALX), while surgical treatment including PLX+PALX was routinely performed at the other institute. We identified patients with recurrence and evaluated initial failure sites. Rates of recurrence in the respective sites were compared according to the type of lymphadenectomy. ResultsOf the 657 patients, 103 (15.7%) suffered recurrence. There was no significant difference between the rate of intrapelvic recurrence in the PLX alone group and that in the PLX+PALX group (4.7% vs. 2.9%, p=0.22). The rate of extrapelvic recurrence in the PLX alone group was significantly higher than that in the PLX+PALX group (16.1% vs. 6.2%, p<0.0001), and the rate of para-aortic node (PAN) recurrence in the PLX alone group was also significantly higher than that in the PLX+PALX group (5.1% vs. 0.6%, p=0.0004). In the analysis of patients who received adjuvant chemotherapy, the rate of PAN recurrence in the PLX alone group was significantly higher than that in the PLX+PALX group (9.5% vs. 1.3%, p=0.0036). ConclusionPAN recurrence was a failure pattern peculiar to the PLX alone group. Adjuvant chemotherapy might not be able to replace surgical removal as a treatment for metastatic lymph nodes.

胃癌治癒切除後の腹部大動脈周囲リンパ節再発に対する外科切除の意義

胃癌治癒切除後の腹部大動脈周囲リンパ節再発に対する外科切除の意義

Brachytherapy Reirradiation with Hyaluronate Gel Injection of Paraaortic Lymphnode Metastasis of Pancreatic Cancer: Paravertebral Approach - A Technical Report with a Case -

Paraaortic lymph nodal (PALN) recurrence is not a rare scenario of abdominal malignancies including pancreas cancer, even after radiotherapy. The role and indication of reirradiation is limited because it is often associated with significant late toxicity in the surrounding normal organs. We developed a new approach and technique of brachytherapy to overcome this difficult situation, with a paravertebral approach and hyaluronate gel injection (HGI). We encountered a patient with pancreatic cancer who developed PALN metastasis as in-field recurrence, 6 months after resection of pancreatic cancer with 50 Gy of preoperative radiotherapy. The applicator brachytherapy needles and gel injection needles were advanced by percutaneous paravertebral approach under local anesthesia, and by injection of a hyaluronate gel to separate the surrounding small intestines and the target. A single fraction of 18 Gy was delivered to the tumor (75.6 Gy equivalent in conventional schedule calculated with LQ model at α/β = 3) and total estimated D2cc (the minimum dose to the most irradiated volume of 2 cc, calculated at α/β = 2) in the small intestines was 61.6 GyE with HGI and 80.6 GyE without. No complications have been observed for six months. Three months later, FDG accumulation had disappeared, the tumor size was reduced, and serum CA-19-9 value decreased from 5150 U/mL to 36.6 U/mL (normal range < 37.5). Conclusively, the brachytherapy with the HGI procedure by paravertebral approach was thought safe and effective in reirradiation of PALN recurrence.

"Very Late" isolated para-aortic nodal recurrence of carcinoma cervix mimicking radiation-induced sarcoma

Only a minority of the patients who develop recurrence after definitive treatment for cervical cancer are detected after 5 years (late recurrence); the numbers are lesser still after 10 years (very late recurrence). Among the infrequent cases that do develop "late" and "very late" recurrence, the commonest site is the pelvis. We report an unusually rare recurrence of treated cervical cancer confined to the para-aortic nodal group after a protracted disease-free interval of 13 years. On the basis of the long disease-free interval, location of the mass at the periphery of the radiation field, and aggressive imaging appearance, a diagnosis of radiation-induced sarcoma was considered. However, the final diagnosis of isolated para-aortic nodal recurrence of cervical cancer was rendered based on the histopathological and immunohistochemistry findings, supported by the absence of disease elsewhere on whole-body imaging.

A Case of Rectal Cancer with Long Tumor-free Survival Following the Resection of Para-aortic Lymphnode Recurrence

症例は55歳，女性．1999年9月に直腸癌（RS-S，type 2，5.5×4.0cm大，ss，n4+（19/49），stage IV）に対して低位前方切除術を実施した．UFT 600mg/日内服にて経過観察中，術後2年4カ月のCT検査で大動脈分岐部左に3cm大の腫大リンパ節を指摘された．CEA値も19ng/ml と高値で，大動脈周囲リンパ節再発と診断した．他部位に再発の所見なく，左尿管の一部を付けて再発腫瘍を切除した．切除標本の病理学的検索ではadenocarcinoma，metastaticの診断であった．術後放射線治療（50Gy）を追加し，5'-DFUR 600mg/日+Krestin内服を5年間行った．再手術後9年の現在，再発の徴候なく健在である．再発大腸癌に対する化学療法の治療成績は著明に改善されているが，それのみで治癒を得るには至っていない．孤立性の大動脈周囲リンパ節再発は切除により治癒の可能性もあり，切除の適応についても考慮すべきである．

Repeat Laparoscopic Para-Aortic Lymphadenectomy of an Isolated Lymph Node Recurrence in Patient with Stage IB2 Cervical Cancer

Study Objective: To report a case of repeat laparoscopic para-aortic lymphadenectomy after surgery and concurrent chemoradiation of cervical cancer, FIGO stage IB2. Design: A case report. Setting: University teaching hospital. Patients: One patuient with isolated recurrent para-aortic lymph node. Intervention: Repeat Laparoscopic Para-aortic Lymphadenectomy. Measurements and Main Results: A 49-year-old woman had an isolated para-aortic lymph node recurrence 12 months after the initial treatment, F-18 fluoro-deoxyglucose-positron emission tomography-computed tomography showed left para-aortic lymph nodes with increased uptake of F-18 fluoro-deoxyglucose. This was successfully removed in a repeat LPAL. She received three cycles of combination chemotherapy and showed a complete clinical response. Conclusion: Repeat LPAL is thus a feasible and effective procedure to remove and confirm of an isolated para-aortic lymph node recurrence after previous surgery and chemoradiation for treating cervical cancer.