Para-aortic Dissection Research Articles

ASO Visual Abstract: The Impact of Additional Para-Aortic Dissection during Pancreaticoduodenectomy for Resectable Pancreatic Cancer.

ASO Visual Abstract: The Impact of Additional Para-Aortic Dissection during Pancreaticoduodenectomy for Resectable Pancreatic Cancer.

Isolated para-aortic nodal recurrence after treatment of early stage cervical carcinoma

ObjectiveSurgical evaluation of lymph node metastasis is paramount in the treatment of cervical cancer. We sought to explore the outcomes of patients with and without para-aortic lymphadenectomy undergoing curative-intent radical hysterectomy for stage IA-IIA cervical cancer. MethodsInstitutional data were retrospectively reviewed to identify women undergoing curative-intent radical hysterectomy with concurrent lymphadenectomy for stage IA-IIA cervical carcinoma from 2004 to 2021. Any carcinoma histology was allowed. Clinical risk stratification was performed according to GOG 92 and GOG 109 protocols. Disease outcomes, patterns of recurrence, and survival were analyzed with Chi square, t-test, Kaplan-Meier, and Cox proportional hazards multivariable statistics. Results300 patients were identified, 265 met inclusion criteria. Median follow up was 56 months. Pelvic lymphadenectomy (PLND) was performed in 71%, with the remainder undergoing combined para-aortic dissection (PPaLND). Baseline patient demographics and presence of clinical risk factors were well balanced between groups. PPaLND was more common in patients undergoing open surgery (OR 10.58, p <.0001), and tumors were larger in this group (2.96 vs 2.12 cm, p = .0002) and more likely non-squamous histology (OR 2.02, p = .017). Recurrence of disease was present in 13% of cases, with no difference between PLND and PPaLND regardless of histology. There were zero cases of isolated PaLN recurrence in either group. Neither progression free nor overall survival was different between groups. Prophylactic extended field radiation (EFRT) was not prescribed. ConclusionOmission of PaLN dissection, in the absence of suspicious nodes, did not decrease survival. There were no isolated PaLN recurrences after PLND alone.

Mapping of lymph node dissection determined by the epicenter location and tumor extension for esophagogastric junction carcinoma.

Previous studies identified the extent of lymph node dissection for esophagogastric junction (EGJ) carcinoma based on the metastatic incidence. The study aimed to determine the optimal extent and priority of lymphadenectomy based on the therapeutic efficacy from each station. The studies on the lymph node metastasis (LNM) and therapeutic efficacy index (EI) for EGJ carcinomas were identified until April 2022. The obligatory stations with the LNM rates over 5% and therapeutic EI exceeding 2% should be routinely resected for D2 dissection, whereas the optional stations with EI between 0.5% and 2% should be resected for D3 dissection in selective cases. The survey yielded 16 eligible articles including 6,350 patients with EGJ carcinoma. The metastatic rates exceeded 5% at no. 1, 2, 3, 7, 9, 11p, and 110 stations and were less than 5% in abdominal no. 4sa~6, 8a, 10, 11d, 12a, and 16a2/b1 and mediastinal no. 105~112 stations. Consequently, obligatory stations with EI over 2% were largely determined by the epicenter location and located at the upper perigastric, lower mediastinal, and suprapancreatic zones, corresponding to those with rates of LNM over 5%. Consistent with the LNM rates less than 5%, the optional stations with EI between 0.5% and 2% were largely dependent on the degree of tumor extension toward the lower perigastric, splenic hilar (grecurvature), para-aortic (less curvature of the cardia), and middle or upper mediastinal zones. The obligatory stations can be resected as an "envelope-like" wrap by transhiatal proximal gastrectomy with lower esophagectomy, whereas the optional stations for dissection are indicated by the tumor extension. The extended gastrectomy is required for the lower perigastric in the stomach-predominant tumor with gastric involvement exceeding 5.0cm, para-aortic dissection in the less curvature-predominant tumor and splenic hilar dissection in the grecurvature-predominant tumor whereas transthoracic subtotal esophagectomy is required for complete mediastinal dissection and adequate negative margin in the esophagus-predominant tumor with esophageal invasion exceeding 3.0cm.

TRANS-Peritoneal PARA-Aortic Node Dissection Two Different Technique

<h3>Study Objective</h3> Trans-peritoneal para-aortic node dissection two different approach. <h3>Design</h3> Prospective analysis. <h3>Setting</h3> Patient underwent 3D laparoscopy, all procedure done by experienced and qualified team. <h3>Patients or Participants</h3> CA Endometrium (> 50% invasion), CA cervix patients. <h3>Interventions</h3> Laparoscopic transperitoneal para-aortic lymph node dissection. <h3>Measurements and Main Results</h3> all patient reviewed at monthly interval followed by 3 monthly interval with USG (A+P). PET scan done at 6 months did not reveal any recurrence. median follow up 18 months. all patients are diseased free. <h3>Conclusion</h3> Two different approaches for transperitoneal para-aortic dissection possible laparoscopically. since para-aortic dissection is part of pelvic dissection in radical hysterectomy so without changing position of patient and surgeon (surgeon standing on right side of patient) we can achieve complete nodal dissection.

The Impact of Additional Para-aortic Dissection During Pancreaticoduodenectomy for Resectable Pancreatic Cancer.

The short-term outcome and long-term survival of pancreaticoduodenectomy with additional para-aortic dissection (PAD) for patients with resectable pancreatic cancer remain obscure. Consecutive patients who underwent radical pancreaticoduodenectomy for resectable pancreatic cancer in a single high-volume center during a 7-year period were included retrospectively. Both short- and long-term effects of PAD were compared between the PAD group and the no PAD group. Then, the PAD group was divided into the non-metastatic para-aortic lymph node (PALN-) group and the metastatic PALN (PALN+) group to further analyze the prognosis of PALN+. Of the 909 included patients, 280 (30.8%) underwent PAD during pancreaticoduodenectomy. The PAD group had a higher rate of intra-abdominal infection compared with the no PAD group (28.6% vs. 20.7%, P = 0.009) but no differences were found in the incidence of other complications. The overall survival (OS) and recurrence-free survival (RFS) were also comparable between the two groups. Subgroup analysis showed that patients with PALN+ had a worse OS than patients in the PALN- group (median of 14 vs. 20 months, P = 0.048). Multivariate Cox regression analysis further revealed that PALN+ was an independent adverse predictor of OS (hazard ratio: 1.70, P = 0.007). This study suggests that the addition of PAD during pancreaticoduodenectomy does not improve the prognosis of patients with resectable pancreatic cancer and may lead to an increased risk of infection. However, the accurate preoperative assessment and appropriate treatment strategy for patients with PALN+ need further investigation due to the poor prognosis.

Surgical technique for laparoscopic removal of bulky para-aortic nodes without repositioning surgical field during laparoscopic debulking for advanced ovarian cancer.

In the last years, laparoscopy has been progressively introduced in the management of advanced- stage ovarian cancer (AOC) not only to evaluate tumour resectability, but also to perform primary or interval minimally invasive debulking surgery in selected patients. During laparoscopic debulking for AOC, the need to change the surgical field to treat disease in the upper abdomen can be a time-consuming procedure. To demonstrate feasibility, safety and effectiveness of laparoscopic approach to remove bulky para- aortic nodes in AOC with a 30-degree 3D-endoscope without repositioning the laparoscopic surgical field. A 51-year-old woman was referred to our centre due to AOC with bulky para-aortic nodes (7 cm polylobate mass at CT-scan). The narrated surgical video article demonstrates the surgical steps for laparoscopic removal of bulky para-aortic nodes with a 30-degree 3D-endoscope, maintaining the vision from the upper abdomen perpendicular to the main axis of the vascular structures for the whole duration of the surgery ("top-bottom" view), without repositioning surgical field. Complete laparoscopic excision of disease was achieved. Post-operative course was uneventful. Patient recovered from surgery and was able to start adjuvant chemotherapy within 30 days from surgery. Repositioning the surgical field to perform para-aortic dissection can be a time-consuming procedure during laparoscopic debulking for ovarian cancer. Laparoscopic removal of bulky para-aortic nodes with a 30-degree 3D-endoscope and "top-bottom view" is feasible, safe and effective.

LAPOROSCOPIC PELVIC EXENTERATION FOR TREATMENT OF PRIMARY MULTIPLE CANCER. CASE REPORT

This clinical case represents the experience of surgical treatment of a patient with multiple primary metachronous cancer: 1. Sigmoid cancer рТ4NxM0. Resection of sigmoid colon (16.12.2013). Three courses of adjuvant chemotherapy (XELOX). Recurrence (2015). Laparotomy, Colproctectomy with D3 paraaortic lymph dissection. Ileostomy (2015). One course of chemotherapy (XELOX). 2. Upper tract urothelial carcinoma (right ureter) pT2N0M0R0. Right nephroureterectomy with the resection of the bladder and right testicular cord, cystostomy (19.02.2015). Recurrence. Nephrostomy drainage of the left kidney. Adhesive disease. Rectovesical fistula. Taking into account the history and comorbid status of the patient, it was decided to perform laparoscopic supralevator pelvic exenteration, ureterectomy on the left. The duration of the operation was 280 minutes, intraoperative blood loss was 200 ml. The period of stay in intensive care is 24 hours, the patient was discharged on the 7th day after the operation, the resection margin was negative (R0). After 12 months, there is no data for the disease progressed.

Laparoscopic Extraperitoneal Total Retroperitoneal Dissection- the Right Approach.

<h3>Study Objective</h3> To demonstrate our minimally invasive para-aortic and pelvic lymphadenectomy via the retroperitoneal approach. This technique is performed entirely from the renal vein to the circumflex iliac vein extraperitoneally for cases with mainly endometrial cancer, selected cases of ovarian cancer and in rarer situations for advanced cervical cancer cases as a staging procedure. <h3>Design</h3> Analysis of a technique via video. <h3>Setting</h3> Urban general hospital in Japan. <h3>Patients or Participants</h3> More than 900 cases have undergone laparoscopic or robotic extraperitoneal para-aortic dissection and around 19 of these cases have also undergone extraperitoneal pelvic lymphadenectomy. <h3>Interventions</h3> The extraperitoneal approach is performed using a 5mm EndoTIP cannula. We place all 4 retroperitoneal ports along the left flank. For dissection we use a monopolar hook equipped with an aspiration device and advanced bipolar for retroperitoneal dissection. <h3>Measurements and Main Results</h3> The estimated blood loss for para-aortic dissection was only 30ml and 160ml in the pelvic procedure. Only 3 cases of the total 900 cases required a conversion to open laparotomy. We experienced 23 cases of peritoneal tent perforation, but did not abandon the original procedure, rather suture-repaired the hole and continued. <h3>Conclusion</h3> The advantage of this approach is that the operative filed is bowel-free as the peritoneum acts as a natural retractor. This means that there is minimally impact to the bowel. Patients are not required to be placed in a deep Trendelenburg position. Even extensive intraperitoneal adhesion cases have been successfully managed with this procedure making it a patient friendly option.

Robotic Extraperitoneal Para-Aortic and Pelvic Lymphadenectomy with the Aid of the Double Bipolar Method

Study Objective To evaluate the efficacy of robotic extraperitoneal paraaortic dissection using the double bipolar method (DBM). Design We will show our double bipolar technique and give retrospective analysis of data. Setting Urban general hospital. Patients or Participants From December 26th 2018 to April 22nd 2019, 13 patients underwent extraperitoneal paraaortic dissection and 3 patients underwent both paraaortic and pelvic extraperitoneal dissection for stage I ovarian cancer (n=5) and endometrial cancer (n=8)- stage I-III. Interventions Informed consent was gained from all patients. Underlaparoscopic observation, we accessed the retroperitoneal space at the lower left flank extraperitoneally using an Endotip cannula. We expanded the peritoneal pocket to establish pneumo-retroperitoneum. Four extraperitoneal trocars along the left flank were placed. The DBM was originated by a robotic gastrointestinal surgeon, Prof Ichiro Uyama. This technique uses Robotic Maryland forceps for both cutting and coagulation. The cutting device is set with a special energy platform at macromode 60W. The lightning strike cutting mechanism is more precise than other instrumentation such as monopolar scissors and causes minimal thermal spread to adjacent organs. Measurements and Main Results The median number of retrieved lymph nodes in the paraaortic dissection was 32, in the pelvic dissection- 27. The estimated blood loss in the paraaortic dissection was almost 0ml, and 75ml in the pelvic. The median operating time was 147mins for the paraaortic dissection and 50mins for the pelvic dissection. No patients who underwent these interventions suffered organ injury or required a blood transfusion. Conclusion Extraperitoneal approach has the advantage of being a no-bowel operative field. The DBM makes it possible to perform accurate, bloodless dissection making it applicable to extended retroperitoneal dissection. The combination of this approach and technique can potentially be applied to total retroperitoneal dissection including para-aortic and pelvic lymphadenectomy cases.

Sentinel Lymph Node Mapping vs Systematic Lymphadenectomy for Endometrial Cancer: Surgical Morbidity and Lymphatic Complications

Sentinel lymph node (SLN) mapping has been proven to accurately stage endometrial cancer (EC). However, there is a lack of studies comparing the incidence of complications between different lymph node approaches in EC. The objective of the study was to define the complication rates of SLN biopsy in EC patients. A retrospective cohort study SETTING: A tertiary referral hospital PATIENTS: All patients who were surgically treated for EC form April 2013 to March 2018 INTERVENTIONS: Authors evaluated intraoperative complications and 30-day complications using the Memorial Sloan Lettering Cancer Center's Surgical Secondary Events Grading System, separating the patients into 4 groups: group I, hysterectomy (HT); group II, hysterectomy plus sentinel lymph node biopsy (HT+SLN); group III, hysterectomy plus pelvic lymphadenectomy, with or without para-aortic dissection (HT+LND); and group IV, hysterectomy plus lymphadenectomy and sentinel lymph node biopsy (HT+SLN+LND). Authors identified a total of 250 cases. As compared with the HT group, the HT+SLN group did not show any increased risk of complications in terms of intraoperative complications (0 vs 1; p = 1.0) and 30-day complications (8 vs 7; p = .782), but surgical time was approximately 20 minutes longer (p = .016). Performing LND was associated with a greater risk of 30-day complications (hazard ratio [HR]: 3.11; 95% confidence interval [CI]: 1.62-5.98), intraoperative complications (HR: 14.25; 95% CI: 1.85-19.63), and lower-limb lymphedema (HR: 8.14; 95% CI: 1.01-65.27). SLN mapping does not increase morbidity in the surgical treatment of EC patients, and compared with comprehensive lymphadenectomy, it has a lower risk of complications. Our findings support the use of the SLN algorithm in EC patients.

L1 Cell Adhesion Molecule (L1CAM) expression in endometrioid endometrial carcinomas: A possible pre-operative surrogate of lymph vascular space invasion.

BackgroundRisk stratification of endometrial carcinomas is primarily based on surgical staging that requires extensive retroperitoneal lymph node dissection. One of the most powerful predictor of lymph node involvement is the lymph vascular space invasion (LVSI). The objective of this study was to determine the potential of L1 Cell Adhesion Molecule (L1CAM) to predict LVSI and its association with other risk factors in endometrioid endometrial carcinomas.Materials and methodsWe studied 47 consecutive patients aged 37–88 (61.34±10.52). Twenty-three patients (48.9%) were submitted to complete surgical staging. Nine patients (19.1%) underwent surgical staging without para-aortic dissection. Seven (14.9%) were submitted to hysterectomy with no lymph node dissection. Eight patients (17.0%) only had the biopsy material for analysis. The 32 patients submitted to lymphadenectomy were staged according to the FIGO system and classified among the risk categories of the ESMO-ESGO-ESTRO guidelines. The following histological characteristics were analyzed: tumor size (mm), depth of myometrial infiltration, presence of microcystic, elongated, and fragmented (MELF) pattern of myoinvasion, and lymph vascular space invasion (LVSI). Immunohistochemical analyses of mismatch repair (MMR) proteins MLH1, MSH2, MSH6, and PMS2, p53, and L1CAM were performed in formalin-fixed paraffin embedded whole tumor tissue sections.ResultsLVSI was identified in 26/41 (63,4%) of the cases. L1CAM was positive in 8/47 (17%) cases, all of them positive for LVSI and within the high-risk category of ESMO-ESGO-ESTRO. L1CAM-positive cases were associated with high histological grade and p53 aberrant immunohistochemical profile. Besides, it showed a trend to larger tumors, greater depth of myometrial infiltration, and with a higher frequency of the MELF pattern of myoinvasion. LVSI was also associated with FIGO stage, tumor size, depth of myometrial infiltration, and tumor grade.ConclusionsL1CAM is highly associated with LVSI and could be used as a pre-operative predictor of lymph node involvement in endometrioid endometrial carcinomas.

Patterns of FIRST recurrence of stage IIIC1 endometrial cancer with no PARAAORTIC nodal assessment

ObjectiveTo assess the rates and distribution of first recurrence in patients with FIGO stage IIIC1 endometrial cancer (EC) who did not undergo paraaortic dissection at surgical staging. MethodsWe retrospectively selected all (n = 207) stage IIIC1 patients treated at a single institution from 5/1993–1/2017. Sites of first recurrence were identified, disease-free (DFS) and overall survival (OS) calculated, multivariate logistic regression performed to identify factors associated with recurrence. ResultsThree-year DFS and OS were 66.5% and 85.7%, respectively. The most common histology was endometroid (64.2%). Three-year DFS was 81% (SE±3.8%) endometrioid vs. 39.5% (SE±6.6%) non-endometrioid (P < 0.001). Three-year OS was 96.9% (SE±1.8%) endometrioid vs. 65.6% (SE±6.7%) non-endometrioid (P < 0.001). Sixty-two (30.1%) patients recurred. Patterns of recurrence were: 14 (8.3%) multiple sites, 17 (8.2%) abdominal, 14 (6.8%) extra-abdominal, 17 (8.3%) isolated nodal (8 of these (3.9%) paraaortic). Patients with isolated tumor cells (ITCs) in lymph nodes only had 12/71 (17%) recurrence rate vs. 50/135 (37%) for patients with micro−/macrometastasis. On univariate analysis, grade (HR 4.67 95%CI 1.5–14.5, P = 0.008), histology (HR 4.9 95%CI 2.6–9.3, P < 0.001), myometrial invasion (HR 1.9 95%CI 1.04–3.5, P = 0.04), pelvic washing (HR 2.2 95%CI 1.1–4.5, P = 0.03), tumor volume in pelvic LNs (ITC vs. micro−/macrometastasis; HR 0.3 95%CI 0.2–0.7, P = 0.003) were associated with recurrence. On multivariate analysis, only histology was associated with recurrence (HR 7.88 95%CI 3.43–18.13, P < 0.001). ConclusionsIsolated paraaortic recurrence in stage IIIC1 EC is uncommon. Micro−/macrometastasis were associated with twice the recurrence rate compared to ITC. These data will help clinicians counsel patients with stage IIIC1 EC regarding paraaortic assessment.

514 - Laparoscopic Vascular Injury Repair-How Can We Avoid Conversion to Emergency Laparotomy?

Since 1998 we have experienced 1100 laparoscopic or robotic retroperitoneal lymphadenectomies including para-aortic and pelvic dissection. 28 of these cases required vessel repair for inadvertent injury. We will present techniques for safe and sequel-free vascular injury repair. Case 1- Right external iliac artery was injured during robotic pelvic lymphadenectomy. Case 2- Left external iliac artery was injured during laparoscopic pelvic lymphadenectomy. Case 3- Avulsion injury to the left external iliac vein. Case 4- Avulsion injury to the left renal vein during a left-sided para-aortic dissection. Case 5- IVC was injured during right-sided para-aortic lymphadenectomy. All these cases required temporary bleeding control with vascular clamps, atrumatic forceps, vascular tape and/ or pressure application with sponge. All cases were administered with high molecular heparin and holes closed with 4.0–6.0 proline suture. No blood transfusions or emergency conversions to laparotomy were required. Laparoscopic suturing techniques are vital to the safety of retroperitoneal lymphadenectomy.

Pattern of care in operable endometrial cancer treated at a rural-based tertiary care cancer center

An audit was planned to study the demographics, staging, treatment details, and outcomes of operable endometrial cancers. All operable endometrial cancers treated between January 2009 and October 2014 were included in the study. The details regarding demographics, staging, surgical procedure, pathological staging, adjuvant treatment, and outcomes were extracted from the case records. Descriptive statistics was performed. The time-to-event analysis was done by Kaplan-Meier method. Univariate and multivariate analyses were done for disease-free survival (DFS) and overall survival (OS). There were 55 patients with a median age of 59 years (35-73 years). The Eastern Cooperative Oncology Group performance status was 1 in 52 patients (94.5%) and 2 in 3 patients (5.5%). Forty-nine patients (89.1%) had disease restricted to endometrium while 6 patients (10.9%) had cervical involvement. The surgery done was Type I hysterectomy in 49 patients (89.1%), Type II in 5 patients (9.1%), and Type III in 1 patient (1.8%). Pelvic lymph node dissection was done in all patients while para-aortic (infrahilar) dissection was done in 48 patients (87.3%). The pathological stages were Stage IA in 19 patients, Stage IB in 15 patients, Stage II in 4 patients, Stage IIIA in 3 patients, Stage IIIB in 2 patients, Stage IIIC1 in 5 patients, Stage IIIC2 in 4 patients, and Stage IV in 3 patients. Grade 1 tumors were seen in 23 patients, Grade 2 in 13 patients, and Grade 3 in 19 patients. The histology was endometrioid in 44 patients, serous in 6 patients, clear cell in 3 patients, and others in 2 patients. Adjuvant treatment was received by 40 patients. With a median follow-up of 2.5 years, the 3-year DFS and OS were 78% and 82%, respectively. Age >59 years, Stage III or greater, and Grade 3 tumors were independent prognostic factors adversely affecting both DFS and OS. The outcomes in our study are comparable to that seen in Western literature. Elderly status, higher stage, and a poorly differentiated tumor are associated with poor outcomes.

Should Systematic Infrarenal Para-aortic Dissection Be the Rule in the Pretherapeutic Staging of Primary or Recurrent Locally Advanced Cervix Cancer Patients With a Negative Preoperative Para-aortic PET Imaging?

Extended-field chemoradiation is the usual management of patients with locally advanced cervical cancer (LACC) and para-aortic node metastases (PA pN1). It is efficient but not without morbidity. Assessment of PA lymph node positivity by PA lymphadenectomy is the most accurate method to select the candidates for this treatment. Hence, to clarify the dissection pattern, we wanted to test the true incidence of isolated/skip node metastasis, above the level of the inferior mesenteric artery (IMA). All patients with LACC and negative magnetic resonance imaging and positron emission tomography-computed tomography imaging at the PA level were offered a laparoscopic staging encompassing a diagnostic laparoscopy followed, if negative, by an extraperitoneal PA lymphadenectomy. All nodes were removed from both common iliac bifurcations up to the left renal vein. Node groups, below and above the IMA, were separately sent to the pathologist for definitive examination. From January 2010 to December 2013, 196 stage IB1 with pelvic pN1, IB2, to IVA LACC patients from 2 cancer centers who fulfilled the criteria were included in this institutional review board-approved study after informed consent. Thirty patients (15%) had PA pN1. Only 1 patient had positive nodes exclusively located above the IMA (3.3% of the pN1 group; 95% confidence interval, 0%-9.7%). Complications were observed in 15 (7.6%) of 196 patients. Given the very low rate of skip metastases above the IMA and the potential additional morbidity of a systematic extended dissection, a bilateral ilioinframesenteric dissection seems to be an acceptable pattern of PA lymphadenectomy in LACC patients.

Novel technique for the complete staging of endometrial cancer by single-port laparoscopy

ObjectiveOur aim was to evaluate the feasibility of a novel technique using single-port laparoscopy for the complete surgical staging of endometrial cancer. MethodsTotal hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy and para-aortic lymphadenectomy was performed using a single-port device in two steps: first, a retroperitoneal para-aortic dissection was conducted, followed by a transperitoneal pelvic lymphadenectomy and a total hysterectomy. Conventional laparoscopic instruments were used in all cases. Perioperative details were collected. ResultsFour consecutive patients with endometrial cancer underwent single-port laparoscopic staging procedure. All cases were high-risk endometrial cancers (two FIGO stage IA and two IB). Histologic types included three adenocarcinomas and one carcinosarcoma. The median operating time was 280min (ranged 240–320min), and the median length of stay was 3.5days (ranged 3–6days). No complications or conversion to conventional multiport laparoscopy were reported. ConclusionsSingle-port laparoscopic surgical staging for endometrial cancer is a feasible procedure, even when the procedure included a para-aortic lymph node dissection.

Management of Stage I Endometrial Cancer in France: A Survey on Current Practice.

We conducted a survey to assess the performance of preoperative staging and the application of French surgical guidelines in women with presumed stage I endometrial cancer (EC). The survey included 26 questions about the number of patients in low-, intermediate-, and high-risk groups operated on in 2012, the proportion of patients upstaged or downstaged by the examination of the uterus, and the proportion of subsequent surgery for lymph node dissection. Thirty-two (70 %) of the 46 French university hospitals responded to the questionnaire. Among 886 patients with EC treated, 661 had stage 1 EC. The rates of presumed preoperative type 1 low-, intermediate-, high-risk EC and type 2 EC were 310 (46.9 %), 218 (33 %), 39 (5.9 %), and 94 (14.2 %) respectively. Among 567 type 1 patients, 35 % were upstaged and 6 % were downstaged. Fair agreement was found between preoperative and postoperative risk assessment (κ = 0.37). Patients with presumed low- and intermediate-risk EC upstaged postoperatively to FIGO stage II/III were more likely to have a restaging operation than patients upstaged to type 1 high-risk FIGO stage I EC: 37/70 (52.8 %) versus 26/75 (34.6 %), p = 0.027. The proportions of patients undergoing the recommended subsequent pelvic and/or para-aortic lymph node dissection were low: 34/85 (40 %) and 47/145 (32.4 %) respectively. Lymph node samplings were mainly performed by laparoscopy: 31/34 (91.2 %) and 40/47 (85.1 %) for pelvic and para-aortic dissection respectively. Our survey showed that the performance of preoperative assessment of FIGO stage I EC was moderate and that adherence to the guidelines was low.

Diagnostic accuracy of sentinel node in endometrial cancer by using hysteroscopic injection of radiolabeled tracer

ObjectiveRetrospective and perspective series have shown the feasibility of sentinel lymph-node (SLN) identification of pelvic nodes in endometrial cancer using a cervical injection of tracers. We designed a perspective study to assess the detection rate and diagnostic accuracy of the SLN procedure by means of hysteroscopic injection of a radiolabeled tracer in endometrial cancer patients. MethodsPatients with endometrial cancer underwent hysteroscopic technetium injection. SLN assessment was performed intraoperatively. A systematic pelvic and paraaortic dissection was carried out thereafter. SLNs were examined by standard and immunochemistry methods. The primary endpoint was estimation of sensitivity and negative predictive value (NPV) of sentinel-node biopsy. ResultsFrom 2005 to 2010, 80 consecutive patients entered the study. No severe complications occurred during or after the injection or during surgical SLN biopsy. At least one SLN was detected in 76 of the 80 eligible patients. Fifty nine patients were evaluable according to the study protocol. Ten of these patients (17%) had node metastases. Thirty-three patients (56%) had SLN in the para-aortic area. NPV was 98% (95% CI 89.4–100) and sensitivity 90% (55.5–99.8). ConclusionsSLN detection for endometrial cancer patients has a high sensitivity and NPV when injection is carried out by hysteroscopy. The occurrence of a 56% of sentinel node in paraaortic area may suggest a better sensitivity in this area using hysteroscopic injection compared to cervical injection.

How accurate is frozen section histology of pelvic lymph nodes in patients with endometrial cancer?

ObjectiveRecent prospective data support the trend towards systematic retroperitoneal lymphadenect- omy in patients with high-risk endometrial cancer. Because para-aortic node involvement in the absence of pelvic node involvement is uncommon, a reliable finding of negative pelvic lymph nodes (PLN) at intraoperative frozen section examination might allow omitting para-aortic dissection. We analyzed the diagnostic accuracy of frozen section examination of PLN in patients with endometrial cancer. MethodsWe reviewed 131 patients with endometrial cancer who underwent surgery including systematic pelvic lymphadenectomy (n = 101) or pelvic and para-aortic lymphadenectomy (n = 27). Intraoperative frozen section examination of PLN was performed in 72 (55%) patients. Results of frozen section examination were compared with those of final histopathology and the diagnostic accuracy of frozen section examination of PLN was calculated. One pathologist measured the diameters of PLN metastases retrospectively. ResultsA total of 1063 and 2666 PLN were analyzed by frozen section examination and by final histopathology, respectively. PLN metastases were found in 7 cases (10%) at frozen section examination, and in 17 cases (24%) at final histopathology (false negative rate, 59%). No false positive cases were noted. The mean diameter of all PLN metastases at final histopathology was 4.3 mm, as compared to 9.0 mm for the metastases detected at frozen section analyses. The mean diameter of PLN metastases missed at frozen section examination was 2.0 mm. ConclusionIn this review at a single institution, intraoperative frozen section histology missed nearly two of three endometrial cancer patients with positive nodes. These results do not support tailoring the extent of lymphadenectomy according to the results of frozen section examination.

Two Step Laparoscopic Vascular Injury Repair

Objective: We have introduced an open vascular suturing technique into the laparoscopic environment to avoid conversion to laparotomy when accidental vascular injury and massive bleeding occur during laparoscopic retroperitoneal dissection. Methods: Three vascular injury repair scenarios will be presented. Case one suffered an avulsion injury of the IVC during retroperitoneoscopic para-aortic dissection. Case two suffered deep pelvic bleeding due to the laceration of the posterior aspect of the external iliac vein during a laparoscopic pelvic lymphadenectomy.