Para-aortic Lymph Node Recurrence Research Articles

The curative role of radiotherapy in patients with isolated para-aortic node recurrence from cervical cancer and value of squamous cell carcinoma antigen for early detection

The objective of this study was to examine the clinical benefits of routine squamous cell carcinoma antigen (SCC-ag) monitoring of patients with locally advanced cervical cancer. Recurrent disease occurred in 99 uterine cervical cancer patients with elevated pretreatment SCC-ag before primary radiotherapy. Elevated SCC-ag levels persisted in 23 patients after primary radiotherapy (group 1), and SCC-ag was normalized in 76 patients after primary radiotherapy (group 2). The overall survival (OS) rate was higher for patients with SCC-ag elevation as the first sign than for patients with recurrence predicted by other modalities for group 2 patients (P = 0.033). The prediction of isolated para-aortic node recurrence significantly correlated with SCC-ag elevation as an initial sign (P = 0.001). The SCC-ag level before primary radiotherapy (> or = 10.8 ng/mL) significantly affected recurrence predicted by SCC-ag elevation as an initial sign (P = 0.002). For multivariate analysis, the presence of para-aortic node recurrence was statistically significant in OS (P < 0.0001). Routine SCC-ag monitoring of patients with carcinoma of the uterine cervix can lead to the early diagnosis of isolated para-aortic lymph node recurrence, and prolonged survival can be achieved by applying radiation therapy to the para-aortic region. To reduce the number of patients monitored for SCC-ag, we recommend monitoring group 2 patients with pretreatment SCC-ag level before primary radiotherapy > or = 10.8 ng/mL.

Impact of radiation therapy on survival for para-aortic lymph node only recurrence in patients with uterine cervical squamous cell carcinoma

5145 Background: Most patients who had any recurrent sites of cancer, have been considered to be last-stage of life. However, recent advances of clinical research reveal some patients achieve long-term survival even in recurrence cases. Furthermore, patients who had only one recurrent region, even radiation therapy could play an important role. As for uterine cervical squamous cell carcinoma, the most common recurrent site other than pelvis is para-aortic lymph node because of spreading more frequently through lymphatic route than hematogeneous one. Furthermore, improvement of diagnostic imaging enables us to detect more frequently only para-aortic lymph node recurrence. Thus, we conducted the current retrospective study. Methods: Between 1994 and 2003, about 2500 uterine cervical squamous cell carcinoma patients treated with curative intended treatments at Kitasato Univ Hsp or the Cancer Inst Hsp Japan Fdn for Cancer Rsch, Japan. Out of them, 28 patients developed para-arotic lymph node recurrence as the only site of initial tumor progression. These patients were treated with external beam radiation therapy. Radiation therapy protocol was as follows. 1.7–2.0 Gy per fraction, 5 fractions per week and median total dose was 50 Gy (40–56). Nine patients recieved adjuvant chemotherapy (6:BOMP, 2:UFT, 1: FP+TJ). Median serum SCC level was 3.6 ng/ml (1.3 - 92.8) at the detection of para-aortic recurrence. Results: Median follow-up time of all patients was 15 months (2- 62). Three-year overall survival rates of all patients was 26.4%. Stratified by adjuvant chemotherapy, 3-year overall survival rate of adjuvant chemotherapy group was 25.7% and those of radiation alone group was 27.4%, These were almost the same. However, stratified by serum SCC level (cut off level: 15 ng/ml), 3-year overall survival rate of high level group was 0% and those of low level group was 37.5%. Conclusions: The current study suggested that radiation therapy for para-aortic lymph node only recurrence in uterine cervical squamous cell carcinoma could have significant impact on overall survival. Furthermore, low level of serum SCC group could achieve better prognosis of 37.5% of 3-year overall survival. No significant financial relationships to disclose.

Palliative segmental duodenectomy for bleeding, erosive endometrial cancer

Background Endometrial cancer is the fourth most common malignancy among women. Metastases typically involve the lungs, peritoneal surfaces of the abdominal cavity, and lymph nodes outside the pelvis. Case We report an unusually difficult complication of metastatic endometrial cancer occurring in a 57 year-old woman with paraaortic nodal recurrence: refractory occult gastrointestinal bleeding. Repeated upper endoscopic evaluation revealed an extrinsic mass eroding into the third portion of the duodenum. Segmental duodenal resection was performed, and the GI tract was reconstructed with a side-to-side duodenojejunostomy. The postoperative course was uneventful, and the patient experienced durable relief from continued bleeding and impending obstruction. Conclusion We review the role of palliative surgery for bleeding complications of advanced cancer and the alternatives for treating invasive extrinsic lesions of the duodenum.

Cervix carcinoma, concurrent chemoradiotherapy, and salvage of isolated paraaortic lymph node recurrence

To determine the effect of concurrent chemoradiotherapy on the outcome of invasive cervical carcinoma patients with disease recurrence isolated to the paraaortic lymph nodes. Between 1987 and 2003, 816 cervical carcinoma patients received radiotherapy at Mallinckrodt Institute of Radiology. Of these 816 patients, 14 had clinically or radiographically detected isolated paraaortic lymph node metastases. Before 1998, imaging was done if warranted by the presence of one or more classic findings, including lower extremity edema, sciatic pain, and hydronephrosis. After 1998, radiographic imaging was a routine part of follow-up for all patients. The median age at recurrence was 42.5 years (range, 32-54 years). Follow-up for all living patients was current at last follow-up. Full-dose radiotherapy equaled at least 45 Gy. All 7 patients with a classic finding of recurrence, none of whom had been treated to at least 45 Gy and concurrent chemotherapy, were dead of disease within 1.5 years. The 7 patients without a classic finding of recurrence, all of whom had been treated with salvage full-dose concurrent chemoradiotherapy, had a 5-year overall survival rate of 100% (p <0.01). Salvage concurrent full-dose chemoradiotherapy afforded excellent survival of patients who did not have classic findings but had disease recurrence exclusively in the paraaortic lymph nodes. The effectiveness of salvage concurrent full-dose chemoradiotherapy in patients with symptomatic disease recurrence remains unclear. However, chemotherapy or radiotherapy alone produced dismal survival in patients with classic findings of recurrence.

Cervix carcinoma, concurrent chemoradiation,ssalvage of isolated para-aortic lymph node recurrences

Cervix carcinoma, concurrent chemoradiation,ssalvage of isolated para-aortic lymph node recurrences

Cervix carcinoma, concurrent chemoradiation,ssalvage of isolated para-aortic lymph node recurrences

To determine the effect of concurrent chemoradiation therapy on outcome of patients with invasive cervical carcinoma, who suffered disease recurrence isolated to the para-aortic lymph nodes. Between 1987 and 2003, 816 cervical carcinoma patients received radiation therapy. Fourteen patients suffered clinically/radiographically detected isolated para-aortic lymph node metastases. Before 1998, imaging was done if warranted by one or more classic findings including lower extremity edema, sciatic pain, and hydronephrosis. After 1998, radiographic imaging was routinely used in all patients. The median age at recurrence was 42.5 years (range, 32–54.) Follow-up for all patients is current or complete. Full dose radiation therapy equaled at least 45 Gray. All seven patients with a classic finding of recurrence, none treated with full dose concurrent chemoradiation, were dead of disease within 1.5 years. The seven patients without a classic finding of recurrence, all treated with full dose concurrent chemoradiation, had a 5 year overall survival of 100% (p < 0.01.). Salvage concurrent full dose chemoradiation affords excellent survival of patients, without classic findings, who suffer disease recurrence exclusively in the para-aortic lymph nodes. Conversely, chemotherapy or radiation therapy alone produces dismal survival in patients with classic findings of recurrence

Stage I Testicular Seminoma: Para-Aortic and Iliac Irradiation with Reduced Dose after Orchiectomy

Background and Purpose: Radiotherapy remains the treatment of choice for patients with stage I seminoma. The aim of this study is to report preliminary results of reduced dose radiotherapy to ipsilateral pelvic and para-aortic lymph nodes. Materials and Methods: Between February 1996 and December 2001, 53 patients with stage I testicular seminoma were treated with adjuvant radiotherapy after orchiectomy. The median age was 34 years (19–59 years). Four (7.5%) patients had a history of cryptorchidism. Eleven (20.8%) patients showed elevated β-human chorionic gonadotropin. All patients had a radical inguinal orchiectomy and histopathological analysis yielded classic seminoma in 47 (88.7%), spermatocytic in 5 (9.4%) and anaplastic in 1 (1.9%) patients. A total of 19.6–20 Gy in 1.8- to 2-Gy daily fractions was administered to the para-aortic and ipsilateral iliac lymphatics. Results: Median follow-up time was 42 months (12–77 months). One patient developed para-aortic lymph node recurrence at month 28 of the follow-up. Five-year overall and disease-free survivals were 100 and 98%, respectively. Only grade I–II of the Radiation Therapy Oncology Group acute gastrointestinal complications without any severe late toxicity was detected. Conclusion: Reduced dose radiotherapy seems to be as effective as higher doses in the management of stage I seminoma with an acceptable toxicity.

A new ultimate anus-preserving operation for extremely low rectal cancer and for anal canal cancer.

To avoid permanent colostomy, we perform a new ultimate anus preserving operation for extremely low rectal cancer or for anal canal cancer. According to our pathologic study, two different removal methods of anal canal were theoretically considered. One is internal sphincter resection (ISR method), and the other is both deep-superficial external sphincter and internal sphincter resection (ESR method). Six patients received ISR and ten patients ESR. No severe intraoperative complications occurred and the postoperative course was uneventful. All patients receiving ISR had excellent anal function without soiling. Some patients receiving ESR sometimes complained of night soiling but satisfied the anus preservation. The median follow-up was 15 months, (range, 3-28 months). We had recurrences in two female patients receiving ISR. One had para-aortic and lateral lymph node recurrences without anastomotic recurrence. She underwent lateral and para-aortic lymphadenectomy, but died of lung metastasis, regardless of intensive chemotherapy. Another had pelvic recurrence with abdominal dissemination. She underwent abdominoperineal resection and is alive with pelvic re-recurrence. ISR and ESR are excellent procedures for anus preservation, but ISR needs a strict indication.

Hyperfractionated radiotherapy with concurrent chemotherapy for para-aortic lymph node recurrence in carcinoma of the cervix

Purpose To evaluate efficacy, toxicity, and patterns of relapse in patients treated with hyperfractionated radiotherapy (HFRT) with concurrent chemotherapy for para-aortic lymph node (PALN) recurrence of cervical carcinoma. Methods and materials Between September 1997 and October 2000, 12 cervical carcinoma patients with isolated PALN recurrence who had previously received radical or postoperative radiotherapy were treated with HFRT and concurrent chemotherapy. The initial FIGO stage was Stage IB in 4 (33%) patients, Stage IIA in 2 (17%), and Stage IIB in 6 (50%). The radiation field encompassed the gross recurrent PALN with the superior margin at the upper end of the T12 body and the inferior margin between L5 and S1. The fractionated dose was 1.2 Gy in 2 daily fractions, and the median total dose was 60 Gy. The weekly concurrent chemotherapy consisted of paclitaxel in 11 patients and cisplatin in 1. The median number of cycles of chemotherapy was 5. Results The latent period to PALN recurrence from the time of initial treatment for all patients ranged from 2 to 92 months (median: 12 months). One month after treatment, the clinical tumor response evaluated was complete in 33% (4/12) and partial in 67% (8/12). The 3-year overall survival rate and median survival were 19% and 21 months, respectively. The latent period to PALN recurrence was the only significant prognostic factor; the median survival of patients who relapsed in ≤24 months from the initial treatment of cervical carcinoma was 13 months vs. 45 months for those relapsed at >24 months ( p = 0.026). Grade 3–4 hematologic toxicity developed in 2 patients. Six (50%) patients experienced Grade 2 nausea. There were no late gastrointestinal or neurologic complications during the follow-up period. Subsequent distant metastases after PALN treatment developed in 58% (7/12). Conclusion HFRT of 60 Gy to PALN with concurrent chemotherapy could be regarded as an effective treatment modality without significant acute or late toxicity. Patients with a latent period >24 months until PALN recurrence had a more favorable survival rate than those with a latent period ≤24 months. Subsequent distant metastasis after PALN recurrence was the main cause of death and is a problem to overcome in the future.

Hyperfractionated radiotherapy with concurrent chemotherapy for para-aortic lymph node recurrence in cervical cancer

Hyperfractionated radiotherapy with concurrent chemotherapy for para-aortic lymph node recurrence in cervical cancer

Isolated paraaortic lymph node recurrence after definitive irradiation for cervical carcinoma

Purpose: To evaluate the clinical features of isolated paraaortic lymph node (PALN) recurrence after definitive radiotherapy, and analyze the prognostic factors and effect of salvage treatment.Methods and Materials: Of a total 876 patients who received pelvic radiotherapy after the diagnosis of primary cervical carcinoma, 26 were found to have isolated PALN recurrence as the first recurrent site, and these patients enrolled in this study. Only those with primary-site carcinoma controlled and who were free of other distant metastases were eligible. Nineteen of the 26 patients accepted salvage therapy. Fourteen patients accepted concurrent chemoradiation (CCRT), 1 accepted radiation to the paraaortic region, and 4 accepted chemotherapy alone. Clinical parameters evaluated included tumor markers (SCC and CEA) and image studies.Results: Seven of the 26 patients were alive and disease-free. All 7 survivors had salvage treatment with radiation to the paraaortic region and concurrent cisplatin-based chemotherapy. None of the patients receiving chemotherapy or radiation alone enjoyed long-term, disease-free survival. The 5-year survival rate for isolated PALN recurrence of the 14 patients who accepted salvage concurrent chemoradiation (CCRT) was 51.2%. The presence of a clinical symptom at the time of PALN recurrence was analyzed. Seven of the 12 asymptomatic patients and none of the 14 symptomatic patients survived without disease after salvage treatment. The SCC levels at recurrence showed a statistically significant relationship to disease-free survival.Conclusions: An SCC level of ≤ 4 ng/ml and a lack of symptoms at the time of recurrence were good prognostic factors in isolated PALN recurrence after primary radiation therapy. In addition to concurrent CCRT, periodical surveillance with tumor markers and imaging studies allowed early detection and salvage of those patients.

Appraisal of surgical resection of gallbladder cancer with special reference to lymph node dissection.

Radical lymph node dissection in surgery for advanced gallbladder cancer is controversial. The purpose of this study is to evaluate the role of lymph node dissection based on the clinico-pathologic results. Seventy-three patients who underwent radical surgery including systematic dissection of the N1+N2 region lymph node plus some of the para-aortic nodes were reviewed. pT1 patients had no lymph node metastasis, but pT2 and pT3/pT4 patients had lymph node metastasis at a rate of 50.0% (13/26) and 83.3% (25/30), respectively. As infiltration of the hepatoduodenal ligament (Binf) became severe, the rate and extent of lymph node metastasis increased. There were four 5-year survivors with lymph node involvement. The 5-year survival rates are 77.0% in pN0 cases and 27.3% in pN1 cases (P<0.01). There was no difference in survival between pN1 and pN2 patients. However, significant differences in survival were observed between pN0/1 and pN2/3 patients when these patients were limited to Binf0/1. Examination of the recurrence pattern showed that most patients with pN0/1/2 had no regional lymph node recurrence, but there was para-aortic lymph node recurrence in patients with pN3 outside the dissected region. Significant prognostic factors influencing survival after surgery by multivariate analysis were pN2/3, pT, and residual tumor. Systematic lymph node dissection of N1, N2, and part of the para-aortic region improves survival in advanced gallbladder cancer patients, especially in those without either para-aortic lymph node metastases or Binf2/3.

The role of intraoperative radiation therapy (IORT) in the treatment of locally advanced gynecologic malignancies.

The prognosis in women with locally advanced primary or recurrent gynecologic malignancies is rather poor. Doses of external beam radiation necessary to treat gross or microscopic recurrence among patients surgically treated or previously irradiated exceed what is tolerated by normal structures. In this group of patients, intraoperative radiation therapy (IORT) can be utilized to maximize local tumor control, minimizing the radiation exposure of dose-limiting surrounding structures. Review of the available literature indicates that IORT may improve long-term local control and overall survival in women with pelvic sidewall and/or para-aortic nodal recurrence. The most encouraging results have been reported in the cases of microscopic residual disease, following surgical debulking.

DISSECTION OF PARA-AORTIC LYMPH NODE METASTASIS AFTER SURGERY FOR A CANCER OF THE TRANSVERSE COLON

An operated case of para-aortic lymph node recurrence after surgery for a cancer of the transverse colon is reported. A 64-year-old woman underwent an operation for cancer of the transverse colon on September 26, 1995. Six months after the operation, increases in serum CEA and CA19-9 level were found and further exermination revealed para-aortic lymph node swelling from the level of the It. renal vein to the bifurcation of the aorta. Para-aortic lymph node metastasis of the colonic cancer was suspected. There was no evidense of another metastasis in Ga scintigraphy. We judged that the patient was a candidate for operation and performed para-aortic lymphadenectomy. The patient has no sign of recurrence at present, 16 months after the operation. No case of para-aortic lymphadenectomy after operation for the colonic cancer has been reported to this time in Japan. It is suggested that this operation is beneficial for proloning the survival time in case of no evidence of another metastasis.

Recurrent carcinoma of the cervix exclusively in the paraaortic nodes following radiation therapy

Purpose : This is :a retrospective analysis of 1211 patients with invasive carcinoma of the uterine cervix treated with irradiation alone at the Mallinckrodt Institute of Radiology from 1959 through 1986, of whom 20 developed their first recurrence exclusively in the paraaortic lymph nodes. Methods and Materials : The incidence of clinically/radiographically detected paraaortic node recurrence by stage at original diagnosis was 1.8% in Stage IB ( 7 384 patients), 2.3% in Stage IIA ( 3 128 patients), 1.4% in Stage IIB ( 5 353 patients), 1.4% in Stage III ( 4 292 patients), and 5% in Stage IVA ( 1 20 patients). Forty-five percent of para-aortic node recurrences were observed within the first 12 months after initial diagnosis and 75% within the first 2 years. Sciatic pain, leg edema, and hydronephrosis were identified in most patients. Patients were treated with external irradiation only to the paraaortic lymph nodes. Results : All patients died within 2 years of paraaortic recurrence. Median survival for the entire group was 8.7 months. Median survival was 7.5 months for those failing within 24 months of the original diagnosis compared with 17.8 months for those failing after 24 months from original diagnosis ( p = 0.09). Patients who received > 4500 cGy had a median survival of 14.2 months compared with 7.1 months for those treated with < 4500 cGy to the paraaortic recurrence ( p = 0.004). Forty-five percent of patients developed mild to moderate nausea during paraaortic irradiation; however, no severe complications from the radiation therapy were noted. Conclusion : Sciatic pain, leg edema, and hydronephrosis commonly occur in patients with paraaortic node recurrence. The presence of these symptoms in a patient with a history of carcinoma of the cervix should initiate an aggressive evaluation.

Ultrasound in Renal Carcinoma: An Essential in Follow‐up

A total of 115 patients underwent radical nephrectomy for renal carcinoma in this hospital between 1983 and 1990. Follow-up was available in 113 cases (mean 27 months, range 0-93). The overall actuarial survival was 66% at 2 years and 53% at 5 years. Fifty-three patients have been followed up with annual abdominal ultrasound over the last 2 years. Abnormal ultrasound scans were reported in 6 patients (11%) on follow-up. Two had para-aortic lymph node recurrence amenable to further surgery. One patient developed a metachronous tumour and a partial nephrectomy was carried out. Three patients had local recurrence not amenable to further surgery. Ultrasound and computed tomography have found an invaluable place in the pre-operative diagnosis and staging of renal carcinoma. Sixteen of 113 tumours were diagnosed by ultrasound or intravenous urography carried out for some other purpose; 8 were less than 5 cm in diameter and 12 were T category N0M0V0. The 2-year survival rate in this group was 85% (mean 30 months, range 19-67). We consider the routine follow-up of renal carcinoma with clinical examination and annual chest X-ray to be inadequate. The application of ultrasound in the follow-up of these patients has provided a valuable adjunct to our clinical practice. It has allowed the prompt diagnosis of lymph node recurrence or metachronous tumour amenable to secondary surgery with the potential for improved survival in this group of patients. We consider this to be the logical extension of the value of ultrasound in the pre-operative diagnosis of renal carcinoma.

The influence of staging laparotomy for cervical cancer on patterns of recurrence and survival.

A matched paired study of surgically staged and non-surgically staged patients with stage II and III cervical carcinoma from October 1974 through August 1987 was retrospectively performed. Eight of 55 (13.8%) had para-aortic lymph node involvement. After tailored extended field radiation 2/8 (25%) remain alive without evidence of disease. Patient survival although slightly in favor of the unstaged group was similar. Patterns of recurrence were similar amongst treatment groups. Para-aortic nodal recurrence, despite tailored radiation therapy, was identical (5.4%) in the staged and unstaged groups. Only one patient (not surgically staged) had an isolated para-aortic recurrence. With the morbidity of an operative procedure and similar survival rates and para-aortic nodal recurrence rates, the value of staging laparotomy in improved patient survival is questioned. Pelvic failure and other distant metastases continue to be the major sites of recurrences.

Isolated Para-Aortic Lymph Nodes Recurrence in Carcinoma Cervix

Background: To evaluate the presentation of isolated para-aortic lymph node recurrence after definitive treatment, and to analyze the effect of salvage treatment on the survival rate. Methods: A retrospective study was done for patients with invasive carcinoma of the uterine cervix treated with various modalities of treatment at Shaukat Khanum Memorial Cancer Hospital Research Center Lahore Pakistan from December, 1999 to August 2004. Results: The incidence of radiographically detected para aortic lymph node recurrence was 3.7% by FIGO stage at original diagnosis was 3 (50 %) in stage IIIB, 2 (33.3%) in post hysterectomy status and 1 (16.7%) in stage IB cervical carcinoma. Total 4 (66.7%) patients with para-aortic lymph nodes recurrences were identified with in the first 12 months after the initial treatment and 2(33.3%) had their recurrence after 12 month. Leg swelling, low back pain and hydronephrosis were observed when inquired for the presentation in those patients with recurrence in paraarotic lymph nodes. Hydronephrosis was the commonest finding (50%) either alone or in association with other symptoms. And 3 (50%) of the patient were died within two year of the diagnosis of recurrence.Three patients are still on follow up, one with progressive disease in liver and one with chronic renal failure, and one asymptomatic. Patient who received radiation alone had overall survival of 3.16 months after the recurrence compared with &gt;12 months overall survival for those treated with chemotherapy. Conclusions: Symptoms like leg swelling, low back pain and hydronephrosis helps a lot to detect the early paraaortic recurrence, hydronephrosis being commonest. Although the number of patients with para-aortic recurrence were very small and the follow up time was too short to make any recommendations for salvage treatment or survival advantages, as a definitive treatment for isolated para aortic lymph nodes we can offer both radiotherapy or chemotherapy. Key words: cervix; carcinoma; lymph nodes; para-aortic; recurrence. DOI: 10.3126/jnhrc.v7i2.3016 Journal of Nepal Health Research Council Vol.7(2) Apr 2009 103-107