Para-aortic Node Sampling Research Articles

Intraoperative paraaortic lymph node sampling during resection for pancreatic cancer: evolving role in the modern chemotherapy era

BackgroundThe role of paraaortic lymph node (PALN) sampling for pancreatic cancer (PC) remains controversial. This study aimed to assess the yield of PALN sampling and its impact on long-term outcomes. MethodsPatients treated from 2005 to 2018 were included. Since 2015, patients with borderline resectable or unresectable (BR/UR) tumours received standardized neoadjuvant therapy (NAT), whereas patients with resectable tumours underwent upfront resection. ResultsAmong 771 patients with PALN excision, metastasis was confirmed in 76 patients (10%) and 59 proceeded to planned resection. PALN metastasis was associated with early recurrence and shorter survival after upfront resection (1-year recurrence-free rate: 23% vs 57% for resectable tumours, P < 0.001, 9% vs 52% for BR/UR tumours, P = 0.006; median overall survival (OS): 19 vs 31 months for resectable tumours, P < 0.001, 17 vs 23 months for BR/UR tumours, P = 0.057). In contrast, they were both similar between patients with/without PALN metastasis following NAT for BR tumours (1-year recurrence-free rate, 50% vs 58%, P = 0.88; median OS, 28 vs 35 months, P = 0.45, respectively). ConclusionsOccult metastasis to PALNs is not uncommon in patients with potentially resectable PC. Its prognostic impact depends on the treatment strategy, and the intraoperative decision for resection should be individualized.

Patterns of spread and genetic mutations of primary endometrioid carcinomas of the ovary (168)

<b>Objectives:</b> Primary endometrioid carcinoma of the ovary is rare and comprises approximately ten percent of all primary ovarian carcinomas. Less is known about their pattern of spread and genetic alterations. Thus, the objective of this study was to characterize patterns of spread, rate of recurrence, and genetic mutations in a cohort of patients with primary endometrioid ovarian carcinoma. <b>Methods:</b> After obtaining institutional review board approval, all patients diagnosed with primary endometrioid adenocarcinoma of the ovary between January 1, 2012, and May 11, 2021, we re identified from an institutional pathology database. All tissue diagnoses were subject to expert pathologic review to confirm accuracy. Patients with co-existing neoplasms were excluded. Demographic and disease-related data were collected from pathology reports and clinical records, and time to recurrence and death were calculated if applicable. Statistical analyses were performed using SAS statistical software version 9.4. <b>Results:</b> Sixty-three patients were identified for analysis. Median age at diagnosis was 60 years (range: 22-90) and the median CA-125 at presentation was 133 U/mL (mean: 1140 U/mL, range: 7-21,545 U/mL). Assigned FIGO stage after surgery included IA in 17 (27%), IC in 24 (38%), II in 17 (27%), III in four patients (6%), and assigned histologic grades were: grade 1 in 32%, grade 2 in 43%, and grade 3 in 25% of patients. The mean ovarian tumor size was 12.7cm (range: 4.1-22cm). At either primary or re-staging surgery, 41 (65%) patients had pelvic lymph node sampling, and 33 (52%) had para-aortic lymph node sampling. The median number of pelvic lymph nodes removed was 12 (mean: 13.1; range: 1-46), and the median number of paraaortic lymph nodes removed was six (mean: 8.7; range: 1-46). All assessed lymph nodes were negative for metastases. Twenty-eight patients had germline mutational status documented. Only two patients had pathologic mutations identified - one in <i>BRCA1</i> and one in <i>BRCA2</i>. One additional patient was found to have two variants of unknown significance (VUS) in the <i>BRCA2</i> gene. Two further patients were negative for germline <i>BRCA</i> mutations but had a positive HRD score on tumor analysis. Median follow-up for patients alive at the time of data cutoff was 42 months (range: 4-70). The median progression-free survival (PFS) and overall survival (OS) for the cohort of patients who completed primary therapy were 42 and 44 months, respectively. Ten out of 63 patients (16%) experienced recurrence(s) with a median time to recurrence of 25 months. Four patients died of disease with a median OS of 31 months. <b>Conclusions:</b> No nodal metastases were identified in a cohort of comprehensively surgically staged patients with primary endometrioid ovarian carcinoma. Surgeons may consider omitting re-staging operations in patients with partially-staged but completely resected endometrioid carcinoma, regardless of grade. Germline <i>BRCA1</i> and <i>BRCA2</i> mutations were seen less frequently compared to high-grade serous carcinomas.

Successful open radical gastrectomy for locally advanced or metastatic gastric cancer patients who suffered from coronavirus disease 2019 during preoperative chemotherapy: a report of three cases

BackgroundAccording to previous reports, in patients with preoperative coronavirus disease 2019 (COVID-19) infection, mortality is increased if they undergo surgery within 6 weeks of diagnosis. However, the optimal timing and preoperative examination for gastrectomy with a previous COVID-19 infection are still controversial. We experienced three cases in which patients successfully underwent open radical gastrectomy following preoperative chemotherapy even though they developed COVID-19 infection during the chemotherapy.Case presentationCase 1: A 58-year-old man with locally advanced gastric cancer caught COVID-19 during preoperative chemotherapy comprising 5-fluorouracil, calcium folate, oxaliplatin, and docetaxel. Although the patient had specific lung shadows indicating COVID-19 infection and deep venous thrombosis in the lower extremities, he underwent distal gastrectomy 10 weeks after the COVID-19 diagnosis. He had a good postoperative course. Case 2: A 56-year-old man with gastric cancer and lymph node and peritoneal metastasis caught COVID-19 during palliative chemotherapy comprising S-1, oxaliplatin, and trastuzumab. He underwent total gastrectomy as conversion surgery 8 weeks after COVID-19 infection. His postoperative course was uneventful. Case 3: A 55-year-old man with gastric cancer and paraaortic lymph node and liver metastases caught COVID-19 during S-1 and oxaliplatin treatment as neoadjuvant chemotherapy. He underwent distal gastrectomy, paraaortic lymph node sampling, and partial hepatectomy 8 weeks after COVID-19 infection although he had residual lung shadows and deep venous thrombosis in the lower extremities. He had an uneventful postoperative course.ConclusionsComputed tomography for preoperative evaluation was performed for all three patients and revealed that lung shadows remained post-COVID-19 infection. Despite this finding, the patients had good operative courses and were discharged as planned. Surgery after 7 weeks from the diagnosis of COVID-19 infection can be performed safely even when patients are post-chemotherapy and have residual lung findings and deep venous thrombosis. This report may contribute to the development of a consensus on performing safe gastrectomy for advanced gastric cancer in patients previously infected with COVID-19.

A case of Epstein Barr virus-associated primary squamous cell carcinoma of stomach

BackgroundPrimary squamous cell carcinoma (SCC) of stomach is extremely rare. The pathogenesis of SCC of stomach remains unclear. There is only one report that Epstein Barr virus (EBV) infection may be involved in the pathogenesis of SCC arising in the stomach ever before. Here, we report a case of Epstein Barr virus infection-associated primary SCC of stomach in a 70-year-old woman. She was presented to the referring hospital with hematemesis. Initial endoscopy revealed a bleeding gastric ulcer in the upper part of gastric corpus and the coagulation therapy was followed. After a 3-month follow-up, endoscopy revealed a submucosal tumor-like protrusion instead of an ulcer. Computed tomography revealed a mass in the upper part of stomach and swollen lymph nodes along with the lesser curvature and para-aortic lymph node. Biopsy could not confirm the definitive diagnosis. We performed total gastrectomy with para-aortic lymph node sampling. Histological analysis revealed squamous cell carcinoma with EBV infection with lymph node metastases. Tumor cells were positive for EBV-encoded small RNA (EBER) by in situ hybridization. The postoperative course was uneventful and the patient was discharged on day 11 after the operation. CapeOX was started as adjuvant chemotherapy, and the patient remains alive without recurrence 7 months after surgery.ConclusionThis is the first case report of EBV infection-associated primary SCC of the stomach diagnosed by in situ hybridization of EBER. EBV infection may be related to the pathogenesis of primary SCC. Further evidence and studies are required to establish optimal strategy for this rare disease.

Survival in resectable pancreatic ductal adenocarcinoma with para-aortic lymph node dissection: A retrospective study in Vietnamese population

BackgroundPancreatic ductal adenocarcinoma (PDAC) has a high recurrence rate and poor outcome. Lymph node (LN) metastasis, especially para-aortic LN (PALN), is an important prognostic factor. PALN assessment through sampling with frozen-section analysis is a validated method. Our aim was to evaluate the prognostic impact of PALN on overall survival (OS) in patients who underwent standard pancreaticoduodenectomy, lymphadenectomy with PALN sampling, as well as to identify other prognostic factors for survival. MethodsOur retrospective study included 89 PDAC patients undergoing radical resection with PALN sampling. The patients were classified into PALN(+) (n = 11) and PALN(−) (n = 78). Univariate and multivariate analyses of 1-year and 3-year OS and Kaplan-Meier model were used. ResultsOS after 1-year for PALN(+) and PALN(−) was 18.2 and 56.4%, after 3-year was 15.4% and 0%, respectively. Tumor differentiation, LN metastasis (LN(−), LN(+) PALN(−), LN(+) PALN(+)) were significant prognostic factors in both univariate and multivariate analyses for 1-year OS, and neural invasion (PN) was the solely significant factor for 3-year OS (p < 0.05). Kaplan-Meier estimate showed that OS of PALN(+) and PN (+) was significantly lower than the negative group, respectively (p < 0.05). No statistical difference in OS was seen between LN(−) and LN(+) PALN(−); and between LN(+) PALN(−) and PALN(+) (p = 0.107). Patients with PN (−) PALN(+) had similar OS compared to PN (+) PALN(−) (p > 0.05). ConclusionPDAC had a poor outcome despite treatment with radical resection. Further follow-up should be conducted to determine the role of surgery in PALN(+)and PN invasion.

SP-0743: For the motion rebuttal: Para-aortic lymph node sampling should always be performed in case of pelvic N + disease

SP-0743: For the motion rebuttal: Para-aortic lymph node sampling should always be performed in case of pelvic N + disease

Significance of para-aortic lymph node evaluation in patients with FIGO IIIC1 cervical cancer.

This study investigated the effect of para-aortic lymph node sampling or dissection in recently revised International Federation of Gynecology and Obstetrics IIIC1p cervical cancer treated with primary surgery and adjuvant radiation therapy with concurrent chemotherapy. We retrospectively reviewed the records of 343 patients with early-stage cervical cancer and pathologically proven pelvic lymph node metastasis following curative surgery from 2001 to 2014. No patient had imaging evidence of para-aortic lymph node involvement, and all patients received adjuvant concurrent chemotherapy with or without concurrent chemotherapy. We investigated the significance of para-aortic lymph node sampling or dissection on disease-free survival and overall survival. After median follow-up of 58.3months, 5-year disease-free survival and overall survival in all patients were 69.9 and 80.2%, respectively. Disease-free survival and overall survival did not differ between the para-aortic lymph node dissection group and the No para-aortic lymph node dissection group (P=0.700 and P=0.605). However, patients with para-aortic lymph node-positive disease had poorer disease-free survival and overall survival compared with those with para-aortic lymph node-negative disease (P<0.001 and P<0.001). This study found no survival benefit of para-aortic lymph node evaluation among patients with International Federation of Gynecology and Obstetrics IIIC1p cervical cancer who were clinically para-aortic lymph node-negative. Although para-aortic lymph node metastasis is a poor prognosticator, the benefit of para-aortic lymph node dissection in terms of survival needs further investigation.

SUN-481 A Coexisting Primary Papillary Thyroid Carcinoma in a Case of Malignant Struma Ovarii with Follicular Thyroid Carcinoma: 2 Types of Thyroid Cancer in the Same Patient

Introduction: Struma ovarii is a rare monodermal variant of ovarian teratoma diagnosed when thyroid tissue is more than 50% of the overall tissue. It represents only 1% of all ovarian tumors. The vast majority of struma ovarii are benign (95%); however, malignant tumors have been reported in a small percentage of cases. The most common type is papillary carcinoma(PTC), followed by typical follicular carcinoma found in the pathology after surgical oophorectomy. We report a case of malignant struma ovarii with follicular carcinoma in the setting of additional micro PTC found after total thyroidectomy. Case report: A 48-year-old female presented with right-sided pelvic pain and a mobile pelvic mass. Pelvic MRI showed noted a large complex solid mass with cystic components in the right adnexa. It measured 7.7 x 8.4 x 6.7 cm. Subsequently, the patient underwent a robotic hysterectomy, bilateral salpingo-oophorectomy (TAHBSO), bilateral pelvic and para-aortic lymph node sampling, omentectomy and resection of nodules. Final pathology noted an ovary with struma ovarii with well-differentiated follicular carcinoma, peritoneal nodules containing thyroid tissue and benign lymph nodes. Subsequently, iodine 123 SPECT CT showed physiologic uptake in the thyroid with increased uptake in the pelvis, right perirectal region indicating residual thyroid tissue. The patient underwent total thyroidectomy with radioactive ablation with I131 (154.7 mCi). Pathology detected incidental 0.5mm micro PTC and it was classified as staged pT1aN. 6 months postoperatively, thyroglobulin (Tg) and Tg antibodies were undetectable with no abnormalities found on repeat whole-body scans. The patient has been following up with no new issues for the past 5 years indicating a good prognosis with low risk of recurrence. Discussion and Conclusion: In the literature, Struma ovarii containing thyroid-type carcinoma and papillary or follicular thyroid carcinoma metastasizing to the ovary has been documented. The standard treatment of a patient with malignant struma ovarii is TAHBSO and complete surgical staging, including peritoneal washings for cytology, pelvic and para-aortic lymph node sampling, and omentectomy. In cases with the residual malignant disease after surgery, total thyroidectomy and radioactive ablation are recommended. Our case is a unique case given the presence of 2 different thyroid carcinoma in the same patient. In addition, our patient had multiple risk factors for recurrence including large lesions>4 cm, extra ovarian extension, and the coexisting synchronous primary thyroid cancer, however, she had a good prognosis with no recurrence during the 5 years follow up period.

How to Approach Para-Aortic Lymph Node Metastases During Exploration for Suspected Periampullary Carcinoma: Resection or Bypass?

BackgroundIntraoperative para-aortic lymph node (PALN) sampling during surgical exploration in patients with suspected pancreatic head cancer remains controversial.ObjectiveThe aim of this study was to assess the value of routine PALN sampling and the consequences of different treatment strategies on overall patient survival.MethodsA retrospective, multicenter cohort study was performed in patients who underwent surgical exploration for suspected pancreatic head cancer. In cohort A, the treatment strategy was to avoid pancreatoduodenectomy and to perform a double bypass procedure when PALN metastases were found during exploration. In cohort B, routinely harvested PALNs were not examined intraoperatively and pancreatoduodenectomy was performed regardless. PALNs were examined with the final resection specimen. Clinicopathological data, survival data and complication data were compared between study groups.ResultsMedian overall survival for patients with PALN metastases who underwent a double bypass procedure was 7.0 months (95% confidence interval [CI] 5.5–8.5), versus 11 months (95% CI 8.8–13) in the pancreatoduodenectomy group (p = 0.049). Patients with PALN metastases who underwent pancreatoduodenectomy had significantly increased postoperative morbidity compared with patients who underwent a double bypass procedure (p < 0.001). In multivariable analysis, severe comorbidity (ASA grade 2 or higher) was an independent predictor for decreased survival in patients with PALN involvement (hazard ratio 3.607, 95% CI 1.678–7.751; p = 0.001).ConclusionIn patients with PALN metastases, pancreatoduodenectomy was associated with significant survival benefit compared with a double bypass procedure, but with increased risk of complications. It is important to weigh the advantages of resection versus bypass against factors such as comorbidities and clinical performance when positive intraoperative PALNs are found.

Laparoscopic radical resection of cervical cancer

: One 40-year-old female, G3P2+1, complained of irregular vaginal bleeding for 1+ month. The gynecological examination indicated that the vulva and vagina were normal, one cauliflower hyperplasia of 2+ cm, which was fragile and with contact bleeding, was seen on the cervix, and no tumor was invaded to the fornix, the uterus was normal, and the left uterosacral ligament was thickened and shortened. Cervical biopsy revealed poorly differentiated squamous cell carcinoma. So, the diagnosis was cervical poorly differentiated squamous cell carcinoma staging IB2. The patient chose a laparoscopic approach to cervical cancer after being informed of the benefit as well as the potential risks of minimally invasive surgical procedure (MIS) for radical hysterectomy (RH) and open RH as well as the radiotherapy. The procedure included laparoscopic RH, double salpingectomy, pelvic lymph node dissection, para-aortic lymph node sampling, and ovarian displacement.

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

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

Role of para-aortic lymph node sampling in pancreatic cancer surgery.

715 Background: In the management of pancreatic cancer, para-aortic lymph node (PALN) metastasis is regarded as distant metastasis, and systemic treatment is recommended. However, imaging study is not perfect to detect all PALN metastasis and the management of intraoperatively discovered PALN has been controversial. We hypothesized that sampling of PALNs on exploration could allow us to avoid pancreatic resection for patients who would not benefit. In this study, we evaluated the incidence and the effect on the long-term outcomes for patients with potentially resectable pancreatic cancer. Methods: Three hundred and ninety-two patients who had PALNs sampled upon potentially resectable pancreatic cancer from 2005 through 2014 were included in the study. All patients were appropriately staged preoperatively with CT/MRI and those with suspected PALN metastasis were not considered as candidates for resection. The patients whose resections were aborted because of liver metastasis or peritoneal dissemination discovered on exploration, or those who died within 30-days after the operation were not included. Evaluated outcomes were incidence of PALN metastasis and their recurrence-free and overall survivals (RFS, OS). Results: The patients’ median age was 74 years, and 58.6% was man. 67.8% had tumors at pancreatic head. Preoperative chemotherapy was given only on 16 patients (3.2%). Among 392 patients with PALNs sampled, 53 (13.5%) patients had metastasis; Resection was completed on 40 patients and resection was aborted on the rest. Among patients who underwent pancreatic resection, median RFS and OS were 10 and 12 months for patients with PALN metastasis, compared to 17 and 26 months for those without PALN metastasis (p &lt; 0.001 for RFS and p &lt; 0.001 for OS). The 5-year-OS rates for patients with/without PALN metastasis were 5.9% and 25% (p &lt; 0.001). Among 53 patients with PALN metastasis, OS were not different between the patients who underwent resection and those who did not (median 13 months vs 17 months, p = 0.06), and there were no recurrence-free survivors. Conclusions: PALN sampling and evaluation before committing to resection is useful to identify the patients who can unlikely benefit and to avoid unnecessary morbid operation.

Role of para-aortic lymph node sampling for patients with potentially resectable biliary cancer.

540 Background: While paraaortic lymph node (PALN) metastasis has been known as poor prognostic indicator for patients with biliary cancer and is regarded as distant metastasis in AJCC staging system. However, preoperative diagnosis of PALN metastasis by current imaging studies is not accurate and the incidence of PALN metastasis among patients with potentially resectable biliary cancer and its impact on their long-term outcomes remain unclear. Methods: The patients who underwent exploratory laparotomy with PALN sampling for potentially resectable biliary cancer at our institution from 2006 through 2018 were included. All patients were appropriately staged preoperatively with CT/MRI and patients with suspected PALN metastasis preoperatively were not considered resectable disease, and thus, such patients were not included. The incidence of PALN metastasis and long-term outcomes (recurrence-free and overall survivals [RFS, OS]) for patients with/without PALN metastasis were compared. Results: Total 383 patients with three types of biliary cancers (164 perihilar cholangiocarcinoma [PHCC], 115 distal cholangiocarcinoma [DCC] and 104 gallbladder cancer [GBCA]) were included. The median age was 71 years and 65% were man. Majority of them (362 patients [95%]) completed planned resection and 9 patients (2%) died of post-operative complications. PALN metastasis was confirmed on 33 patients (9%) among the entire cohort; the yield of positive PALN sampling was the highest in the patients with GBCA (14%), followed by 9% in those with PHCC and 4% in those with DCC. Among 33 patients with positive PALN, 20 underwent tumor resection. Median RFS and OS following resection for the patients with PALN metastasis were 11 months and 22 months, respectively, compared to 46 months and 56 months for those without, respectively ( p&lt; 0.001 for both RFS and OS). There were no survivors beyond 5-years among those with PALN metastasis. Conclusions: The yield of routine intraoperative PALN sampling is not small even among patients with potentially resectable biliary cancer and positive PALN indicates poor long-term outcomes. This procedure can provide the opportunity to avoid morbid operation for patients who unlikely benefits.

CXCR7, a Prognostic Biomarker in Cervical Squamous Cell Carcinoma, May Be a Screening Index for Treatment Options at Stages IB1 and IIA1.

PurposeRecent studies indicate that CXC chemokine receptor type 7 (CXCR7) is associated with tumorigenesis, progression, and metastasis of various cancers, but its roles and molecular mechanisms of action in cervical squamous cell carcinoma (CSCC) remain unclear. Our purpose was to explore the expression patterns of CXCR7 and epidermal growth factor receptor (EGFR) in CSCC and to identify possible correlations with clinical characteristics. We also tested whether CXCR7 can be a screening index for treatment options for CSCC stages IB1 and IIA1.MethodsExpression of CXCR7 and EGFR in tumors from 165 patients with CSCC was evaluated by immunohistochemistry and compared with the clinical data including survival.ResultsPatients at CSCC stages IB1 and IIA1 received different treatment options, including radical hysterectomy, pelvic lymph node dissection, and para-aortic lymph node sampling (RH group, 67 patients) or pelvic external-beam radiation therapy with brachytherapy (EBRT group, 34 patients). Disease-free survival (DFS) and overall survival (OS) were compared between two groups at different CXCR7 expression levels. Immunohistochemical staining showed that CXCR7, EGFR, phospho-ERK, and phospho-AKT amounts increased from normal cervical epithelia and cervical intraepithelial neoplasia to CSCC, and CXCR7 was associated with the disease stage, lymph node metastasis, tumor size ≥40 mm, and EGFR expression. Kaplan–Meier analysis revealed that CXCR7 and EGFR expression was associated with shorter DFS and OS. Multivariate analysis suggested that CXCR7 was independently associated with DFS and OS. Prevalence of recurrence and distant metastasis was significantly lower in the EBRT group than in the RH group during CXCR7 expression. Besides, CXCR7 knockdown significantly decreased the proliferation and invasion of CSCC cells.ConclusionCXCR7 is coexpressed with EGFR, which may be involved in ERK or AKT pathway activation. CXCR7 may be a screening index for treatment options at CSCC stages IB1 and IIA1.

A Study of Sentinel Lymph Node Biopsy in Laparoscopic Radical Hysterectomy for Early Invasive Cervical Cancer with Nano-Carbon Combined with Indocyanine Green

Study Objective This study was the first to investigate the application of phthalocyanine green and nano-carbon suspension injection as a lymphatic tracer in laparoscopic radical resection of cervical cancer. The comparative value of its application in lymphatic imaging and sentinel lymph node identification was analyzed. The factors of the tracer results provide a reference for the application of clinical tracers. Design The patients were divided into nano-carbon group and indocyanine green group. Setting Xinxiang City Central Hospital Gynecologic Oncology, China. Patients or Participants Seventy-five patients with early stage cervical cancer were enrolled. Interventions Nano-carbon suspension injection and indocyanine green were injected from the cervix before operation, and black was recognized under laparoscopy. Lymph nodes and fluorescent lymph nodes were taken as SLN and excised. All patients underwent laparoscopic pelvic lymphadenectomy plus extensive hysterectomy (+ abdominal para-aortic lymph node sampling). All specimens were sent to routine examination. Measurements and Main Results There were no significant differences in age, tumor stage, and histological type between the two groups (P>0.05). SLN was detected in 25 cases of phthalocyanine green group, totaling 1006, the detection rate was 100%; the accuracy of SLN biopsy was 100%. There were 50 cases of nano-carbon suspension group, 39 cases of SLN were detected, a total of 1476, the discovery rate was 78%, the specificity was 76%; there was no statistical difference between the two groups (P> 0.05) However, the difference in the operation time between the two groups was statistically significant (P Conclusion The application of phthalocyanine green and nano-carbon suspension in the detection of SLN in cervical cancer is feasible, but the phthalocyanine green fluorescence detection method is more prominent in visual effect, which can significantly shorten the operation time.

Clinical Study of Nano-carbon Combined With 3D Laparoscopic Sentinel Lymph Node Biopsy for Early Cervical Cancer

Study Objective To investigate the feasibility and clinical application of early cervical application of nano-carbon tracer imaging of sentinel lymph node (the SLN) under laparoscopic 3D. Design 50 patients diagnosed with early cervical cancer patients, cervical injection nanometers from preoperative Carbon-suspended injection.3D laparoscopic direct recognition of black-stained lymph nodes as SLN and excision, followed by laparoscopic pelvic lymphadenectomy + extensive hysterectomy (+ abdominal para-aortic lymph node sampling). Setting Xinxiang City Central Hospital Gynecologic Oncology, China. Patients or Participants 50 patients diagnosed with early cervical cancer patients were enrolled. Interventions 3D laparoscopic direct recognition of black-stained lymph nodes as SLN and excision, followed by laparoscopic pelvic lymphadenectomy + extensive hysterectomy (+ abdominal para-aortic lymph node sampling). Measurements and Main Results A total of 1476 lymph nodes were removed from 50 patients. SLN was successfully detected. The detection rate of SLN was 100% (50/50). A total of 445 SLNs were detected, accounting for 43.20% (445/1030) of the total number of lymph nodes. SLNB detection sensitivity 100% (50/50), specificity 100.00% (50/50), SLN prediction of pelvic lymph node status and postoperative pathological examination coincidence rate of 100% (50/50), negative predictive value of 100.00% (50/50). Conclusion The metastatic state of SLN in early cervical cancer is consistent with the true metastatic state of pelvic lymph nodes, which has a more accurate pathological representative significance. Laparoscopic detection of SLN in early cervical cancer using nano-carbon tracer is a comparative method. Safe and feasible, SLNB has to replace traditional cervical cancer pelvic lymphadenectomy, narrowing the scope of surgery and reducing trauma.

"Laparoscopic Para-Aortic Lymph Node Sampling" First Approach for Pancreatic Adenocarcinoma as an Oncological Practice.

Background: In the setting of pancreatic ductal adenocarcinoma (PDAC), para-aortic lymph node (PALN) involvement is considered as a metastasis disease. To date, no morphological examination can effectively identify lymph node metastasis, and a significant number of patients undergo futile invasive laparotomy for PALN involvement. From an oncological point of view, laparoscopy represents a better approach for PALN sampling. The main aim of the study is to propose a laparoscopic PALN sampling first approach. We describe the surgical technique and demonstrate its technical feasibility as a routine approach as the first surgical step before pancreaticoduodenectomy for localized PDAC. Materials and Methods: During a first step of staging laparoscopy, PALN sampling was done for 31 patients with localized PDAC between November 2015 and February 2017. Demographic data and intraoperative, postoperative, and pathological criteria were evaluated. The surgical technique is described in detail. Results: The median operative time was 35 (range 18-65) minutes. The median number of PALN analyzed per patient was 2 (range 1-5). Four (13%) of 31 patients had positive PALN in frozen section analysis. No severe complication was reported for patients with positive PALN, receiving laparoscopic exploration and PALN sampling. The median hospital stay for patients with positive PALN was 2 (range 1-7) days. Conclusion: To avoid futile laparotomy, a staging laparoscopy is usually carried out. We report the feasibility and safety of laparoscopic PALN sampling and suggest its systematic realization during staging laparoscopy as a first step in patients with localized PDAC before pancreaticoduodenectomy.

LESS with Suture Suspension for Early-Stage Adnexa Cancer Staging.

Background and Objective:Laparoendoscopic single-site surgery has been used in treating gynecologic diseases including early-stage cervical and endometrial cancer, but less so in early-stage adnexal cancer. We aimed to demonstrate the use of laparoendoscopic single-site surgery with suture suspension for staging of early-stage ovarian/fallopian-tube cancer and describe the study results.Methods:Seven patients with early-stage adnexal cancer underwent staging surgery via laparoendoscopic single-site surgery at West China Second University Hospital of Sichuan University from November 2017 to September 2018.Results:All cases were successfully staged via this technique. Two patients underwent the high-level para-aortic lymphadenectomy up to the infrarenal vein, and four patients underwent para-aortic lymphadenectomy at the level of the inframesenteric artery; one patient underwent the para-aortic lymph node sampling. The operation time was 305–365 minutes. The estimated intraoperative blood loss was 50–200 mL. No intra-operative complications occurred; one patient developed pneumonia 48 hours postoperation. The number of pelvic and para-aortic nodes was 15–39 and 1–18, respectively. Pain scores 12 and 24 hours postsurgery were 2–3 and 1–2 with the use of butorphanol tartrate, respectively. On 4–14 months followup, the umbilical incision had good cosmesis; no umbilical hernia or vaginal dehiscence and no neoplasm recurrence were noted.Conclusion:Laparoendoscopic single-site surgery may be a feasible and safe technique for staging early-stage ovarian/tubal cancer. This approach has some advantages included providing easier access to the upper abdominal regions when performing high-level infrarenal para-aortic lymphadenectomy; the 2-cm elastic incision favors fast specimen extraction and colpotomy are avoided. However, the long-term oncologic outcomes need to be further investigated.

Predictors of Pelvic Recurrence in Stage IB Grade 2-3 Endometrioid Endometrial Adenocarcinoma Treated with Post-Operative Vaginal Brachytherapy

Optimal adjuvant management of surgically staged FIGO stage IB grade 2 (G2) and grade 3 (G3) endometrial endometrioid adenocarcinoma (EAC) is controversial. The objective of this study is to report outcomes utilizing adjuvant vaginal brachytherapy (VB) without pelvic radiotherapy (RT) for patients with surgically staged IB G2 and G3 EAC and to analyze rates and predictors of pelvic recurrence. Retrospective review of an institutional database identified patients diagnosed between 2005-2015 with 2009 FIGO stage IB G2 and G3 EAC. All patients underwent comprehensive surgical staging and VB as the sole adjuvant RT as per institutional guidelines during the study period. Disease free survival (DFS) was calculated from the date of primary surgery to date of last follow up or recurrence, and a minimum of 6 months follow-up was required for inclusion. Kaplan-Meier methods were used to estimate DFS. Pearson chi-squared test was used to determine association of pathologic variables and pelvic recurrence. A total of 78 patients were identified for inclusion. The median age at diagnosis was 67 (range, 42-93). Surgical staging included hysterectomy, bilateral salpingo-oopherectomy, pelvic washings, pelvic lymph node dissection (98.7%), and paraaortic node sampling (78.2%). Fifty-five patients (71%) had G2 EAC and 23 (29%) had G3 EAC. Lymphovascular invasion (LVI) was observed in 37 (47%), lower uterine segment involvement (LUSI) in 38 (49%), and outer 1/3rd myometrial invasion (MMI) (defined as ≥ 67% MMI) in 39 (50%). Median number of pelvic lymph nodes removed was 18. The majority (88.5%) received VB alone and 11.5% received VB in combination with chemotherapy. Median follow up was 45.5 months (range 6.3-151.8) and 3-year estimated DFS was 84.7% for the entire cohort. There were a total of 11 recurrences, of which 3 (27.3%) were distant only. The remainder (72.3%) had a pelvic component including 5 which were pelvic and distant and 3 which were isolated to the pelvis. Median time to recurrence was 27.8 months (range, 11.5 - 46.9). On univariate analysis, G3 versus G2 (p = 0.600), LVI present versus absent (p = 0.388), and ≥20 versus <20 pelvic nodes dissected (p = 0.051) were not associated with higher pelvic recurrence risk. Presence of LUSI (p = 0.03) and outer 1/3rd MMI (p = 0.03) were associated with increased risk of pelvic failure. Stage IB G2 and G3 patients treated with adjuvant VB following surgical staging overall fared well, and isolated pelvic recurrences were few in number. While grade and LVI were not associated with increased pelvic failure in this cohort, the association of LUSI and outer 1/3rd MMI is intriguing. Further investigation into risk factors for pelvic recurrence in stage I EAC would be valuable to identify subgroups which benefit the most from pelvic RT.

Totally Laparoscopic Radical Resection of Gallbladder Cancer: Technical Aspects and Long-Term Results.

Gallbladder cancer (GBC) is a rare tumor in developed countries. Chile has one of the highest incidences worldwide. For patients affected by resectable T1b or more advanced GBC, radical cholecystectomy (RC) is considered the standard therapy. Our aim is to describe the surgical technique and clinical-pathological results of patients undergoing totally laparoscopic radical resection of GBC. Patients undergo laparoscopic radical resection for primary and incidental GBC, between the years 2009 and 2016 in two centers from Chile. Patients in whom suspected bile duct invasion, frozen biopsy did not confirm cancer and para-aortic lymph node sampling was positive were excluded. Eighteen patients were operated, 77.8% were female with median age of 60.5year, and 16 patients had previous cholecystectomy with incidental cancer finding. The median operative time was 490min (400-550). No conversion to open surgery occurred. All patients achieved a R0 resection. Postoperative complications occurred in 2 patients (11.1%), and there was not mortality. After a median follow-up of 59months, the 5-year survival was 80.7%. This study shows the technical feasibility of the totally laparoscopic approach for radical resection of GBC with the same principles of classical open surgery. It appears that long-term oncological findings would also be similar at least in less advanced lesions.