Pelvic Lymphadenectomy In Endometrial Cancer Research Articles

A selective anatomically based lymph node sampling can replace a side specific pelvic lymphadenectomy in endometrial cancer with failed sentinel node mapping

AimTo evaluate the locations of metastatic pelvic sentinel nodes (SLN) and the proportion of SLNs outside and within defined typical anatomical positions along the upper paracervical lymphatic pathway (UPP). Patients and methodsConsecutive women with endometrial cancer (EC) of all risk groups underwent pelvic SLN-detection using cervically injected indocyanine green (ICG). A strict anatomically based algorithm and definitions of SLNs was adhered to. The positions of ICG-defined SLNs were intraoperatively depicted on an anatomical chart. All SLNs were examined using ultrastaging and immunohistochemistry. The proximal third of the obturator fossa and the interiliac area were defined as typical positions. The parauterine lymphovascular tissue (PULT) was separately removed. The proportions of metastatic SLNs, overall and isolated, typically, and atypically positioned were analyzed per woman. ResultsA median of two (range 1–12) SLN metastases along the UPP including the PULT were found in 162 women. 41 of 162 women (25.3 %) had isolated metastases in the obturator fossa harboring 49.1 % of all SLN metastases. Three women (1,9 %) had isolated PULT metastases. SLN metastases outside typical positions were identified in 28/162 women (17.3 %); isolated metastases were seen in seven women (4.3 %), so 95.7 % of pelvic node positive women had at least one metastatic SLN located at a typical position. ConclusionA selective removal of lymph nodes at typical proximal obturator and interiliac positions and the PULT can replace a full side specific pelvic LND when SLN mapping is unsuccessful. The obturator fossa is the predominant location for metastatic disease.

Disease-Free and Overall Survival Implications of Pelvic Lymphadenectomy in Endometrial Cancer: A Retrospective Population-Based Single-Center Study

The role of pelvic lymphadenectomy in endometrial cancer remains unclear. In this study, we aimed to investigate the influence of lymphadenectomy on progression-free and overall survival among patients diagnosed with endometrial carcinoma. This retrospective single-center study included 1532 patients operated on in a Polish reference center for gynecologic oncology at Holy Cross Hospital, Kielce, between 2002 and 2020. A total of 1004 patients underwent systematic lymphadenectomy as a part of their surgical procedure. The median number of collected lymph nodes was seven. In total, 11.6% of patients were found to have lymph node invasion. The number of lymph nodes removed correlated with patient survival. In patients in whom the number of removed lymph nodes was above the median (>7), the risk of death was reduced (HR 0.68, p = 0.002). The risk of death correlated with the presence of lymph node metastasis (HR 4.12, p < 0.001). The risk of cancer progression was associated with the number of lymph nodes removed (HR 0.54, p = 0.006), and the risk of EC recurrence was greater in patients with lymph node metastasis (HR 1.94, p = 0.016). Our study provides additional evidence that systematic lymphadenectomy may influence the disease-free and overall survival of patients with endometrial cancer. The number of lymph nodes removed correlated with patient prognosis. Further studies are needed to evaluate the use of lymphadenectomy in endometrial cancer treatment.

Lymphatic Complications Following Sentinel Node Biopsy or Pelvic Lymphadenectomy for Endometrial Cancer.

Sentinel node biopsy (SNB) is performed worldwide in patients with endometrial cancer (EC). The aim of this study was to evaluate and compare the occurrence rate of lymphatic complications between SNB and pelvic lymphadenectomy (LND) for EC. The medical records of women who underwent SNB or pelvic LND for EC between September 2012 and April 2022 were assessed. A total of 388 patients were enrolled in the current study. Among them, 201 patients underwent SNB and 187 patients underwent pelvic LND. The occurrence rates of lower-extremity lymphedema (LEL) and pelvic lymphocele (PL) were compared between the patients who underwent SNB and those who underwent pelvic LND. The SNB group had a significantly lower occurrence rate of lower-extremity LEL than the pelvic LND group (2.0% vs. 21.3%, p < 0.01). There were no patients who had PL in the SNB group; however, 4 (2.1%) patients in the pelvic LND group had PL. The occurrence rates of lower-extremity LEL and PL were significantly lower in patients who underwent SNB than those who underwent pelvic LND. SNB for EC has a lower risk of lymphatic complications compared to systemic LND.

Incidental damage of obturator nerve during laparoscopic pelvic lymphadenectomy in endometrial cancer – Demonstration of a successful repairing procedure

ObjectiveIn order to highlight the importance of intraoperative complications and their management, we demonstrate a video of an iatrogenic left obturator nerve lesion during a pelvic lymphadenectomy for endometrial cancer staging. The repair was promptly performed using an intracorporeal laparoscopic suture for an end-to-end tension-free nerve anastomosis. DesignStepwise demonstration of the technique with narrated video footage. SettingA 70-year-old woman with a stage IB grade I endometrial adenocarcinoma was submitted to a surgical laparoscopic staging with total hysterectomy(TH), bilateral adnexectomy(BA), and bilateral pelvic and lomboaortic lymphadenectomy. After an uneventful retroperitoneal lomboaortic lymphadenectomy, the left paravesical space was dissected until the obturator fossae and a left pelvic lymphadenectomy followed, during which the left obturator nerve was accidentally transected with LigaSure™. InterventionsA careful inspection revealed an almost complete transection (80%) of the nerve, with both proximal and distal cut ends identifiable and no fraying of the edges. The thickness of the non-sectioned nervous portion was less than 3 mm, but a tension-free reattachment of both edges seemed manageable. The edges were oriented towards each other and a single stitch suture was placed using a 5–0 prolene, providing an epineural end-to-end coaptation. To reinforce the suture, a Fibrin sealant Tissucol® was applied. The contralateral pelvic lymphadenectomy was then performed, followed by TH and BA. The pieces were removed through the vagina using an endobag. The patient was discharged on the second postoperative day. During the follow-up, there were no signs of diminished adductor function, and neither there was any other detectable residual neuropathy or neurologic deficit involving the left thigh. ConclusionIt is crucial to identify intraoperative complications and to develop abilities to manage them. This video proves that it is possible to repair a transected obturator nerve using laparoscopy, when performed by an experienced onco-gynecologist, with extremely good functional results.

Application of thrombin gel matrix for the prevention of lymphocele in patients with endometrial cancer: A prospective randomized trial

ObjectiveTo evaluate a thrombin gel matrix (TGM), Floseal, for the prevention of lymphocele in patients with endometrial cancer who underwent pelvic lymphadenectomy. MethodsA total of 79 consecutive patients with endometrial cancer were randomly allocated to one of two groups: the TGM group and control group. After completion of the lymphadenectomy, 5 mL of Floseal was applied to the bilateral pelvic sidewalls, especially the femoral canal, obturator, and common iliac vessels areas. Computed tomography scans were obtained for lymphocele evaluation 2 months after the surgery. ResultsThree patients from the TGM group, and four patients from the control group were lost during follow-up, and data from 36 participants from each group were analyzed. As the primary outcome, lymphocele developed in 12 patients in both groups (33 %). There was no significant difference between the groups in terms of lymphocele and symptomatic lymphocele development. Lymphocele localization was also not different between the two groups, but the diameter of the lymphoceles detected in the TGM group was significantly greater (p = 0.021). The mean drainage days was significantly shorter in the TGM group (p = 0.015). The amount of drainage was also less in the TGM group, but the difference was not statistically significant. ConclusionThrombin gel matrix applied to the pelvic sidewalls does not reduce the incidence of symptomatic or asymptomatic lymphoceles after pelvic lymphadenectomy in endometrial cancer. However, it can reduce the amount of drainage and the number of drainage days so it can help to shorten hospitalization.

Case Series for Same-Day Discharge for Minimally Invasive Robotic Surgery for Endometrial Cancer

Study Objective Goal of this study is to present a cases series endorsing same-day discharge after minimally invasive robotic surgery for endometrial cancer and to determine factors that affect the length of hospital stay. Design Retrospective study is comprised of all cases (N = 50) by a single gynecologic oncologist (July 1, 2017 to January 30, 2019) that involved a robotic total hysterectomy (RTH) with bilateral salpingo-oophorectomy (BSO) and total pelvic lymphadenectomy for endometrial cancer. Categorical and continuous variables were analyzed using the Chi-square test and unpaired t-test respectively. Bivariate correlation analysis was utilized to determine risk factor influence on length of stay. Setting This study was conducted in El Paso, TX, a borderland city primarily comprised of a Hispanic population. Patients or Participants 50 patients who underwent robotic total hysterectomy with bilateral salpingo-oophorectomy and total pelvic lymphadenectomy for surgical treatment of endometrial cancer. Interventions N/A. Measurements and Main Results Total of 50 women with a median age of 62 years-old underwent RTH/BSO and surgical staging, and 62% (31) of patients were successfully discharged the same day ( 2 hrs.), or increased surgical complexity (para-aortic lymphadenectomy and/or omentectomy). Conclusion Same-day discharge is feasible following minimally invasive robotic surgery for endometrial cancer, despite older age, multiple comorbidities, later surgery time of day, and higher surgical stage.

Combined modality adjuvant therapy for high-risk endometrial cancer

Combined modality adjuvant therapy for high-risk endometrial cancer

Extraperitoneal Endoscopic Total Retroperitoneal Lymphadenectomy: No Bowel Surgery

Study ObjectiveWe describe our ultra-minimally invasive retroperitoneal lymphadenectomy using the extraperitoneal approach. This technique was developed to make traditionally invasive oncologic surgery more patient friendly and safer by eliminating the bowel from the operative field. DesignDescription of a surgical technique. Canadian Task Force II-3. SettingUrban general hospital in Japan. Patients320 Women undergoing endoscopic extraperitoneal paraaortic and pelvic lymphadenectomy for endometrial cancer from Jan 2001 to Dec 2013. InterventionsPatients underwent endoscopic extraperitoneal para-aortic and pelvic lymphadenectomy for endometrial cancer. We accessed the retroperitoneal space with a visual access cannula (Endotip). This device easily facilitates peritoneal tenting. After expanding the extraperitoneal space by blunt dissection with forceps, carbon dioxide was infused. The upper limit of our dissection was the renal vein and the lower limit was the iliac circumflex vein. The extraperitoneal approach naturally creates a bowel-free operative field, even when dissecting in the pelvis. This approach only requires a 5-mm access hole, making it the least invasive approach to this kind of surgery. Measurements and Main ResultsThe 5-year survival rates for this intervention combined with hysterectomy and bilateral adnexectomy are extremely favorable at 90% for patients with stage I to III disease, making this technique a viable minimally invasive approach for selected patients. ConclusionWe can achieve a total para-aortic and pelvic retroperitoneal dissection with this extraperitoneal approach without the bowel invading the operative field. This procedure is focused on the barrier-free nature of working in the retroperitoneal space, meaning a space that is not hindered by the invasion of the bowel or other intraperitoneal structures.

Lower-limb drainage mapping for lymphedema risk reduction after pelvic lymphadenectomy for endometrial cancer

Objective: To evaluate the feasibility of identifying the lower-limb drainage nodes (LLDNs) during pelvic lymphadenectomy for endometrial cancer to describe lower-limb drainage and to assess the diagnostic value of the mapping technique.

Lower-Limb Drainage Mapping for Lymphedema Risk Reduction After Pelvic Lymphadenectomy for Endometrial Cancer

Pelvic lymphadenectomy is associated with a significant risk of lower-limb lymphedema. In this proof-of-concept study, we evaluated the feasibility of identifying the lower-limb drainage nodes (LLDNs) during pelvic lymphadenectomy for endometrial cancer. Secondary objectives were to map lower-limb drainage and to assess the diagnostic value of our mapping technique. This prospective study included patients with endometrial cancer requiring pelvic lymphadenectomy, without neoadjuvant radiotherapy or chemotherapy and without history of lower-limb surgery. A radiopharmaceutical was injected into both feet on the day before surgery. LLDNs were identified using preoperative lymphoscintigraphy and intraoperative isotopic probe detection, then removed before complete pelvic lymphadenectomy. LLDNs and pelvic lymphadenectomy specimens underwent separate histological analysis. Of the 12 patients with early-stage endometrial cancer, 10 underwent preoperative lymphoscintigraphy, which consistently identified inguinal, femoral, and pelvic LLDNs (detection rate: 100%). The intraoperative detection rate was 83% (10/12). Median number of hot nodes per patient was 5 nodes (range: 3-7) on the right and 3 nodes (range: 2-6) on the left. Of 107 LLDNs, 106 were in the external iliac area, including 38 in the lateral group and 45 in the intermediate and medial groups. None of the patients had node metastases at any site. No early complications related to the technique occurred. Our mapping technique appears feasible, safe, and associated with a high LLDN identification rate. LLDN mapping may allow the preservation of LLDNs, thereby decreasing the risk of lower-limb lymphedema and improving quality of life.

Lower-limb drainage mapping for lymphedema risk reduction after pelvic lymphadenectomy for endometrial cancer.

e15558 Background: Pelvic lymphadenectomy is associated with a significant risk of lower-limb lymphedema. In this proof-of-concept study, we evaluated the feasibility of identifying the lower-limb drainage nodes (LLDNs) during pelvic lymphadenectomy for endometrial cancer. Secondary objectives were to map lower-limb drainage and to assess the diagnostic value of our mapping technique. Methods: Prospective study of patients with endometrial cancer requiring pelvic lymphadenectomy, with no neoadjuvant radiotherapy or chemotherapy and no history of lower-limb surgery. A radiopharmaceutical was injected into both feet on the day before surgery. LLDNs were identified using preoperative lymphoscintigraphy and intraoperative isotopic probe detection then removed before complete pelvic lymphadenectomy. LLDNs and pelvic lymphadenectomy specimens underwent separate histological analysis. Results: Of the 12 patients with early-stage endometrial cancer, 10 underwent preoperative lymphoscintigraphy, which consistently identified inguinal, femoral and pelvic LLDNs. The intraoperative detection rate was 83% (10/12). The 2 patients with no LLDNs detected intraoperatively had lymphoscintigraphy-detected LLDNs. Median number of hot nodes per patient was 5 (3-7) on the right and 3 (2-6) on the left. Of 107 LLDNs, 106 were in the external iliac area, including 38 in the lateral group and 45 in the intermediate and medial groups. None of the patients had node metastases at any site. No early complications related to the technique occurred. Conclusions: Our mapping technique appears feasible, safe, and associated with a high LLDN identification rate. LLDN mapping may allow the preservation of LLDNs, thereby decreasing the risk of lower-limb lymphedema and improving quality of life.

Robotic-Assisted Laparoscopic Transection and Repair of an Obturator Nerve During Pelvic Lymphadenectomy for Endometrial Cancer

Obturator nerve injury may occur in gynecologic surgery, particularly in cases in which extensive pelvic sidewall retroperitoneal dissection is performed. The lack of tactile feedback from the robotic surgical system may contribute to obturator nerve injury. If surgical division occurs, microsurgical end-to-end anastomosis of the obturator nerve may be performed. A 76-year-old woman with stage IA endometrial adenocarcinoma sustained a left obturator nerve transection during pelvic lymphadenectomy that was recognized immediately. Robotic-assisted laparoscopic repair was performed successfully, with the patient experiencing no residual neuropathy 6 months postoperatively. Robotic-assisted laparoscopic repair is feasible for the treatment of obturator nerve injury.

Efficacy of Systematic Pelvic Lymphadenectomy in Endometrial Cancer (MRC ASTEC Trial)

Efficacy of Systematic Pelvic Lymphadenectomy in Endometrial Cancer (MRC ASTEC Trial)

Evaluation of The Efficacy of Systematic Pelvic Lymphadenectomy in Endometrial Cancer

Evaluation of: The ASTEC Study Group: Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomized study. Lancet 373, 125–136 (2009). Pelvic lymph node metastasis is one of the most common causes of extrauterine tumor spread in early-stage endometrial uterine cancer. Many retrospective studies have shown the significance of pelvic lymphadenectomy in patients with what was suspected preoperatively to be early-stage endometrial carcinoma. The study evaluated here is the largest prospective randomized trial evaluating pelvic lymphadenectomy in early-stage endometrial cancer, and provides the direct and fully reported overall and recurrence-free survival rates comparing standard surgery with standard surgery plus pelvic lymphadenectomy in patients with early-stage endometrial carcinoma. Overall, the results showed no evidence of benefit in terms of overall or recurrence-free survival for pelvic lymphadenectomy in women with early-stage endometrial cancer. However, this trial analyzed the results of overall and recurrence-free survival without considering the combination of histopathological prognostic risk factors. It may be important to analyze overall and recurrence-free survival between the subgroups by combination of the histopathological prognostic risk factors. A large, prospective clinical trial might be necessary to evaluate the role of pelvic lymphadenectomy by considering the combination of histopathological prognostic risk factors in early-stage endometrial cancer.

Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study

SummaryBackgroundHysterectomy and bilateral salpingo-oophorectomy (BSO) is the standard surgery for stage I endometrial cancer. Systematic pelvic lymphadenectomy has been used to establish whether there is extra-uterine disease and as a therapeutic procedure; however, randomised trials need to be done to assess therapeutic efficacy. The ASTEC surgical trial investigated whether pelvic lymphadenectomy could improve survival of women with endometrial cancer.MethodsFrom 85 centres in four countries, 1408 women with histologically proven endometrial carcinoma thought preoperatively to be confined to the corpus were randomly allocated by a minimisation method to standard surgery (hysterectomy and BSO, peritoneal washings, and palpation of para-aortic nodes; n=704) or standard surgery plus lymphadenectomy (n=704). The primary outcome measure was overall survival. To control for postsurgical treatment, women with early-stage disease at intermediate or high risk of recurrence were randomised (independent of lymph-node status) into the ASTEC radiotherapy trial. Analysis was by intention to treat. This study is registered, number ISRCTN 16571884.FindingsAfter a median follow-up of 37 months (IQR 24–58), 191 women (88 standard surgery group, 103 lymphadenectomy group) had died, with a hazard ratio (HR) of 1·16 (95% CI 0·87–1·54; p=0·31) in favour of standard surgery and an absolute difference in 5-year overall survival of 1% (95% CI −4 to 6). 251 women died or had recurrent disease (107 standard surgery group, 144 lymphadenectomy group), with an HR of 1·35 (1·06–1·73; p=0·017) in favour of standard surgery and an absolute difference in 5-year recurrence-free survival of 6% (1–12). With adjustment for baseline characteristics and pathology details, the HR for overall survival was 1·04 (0·74–1·45; p=0·83) and for recurrence-free survival was 1·25 (0·93–1·66; p=0·14).InterpretationOur results show no evidence of benefit in terms of overall or recurrence-free survival for pelvic lymphadenectomy in women with early endometrial cancer. Pelvic lymphadenectomy cannot be recommended as routine procedure for therapeutic purposes outside of clinical trials.FundingMedical Research Council and National Cancer Research Network.

Laparoscopic Marsupialization of Pelvic Lymphocele under Transvaginal Ultrasonographic Guidance

Lymphocyst formation is a common complication of pelvic lymphadenectomy. We treated a 54-year-old woman with lymphocele by laparoscopic marsupialization. She developed hydronephrosis as a result of retroperitoneal lymphocele after total abdominal hysterectomy and pelvic lymphadenectomy for endometrial cancer. Laparoscopic marsupialization under transvaginal ultrasonographic guidance was chosen because conservative therapy including percutaneous or transvaginal drainage ran the risk of bowel perforation. The 6-cm collection was opened and its edges were coagulated electrosurgically and sutured with the surrounding peritoneum. The postoperative course was satisfactory, and hydronephrosis was resolved. This highly effective minimally invasive procedure was beneficial to the patient.

Laparoscopic marsupialisation of pelvic lymphocysts following total abdominal hysterectomy and pelvic lymphadenectomy for endometrial cancer: A case report

Lymphocele formation, a common complication of pelvic lymphadenectomy, can produce considerable morbidity. Treatment is sometimes problematic. We treated a 54-year-old woman with a symptomatic lymphocele by laparoscopic marspialization.She developed hydronephrosis due to a retroperitoneal lymphocele following total abdominal hysterectomy and pelvic lymphadenectomy for endometrial cancer. Because conservative therapy, including percutaneous or transvaginal drainage, had a risk of bowel perforation, we chose laparoscopic marsupialisation under transvaginal ultrasonographic guidance. The 6-cm collection was opened, and the edges were cauterized and sutured with the surrounding peritoneum. The postoperative course was satisfactory and the hydronephosis resolved. This highly effective, minimally invasive procedure offers a significant advantage to the patient.