Perform Lymph Node Dissection Research Articles

The Current Role of Lymph Node Dissection in the Management of Renal Cell Carcinoma

The role of lymph node dissection remains controversial in the surgical management of renal cell carcinoma. Incidental renal masses are being diagnosed at increasing rates due to the routine use of CT scans. Despite the increase in incidental diagnosis of renal masses, 20% to 30% of patients present with metastatic disease. Currently, surgeons do not routinely perform lymph node dissection unless there is gross evidence of lymphadenopathy, as patients without clinical evidence of lymphadenopathy rarely have positive nodes at the time of surgery. Patients with metastatic disease to the regional lymph nodes have a poor overall prognosis. However, some evidence supports a therapeutic benefit of lymphadenectomy in these patients. Further, the staging information gained from diagnosing lymph node involvement may allow for the use of new agents to treat metastatic disease and effect outcomes.

Abstract 875: Ovarian and uterine carcinosarcoma: A comparative analysis of prognostic variables and survival outcomes

Abstract Objective: Carcinosarcomas (malignant mixed mullerian tumor) of the female genital tract are rare tumors associated with poor outcome. Previous studies have demonstrated that even tumors of similar histology originating in organs that are in proximity may be biologically distinct entities by virtue of their occurrence through different molecular pathways. The objective of this study was to identify site specific differences in the clinical behavior and survival outcome of carcinosarcomas originating in female genital tract by comparing carcinosarcomas arising in the uterus and ovaries. Methods: Data on patients with uterine carcinosarcoma and ovarian carcinosarcoma were extracted from the Surveillance, Epidemiology, and End Results database between 1988 and 2005. Kaplan-Meier log rank and Cox proportional hazards models were used for survival analysis and to identify possible predictors for survival. Results: The identified cohort included 3,683 women, with 2,759 (75%) uterine carcinosarcomas and 924 (25%) ovarian carcinosarcomas. Uterine carcinosarcoma patients were older than patients with ovarian carcinosarcoma (median age 67.61 vs. 65.83 years, p<0.001). Women with uterine carcinosarcomas compared with ovarian carcinosarcoma were more often African American (17.3% versus 6%; P<0.001) and presented more often with early stage disease (Stage I/II 56.6% compared with 24.6%; P <0.001). Uterine compared to ovarian carcinosarcomas differed significantly with regards to the performance of salpingo-oopherectomy (96 % versus 99.4 %; P = 0.001), lymphadenectomy (62.6% versus 41.2%; P <0.001), and administration of radiotherapy (38.2% versus 4.8%; P <0.001). No difference was found in survival between patients with uterine and ovarian carcinosarcoma on stage- stratified Kaplan- Meier survival analysis or multivariate analysis using Cox model. Although, age (p<0.001), race (p<0.001), marital status (p<0.001), stage (p<0.001), lymphadenectomy (p<0.001), and radiation (p=0.005) were all significant prognostic factors in uterine carcinosarcoma, only age (p=0.001), stage (p<0.001), and lymphadenectomy(p<0.001) reached statistical significance in ovarian carcinosarcoma on multivariate analysis. Conclusion: Ovarian carcinosarcomas present at a more advanced stage and have a comparable prognosis at each stage with uterine carcinosarcomas. Improved survival observed in lymphadenectomy group argues in favor of routinely performing lymph node dissection in patients with uterine and ovarian carcinosarcoma. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 875.

Urologic pelvic surgery following mesh hernia repair

Few and controversial reports have recently appeared on the role of previously performed surgery in the inguinal region using a prosthetic mesh and the ensuing difficulties encountered by urologists during radical retropubic prostatectomy. We analyzed our experience with various surgical urological procedures performed after prior low abdominal wall hernia repair with synthetic mesh. We reviewed our database for all patients who underwent mesh repair of lower abdominal hernias and subsequent urologic surgery in our department between 2002 and 2008. Their perioperative parameters, complications, and postoperative outcomes were analyzed. Twenty-three patients (one female) underwent pelvic urologic surgery for benign and malignant disease after having undergone previous prosthetic hernia repair. The mean patient age was 75.3 years (range 58-91). The mean interval between hernia repair and pelvic urologic surgery was 3.8 years (range 1-7). Twenty-two patients underwent previous mesh inguinal hernia repair and one had prosthetic postoperative ventral hernia repair after a transabdominal hysterectomy. The urologic procedures included 16 open suprapubic prostatectomies, two radical cystoprostatectomies, one bladder augmentation, and four laparoscopic radical prostatectomies. Severe postoperative complications were abortion of surgery (n = 1), inability to perform lymph node dissection (n = 2), bleeding (n = 1), bladder injury (n = 2), and additional surgery (n = 3: mesh removal, transurethral prostatectomy, and transurethral fulguration of the prostatic fossa). Prior application of synthetic mesh during abdominal wall surgery creates difficulties during subsequent urological procedures and may dictate change in operative planning. Nevertheless, the surgery is feasible and should not be ruled out.

Clinical experience with extended lymph node dissection during radical prostatectomy

14545 Background: The value of the extent of lymph node dissection at radical prostatectomy remains controversial. We report our experience with extended lymph node dissection in patients undergoing open radical prostatectomy. Methods: 201 consecutive patients with cT1c-cT3a prostate cancer who underwent open radical prostatectomy with an extended regional lymph node (LN) dissection of up to six packets (iliac, hypogastric, and obturator; right and left) by a single surgeon at The Methodist Hospital between July 2002 and April 2004 were studied. No patient was treated with adjuvant radiation or hormonal therapy before elevated PSA levels were observed. Ultrasensitive PSA (uPSA) using the 3rd generation Immulite assay (DPC) was performed periodically beginning at 6 weeks post operatively. A uPSA level ≥ 0.03 ng/mL and rising on at least one subsequent uPSA obtained at least six weeks later was classified as a biochemical recurrence (BCR). Results: The mean patient age was 59 years at the time of surgery (median, 59; range, 39 to 73 years). Median follow-up after surgery was 21 months (range 1–37 months). Gleason Score was ≤ 6, 7, and 8–10 in 37%, 53% and 10% of patients, respectively. Sixty-two patients had extra prostatic extension and 16 patients had seminal vesicle involvement. A total of 3125 pelvic lymph nodes were removed (per patient: mean, 15.64; median, 15; range 4–42). Of these 22 LN (0.71%) were positive in 11 (5.5%) patients. By specified region, 2/1775 (0.23%) of iliac nodes, 6/642 (0.93%) of hypogastric nodes and 9/708 (1.27%) of obturator nodes were positive. Of the 11 patients with positive LN, 3/11 (27.27%) had positive iliac nodes, 6/11 (54.54%) had positive hypogastric nodes, and 6/11 (54.54%) had positive obturator nodes. Using a very stringent definition of BCR in order to compensate for the relatively short follow-up period, the 2 year progression-free survival (PFS) for patients with at least one positive LN was 37.5%. Conclusions: Extended LN dissection may alter the biology of early nodal metastatic prostate cancer and lead to longterm PFS without additional therapy. A higher percentage of patients and nodes are positive in the hypogastric and obturator regions, supporting the rationale to include these with the iliac nodes when performing LN dissection. No significant financial relationships to disclose.

Sentinel-Lymphadenektomie beim Prostatakarzinom

There is no consensus on which prostate cancer patients should undergo lymph node removal and which lymph nodes should be included. Therefore, most clinicians rely on nomograms and dispense with lymph node dissection in patients with low-risk disease. Meanwhile, there are some studies which prove that there are also lymph node metastases in patients with low-risk prostate cancer and that lymph node metastases are predominantly localized outside the region of standard lymphadenectomy. In more than 800 men we could show that lymph node metastases were found more often than shown in the Partin tables. These lymph node metastases were detected by sentinel lymph node dissection outside the region of standard and extended lymphadenectomy. Because of insufficient preoperative diagnostics it is unclear which patients have positive lymph nodes. Therefore, it is useful to perform lymph node dissection in every patient. Men with positive nodes could have a better prognosis, when sentinel and extended lymph node dissection are performed.

Laparoscopic lymph node dissection around the inferior mesenteric artery for cancer in the lower sigmoid colon and rectum

When we perform laparoscopic lymph node dissection around the inferior mesenteric artery (IMA), we preserve the left colic artery (LCA) to maintain the blood supply to the proximal sigmoid colon. In this study, we present our laparoscopic D2 and D3 lymph node (LN) dissection technique and evaluate its applicability and safety. We performed LN dissection on 23 rectal and lower sigmoid colon cancer cases from April 2002 to December 2004. For D3 LN dissection, the incision to the mesosigmoid extends to just before the root of the IMA, which is exposed with an ultrasonic cutting and coagulating surgical device to avoid bleeding. Then, the arterial wall is exposed with a dissecting electrocautery spatula down to the LCA, at least 2 cm of which is exposed. Adipose tissue surrounding the IMA and inferior mesenteric vein is dissected. For D2 LN dissection, we partially expose the IMA to confirm the location of the LCA. The mean times taken for D2 and D3 LN dissections were 36.2 and 68.2 min, respectively. Both procedures took longer in male patients. There was a trend for the procedure overall to take less time in female patients. However, D2 dissection took significantly longer in male than female patients (p < 0.05). In women, D3 dissection took significantly longer than D2 (p < 0.05), but this trend was not seen in men. Increased experience among surgeons with this procedure was associated with significantly faster LN dissections in men (p < 0.05), but not in women (p = 0.493). Pearson product moment analysis identified a relationship between body mass index (BMI) and the time taken for D2 LN dissection (r = 0.765), but not D3 LN dissection (r = 0.158). There was no treatment-related morbidity with this technique. This method was safe and feasible for all patients in this series, but takes longer to perform in male patients.

Radical Perineal Prostatectomy: A Novel Approach For Lymphadenectomy from Perineal Incision

A major disadvantage of radical perineal prostatectomy is that lymphadenectomy cannot be performed through the same incision. We developed a novel approach to access the obturator and internal iliac lymph nodes, partially the external iliac lymph nodes, via the perineal incision. We describe the method of lymphadenectomy. After moving the rectum off of the prostate we separate the levator ani muscle and endopelvic fascia from the lateral prostate with finger dissection. A trocar mounted balloon distention device is inserted toward this space and distended with 200 cc air to create an intrapelvic space. Using several retractors or laparoscopy for viewing we first identify the obturator nerve and then the external iliac vessels next in order of depth. By retracting the obturator nerve with vessel tape we perform lymph node dissection between the obturator nerve and external iliac vessels under direct vision or laparoscopic guidance. We have performed this technique in 20 consecutive patients because of prostate specific antigen greater than 10 ng/ml, Gleason score greater than 7 or bilateral disease. Bilateral lymph node dissection required 15 to 20 minutes. No major bleeding or complications occurred. The number of nodes was similar to that in our retropubic prostatectomy series because of the limited lymphadenectomy that we usually performed. Fecal incontinence and potency results were almost the same as in patients without lymphadenectomy. Although urinary continence was not good at catheter removal on day 7, patients became dry in 1 to 6 months. This method resolves the major disadvantage of perineal prostatectomy. Radical perineal prostatectomy with lymphadenectomy via the same incision is feasible and reproducible.

A CASE OF ADULT VILIRIZING ADRENOCORTICAL CARCINOMA

A rare case of adrenocortical carcinoma in an adult with vilirism is reported. A 25-year-old woman, with hirsutism, acne, and amenorrhea was diagnosed as having an androgen producing tumor of the right adrenal gland by abdominal computed tomography, ultrasonography and endocrinal examinations. We resected the tumor and performed lymph node dissection. The tumor had a smooth surface and a cystic region, but was not invasive. Histopathological study revealed adrenocortical carcinoma. Adrenocortical carcinoma with vilirism in adults is very rare, and have been only 14 cases reported in Japan previously. The prognosis of adrenocortical carcinoma is very poor, and additional follow up should be performed.