Periaortic Lymph Node Metastases Research Articles

Metachronous common iliac lymph node metastasis after rectosigmoid colon cancer resection: A case report.

Introduction and importanceMetastases to common iliac lymph nodes from cancer of the rectosigmoid are extremely rare. We report a patient with a right common iliac lymph node metastasis after rectosigmoid cancer resection.Case presentationThe patient is a 57-year-old woman diagnosed with rectosigmoid cancer (Stage IIIc) who underwent laparoscopic resection followed by 8 courses of adjuvant chemotherapy with capecitabine. Sixteen months after resection, an intra-abdominal mass and a left lung nodule were found on computed tomography scans, which were suspected to be recurrences. Exploratory laparoscopy showed that the abdominal lesion was an enlarged common iliac lymph node, which was completely excised. No other intraabdominal recurrences were found. Subsequently, a left upper lobe lung metastasis was resected thoracoscopically. However, multiple lung metastases developed four months after the lung resection, and systemic therapy was begun.Clinical discussionA lower incidence of lateral lymph node metastases from cancer in the rectosigmoid has been reported. Direct lymphatic pathways from the sigmoid colon or rectosigmoid to lateral lymph nodes have been suspected, which may be associated with the poor prognosis in this patient.ConclusionA metachronous metastasis to a common iliac lymph node from primary rectosigmoid cancer is reported. Common iliac lymph node metastases from rectosigmoid cancer might have more malignant potential, and should be treated in the same manner as peri-aortic lymph node metastases.

Ovarian Carcinoid Tumor with Nodal Metastases: Case Report

Primary ovarian carcinoid tumors are very rare, they represent less than 0.1% of all ovarian cancers. The insular type is the most common, followed by the stromal, trabecular and mucinous types. A woman of 47 years old presented with lower abdominal pain, ultrasound evaluation revealed a voluminous pelvic mass on the right side. The patient underwent debulking surgery, it was diagnosed a carcinoid of the left ovary with prevalent trabecular and partly cribriform and insular pattern. Our patient had periaortic lymph node metastases, in this respect there is no evidence of involvement of lymph nodes for primary ovary, especially in the trabecular form, except for intestinal and pulmonary carcinoids. Therefore, this is the fi rst case of mixed primary ovarian carcinoid, particularly in predominantly trabecular form, with lymph node metastases, as described in the literature.

Percent surface area involvement is a predictor of lymph node metastasis in endometrial cancer

Objective. To determine if percent surface area involvement (SAI) of tumor in endometrial cancer is predictive of lymph node metastasis. Methods. A retrospective study was performed of all patients diagnosed with endometrial cancer at Magee Women's Hospital between January 1990 and December of 1995. Papillary serous and clear cell histologic subtypes were excluded. Pathology reports were reviewed for percent SAI, myometrial invasion, grade, histologic subtype, lymphvascular space invasion, and lymph node metastasis. Percent SAI was categorized into three groups: < 35%, 35–80%, and > 80%. The primary outcome variables were pelvic or periaortic lymph node metastasis. Univariate and multivariate analysis logistic regression models were used to determine predictors of nodal metastasis. Results. Of 558 patient records reviewed, 319 had lymph node dissections performed and 42 (13%) of those patients had positive lymph nodes. Two of 79 (3%) patients with < 35% SAI had lymph node metastasis, 17 of 165 (10%) patients with 35–80% SAI had lymph node metastasis, and 23 of 75 (31%) patients with > 80% SAI had lymph node metastasis. The percent SAI was significantly associated with lymph node metastasis ( p < 0.001). Multivariate logistic regression indicated that for patients with > 80% SAI, the odds of having lymph node metastasis were 10.8 times (CI 1.3–90.4) that for patients with similar tumor histology, grade, and invasion, but < 35% SAI ( p = 0.03). A subset analysis of patients with superficial myometrial invasion was performed and 16% of patients with < 50% myometrial invasion and > 80% SAI had positive lymph nodes, while only 1.4% of patients with < 50% myometrial invasion and < 35% SAI had positive lymph nodes ( p = 0.02). Conclusion. Our analysis indicates that percent SAI is an independent risk factor for lymph node metastasis. Furthermore, assessing SAI with myometrial invasion gives a more accurate prediction of lymph node metastasis than myometrial invasion alone. This becomes clinically relevant when assessing risk factors for lymph node metastasis intraoperatively.

How to manage locally advanced primary and recurrent cancer of the uterine cervix: The surgeon's view

Locally advanced cancer of the uterine cervix covers a broad disease spectrum comprising primary tumours of >4 cm in size or FIGO stage >IIA and all local tumour relapses except the rare cases of small recurrences in a retained cervix. Treatment designs have to consider the probability of pelvic and periaortic lymph node metastases and – albeit less frequent in primary disease – distant metastases. Established treatment standards aiming to achieve pelvic and eventually periaortic tumour control are chemoradiation for locally advanced primary disease as well as post-surgical pelvic recurrences, and pelvic exenteration for post-radiation central relapses. A subset of patients with pelvic side wall relapses can now be successfully treated by laterally extended endopelvic resection as well. Based on the current results it is not evident whether neoadjuvant chemotherapy, radical hysterectomy and eventually adjuvant radiation are comparable or superior treatment alternatives for locally advanced intermediate stage cases. Likewise, the benefit of (laparoscopic) surgical staging including the exstirpation of bulky pelvic and periaortic lymph nodes has not been convincingly demonstrated to date. Both surgical treatment concepts need further well-designed prospective randomized trials for their evaluation. From the surgeon's perspective total mesometrial resection, therapeutic lymph node dissection, laterally extended endopelvic resection and new developments in restoration/substitution of pelvic functions have the potential to improve the therapeutic index for defined cohorts of patients suffering from locally advanced cancer of the uterine cervix.

Isolated Periaortic Lymph Node Metastasis From Uterine Cervical Cancer Treated by Stereotactic Radiation Therapy Using CyberKnife

Isolated Periaortic Lymph Node Metastasis From Uterine Cervical Cancer Treated by Stereotactic Radiation Therapy Using CyberKnife

Radiation therapy with or without chemotherapy for cervical cancer with periaortic lymph node metastasis.

The purpose of this article is to evaluate the efficacy of chemoradiation therapy (CRT) and radiation therapy (RT) alone for cervical cancer with periaortic nodal metastasis (PANM). Twenty-one patients with cervical cancer with PANM were identified. Eleven patients received concomitant CRT with cisplatin-based chemotherapy and 10 received RT alone. The median age was 44 years. Ten, 5, and 6 patients had International Federation of Gynecology and Obstetrics stages IB, IIB, and IIIB disease. The RT doses to point A and the periaortic region were 80 to 85 Gy (low dose rate equivalent) and 45 Gy. The median follow-up was 26 months (range 3 to 141 months). The 1- and 3-year disease-specific survival were 81.8% and 81.8%, and 70% and 30%, respectively, for the CRT and RT groups, (P = 0.11). The 1- and 3-year pelvic and periaortic control rates (PPC) were 100% and 100% (CRT), and 56.3% and 42.2% (RT) (P = 0.03). The 1- and 3-year free-from-distant metastasis (DM) rates were 81.8% and 81.8% (CRT), and 78.7% and 49.2% (RT) (P = 0.54). All patients who developed DM died of their disease. CRT is a feasible treatment option to improve the PPC for these patients. Because of the high rate of distant metastasis despite PPC, more effective systemic therapy should be explored.

Orthotopic treatment model of prostate cancer and metastasis in the immunocompetent mouse: efficacy of flt3 ligand immunotherapy.

We established an orthotopic treatment model of prostate cancer to generate reproducible primary and metastatic carcinoma in immunocompetent C57BL/6 mice. Using an in vivo selection scheme of intraprostatic implantation of TRAMP-C1 cells, primary prostate tumors were cultured and recycled three times by intraprostatic injection resulting in the selection and establishment of the recycled cell line TRAMP-C1P3. Prostate tumors were detected approximately 30 days post-implantation with periaortic lymph node metastasis in 19/20 (95%) of mice. Tissue culture amplification, DNA ploidy and PCR amplification of the SV40 transgene were used to detect metastatic TRAMP-C1P3 in lymph node specimens. Tissue culture amplification and DNA ploidy were as sensitive as SV40 transgene amplification by PCR in detection of early metastatic disease in draining lymph nodes. To establish the use of the orthotopic model of prostate cancer for immunotherapy, mice were injected orthotopically with TRAMP-C1P3 cells and 7 days post-implantation treated daily for 28 days with either flt3L or carrier control. Carrier-treated mice had clinically detectable prostate tumors, lymph node metastasis and were moribund at 29-35 days, whereas flt3L therapy markedly suppressed primary TRAMP-C1P3 growth and lymph node metastasis, and prolonged survival. In summary, we have established a reproducible and clinically relevant orthotopic treatment model of prostate cancer in immunocompetent mice with application to a variety of therapeutic strategies. We demonstrate that flt3L treatment suppressed orthotopic prostate tumor growth and lymph node metastasis reinforcing a role for flt3L as an immunotherapeutic strategy for prostate cancer.

Radiation therapy with or without chemotherapy for cervical cancer with periaortic lymph node metastasis

Radiation therapy with or without chemotherapy for cervical cancer with periaortic lymph node metastasis

Tumor angiogenesis in pheochromocytomas and paragangliomas

Angiogenesis correlates with growth and likely metastases in several tumors. To determine whether it has a similar role in pheochromocytomas, immunohistochemical staining of factor VIII was done on the tumor tissue of 42 patients. Formalin-fixed, paraffin-embedded tissue was obtained from 29 women and 13 men with 24 primary adrenal and 18 extraadrenal pheochromocytomas. Patients were divided into two groups. Group 1 included 32 patients with benign pheochromocytomas, and group 2 included 10 patients with malignant tumors evidenced by capsular or vascular invasion (six), liver metastases (three), or periaortic lymph node metastases (one). Blood vessels highlighted by factor VIII staining of endothelial cells with labeled streptavidin-biotin were counted under light microscopy. Mean vessel count within a 10 mm2 micrometer disk was calculated under x100, x200, and x400 magnification fields. There were no significant differences in patient age or clinical symptoms between the groups. The mean tumor size in group 2 of 8.8 +/- 5.3 cm was larger than the mean of 4.8 +/- 2.8 cm in group 1 (p < 0.005). The mean counts of vessels in the x100, x200, and x400 magnification fields were 102 +/- 48, 40 +/- 18, and 19 +/- 9 in group 1, and 203 +/- 77, 73 +/- 28, and 37 +/- 15 in group 2. The number of blood vessels in group 2 was significantly higher than in group 1 (p < 0.001) in each studied field. In this study the number of tumor blood vessels correlated with the invasive behavior of pheochromocytomas. Tumor angiogenesis may be useful in determining the likelihood of malignant behavior in pheochromocytomas.

DIAGNOSING ABILITY OF CT ON PERIAORTIC LYMPH NODE METASTASIS OF GASTRIC CANCER

One-hundred and two resected cases of advanced gastric cancer were subjected to a study of investigating whether preoperative CT could identify the presence of periaortic lymph node metastasis of gastric cancer. According to our diagnosis criteria, the correct diagnosing rate was 88.2%, specificity was 97.4%, and sensitivity was 60.0%. These figures allowed to consider that the diagnosing ability of CT was high. However, false-negative cases amounted to 10, or 11.8%. When the false-negative cases were reviewed by macroscopic and histological types of primary lesions, no significant difference in macroscopic type was found, but an increasing tendency in falsenegative results was observed in poorly differentiated type. From these findings preoperative CT was considered useful to know the presence of periaortic lymph node metastasis of gastric cancer. For probable false-negative result, our efforts to minimize it would mandatory by diagnosing based on histological type of the primary lesion.

Parasternal mediastinoscopy: Assessment of operability in left upper lobe lung cancer: A prospective analysis

Between 1976 and 1984, 242 patients with presumably operable lung cancer were treated surgically. In the Canisius Wilhelmina Hospital, Nijmegen, The Netherlands, in the period 1976 to 1980, 109 of 131 (83.2%) patients underwent cervical mediastinoscopy to assess operability. They were studied retrospectively. During this examination, lymph node metastasis was demonstrated in three of 19 (15.8%) patients with left upper lobe lung cancer. At thoracotomy after a normal cervical mediastinoscopic study or no mediastinoscopic study, periaortic lymph node metastases were found in eight of 34 (23.5%) patients with left upper lobe lung cancer. In the period 1981 to 1984, the value of left parasternal mediastinoscopy was studied prospectively in patients with left lung cancer in the Canisius Wilhelmina Hospital, Nijmegen; in the Lung Centre of the Radboud University Hospital, Nijmegen; and in the Lung Center of the Dekkerswald Medical Centre, Groesbeek. Cervical or cervical and parasternal mediastinoscopy were performed in 69 of 111 (62.2%) patients. At parasternal mediastinoscopy performed after a normal cervical mediastinoscopic study, periaortic lymph node metastases were found in seven of 31 (22.6%) patients with left upper lobe lung cancer. All periaortic lymph node metastases showed intranodal and extranodal growth. The resectability rate in left upper lobe lung cancer was 79.4% in the retrospective group and 96.5% in the prospective group. There were no serious complications after parasternal mediastinoscopy. These data point to the reliability of parasternal mediastinoscopy in the assessment of left upper lobe lung cancer. The study provides essential information for the staging and treatment of non-small cell lung cancer of the left upper lobe.

Survival and patterns of recurrence in cervical cancer metastatic to periaortic lymph nodes: A Gynecologic Oncology Group study

Ninety-eight of 621 evaluable patients (16%) with cervical cancer enrolled into Gynecologic Oncology Group protocols were found to have periaortic lymph node metastases at staging laparotomy or at exploration for definitive operative management. As expected there was a progressive increase in the prevalence of periaortic metastases including 5% of 150 patients with Stage IB, 16% of 222 patients with Stage II, and 25% of 135 patients with Stage III. Periaortic lymph node metastases in the absence of pelvic lymph node metastases was an infrequent occurrence in patients so evaluated. The median survival of patients with periaortic metastases was 15.2 months with a survival probability of 25% at 3 years. The median duration of survival following recurrence was only 5 months. Recurrences were divided approximately equally between the pelvis and distant sites.

Multivariate analysis of a personal series of 247 patients with liver metastases from colorectal cancer. II. Treatment by intrahepatic chemotherapy.

One hundred and seventeen patients with colorectal hepatic metastases had insertion of catheters for infusional chemotherapy. The two-year survival estimate of patients with less than 50% hepatic replacement and no other adverse factors was 37%. Nine of 39 patients in this group are alive at 24 months. The catheters were placed into the hepatic artery (HA), 23; into the portal venous system (PV), 18; into both HA and PV, 64; or into an accessory HA following ligation, 12. Fifty-nine patients had ligation of the common HA also. The 30-day postoperative mortality rate was 1.7% (2/117) and morbidity was 37.6%. The majority of complications were related to fever (61%, 27/44). Over the past 2 years, 87% of patients have been discharged within 10 days following surgery. Preoperative CEA ranged from 0.5-12,150 ng/ml (median 165 ng/ml); 93% (78/84) had plasma CEA levels exceeding 5 ng/ml. All patients had careful intraoperative staging: per cent hepatic replacement (PHR) ranged from 5-95% (median 60%); portal, celiac, or periaortic lymph node metastases were observed in 31% (36/117). Initial intrahepatic chemotherapy programs consisted of either CAMF (9 patients), MAFL (60 patients), BFS (22 patients), continuous infusion FUDR (14 patients), or miscellaneous drugs (4 patients). Median survival time of 109 evaluable patients was 11.5 months. The effect of 20 variables on the observed survival time was analyzed using a multivariate proportional hazard model. Three variables were found to have influenced survival: PHR emerged as the most significant, p = 0.000001. Increased PHR was associated with decreased survival time. Lymph node metastases and prior chemotherapy were prognostic factors also, p = 0.0006 and p = 0.03, respectively. No patient with PHR greater than 80% lived more than 8 months. Utilization of these variables would appear to be necessary for accurate stratification and evaluation of future chemotherapy trials in patients with colorectal hepatic metastases.

Modification of radiation therapy following operative evaluation of patients with cervical carcinoma

Twelve of thirty-nine patients with cervical cancer who underwent bilateral pelvic and periaortic lymphadenectomy through an extraperitoneal approach had lymph node metastases. Four patients had metastases to pelvic lymph nodes only and eight had metastases to common iliac or periaortic lymph nodes in addition to other pelvic lymph nodes. The operative findings permitted the modification of radiation therapy on the basis of known extent of tumor. All patients with common iliac or periaortic lymph node metastases had ports of external therapy extended to the level of the diaphragm and had more emphasis placed on external radiation therapy and less on intracavitary therapy. The sequence of operation through an extraperitoneal approach followed by conventional or extended radiation therapy was tolerated with minimal morbidity and no mortality.

IS POSITIVE PELVIC LYMPHADENOPATHY A CONTRAINDICATION TO RADICAL SURGERY IN RECURRENT CERVICAL CARCINOMA?

Abstract The extent of disease at the time of surgical exploration determines whether radical surgery can be performed in the patient who has a postirradiation cervical cancer recurrence. Contraindications to extirpative surgery includes spread of disease beyond the confines of the removable organs. This includes common iliac and periaortic lymph node metastasis. Some authors have advocated aborting the procedure when pelvic nodes are involved. In a review of 170 patients undergoing radical surgery for cervical cancer recurrence, 25% with positive nodes survived 5-yr compared with 36% with negative nodes. The finding of positive pelvic lymph nodes in itself should not be the sole reason for abandoning the operative procedure.

Is positive pelvic lymphadenopathy a contraindication to radical surgery in recurrent cervical carcinoma?

The extent of disease at the time of surgical exploration determines whether radical surgery can be performed in the patient who has a postirradiation cervical cancer recurrence. Contraindications to extirpative surgery includes spread of disease beyond the confines of the removable organs. This includes common iliac and periaortic lymph node metastasis. Some authors have advocated aborting the procedure when pelvic nodes are involved. In a review of 170 patients undergoing radical surgery for cervical cancer recurrence, 25% with positive nodes survived 5-yr compared with 36% with negative nodes. The finding of positive pelvic lymph nodes in itself should not be the sole reason for abandoning the operative procedure.