Positive Para-aortic Nodes Research Articles

Is there a benefit of pretreatment laparoscopic transperitoneal surgical staging in patients with advanced cervical cancer?

Objective. At present, cervical cancer remains the only gynecologic tumor, which is staged by clinical examination according to FIGO. This is associated with a high percentage of over- and understaging of tumor extent. With the operative, especially laparoscopic staging, exact information about intraabdominal tumor spread, lymph node metastases, and involvement of adjacent organs is possible. However, the advantage of operative staging is still discussed controversially. The aim of this study is to describe the laparoscopic transperitoneal staging procedure in patients with cervical cancer and their oncologic outcome after primary chemoradiation. Methods. From November 1994 to October 2003, 456 consecutive patients with histologically confirmed primary cervical cancer were admitted to the Department of Gynecology of the Friedrich–Schiller-University Jena, Germany. Out of these, 84 patients with locally advanced tumor (tumor size ≥4 cm) and/or lymph node involvement and/or tumor infiltration to bladder or rectum were selected by a standardized laparoscopic staging procedure for primary chemoradiation. Data of surgery, chemoradiation, and follow-up were analyzed retrospectively for these patients. Results. The mean age of the patients was 54 years (26–80), and the mean body-mass-index was 24.8 (17.9–42.2). Preoperative clinical evaluation showed a stage distribution according to FIGO with stage IB1 in 15.5%, IB2 in 15.5%, IIA in 8.3%, IIB in 23.8%, IIIA in 8.3%, IIIB in 21.4%, IVA in 6%, and IVB in 1.2%. In 15 out of 84 (17.8%) patients, intraabdominal tumor spread was diagnosed by laparascopy. In 24 out of 84 (28.5%) patients, invasion of bladder and/or rectum was proven histologically after biopsy. In 60 out of 84 (71%) patients, lymph node metastases were confirmed histologically. In 2 out of 13 patients with FIGO-stage Ib1, skip metastases in infrarenal paraaortic lymph nodes were seen. Removal of more than 5 pelvic and/or more than 5 positive paraaortic lymph nodes was associated with significant improvement of overall survival. According to the histological findings following laparoscopic staging in 36 out of 84 (43%) patients, a higher tumor stage was diagnosed. If tumor involvement of lymph nodes is also included, an upstaging in 73/84 (87%) of patients has to be noted down. Downstaging was not necessary in any patient following laparoscopic evaluation. Conclusion. Only operative staging gives exact information about tumor extension in patients with locally advanced and/or nodal positive cervical cancer and allows individual treatment planning. This can be done successfully by a transperitoneal laparoscopic approach without serious adverse effects delaying chemoradiation. Debulking of tumor-involved lymph nodes significantly improves overall survival and should be performed prior to primary chemoradiation. Laparoscopic staging should be the basis for all treatment studies in order to group patients according to true tumor extent.

Clinical implication of laparoscopic pelvic lymphadenectomy in patients with vulvar cancer and positive groin nodes

Objective. At present, no clear guidelines for the treatment of patients with vulvar cancer and positive groin nodes exist. In general, the decision for additional pelvic radiation is based on findings by imaging techniques and/or the number of groin nodes involved. The aim of this case series was to demonstrate that histologic result of laparoscopic removed pelvic lymph nodes can be used to select patients who should not undergo pelvic irradiation. Methods. From July 1997 to October 2004, 12 consecutive patients with primary or recurrent vulvar cancer underwent laparoscopic pelvic lymphadenectomy following primary or secondary surgical treatment. Results. There were 8 patients with primary cancer of the vulva and 4 patients with recurrent disease in the inguinal and/or pelvic lymph nodes. The mean age was 61 (26–83) years and the mean body-mass-index was 27.1 (20.8–36.6). Positive groin nodes were found in five patients on the right side and in five patients on the left side; in one patient, positive groin nodes were present in both sides. In another patient with a history of vulvar cancer and positive groin nodes the CT-scan indicated the presence of positive iliac and paraaortic lymph nodes. Only in two patients tumor involved lymph nodes were diagnosed by laparoscopic pelvic lymphadenectomy (one left-sided, one right-sided). The number of harvested pelvic lymph nodes was 13.7 (5–20) in unilateral and 27.8 (16–37) in bilateral lymphadenectomy. The histologic examination of removed pelvic lymph nodes confirmed pelvic radiation in only 2 out of 12 patients, whereas 10 patients were spared from whole pelvis irradiation. Conclusion. With respect to small sample size, laparoscopic lymphadenectomy seems to be a good tool to avoid unnecessary pelvic radiation in patients with vulvar cancer and confirmed positive groin nodes.

Combined chemoradiation (CRT) with high dose rate brachytherapy (HDR) for locally advanced cervical cancer: A regional experience

5162 Background: CRT with HDR has become standard practice for patients (pts) with locally advanced cervical cancer. However, the clinical outcome data remains sparse in patients treated with CRT-HDR compared to CRT-low dose rate brachytherapy (LDR). This is a report of Sacramento regional experience utilizing CRT-HDR over a 10-year period. Methods: 232 pts with locally advanced cervical carcinoma (FIGO Stage IB2/IIA: 15%, IIB: 53%, III: 28%, IVA: 3%) who were treated with concurrent chemotherapy (5FU ± CDDP every 4 weeks or CDDP weekly), external beam RT and HDR with a curative intent from 3/91 to 10/01 were analyzed retrospectively. 74 pts had lymph node (LN) involvement pathologically or radiographically, of whom 30 had positive paraaortic LN. 100 pts (43%) received an extended field RT. 175 pts completed treatment within 8 weeks. The survival analysis and the association of independent variables (e.g. age, stage, tumor size, LN status, treatment duration) with overall (OS) and disease-free survival (DFS) were performed using the Kaplan-Meier method and Cox proportional hazards model, respectively. Results: Median follow-up of 139 surviving pts was 4 years with 20 lost to follow-up within a year. The estimated 5-year OS and DFS rates for all pts were 58% and 63%. 21 pts had documented in-field failure and 57 had distant metastases. Advanced stage and LN involvement predicted for worse DFS (p<0.001, p<0.015 respectively). In a multivariate analysis, only the stage predicted for worse OS and DFS (p<0.015) and treatment duration predicted for worse OS (e.g. increase of 1 treatment day was associated with 1% increased hazard of death). Grade 3/4 late effects were observed in small bowel (6%), rectum (4%), and bladder (8%). Conclusions: Aggressive CRT integrating HDR is feasible in this high-risk population. The late effects were comparable to CRT-LDR data reported in RTOG 90–01. This experience included many patients ineligible for RTOG 90–01 due to worse prognoses (e.g., hydronephrosis/renal dysfunction, paraaortic LN involvement). Nevertheless, the OS and DFS were favorable. Comparison of survival data of our cohort to those of RTOG 90–01 will be presented. No significant financial relationships to disclose.

Adjuvant pelvic radiation therapy and high dose rate brachytherapy for pathologic stage III endometrial cancer

5157 Background: There is a paucity of data regarding the use of adjuvant external beam radiotherapy (RT) and high dose rate (HDR) brachytherapy in the treatment of patients with stage III endometrial cancer. Methods: A retrospective review of 40 pathologic FIGO stage III endometrial cancer patients treated between 1996 and 2003 at McGill University was performed. Patients with papillary serous and clear cell carcinomas were excluded. All patients underwent surgery followed by adjuvant RT. Nodal sampling was performed in 25 patients (63%). External beam RT of 45 to 50.4 Gy in 23 to 28 fractions was delivered to the whole pelvis in all patients and with extended fields in one patient (5%) with positive para-aortic nodes. HDR brachytherapy of 6 to 18 Gy in 1 to 3 fractions was delivered to the vaginal vault in 30 patients (75%). Results: Median age at diagnosis was 58 years. Patients had stage IIIA disease in 24 cases (60%), stage IIIB in 2 cases (5%), and stage IIIC in 14 cases (35%). Tumors were histologi...

Outcomes of abandoned radical hysterectomy in patients with stages IB–IIA cervical cancer found to have positive nodes during the operation

The objective of this study was to evaluate the outcomes of stages IB–IIA cervical cancer patients whose radical hysterectomy (RH) was abandoned for positive pelvic nodes detected during the operation compared with those found to have positive nodes after the operation. Among 242 patients with planned RH and pelvic lymphadenectomy (RHPL) for stages IB–IIA cervical cancer, 23 (9.5%) had grossly positive nodes. RH was abandoned, and complete pelvic lymphadenectomy was performed. Of these 23 patients, 22 received adjuvant chemoradiation, and the remaining 1 received adjuvant radiation. Four patients with positive para-aortic nodes were additionally treated with extended-field irradiation. When compared with 35 patients whose positive nodes were detected after the operation, there were significant differences regarding number of positive nodes and number of patients receiving extended-field irradiation. Complications in both groups were not significantly different, but the 2-year disease-free survival was significantly lower in the abandoned RH group compared with that of the RHPL group (58.5% versus 93.5%,P= 0.01). In conclusion, the survival of stages IB–IIA cervical cancer patients whose RH was abandoned for grossly positive pelvic nodes was significantly worse than that of patients whose node metastasis was identified after the operation. This is because the abandoned RH group had worse prognostic factors.

Outcomes of abandoned radical hysterectomy in patients with stages IB?IIA cervical cancer found to have positive nodes during the operation

The objective of this study was to evaluate the outcomes of stages IB-IIA cervical cancer patients whose radical hysterectomy (RH) was abandoned for positive pelvic nodes detected during the operation compared with those found to have positive nodes after the operation. Among 242 patients with planned RH and pelvic lymphadenectomy (RHPL) for stages IB-IIA cervical cancer, 23 (9.5%) had grossly positive nodes. RH was abandoned, and complete pelvic lymphadenectomy was performed. Of these 23 patients, 22 received adjuvant chemoradiation, and the remaining 1 received adjuvant radiation. Four patients with positive para-aortic nodes were additionally treated with extended-field irradiation. When compared with 35 patients whose positive nodes were detected after the operation, there were significant differences regarding number of positive nodes and number of patients receiving extended-field irradiation. Complications in both groups were not significantly different, but the 2-year disease-free survival was significantly lower in the abandoned RH group compared with that of the RHPL group (58.5% versus 93.5%, P= 0.01). In conclusion, the survival of stages IB-IIA cervical cancer patients whose RH was abandoned for grossly positive pelvic nodes was significantly worse than that of patients whose node metastasis was identified after the operation. This is because the abandoned RH group had worse prognostic factors.

Lymph-vascular space invasion and number of positive para-aortic node groups predict survival in node-positive patients with endometrial cancer

Objective. The aim of this study was to determine pathologic variables associated with disease-specific survival of node-positive patients with endometrial carcinoma treated with combination of surgery including pelvic and para-aortic lymphadenectomy and adjuvant chemotherapy. Methods. Survival of 55 node-positive endometrial carcinoma patients prospectively treated with surgery and adjuvant chemotherapy between 1982 and 2002 at Hokkaido University Hospital was compared to various histopathologic variables. All patients underwent primary surgical treatment including pelvic and para-aortic lymphadenectomy followed by adjuvant chemotherapy consisting of intravenous cisplatin, doxorubicin, and cyclophosphamide. Survival analyses were performed by the Kaplan–Meier curves and the log-rank test. Independent prognostic factors were determined by multivariate Cox regression analysis using a forward stepwise selection. Results. Among 303 consecutive endometrial cancer patients treated during the period of this study, 55 patients (18.2%), including 44 without peritoneal metastasis (FIGO stage IIIc) and 11 with peritoneal metastasis (FIGO stage IV), were found to have retroperitoneal lymph node metastasis. Multivariate Cox regression analysis revealed that peritoneal metastasis and lymph-vascular space invasion (LVSI) were independently related to poor survival in node-positive endometrial carcinoma. The estimated 5-year survival rate of stage IIIc patients with or without moderate/prominent LVSI was 50.9% and 93.3%, respectively with statistically significant difference ( P = 0.0024). The estimated 5-year survival rate of stage IV patients was 20.0%. Prognosis of stage IIIc patients could be stratified into three groups by the number of positive para-aortic node (PAN) with an estimated 5-year survival rate of 86.4% for no positive PAN ( n = 23), 60.4% for one positive PAN ( n = 13), and 20.0% for ≥ 2 positive PAN ( n = 8). The difference of survival rate between no or one positive PAN and ≥ 2 positive PAN was statistically significant ( P = 0.0007 for no positive PAN vs ≥ 2 positive PAN, P = 0.0319 for one positive PAN vs ≥ 2 positive PAN). Multivariate analysis including number of positive PAN groups showed that LVSI, number of positive PAN groups were independent prognostic factors for survival. Survival of patients with stage IIIc disease could be stratified into three groups by combination of LVSI and number of positive PAN groups with an estimated 5-year survival rate of 93.3% for no or one positive PAN group with nil or minimal LVSI, 62.6% for no or one positive PAN group with intermediate or prominent LVSI, and 20.0% for ≥ 2 positive PAN groups irrespective of LVSI ( P = 0.0002 for no or one positive PAN group with nil or minimal LVSI vs ≥ 2 positive PAN groups, P = 0.0223 for no or one positive PAN group with nil or minimal LVSI vs no or one positive PAN group with intermediate or prominent LVSI, P = 0.0388 for no or one positive PAN group with intermediate or prominent LVSI vs ≥ 2 positive PAN groups). Conclusions. LVSI and number of positive PAN groups were independent prognostic factors for stage IIIc endometrial cancer patients. Postoperative therapy and follow-up modality need to be individualized according to LVSI and the number of positive PAN for stage IIIc patients. New molecular markers to predict the prognosis of endometrial cancer patients preoperatively should be found for individualization of treatment. New chemotherapy regimen including taxane needs to be considered as an adjuvant therapy for patients with node-positive endometrial cancer.

IMRT dose escalation for positive para-aortic lymph nodes in patients with locally advanced cervical cancer while reducing dose to bone marrow and other organs at risk

Purpose To evaluate the feasibility of dose-escalated para-aortic lymph node (PALN) intensity modulated radiation therapy (IMRT) in reducing the dose to bone marrow, bowel, spinal cord, and kidneys, compared with conventional radiation techniques of PALNs in patients with locally advanced cervical cancer and PALN metastases. Methods and materials Computed tomography scans and MRI studies of 5 cervical cancer patients with PALN involvement were transferred to an IMRT treatment planning workstation (Eclipse/Helios) for image fusion and definition of target volumes and critical structures. The positive PALNs identified on fused computed tomography–magnetic resonance images were defined as the gross target volume (GTV), and the PALN region was defined as the planning target volume. There were 2 distinct treatment regions: the PALN region superior to the isocenter and the whole-pelvis region inferior to the isocenter. Three treatment planning techniques were compared: AP/PA (both regions), 4-field box (both regions), and PALN-IMRT with 4-field box to the whole-pelvis field. With IMRT, the radiation dose to the GTV was escalated from the conventional 45 Gy to 60 Gy (2.4 Gy/fraction), whereas the planning target volume and whole-pelvis region received 45 Gy. The treatment planning isocenter was placed at the L4–L5 vertebral body interspace, and this allowed the two treatment regions to be abutted using independent jaws. Results This study has demonstrated the feasibility of escalating the dose delivered to grossly positive PALNs to 60 Gy (2.4 Gy/fraction) with a 95.6% median GTV coverage, concomitantly with conventional treatment of the whole-pelvis region. PALN-IMRT significantly reduced V 40 bone marrow compared to the AP/PA and 4-field box techniques with a median of 21.3%, 98%, and 49.7%, respectively. The PALN-IMRT and 4-field box techniques showed a reduction in V 45 bowel over the AP/PA technique, but a level of statistical significance was not reached. The spinal cord received a significantly higher maximum dose when PALNs were treated with AP/PA fields. Alternatively, the use of the 4-field box technique yielded a significant increase in V 22 kidney on both sides. The placement of the treatment planning isocenter at the L4–L5 interspace allowed the PALN-IMRT and whole-pelvis regions to be treated with a relatively uniform dose at the abutment region. Conclusion In this dosimetric analysis, we demonstrated that dose-escalated PALN-IMRT with conventional whole-pelvis radiotherapy is feasible with significant sparing of critical normal structures compared to PALN conventional radiation techniques.

The impact of aborted radical hysterectomy in patients with cervical carcinoma

Objective.To determine the impact of an aborted radical hysterectomy on morbidity and overall survival in patients undergoing surgical treatment for early stage cervical carcinoma. Methods.Following IRB approval, a computerized database identified 304 women treated with radical surgery for early stage cervical carcinoma from 1994 to 2000 of which 23 (8%) had an aborted radical hysterectomy. Results.Of the 23 patients, 17 patients had a IB1 lesion, 4 patients had a IB2 lesion, and 2 patients had a IIA lesion. Median age was 42 years (range 28–60). Twenty-one patients had squamous cell carcinoma and two patients had adenocarcinoma. Radical hysterectomy was aborted for the following reasons: 11 patients had pelvic extension, seven had positive pelvic nodes, and five patients had positive paraaortic nodes. All 23 patients received postoperative radiation therapy; additionally, 12 patients received concurrent chemotherapy consisting of platinum with or without 5-FU. There were four operative complications (17%) including deep vein thrombosis, wound infection, blood transfusion, and an ileus. Four patients (17%) had radiation-associated complications. Six of 23 (26%) patients experienced a recurrence. The 5-year overall survival was 83% with a median follow-up of 59 months (range 12–107 months). Conclusions.A small percentage of patients (8%) with early stage cervical carcinoma will have an aborted radical hysterectomy for pelvic extension or positive nodes. Fortunately, these patients still have a favorable prognosis with postoperative radiation therapy. Aborted radical surgery does not significantly increase overall complications.

A comparison of stages IB1 and IB2 cervical cancers treated with radical hysterectomy. Is size the real difference?

To compare stages IB1 and IB2 cervical cancers treated with radical hysterectomy (RH) and to define predictors of nodal status and recurrence. Patients with stage IB cervical cancers undergoing RH between 1990 and 2000 were evaluated and clinicopathological variables were abstracted. The perioperative complication rate, estimated blood loss (EBL), and OR time were also tabulated. Variables were analyzed using X(2) and t tests. Disease-free survival (DFS) was calculated by Kaplan-Meier method. Multivariate analysis was performed via stepwise logistic regression. Cox-proportional hazards were used to identify independent predictors of recurrence. RH was performed on 109 stage IB1 and 86 stage IB2 patients. Mean age, EBL, and perioperative complication rates were similar. Overall, 38 patients (14 IB1 vs. 24 IB2) had positive nodes (P = 0.01) including 9 patients with positive para-aortic nodes (2 IB1 and 7 IB2). Parametrial involvement (PI) and outer 2/3 depth of invasion (DOI) were significantly more common in the IB2 tumors as well. Patients with IB2 disease received adjuvant radiation more frequently than IB1 patients (52% vs. 37%, P = 0.04). Univariate predictors of nodal status included lymphovascular space involvement (LVSI) (P = 0.001), DOI (P = 0.011), PI (P = 0.001), and stage (P = 0.011). Multivariate analysis identified only LVSI (OR 6.4, CI 2.4-17, P = 0. 0002) and PI (OR 8, CI 3.1-20, P = 0. 0001) as independent predictors of positive nodes. With a median follow-up of 35 months, estimates of DFS revealed tumor size (P = 0.008), nodal status (P = 0.0004), LVSI (P = 0.002), PI (P = 0.004), and DOI (P = 0.0004) as significant univariate predictors. Neoadjuvant chemotherapy, age, grade, histology, and adjuvant radiation were not associated with recurrence. The significant independent predictors of DFS were LVSI (ROR 5.7, CI 2-16, P = 0.0064) and outer 2/3 DOI (OR 5.8, CI 2-20, P = 0.0029). Neither tumor size nor nodal status was a significant predictor of DFS. The prognosis in stage IB cervical cancer seems to be most influenced by presence of LVSI and DOI and not by tumor size as the staging criteria would suggest. These factors are best determined pathologically after radical hysterectomy. This report contains the largest comparison of IB1 and IB2 patients managed by RH. Tumor size failed to predict recurrence or nodal status when stratified by LVSI, DOI, and PI. Treatment decisions based on tumor size alone should be reconsidered.

Two isocenter treatment technique for pelvic malignancies with positive pelvic and para-aortic lymph nodes using intensity modulated fields

Treatment of regional lymph nodes for pelvic malignancies such as genitourinary and gynecologic cancers, has significant impact on patient survival. The treatment technique for the pelvic and para-aortic lymph nodes has not changed in the last decade, due to the large treatment volume and the limitation of field size. Conventional treatment technique for this type of tumor includes anterior-posterior fields for the superior portion of the tumor and a four-field box for the inferior portion, allowing a proper field gap at the patient surface.

Two isocenter treatment technique for pelvic malignancies with positive pelvic and para-aortic lymph nodes using intensity modulated fields

Two isocenter treatment technique for pelvic malignancies with positive pelvic and para-aortic lymph nodes using intensity modulated fields

A multivariate analysis on histopathologic prognostic factors for predicting outcome of node-positive endometrial carcinoma

5064 Background: Prognosis of advanced endometrial cancer patients (stage IIIc and IV) is poor. In order to clarify the histopathologic prognostic factors of node-positive endometrial cancer, we performed the following analysis. Methods: A retrospective review of 55 node-positive endometrial cancer patients (44 in stage IIIc and 11 in stage IV) among 303 patients treated between 1982 and 2002 at Hokkaido University Hospital was performed. All Patients underwent primary surgical treatment including pelvic and para-aortic lymphadenectomy followed by adjuvant chemotherapy consisting of intravenous cisplatin, doxorubicin, and cyclophoshamide. Survival analyses were performed by the Kaplan-Meier curves and the log-rank test. Independent prognostic factors were determined by multivariate Cox regression analysis. Results: Multivariate analysis revealed that FIGO (1988) stage and lymph-vascular space invasion (LVSI) of the tumor were found to be independently related to poor survival . The estimated 5-year survival rate of stage IIIc patients with or without moderate/prominent LVSI was 50.9 % and 93.3 %, respectively. The difference of survival rate was statitstically significant (p=0.0024). The estimated 5-year survival rate of stage IV patients was 20.0%. In stage IIIc patients, multivariate analysis showed that LVSI alone was found to be an independent prognostic factor for survival. Prognosis of stage IIIc patients could be stratified into three groups by the number of positive para-aortic lymph node (PAN) with an estimated 5-year survival rate of 86.4% for no positive PAN (n=23), 60.4% for 1 positive PAN (n=13), 20.0% for >=2 positive PAN (n=8). The difference of survival rate between no or one positive PAN and >=2 PAN was statistically significant (p=0.0007 for no positive PAN vs >=2 PAN, p=0.0319 for one positive PAN vs >=2 positive PAN). Conclusions: LVSI was an independent prognostic factor for stage IIIc patients and their prognosis was stratified by the number of positive PAN. Postoperative therapy and follow-up modality need to be individualized according to LVSI and the number of positive PAN for stage IIIc patients. No significant financial relationships to disclose.

A multivariate analysis on histopathologic prognostic factors for predicting outcome of node-positive endometrial carcinoma

5064 Background: Prognosis of advanced endometrial cancer patients (stage IIIc and IV) is poor. In order to clarify the histopathologic prognostic factors of node-positive endometrial cancer, we performed the following analysis. Methods: A retrospective review of 55 node-positive endometrial cancer patients (44 in stage IIIc and 11 in stage IV) among 303 patients treated between 1982 and 2002 at Hokkaido University Hospital was performed. All Patients underwent primary surgical treatment including pelvic and para-aortic lymphadenectomy followed by adjuvant chemotherapy consisting of intravenous cisplatin, doxorubicin, and cyclophoshamide. Survival analyses were performed by the Kaplan-Meier curves and the log-rank test. Independent prognostic factors were determined by multivariate Cox regression analysis. Results: Multivariate analysis revealed that FIGO (1988) stage and lymph-vascular space invasion (LVSI) of the tumor were found to be independently related to poor survival . The estimated 5-year survival rate of stage IIIc patients with or without moderate/prominent LVSI was 50.9 % and 93.3 %, respectively. The difference of survival rate was statitstically significant (p=0.0024). The estimated 5-year survival rate of stage IV patients was 20.0%. In stage IIIc patients, multivariate analysis showed that LVSI alone was found to be an independent prognostic factor for survival. Prognosis of stage IIIc patients could be stratified into three groups by the number of positive para-aortic lymph node (PAN) with an estimated 5-year survival rate of 86.4% for no positive PAN (n=23), 60.4% for 1 positive PAN (n=13), 20.0% for >=2 positive PAN (n=8). The difference of survival rate between no or one positive PAN and >=2 PAN was statistically significant (p=0.0007 for no positive PAN vs >=2 PAN, p=0.0319 for one positive PAN vs >=2 positive PAN). Conclusions: LVSI was an independent prognostic factor for stage IIIc patients and their prognosis was stratified by the number of positive PAN. Postoperative therapy and follow-up modality need to be individualized according to LVSI and the number of positive PAN for stage IIIc patients. No significant financial relationships to disclose.

Preliminary report of using FDG-PET to detect extrapelvic lesions in cervical cancer patients with enlarged pelvic lymph nodes on MRI/CT

Purpose To evaluate, in a prospective study, the effects of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) on the detection of extrapelvic lesions, the design of whole pelvis or extended field radiotherapy, and subsequent failure patterns for patients with cervical cancer and enlarged pelvic lymph nodes (LNs) shown on MRI or CT. Methods and materials Between April and December 2001, 19 consecutive patients underwent an additional FDG-PET examination before concurrent chemoradiotherapy. The inclusion criteria for the study were at least one enlarged pelvic LN ≥10 mm in its maximal dimension as shown on radiologic images and no extrapelvic tumors detected by conventional examination. The PET findings of the primary tumor, pelvic LNs, and extrapelvic lesions were investigated and compared with the MRI/CT findings. Tumor FDG uptake was quantitated with the maximal pixel standardized uptake value. Results Except for 1 patient with diabetes mellitus who was excluded from analysis, 18 cervical tumors had significant FDG uptake (maximal pixel standardized uptake value >8). A total of 39 pelvic LNs were reported, and the agreement of positive pelvic LNs between MRI/CT and PET was 79.5%. Five patients (28%) had positive paraaortic LNs on FDG-PET, and their treatment fields were extended to include the paraaortic region. In addition to the paraaortic LNs, 1 patient also had metastasis at the left supraclavicular node. After a minimum follow-up of 12 months (median 15.9), 4 patients (22.2%) developed new extrapelvic metastases. The disease-free survival rate was 78% at 12 months. Conclusion FDG-PET is a useful tool to detect paraaortic LN metastasis and determine the appropriate treatment field for cervical cancer with enlarged pelvic LNs on MRI/CT. The preliminary data suggest that pretreatment FDG-PET can supplement conventional imaging studies, but still has limitations in the detection of microscopic disease.

Treatment planning guidelines regarding the use of CT/PET-guided IMRT for cervical carcinoma with positive paraaortic lymph nodes

Purpose Computed tomography (CT)/positron emission tomography (PET)-guided intensity-modulated radiotherapy of the paraaortic lymph nodes (PALNs) has been proposed for patients with cervical carcinoma and paraaortic metastasis. This investigation attempted to determine the guidelines regarding the selection of appropriate treatment parameters (e.g., number of beams, beam geometry) and organ-specific parameters (e.g., importance weighting and tolerance dose) for intensity-modulated radiotherapy planning for the PALNs. Methods and materials Patients underwent imaging using CT and PET. The images were registered, and the structures were contoured. A goal dose of 50.4 Gy and 59.4 Gy was assigned to the clinical target volume (lymph node bed) and gross tumor volume (PET-delineated PALNs), respectively. For each patient, multiple treatment plans using various beam geometries and planning parameters were executed and evaluated in terms of the dose–volume histograms of the target and critical structures. Results Acceptable sparing of the stomach, liver, and colon was achieved, regardless of the number of beams used. Sparing of the spinal cord was strongly dependent on the number and arrangement of the beams. Varying the number and arrangement of the beams affected small intestine sparing, but the amount of sparing was limited because the small intestine overlapped the target volumes, and, therefore, received the prescription dose. Adjusting the number of beams, beam angles, and prescription parameters provided minimal improvement in kidney sparing. Conclusion We successfully developed treatment plans that deliver 59.4 Gy to the positive PALNs and 50.4 Gy to the paraaortic region using CT/PET-guided intensity-modulated radiotherapy.

Laparoscopic-Assisted Radical Vaginal Hysterectomy: Prospective Evaluation of 200 Patients With Cervical Cancer

Hertel, Hermann; Köhler, Christhardt; Michels, Wolfgang; Possover, Marc; Tozzi, Roberto; Schneider, Achim

Cytoprotection/radioprotection with amifostine: potential role in cervical cancer and early findings in the radiation therapy oncology group C-0116 trial

Concurrent cisplatin-based chemoradiation therapy is now considered the standard treatment for locally advanced cervical carcinoma. Available data also suggest that combined-modality therapy improves outcome compared with radiation therapy alone in disease with positive para-aortic lymph nodes. However, radiation therapy alone is associated with significant toxicity in cervical cancer, and toxicity is increased with chemoradiation therapy. The cytoprotectant/radioprotectant agent amifostine (Ethyol; MedImmune, Inc, Gaithersburg, MD) has been found to reduce toxicities associated with cisplatin, radiation, and combined modality approaches in the treatment of several tumor types. The limited available data on the use of amifostine in patients with cervical or pelvic cancers indicate a benefit in reducing chemoradiation toxicity, although cisplatin regimens used in the early investigations in cervical cancer are no longer considered optimal. In the Radiation Therapy Oncology Group C-0116 phase I/II trial, patients with cervical cancer with positive para-aortic or high common iliac nodes are to receive extended-field radiation and intracavitary brachytherapy plus weekly cisplatin in the first part of the study; in the second part of the trial, patients are also to receive amifostine. The trial should provide important information on the potential for adjunctive amifostine use in chemoradiation therapy for cervical cancer.

The value of pelvic and para-aortic lymphadenectomy in endometrial cancer to avoid unnecessary radiotherapy.

The case histories of 95 patients with endometrial carcinoma treated between July 1998 and December 2002 were reviewed. These patients were staged according to FIGO classification and included peritoneal cytology, total abdominal hysterectomy/bilateral salpingo-oophorectomy (TAHBSO), and pelvic with or without para-aortic lymphadenectomy. The FIGO surgical stages were as follow: IA, 9 (9.5%); IB, 35 (36.8%); IC, 16 (16.8%); IIB, 10 (10.5%); IIIA, 5 (5.3%); IIIB, 1 (1.1%); IIIC, 19 (20.0%). In addition to TAHBSO, 47 (49.5%) patients had pelvic lymphadenectomy whereas 48 (50.5%) had both pelvic and para-aortic lymphadenectomy. Nineteen (20.0%) of 95 patients had nodal metastases. Positive pelvic and para-aortic lymph nodes were found in 15 (15.8%) of 95 and 12 (25.0%) of 48 patients, respectively. According to the result of the lymphadenectomy, 19 (20.0%) patients had their surgical stage upgraded to stage IIIC and 61 (64.2%) patients had a change in their management plan. Twelve (12.6%) patients required extended field irradiation due to para-aortic nodal metastases and 49 (51.6%) patients with negative nodes avoided postoperative external radiotherapy. By defining the lymphatic spread via surgical staging, postoperative radiotherapy can be recommended to patients with nodal metastases, while it can be withheld from those patients with negative nodes, irrespective of the presence of risk factors.

The value of pelvic and para-aortic lymphadenectomy in endometrial cancer to avoid unnecessary radiotherapy

The case histories of 95 patients with endometrial carcinoma treated between July 1998 and December 2002 were reviewed. These patients were staged according to FIGO classification and included peritoneal cytology, total abdominal hysterectomy/bilateral salpingo-oophorectomy (TAHBSO), and pelvic with or without para-aortic lymphadenectomy. The FIGO surgical stages were as follow: IA, 9 (9.5%); IB, 35 (36.8%); IC, 16 (16.8%); IIB, 10 (10.5%); IIIA, 5 (5.3%); IIIB, 1 (1.1%); IIIC, 19 (20.0%). In addition to TAHBSO, 47 (49.5%) patients had pelvic lymphadenectomy whereas 48 (50.5%) had both pelvic and para-aortic lymphadenectomy. Nineteen (20.0%) of 95 patients had nodal metastases. Positive pelvic and para-aortic lymph nodes were found in 15 (15.8%) of 95 and 12 (25.0%) of 48 patients, respectively. According to the result of the lymphadenectomy, 19 (20.0%) patients had their surgical stage upgraded to stage IIIC and 61 (64.2%) patients had a change in their management plan. Twelve (12.6%) patients required extended field irradiation due to para-aortic nodal metastases and 49 (51.6%) patients with negative nodes avoided postoperative external radiotherapy. By defining the lymphatic spread via surgical staging, postoperative radiotherapy can be recommended to patients with nodal metastases, while it can be withheld from those patients with negative nodes, irrespective of the presence of risk factors.