Positive Para-aortic Nodes Research Articles

Clear cell carcinoma of the cervix: A multi-institutional review in the post-DES era

Objective To conduct an outcome analysis of patients with cervical clear cell carcinoma (CCCC) in the post-DES era. Methods A retrospective review was conducted at 3 major gynecologic cancer centers of all primary CCCC between 1982 and 2004. Results CCCC was confirmed in 34 patients. Median age was 53 years. DES exposure was confirmed in 2 (6%) patients. A history of smoking was elicited in 22%, and of abnormal Pap smear 18% patients. Primary surgical resection was performed in all stage I or IIA patients ( n = 26); they displayed superior 3-year overall survival (OS) compared to advanced stage ( n = 8) patients (91% vs. 22%, p < 0.001). Pelvic lymph node involvement was noted in 25%; all patients with positive para-aortic nodes (20% of patients sampled) had positive pelvic nodes. All node positive patients were treated with adjuvant radiation, but nevertheless displayed reduced progression free (31% vs 92%, p < 0.001) and overall survival (80% vs. 100%, p = 0.02). Adjuvant radiotherapy did not appear to impact OS in patients with negative lymph nodes. Discussion This series provides insight into the management of early stage CCCC in the post-DES era. Although these patients may be at slightly higher risk of nodal spread, clear cell histology by itself does not appear to portend a worse prognosis than squamous cell carcinoma of the cervix in the absence of traditional risk factors. Our data suggest that patients with low risk early stage CCCC may be managed with radical surgery alone, without the need for adjuvant chemotherapy or radiation.

Extraperitoneal para-aortic lymph node evaluation for cervical cancer via pfannenstiel incision: Technique and peri-operative outcomes

Objective To examine surgico-pathologic outcomes following extraperitoneal para-aortic lymph node dissection (EPLND) via pfannenstiel compared to paramedian incision prior to radiation in patients with cervical cancer. Methods At our institution, patients with locally advanced cervical cancer undergo, EPLND. From 1990 to 2000, EPLND was performed via paramedian incision (PM) primarily to identify positive para-aortic lymph nodes (PALN). From 2000 to present, a complete pelvic and para-aortic lymphadenectomy was performed via pfannenstiel incision (PF). Records for all patients undergoing EPLND were reviewed. Pathologic findings, post-operative complications, and time to initiation of radiation (TRT) were abstracted. Results 93 patients underwent EPLND, 48 via PF and 45 via PM incision. The mean age and body mass index did not differ between the two groups. Stage distribution was similar: IB2 8 vs. 0%; IIB 44 vs. 44%; IIIA/B 35 vs. 44%; IVA 13 vs. 11%, respectively. Positive PALN were identified in 44% of PF patients and 29% of PM patients ( p = ns). TRT was not significantly different at 36.4 vs. 28.8 days, respectively. There were more complications among the PF group including cellulitis and lymphocyst formation. Pre-treatment computed tomography (CT) scan had positive and negative predictive values of only 86 and 66% for evaluation of PALN involvement. Conclusions We present an extraperitoneal method for removal of the pelvic and para-aortic lymph nodes with acceptable complications and no significant delay to initiate chemoradiation. Accurate assessment of lymphatic metastases results in modification of the radiation field, which, along with surgical debulking, may impact overall survival.

Should we modify the current FIGO staging system for stage IIIC ovarian cancer?

Should we modify the current FIGO staging system for stage IIIC ovarian cancer?

Surgery for hilar cholangiocarcinoma: The Leeds experience

Aim To review the experience with hilar cholangiocarcinoma and to determine the results of a radical surgical approach in a UK centre. Methods A 10-year review of all patients treated surgically for proximal bile duct carcinoma at a single surgical unit was conducted. Patient demographics, disease details and histopathology reports were reviewed. From January 1993 through December 2003, 106 patients were admitted with the diagnosis of hilar cholangiocarcinoma and 61 patients received surgical exploration. Results Tumours were staged as follows (UICC 6th edition): stage IB, n = 10 IIA, n = 9; IIB, n = 20; III, n = 8; IV, n = 14. Out of 61 patients, 44 had a resection (3 bile duct resection alone, 41 liver resection with bile duct resection), 5 were considered unresectable and 12 underwent liver transplantation (LT). The caudate lobe was excised in 34 of the patients and regional lymphadenectomy was systematically carried out. Para-aortic lymphadenectomy was performed in 17 cases. Portal vein resection was needed in 17 and hepatic artery resection was performed in 4 cases. Negative histologic margins (R0) were achieved in 20 patients and microscopic margin involvement (R1) was seen in 16. In the remaining 8 resected patients, localised metastasis were found (peritoneal deposits in 2, liver metastasis in 4 and positive para-aortic lymph nodes in 2); nevertheless the resection was performed and it was considered R2. Overall survival at 3 and 5 years for patients who underwent a resection was 43% and 28% including postoperative deaths. The 1-, 3- and 5-year actuarial survival rates for patients who underwent R0 resection were 78%, 64% and 45% respectively, including the postoperative deaths ( n = 3). The median survival time was 41.1 months. The 1-, 3- and 5-year actuarial survival rates for R1 resection and R2 were 60%, 26%, 26% and 25% and 0% respectively, while the median survival time for these groups was 15.4 and 6.8 months respectively. The actuarial survival rate at 1, 3 and 5 years for well-differentiated tumours (G1) was 73%, 54% and 40% (median 39.7 months). The figures for G2 were 60%, 48% and 0%. The figures for G3 (poorly differentiated) were 16% and 0% at three years ( p = 0.03).The overall survival at 3 and 5 years for those patients who had a liver transplant was 41% and 20% including early postoperative mortality. The tumour grading (presence of poorly differentiated tumour) was found to be the only independent factor affecting the survival time producing a hazard ratio of 4.3 ( p = 0.0034, 95% confidence interval 0.1007–6.342). Conclusions Radical surgical resection is the best treatment for hilar cholangiocarcinoma. R0 resection provides acceptable 5-year survival, but R1 resection may also provide acceptable palliation. In our experience TNM stage and tumour grade were the main determinants of long-term survival.

Extended Field Irradiation and Intracavitary Brachytherapy Combined With Cisplatin Chemotherapy for Cervical Cancer With Positive Para-Aortic or High Common Iliac Lymph Nodes: Results of Arm 2 of RTOG 0116

Extended Field Irradiation and Intracavitary Brachytherapy Combined With Cisplatin Chemotherapy for Cervical Cancer With Positive Para-Aortic or High Common Iliac Lymph Nodes: Results of Arm 2 of RTOG 0116

Laparoscopic para-aortic lymphadenectomy and positron emission tomography scan as staging procedures in patients with cervical carcinoma stage IB2IIIB

The objective of this study was to determine the role of laparoscopic lower para-aortic lymphadenectomy and positron emission tomography (PET) scan in the staging of cervical carcinoma. Ninety consecutive patients with FIGO stage IB2-IIIB were scheduled for laparoscopic para-aortic lymphadenectomy. obvious metastatic para-aortic nodes on computed tomography (CT)/PET or PET-CT. The procedure was stopped when a node was positive on frozen section. In ten patients, no para-aortic lymphadenectomy was performed as scheduled. Forty-seven patients were operated retroperitoneally, 22 transperitoneally, and 21 cases were converted from retroperitoneally to transperitoneally. Median number of removed nodes was 6 (1-24). In 10 of 80 patients, para-aortic metastases were diagnosed. Despite a nonsuspect PET result, 5 of 44 patients had positive para-aortic nodes. Two-year survival was 76% and 16% without and with para-aortic metastases, respectively (P = 0.0001). Laparoscopic para-aortic lymphadenectomy showed metastases in 13% of the patients. In the subgroup with negative PET scan, 11% had metastases. The procedure had a low morbidity and identified a group with an extremely poor prognosis.

The prognostic value of pretreatment 2-(18F)-fluoro-2-deoxy-D-glucose positron emission tomography scan in women with cervical cancer

There is substantial risk that prognosis determined with routine clinical staging for cervical cancer may be inaccurate. This is primarily due to understaging due to the lack of detection of nodal disease. This is particularly true for para-aortic nodal metastases. Treatment based on such staging may also be inadequate for the same reason. Positron emission tomography (PET) has been demonstrated to be useful in the staging of cervical cancer and superior to either computed tomography or magnetic resonance imaging in the detection of nodal disease. Our objective was to determine the prognostic value of pretreatment 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) PET scan in women with cervical cancer. We reviewed the records of 56 women with cervical cancer who underwent FDG PET scan prior to treatment. The primary outcome was the effect of abnormal FDG uptake consistent with metastatic nodal disease on 20-month disease-free survival. The pretreatment PET scan demonstrated abnormal FDG uptake in the pelvic nodes alone in 14 (25%) women, in pelvic and para-aortic nodes in 10 (17.9%), and in neither pelvic nor para-aortic nodes in 32 (57.1%). Women with positive pelvic nodes by PET as well as women with positive para-aortic nodes had significantly poorer 20-month disease-free survival compared to women with negative nodes (P= 0.0003 and P= 0.0017, respectively). We conclude that pretreatment FDG PET scan revealing abnormal FDG uptake consistent with nodal disease is a robust predictor of disease recurrence and may alter the therapeutic management of some patients.

Para-Aortic Involvement and Interest of Para-Aortic Lymphadenectomy after Chemoradiation Therapy in Patients with Stage IB2 and II Cervical Carcinoma Radiologically Confined to the Pelvic Cavity

Pelvic radiation therapy with concomitant chemotherapy (PCRT) is the standard treatment of stage IB2/II cervical carcinoma. The impact of concomitant chemotherapy on positive para-aortic nodes (PA+), however, remains unknown. The aim of this study was twofold: to evaluate the rate of histological PA+ after PCRT and to determine the survival of patients with PA+. Patients fulfilling the following inclusion criteria were studied: (1) stage IB2/II cervical carcinoma, (2) histological subtype: squamous cell, adenocarcinoma or an adenosquamous tumor, (3) exclusion of patients with radiological PA+ (CT scan/MRI), (4) pelvic external radiation therapy of 45 Gy with concomitant chemotherapy (cisplatin 40 mg/m2/week) + utero-vaginal brachytherapy, and (5) completion surgery after the end of PCRT including at least a para-aortic lymphadenectomy. Seventy-three patients (16 stage IB2, 57 stage II) treated between 1998 and 2004 fulfilled all the inclusion criteria. PA+ after PCRT were observed in 13 patients (18%) with a median of five (range, 2-22) positive nodes. Overall and disease-free survival at 24 months in patients with PA+ was 40% and 17%. Only two patients with PA+ are currently alive and in remission. The rate of PA+ remains high after PCRT in patients treated for stage IB2/II cervical carcinoma. Furthermore, the survival rate of patients with PA+ is very low. These important results suggest that detection of PA + at the time of completion surgery (after PCRT) is not beneficial for improving survival.

Long-term survival in patients with para-aortic lymph node metastasis with systematic retroperitoneal lymphadenectomy followed by adjuvant chemotherapy in endometrial carcinoma

16011 Background: The purpose of this study was to assess modified radical hysterectomy including systematic pelvic and para- aortic lymphadenectomy followed by adjuvant chemotherapy in patients with para-aortic lymph node metastasis in endometrial carcinoma and to identify the multivariate independent prognostic factors for a long-term survival over the past 10 years. Methods: Between December 1987 and December 2002, we performed modified radical hysterectomy with bilateral salpingo-oophorectomy including systematic pelvic and para-aortic lymphadenectomy, and peritoneal cytology in 284 endometrial carcinoma patients who gave an informed consent at the Department of Gynecologic Oncology of Shikoku Cancer Center. The patients with a tumor confined to the uterus (stage Ic and II) were treated by 3 courses of CEP (cyclophosphamide 750 mg/m2, epirubicin 50 mg/m2, cisplatin 75 mg/m2) regimen 3–4weeks apart, extrauterine lesions involving adnexa and/or pelvic lymph node (PLN), and para-aortic lymph node (PAN) metastasis were treated by 5 and 10 courses, respectively. Multivariate analysis was performed for the prognostic factors and actuarial technique for the survival rate. Results: PLN and PAN metastasis were 9.2% (26/284) and 7.4% (21/284), respectively. The univariate analysis of prognostic factors revealed that FIGO clinical stage, histology, myometrial invasion, adnexal metastasis, lymphvascular space invasion, tumor diameter, peritoneal cytology and retroperitoneal lymph node (RLN) metastasis were significantly associated with 10-year overall survival. A multivariate analysis showed that adnexal metastasis (p=0.0418) and lymphvascular space invasion (p=0.0214) were significantly associated with 10-year overall survival. The 5- and 10-year survival in patients with negative and positive para-aortic lymph node were 96%, 72% and 93%, 62%, respectively (p=0.006). Conclusions: We conclude that surgery with systematic pelvic and para-aortic lymphadenectomy followed by adjuvant chemotherapy might improve a long-term survival in patients with PAN metastasis in endometrial carcinoma. No significant financial relationships to disclose.

Extended-Field Irradiation and Intracavitary Brachytherapy Combined With Cisplatin Chemotherapy for Cervical Cancer With Positive Para-Aortic or High Common Iliac Lymph Nodes: Results of ARM 1 of RTOG 0116

The Radiation Therapy Oncolology Group (RTOG) 0116 trial was designed to test the ability of Amifostine to reduce the toxicity of combined chemotherapy with extended-field radiotherapy and brachytherapy (Part 2), after first determining the toxicity rate for the regimen without Amifostine (Part 1). This manuscript reports the results of Part 1. Eligibility included patients with cervical carcinoma and high common iliac or para-aortic metastasis. Patients received extended-field radiotherapy to 45 Gy (1.8 Gy/fraction) with intracavitary irradiation. The final point A dose was 85 Gy LDR equivalent. Use of HDR was allowed. The positive para-aortic and high common iliac nodes were boosted to 54 to 59.4 Gy. Cisplatin (40 mg/m(2)) was delivered weekly during external beam and once with brachytherapy. The primary endpoint of Part 1 was acute Grade 3/4 toxicity, excluding Grade 3 leukopenia. A total of 26 eligible patients were entered between August 1, 2000, and December 3, 2003. Of these, 21 had para-aortic metastasis (15 also had high common iliac involvement), and 5 had high common iliac involvement only. The median follow-up was 17.1 months (range, 1.8-38.6 months) for all patients and 21.7 months (range, 11.4-38.6 months) for alive patients. The acute Grade 3/4 toxicity rate, excluding Grade 3 leukopenia was 81%. Late Grade 3/4 toxicity was 40%. Eight patients underwent surgery for complications. Sixteen (62%) patients had a complete response for both local and nodal disease. The complete local response was 92%, the complete overall nodal response rate was 62% and the regional and para-aortic nodal response rates were 60% and 71% respectively. Estimated disease-free and overall survival at 18 months are 46% and 60%. Extended field and intracavitary irradiation with cisplatin for para-aortic or high common iliac metastasis from cervical cancer is associated with significant acute and late toxicity.

Prognostic Implication of Para‐aortic Lymph Node Metastasis in Resectable Pancreatic Cancer

The survival curve of patients who undergo surgical resection of pancreatic cancer displays a steep decline within 1 year and a relatively slow decline thereafter. The patients with a short survival time may have identifiable clinicopathologic factors that lead to rapid relapse. We analyzed clinicopathologic factors in 133 patients who underwent margin-negative pancreatoduodenectomy with extended radical lymphadenectomy for invasive ductal carcinoma of the pancreas to detect factors that could be responsible for the short survival. Tumor size, invasion of the anterior pancreatic capsule, retroperitoneal invasion, portal venous invasion, major arterial invasion, and metastasis to the para-aortic lymph nodes were variables associated with survival time in univariate analysis. Metastasis to the para-aortic lymph nodes was the single independent factor with a significant association with mortality in multivariate analysis. Some 84% of the patients who had positive para-aortic lymph nodes died within 1 year, versus 46% of the patients with negative nodes. Although tumors that involve the para-aortic lymph nodes may technically be resectable, the expected postoperative survival time for most patients is less than 1 year. If para-aortic nodal metastasis is detected, alternative treatment strategies should be considered.

1056: Prospective Trial of Concurrent Chemoradiation With IMRT to 60 Gy for Positive Para-aortic Lymph Nodes in Carcinoma of the Cervix

To evaluate the feasibility and toxicity of irradiation of FDG-PET positive para-aortic lymph nodes to 60 Gy in patients with carcinoma of the cervix. This is a prospective pilot treatment study of 14 patients with FDG-PET positive para-aortic lymph nodes from cervical cancer. Patients with evidence of metastatic disease or positive supraclavicular lymph nodes were ineligible. Using IMRT over 30 fractions, 50.4 Gy to the para-aortic lymph node region and 60 Gy to involved para-aortic lymph nodes was delivered. Also, patients received pelvic radiation, intracavitary brachytherapy, and weekly cisplatin for six cycles. Toxicity was evaluated and recorded weekly during therapy and with each follow-up according to the Common Toxicity Criteria (CTC) scale. All 14 patients received the prescribed 60 Gy IMRT to the positive para-aortic lymph nodes. Median follow-up was 9 months (range 1-24). Symptomatic acute grade 3-4 toxicity occurred in only 2 of 14 patients. None required a treatment break due to acute toxicity. Late toxicity was grade 4 proctitis in one. There were no grade 5 toxicities. It is feasible to deliver doses up to 60 Gy to positive para-aortic lymph nodes using IMRT without substantial toxicity.

0429: The Incidence of Positive Para-Aortic Lymph Nodes in Figo Ib-Iib Cervical Cancer in Japan

0429: The Incidence of Positive Para-Aortic Lymph Nodes in Figo Ib-Iib Cervical Cancer in Japan

Analysis of clinicopathologic factors predicting para-aortic lymph node metastasis in endometrial cancer

The purposes of this study were to compare the relationships between para-aortic lymph node metastasis and various clinicopathologic factors to evaluate whether para-aortic lymph node dissection is necessary when treating endometrial cancer. A retrospective study was performed on 841 patients with endometrial cancer, who underwent the initial surgery at the Keio University Hospital. Clinicopathologic factors related to para-aortic lymph node metastasis significant on a univariate analysis were analyzed in a multivariate fashion using a logistic model. According to the multivariate analysis, the clinicopathologic factor most strongly related to the existence of para-aortic lymph node metastasis was positive pelvic lymph node metastasis (P < 0.01). Among the 155 patients who underwent pelvic and para-aortic lymph node dissection, the difference of 5-year overall survival by the presence of retroperitoneal lymph node metastasis was examined by Kaplan-Meier method. The prognosis was poor even if para-aortic lymph node dissection was performed in cases of positive para-aortic lymph node metastasis. In conclusion, when deciding whether to perform para-aortic lymph node dissection in patients with endometrial cancer, it is necessary to consider the pelvic lymph nodal status. If there is no pelvic lymph node metastasis, it could not be necessary to perform para-aortic lymph node dissection.

Efficacy of systematic lymphadenectomy and adjuvant radiotherapy in node-positive endometrial cancer patients

Objective. To assess the efficacy of systematic lymphadenectomy and adjuvant radiotherapy in minimizing pelvic sidewall and para-aortic failures. Methods. Between January 1984 and December 2001, a total of 146 patients with stage III and IV endometrial cancer and lymph node metastases were treated at our institution. Adequate pelvic lymphadenectomy was defined as the removal of more than 10 pelvic lymph nodes, and adequate para-aortic lymphadenectomy was defined as removal of 5 or more para-aortic lymph nodes. The 24 patients who received adjuvant chemotherapy were excluded. We assessed the ability of adequate pelvic and para-aortic lymphadenectomy, together with radiotherapy, to prevent pelvic and para-aortic recurrences. Results. Of the 122 patients studied, 94 (77%) had adequate pelvic lymphadenectomy and 47 (39%) had adequate para-aortic lymphadenectomy. Pelvic radiotherapy was administered to 78% and para-aortic radiotherapy to 29% of patients. Median follow-up of censored patients was 56 months. Twenty-five percent of patients had pelvic sidewall failure at 5 years. Pelvic sidewall failures at 5 years occurred in 57% of patients who had inadequate node dissection and/or no radiotherapy, compared with 10% for those having both adequate lymphadenectomy and radiotherapy ( P < 0.001). After risk factor assessment in a regression model, only treatment with adequate lymphadenectomy and radiotherapy was a significant independent predictor of pelvic control ( P = 0.03). The performance of definitive pelvic lymphadenectomy may have increased treatment-related morbidity in the subgroup of patients who had postoperative radiotherapy. For the 41 patients with positive para-aortic lymph nodes, the 5-year para-aortic failure rate was 34% after adequate lymphadenectomy but without adjuvant para-aortic radiotherapy. Likewise, 69% failed in the para-aortic area when adjuvant para-aortic radiotherapy was administered to patients not having adequate para-aortic lymphadenectomy; however, none of the 11 patients failed in the para-aortic area after adequate lymphadenectomy and para-aortic radiotherapy ( P = 0.08). Conclusions. Adequate (pelvic and para-aortic) lymphadenectomy and adjuvant radiotherapy appear complementary in reducing failures in both the pelvis and para-aortic areas in patients with node-positive endometrial cancer.

Effectiveness of postoperative chemotherapy for para-aortic lymph node metastasis of endometrial cancer

Objective To examine the effectiveness of postoperative chemotherapy for para-aortic lymph node (PAN) metastasis in patients with endometrial cancer. Methods Among 350 clinical stage I–II endometrial cancer patients who underwent systemic pelvic and para-aortic lymphadenectomy during the period 1995 through 2002, 26 patients were identified with PAN metastasis. Of these patients, nine had only one positive PAN and 17 had two or more positive PANs (mean 4.9, range 1–22). All patients were treated postoperatively with a single chemotherapy regimen consisting of ifosfamide, epiadriamycin, and cisplatin scheduled for 5 cycles. Median (range) follow-up for surviving patients was 85 (38–119) months. Treatment outcome, including disease-free survival relative to the number of positive PANs, was investigated. Results Among the 26 patients with PAN involvement, four developed recurrence. Three of the four patients had 10 or more positive PANs. Estimated 5-year disease-free survival rates were 89% for patients with one positive PAN, 82% for those with two or more positive PANs, and 85% for all patients. No significant difference was identified between the first two groups ( P = 0.6543). Conclusions Postoperative chemotherapy can yield a favorable outcome in endometrial cancer patients with PAN metastasis, even those with multiple positive nodes.

Interindividuelle Variabilität der Lymphabflusswege beim Zervixkarzinom. Implikationen für die Bestrahlungsplanung

Lymph node metastases and the number of positive lymph nodes are important prognostic factors for patients with cervical cancer. The most important route is the lateral drainage via the obturator to the internal and external iliac and common iliac area. The risk for common iliac lymph node metastases is increased in patients with positive pelvic or paraaortic lymph nodes. Positive common iliac lymph nodes are associated with a poorer prognosis than positive pelvic lymph nodes excluding common iliac group. For radiation planning in patients with cervical cancer, lymph node regions at high risk for metastases have to be encompassed. Usually, standard fields are used with the upper field border on the fourth/fifth lumbar vertebra. The authors evaluated whether standard fields are sufficient for encompassing the common iliac lymph nodes. Pretreatment computed tomographic (CT) images of 42 patients with cervical cancer were evaluated to locate the aortic bifurcation and the subsequent common iliac lymph drainage. Anatomy of the lymph drain was correlated with standard radiation portals. In 17/42 patients (40%) the aortic bifurcation lay superior to the upper field border. In an additional nine patients (21%) the bifurcation was located on the level of the upper field border. In 26/42 patients (62%) standard radiation fields encompassed the common iliac lymph nodes insufficiently. Common iliac lymph node metastases are found in up to 50% of patients with node-positive cervical cancer. The results of this study demonstrate an unsatisfactory coverage of the common iliac lymph drain by standard fields in most patients. Thus it is necessary to individualize the planning target volume and to include the whole common iliac vessels according to the patient’s anatomy on radiation treatment planning CT in order to improve local control.

Significance of Extensive Surgery Including Resection of the Pancreas Head for the Treatment of Gallbladder Cancer—From the Perspective of Mode of Lymph Node Involvement and Surgical Outcome

The present study aimed to clarify the efficacy of extensive surgery, including pancreas head resection, for more complete lymphadenectomy in the treatment of gallbladder carcinoma. The study involved retrospective analyses of 65 consecutive patients with gallbladder carcinoma who underwent surgical resection between 1982 and 2003. Of these 65 patients, 41.5% displayed node-positive disease and among them 23.1% had positive para-aortic nodes. Of six node-positive 5-year survivors, five underwent pancreatoduodenectomy combined with S4aS5 hepatic subsegmentectomy. The 5-year survival rates were 76.2% for pN0, 30.0% for pN1, 45.8% for pN2, and 0% for pM1[lymph], respectively. Significant differences existed in survival rates. Postoperative recurrence was observed in 24.1% (13/54) of patients who underwent R0 resection. Of the four patients who displayed lymph node recurrence, two had pericholedocal and/or posterior pancreatoduodenal lymph node metastasis at the time of surgery and underwent pancreas-preserving regional lymphadenectomy. These results suggest that extensive resection, including resection of the pancreatic head, is effective in selected patients with up to pN2 lymph node metastasis, as long as complete removal of the cancer can be achieved. Pancreatoduodenectomy combined with S4aS5 hepatic subsegmentectomy should be considered when lymph node metastasis is obvious and the patient is in good condition.

Whole Abdominal Radiotherapy in the Adjuvant Treatment of Patients With Stage III and IV Endometrial Cancer: A Gynecology Oncology Group Study

This study from the Gynecology Oncology Group investigated the use of postoperative whole abdominal radiation therapy in women with stage III and IV endometrial cancer. In the period between December 1986 and February 1994, 180 patients who met study criteria were enrolled in the study. Seventy-seven patients (mean age 63 years) had typical endometrial carcinoma (adenocarcinoma, endometrioid, glassy cell, mixed epithelial, adenosquamous, villoglandular, or undifferentiated) and 103 had papillary serous (median age 68.5 years) or clear cell carcinoma (median age 71 years) (P < .001 for age difference between typical and higher-risk tumors). Papillary serous tumors were more common in black women (78%) than in white women (53%), and grade 3 disease was more common in women with papillary serous/clear cell tumors (66%) than in those with typical endometrial cancer (44%). All patients underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic washings, and selective paraaortic and pelvic lymph node sampling. Radiation therapy was begun within 8 weeks of surgery and consisted of daily doses of 150 cGy to the whole abdomen for 20 days (total 3000 cGy) followed by 180 cGy per day to the pelvis for 11 treatments (total 1980 cGy). Women with positive paraaortic lymph nodes received a paraaortic boost totaling 1500 cGy. The frequency of gross disease and the extent and pattern of spread were similar in both groups except that metastases to the diaphragm were seen more frequently in women with papillary serous/clear cell disease (7.8%) than in those with typical disease (1.3%) (P = .05). Pelvic nodes and paraaortic nodes were positive in 45% and 39%, respectively, of patients with typical endometrial cancer and 51% and 31%, respectively, of patients with high-risk tumors. In this study, 22 patients (21%) had grade 3 or 4 hematologic toxicity associated with treatment. Nearly half of the participants (n = 78, 45%) had at least grade 2, and 11% (n = 20) had grade 3 gastrointestinal toxicity. Seven women developed severe gastrointestinal toxicity (grade 4), including 3 patients with no evidence of disease who died from complications of bowel obstruction. Two patients died from severe hemorrhages, one with a gastrointestinal bleeding 5 months after radiation and one who hemorrhaged after anticoagulation for deep venous thrombosis 60 days after surgery. Grade 3 or 4 hepatic toxicity was seen in 4 women (3%). Twelve patients (7%) experienced serious (grade 3 or 4) cardiovascular complications, including 4 pulmonary emboli and 2 instances of congestive heart failure. Sixty-five percent of patients with typical endometrial cancer and 67% of those with papillary serous/clear cell cancer had a recurrence of disease. Women with typical disease had recurrent disease diagnosed at various locations, but pelvis, abdomen, and lung were the most common (n = 7, 9, and 9, respectively). In the high-risk group, 21 of 69 recurrences were in the abdomen and 15 were in the lung. Among the 77 women with typical endometrial cancers, 58 had stage III disease and 19 had stage IV disease. Three-year survival rates for these patients were 34.5% and 21.1%, respectively. Seventy-five of the 103 participants with papillary serous/clear cell tumors were stage III and 28 were stage IV. Their 3-year survival rates were 48.1% and 10.7%, respectively. Overall survival rates were 31% for patients with typical endometrial cancers and 35% for patients with high-risk tumors. At 3 years, the disease-free survival rates for these groups were 29% and 27%, respectively.

Extended Field Irradiation and Intracavitary Brachytherapy Combined with Cisplatin Chemotherapy for Cervical Cancer with Positive Para-aortic or High Common Iliac Lymph Nodes: Results of Arm 1 of RTOG 0116

Extended Field Irradiation and Intracavitary Brachytherapy Combined with Cisplatin Chemotherapy for Cervical Cancer with Positive Para-aortic or High Common Iliac Lymph Nodes: Results of Arm 1 of RTOG 0116