Presacral Nodes Research Articles

Extended Versus Limited Lymph Node Dissection in Bladder Cancer Patients Undergoing Radical Cystectomy: Survival Results from a Prospective, Randomized Trial

BackgroundThe extent of lymph node dissection (LND) in bladder cancer (BCa) patients at the time of radical cystectomy may affect oncologic outcome. ObjectiveTo evaluate whether extended versus limited LND prolongs recurrence-free survival (RFS). Design, setting, and participantsProspective, multicenter, phase-III trial patients with locally resectable T1G3 or muscle-invasive urothelial BCa (T2-T4aM0). InterventionRandomization to limited (obturator, and internal and external iliac nodes) versus extended LND (in addition, deep obturator, common iliac, presacral, paracaval, interaortocaval, and para-aortal nodes up to the inferior mesenteric artery). Outcome measurements and statistical analysisThe primary endpoint was RFS. Secondary endpoints included cancer-specific survival (CSS), overall survival (OS), and complications. The trial was designed to show 15% advantage of 5-yr RFS by extended LND. Results and limitationsIn total, 401 patients were randomized from February 2006 to August 2010 (203 limited, 198 extended). The median number of dissected nodes was 19 in the limited and 31 in the extended arm. Extended LND failed to show superiority over limited LND with regard to RFS (5-yr RFS 65% vs 59%; hazard ratio [HR]=0.84 [95% confidence interval 0.58–1.22]; p=0.36), CSS (5-yr CSS 76% vs 65%; HR=0.70; p=0.10), and OS (5-yr OS 59% vs 50%; HR=0.78; p=0.12). Clavien grade ≥3 lymphoceles were more frequently reported in the extended LND group within 90d after surgery. Inclusion of T1G3 tumors may have contributed to the negative study result. ConclusionsExtended LND failed to show a significant advantage over limited LND in RFS, CSS, and OS. A larger trial is required to determine whether extended compared with limited LND leads to a small, but clinically relevant, survival difference (ClinicalTrials.gov NCT01215071). Patient summaryIn this study, we investigated the outcome in bladder cancer patients undergoing cystectomy based on the anatomic extent of lymph node resection. We found that extended removal of lymph nodes did not reduce the rate of tumor recurrence in the expected range.

Difference in Frequency and Distribution of Nodal Metastases Between Intermediate and High Risk Prostate Cancer Patients: Results of a Superextended Pelvic Lymph Node Dissection.

Objectives: To evaluate the frequency and distribution of pelvic nodes metastases, in intermediate-high risk prostate cancer (PCa) patients (pts), who underwent open radical prostatectomy (ORP) and superextended pelvic lymph node dissection (sePLND).Patients and Methods: We retrospectively evaluated 630 consecutive pts with clinically localized, intermediate-high risk PCa, treated with ORP and sePLND from 2009 to 2016 at a single institution. The sePLND always removed all nodal/fibro-fatty tissue of the internal iliac, external iliac, obturator, common iliac, and presacral regions.Results: Positive lymph nodes (LN+) were found in 133 pts (21.1%). The median number of removed nodes and LN+ was 25 and 1, respectively. LN+ were found in 64 (48.1%), 58 (43.6%), 53 (39.8%), 16 (12%), and 20 (15%) pts and were present as a single site in 27 (20.3%), 22 (16.5%), 20 (15%), 0, and 6 (4.5%) cases in the internal iliac, external iliac, obturator, common iliac, and presacral chain, respectively. An ePLND would have correctly staged 127 (95%) pts but removed all LN+ in only 97 (73%) pts. Presacral nodes harbored LN+ in 20 patients. Among them, 18 were high-risk patients. Moreover, all but 1 pts with common iliac LN+ were in high risk group.Conclusions: These results suggest that removal of presacral and common iliac nodes could be omitted in intermediate risk pts. However, a PLND limited to external iliac, obturator, and internal iliac region may be adequate for nodal staging purpose, but not enough accurate if we aim to remove all possible site of LN+ in high risk pts.

Pattern of node metastases in patients treated with radical cystectomy and extended or superextended pelvic lymph node dissection due to bladder cancer

BackgroundPelvic lymph node dissection (PLND) has a diagnostic and therapeutic role during radical cystectomy in bladder cancer patients. However, at the time, no prospective data supports the value of extended PLND in improving survival expectances. We sought to describe incidence and location of node metastases in patients treated with extended and superextended PLND. MethodsWe evaluated 653 contemporary patients with clinically nonmetastatic high risk nonmuscle invasive or muscle-invasive bladder cancer treated with radical cystectomy and extended or superextended PLND without neoadjuvant chemotherapy at a single tertiary referral center between 1990 and 2013. Limited PLND is defined as the removal of obturator and internal iliac nodes. Standard included also the external iliac nodes. Extended includes also common and presacral nodes. Finally, superextended PLND includes all the nodes removed along the inferior mesenteric artery. We evaluated incidence of pathologically node metastases. Logistic regression analyses evaluate preoperative and pathologic characteristics to the risk of harboring node metastases in the extended and superextended template. ResultsOverall, 191 (29.3%) patients were found with pathologically node confirmed metastases. Of these, 56 (29.3%) patients were found with a single node metastasis, while 135 (70.7%) had multiple node metastases. The vast majority of patients were found with node metastases standard template (n = 172, 26.3%), on the other hand 30 (4.6%) and 21 (3.2%) patients had node metastases in extended and superextended templates, respectively. However, of these only 2 patients were found without concomitant lymph node metastases in the limited or standard templates. On multivariable analyses, cN+ status (odds ratio = 4.40, P<0.001) and cT3–4 vs. cT1–2 (odds ratio = 2.25, P<0.001) were associated with an increased risk of harboring node metastases in the extended or superextended template. ConclusionsWe found that the majority of patients harbored node disease in the limited or standard node dissection pattern. On the other hand, only a minority of patient were found with a disease in extended or superextended template without harboring a concomitant node disease in the limited pattern.

Is two-dimensional field definition sufficient for pelvic node coverage in rectal cancer compared to technical three-dimensional definition?

To assess the effectiveness of the potential advantages with 3-dimensional-based treatment planning versus 2-dimensional pelvic bone-based treatment planning in patients with rectal cancer, controlled for clinical stage. Areas at risk from computed tomography in 30 patients were delineated: mesorectum, presacral, internal iliac, obturator and external iliac nodes. Two planning target volumes per patient were created: PTV_T3 (M + PSN + ON + IIN) and PTV_T4 (M + PSN + ON + IIN + EIN). Two- and 3-dimensional treatment plans for each planning target volume were calculated. Three analyses were performed: 1) mean volume receiving doses >95% and >105%; according to the percentage of prescribed dose to cover at least 95% of the planning target volume, the treatment plan was defined as optimal dose >95%, acceptable dose between 95% and 90%, inferior dose <90%; 2) comparison of the percentage of volume covered by the dose for 2- vs 3-dimensional; 3) determination of the doses at which the lack of volume coverage started to decrease significantly. For PTV_T3, the following was seen: 1) 2D vs 3D comparison showed optimal PTV_T3 coverage in 76.7% and 96.7%, respectively; 2) 2D vs 3D TP coverage difference was significant between 29%-95% of the total dose; 3) the lack of volume coverage started at 30% for 2D and 89% for 3D. For PTV_T4, the following was seen: 1) 2D vs 3D comparison showed an optimal PTV_T4 coverage in 33.3% and 86.7%, respectively; 2) 2D vs 3D TP coverage difference was significant between 7%-97% of the total dose; 3) the lack of volume coverage started at 7% for 2D and 87% for 3D. The 3D treatment planning was superior to 2D treatment planning in covering areas at risk for pelvic recurrence in patients treated for rectal cancer. The areas with suboptimal coverage may lead to an increased risk of recurrence and should be correlated with the patterns of recurrence.

Robot-assisted radical cystectomy - first Polish clinical outcomes.

IntroductionUrothelial cell carcinoma is the most common neoplasm of the genito-urinary tract, which, in advanced stages, is treated with radical cystectomy with pelvic lymphadenectomy. It can be performed by an open or minimally invasive approach (laparoscopic and robot-assisted radical cystectomy).Large meta-analyses showed a significantly lower complication rate in the RARC (robot-assisted radical cystectomy) group compared to ORC (open radical cystectomy) in thirty and ninety days after surgery, with similar oncological and functional outcomes. The clinical outcomes of the first forty Polish RARC are explored in this article.Material and methodsThe Polish Radical Robotic Cystectomy Program (PRRC) was started in 2016 at the Nicolaus Copernicus Hospital in Toruń. Forty consecutive patients, with indications for cystectomy were included into the study. During radical robot-assisted cystectomy, obturator, external, internal, common iliac and presacral lymph nodes were dissected. Oncological outcomes, early complication rate, and the clinical variables were analyzed.ResultsThe mean age in the study group was sixty-seven years, with the majority of patients being overweight and assessed as American Society of Anesthesiology Scale (ASA) – ASA III and ASA IV (2/3 of patients).RARC was performed, with the median time of surgery being 324 minutes (170 minutes being the shortest). Mean blood loss was 365 ml (lowest – 50 ml), and only 2 patients required intraoperative blood transfusion.Twenty patients had ileal conduit, and nineteen had other methods of urinary diversion. Only twenty-nine out of forty patients had minor complications (Clavien I and II), 11 had Clavien III and IV. Clavien V was not present. Only 3 patients required reoperation.ConclusionsRARC is a reproducible oncological procedure, which can be safely performed in centers with robotic expertise, with acceptable operative time, complications, and functional and oncologic outcomes.

Identifying candidates for super-extended staging pelvic lymph node dissection among patients with high-risk prostate cancer.

To assess if the preoperative lymph node invasion (LNI) risk could be used to tailor the extent of pelvic lymph node dissection (PLND) according to individual profile in patients with prostate cancer (PCa) undergoing radical prostatectomy (RP), and to identify those who would benefit from the removal of the common iliac and pre-sacral nodes. A total of 471 patients with high-risk PCa treated with RP and a super-extended PLND that included the removal of the pre-sacral and common iliac nodes between 2006 and 2016 were identified. The risk of LNI was calculated according to the Briganti nomogram. Multivariable logistic regression analyses assessed the association between LNI risk and involvement of the common iliac and pre-sacral regions. The risk of positive common iliac and pre-sacral nodes was plotted over the LNI risk using the LOWESS-smoothed fit curve. The median preoperative LNI risk was 25.5%. The median number of nodes removed was 23, and 171 (36.3%) patients had LNI. Overall, 61 (13.0%) and 28 patients (5.9%), respectively, had positive common iliac and pre-sacral nodes alone or in combination with other sites. The LNI risk was associated with the involvement of the common iliac and pre-sacral regions (all P < 0.001). The proportion of patients with positive common iliac and pre-sacral nodes progressively increased according to the LNI risk. The adoption of a 30% threshold would result in avoiding the removal of the common iliac and pre-sacral nodes in >60% cases, with a risk of missing LNI in these regions of <5%. Fewer than 5% of patients with an LNI risk of <30% harbour positive common iliac and pre-sacral nodes. A super-extended PLND that includes the dissection of these regions should be considered exclusively in patients with an LNI risk ≥30%.

Tips and Tricks for Robot-Assisted Laparoscopic Radical Cystoprostatectomy and Pelvic Lymph Node Dissection

Introduction: Radical cystoprostatectomy and bilateral pelvic lymph node dissection remain the standard therapy for muscle-invasive urothelial carcinoma of the bladder. A minimally invasive robotic approach to the extirpative portion of radical cystectomy has become increasingly prevalent. We sought to develop a step-by-step video to share the lessons learned in our initial series of robotic cystectomy cases. Materials and Methods: Eighty-one patients underwent robot-assisted laparoscopic radical cystectomy by a single surgeon from March 2011 to June 2017. Patient demographics, pathologic analysis, and outcomes were obtained. Surgical Technique: We begin with a posterior dissection developing a plane between the rectum and prostate. We then proceed with a unilateral approach taking the lymph nodes and pedicles on one side, then replicate a similar procedure on the contralateral side. The left ureter is passed under the mesocolon and the presacral nodes are removed. We then complete the cystoprostatectomy with anterior dissection of the prostate apex. Although urinary diversion was not demonstrated in this video, extracorporeal urinary diversion was completed for ileal conduits and continent diversions, whereas a hybrid approach was performed for ileal neobladders. Results: The mean age at surgery was 70 years (range 51–89) and 76% were men. Thirty-eight percent underwent neoadjuvant chemotherapy, and 62% ileal conduit, 32% ileal neobladder, and 5% continent urinary diversions were created. Overall 90 day Clavien I-II complication rates were 27% and Clavien III-V complication rates were 11%. Final pathology report included T0-T2 (40%), T2 (14%), and T3-T4 (46%), and 31% were positive lymph nodes. There was one positive surgical margin and mean lymph node counts were 29 (range 3–87). Overall survival was 74% with a mean follow-up of 44 months (range 1–78). Conclusions: Robot-assisted laparoscopic radical cystoprostatectomy and extended pelvic lymph node dissection can be performed safely with favorable pathologic outcomes in surrogates of surgical margins and a number of lymph nodes were removed. Long-term outcomes will need to mature. With increasing experience, our results have suggested that this procedure can be performed expeditiously without sacrificing pathologic and clinical outcomes. No competing financial interests exist. The authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure. Runtime of video: 10 mins

Laparoscopic Transperitoneal Para-Aortic Lymphadenectomy in 10 Steps

Study ObjectiveLaparoscopic transperitoneal lymphadenectomy has a few advantages. First, it is a minimally invasive approach, and the transperitoneal approach is also the best option when intra-abdominal surgery is indicated. Although the procedure was described more than 2 decades ago, there is a lack of diffusion of the technique. The main objective of this video is standardization and a simple description of the technique. We described this procedure in 10 logical steps, which should help to understand and perform this procedure. MethodsThis video presents a systematic approach to transperitoneal lumboaortic lymphadenectomy, which is clearly divided in 10 steps ordered in a counterclockwise direction. ResultsThe 10 steps are as follows: step 1, retroperitoneal access; step 2, creating a space for subsequent lymphadenectomy and identification of anatomic landmarks; step 3, left common iliac lymph node dissection; step 4, right common iliac lymph node dissection; step 5, presacral lymph node dissection; step 6, lateroaortal lymph node dissection; step 7, laterocaval lymph node dissection; step 8, aortocaval lymph node dissection; step 9, vaginal extraction of bags with specimens; and step 10, vaginal suture. ConclusionsLaparoscopic transperitoneal access to lumboaortic lymph nodes is an effective method of lymphadenectomy, which may bring benefits to a patient and physician. The presented 10 steps help to perform each part of surgery in a logical sequence, making the procedure ergonomic and easier to adopt and learn. Standardization of laparoscopic techniques could help to reduce the learning curve.

Re: Robot-assisted Salvage Lymph Node Dissection for Clinically Recurrent Prostate Cancer

Abstract Background Salvage lymph node dissection has been described as a feasible treatment for the management of prostate cancer patients with nodal recurrence after primary treatment. Objective To report perioperative, pathologic, and oncologic outcomes of robot-assisted salvage nodal dissection (RASND) in patients with nodal recurrence after radical prostatectomy (RP). Design, setting, and participants We retrospectively evaluated 16 patients affected by nodal recurrence following RP documented by positive positron emission tomography/computed tomography scan. Surgical procedure Surgery was performed using DaVinci Si and Xi systems. A pelvic nodal dissection that included lymphatic stations overlying the external, internal, and common iliac vessels, the obturator fossa, and the presacral nodes was performed. In 13 (81.3%) patients a retroperitoneal lymph node dissection that included all nodal tissue located between the aortic bifurcation and the renal vessels was performed. Measurements Perioperative outcomes consisted of operative time, blood loss, length of hospital stay, and complications occurred within 30 d after surgery. Biochemical response (BR) was defined as a prostate-specific antigen level Results and limitations Median operative time, blood loss, and length of hospital stay were 210min, 250ml, and 3.5 d. The median number of nodes removed was 16.5. Positive lymph nodes were detected in 11 (68.8%) patients. Overall, four (25.0%) and five (31.2%) patients experienced intraoperative and postoperative complications, respectively. Overall, one (6.3%) and four (25.0%) patients had Clavien I and II complications within 30 d after RASND, respectively. Overall, five (33.3%) patients experienced BR after surgery. Our study is limited by the small cohort of patients evaluated and by the follow-up duration. Conclusions RASND represents a feasible procedure in patients with nodal recurrence after RP and provides acceptable short-term oncologic outcomes, where one out of three patients experience BR immediately after surgery. Long-term data are needed to confirm the effectiveness of this approach. Patient summary We report our initial experience with robot-assisted salvage nodal dissection for the management of patients with lymph node recurrence after radical prostatectomy. This technique represents a feasible and effective approach, where no high-grade complications were recorded and one out of three patients experienced biochemical response at 40 d after surgery.

Description of a reproducible anatomically based surgical algorithm for detection of pelvic sentinel lymph nodes in endometrial cancer

To describe and evaluate a reproducible, anatomically based surgical algorithm, including reinjection of tracer to enhance technical success rate, for detection of pelvic sentinel lymph nodes (SLNs) in endometrial cancer (EC). A prospective study of 102 consecutive women with high risk EC scheduled for robotic surgery was conducted. Following cervical injection of a fluorescent dye, an algorithm for trans- and retroperitoneal identification of tracer display in the lower and upper paracervical pathways was strictly adhered to. To enhance the technical success rate, this included ipsilateral reinjection of tracer in case of non-display of any lymphatic pathway. The lymphatic pathways were kept intact by opening the avascular planes. To minimize disturbance from leaking dye, removal of SLNs was first performed along the lower paracervical (presacral) pathways followed by the more caudal upper paracervical pathways. In each pathway, the juxtauterine node with an afferent lymph vessel was defined as an SLN. After removal of SLNs, a complete pelvic and, unless contraindicated, infrarenal paraaortic lymph node dissection was performed. The bilateral detection rate including tracer reinjection was 96%. All 24 (23.5%) node positive patients had at least one metastatic SLN. Presacral lymph node metastases were discovered in 33.3% of the node positive patients. One patient (4.2%) had an isolated presacral lymph node metastasis. The described cranial-to-caudal anatomically based surgical SLN algorithm, including a presacral dissection and reinjection of tracer, results in a high SLN detection rate and identified all patients with lymph node metastases.

MP47-11 EXTENDED PELVIC LYMPH NODE DISSECTION FOR INTERMEDIATE-HIGH RISK PROSTATE CANCER: FREQUENCY AND DISTRIBUTION OF NODAL METASTASES.

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy IV1 Apr 2017MP47-11 EXTENDED PELVIC LYMPH NODE DISSECTION FOR INTERMEDIATE-HIGH RISK PROSTATE CANCER: FREQUENCY AND DISTRIBUTION OF NODAL METASTASES. Marco Roscigno, Maria Nicolai, Richard LJ Naspro, Federico Pellucchi, Laura B Cornaghi, Daniela Chinaglia, Antonino Saccà, and Luigi F Da Pozzo Marco RoscignoMarco Roscigno More articles by this author , Maria NicolaiMaria Nicolai More articles by this author , Richard LJ NasproRichard LJ Naspro More articles by this author , Federico PellucchiFederico Pellucchi More articles by this author , Laura B CornaghiLaura B Cornaghi More articles by this author , Daniela ChinagliaDaniela Chinaglia More articles by this author , Antonino SaccàAntonino Saccà More articles by this author , and Luigi F Da PozzoLuigi F Da Pozzo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1471AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Standard extended pelvic lymph node dissection (ePLND) included the removal of external iliac, obturator and internal iliac chains. However, mapping studies demostrated that extending template up to the ureteric crossing would remove approximately 75% of all primary landing sites, and suggested to add presacral node dissection to ePLND, in order to correctly remove nodal metastases in 97% of patients. The aim of this study is to describe the frequency and distribution of metastases to pelvic nodes, in patients (Pts) with clinically localised, intermediate-high risk prostate cancer (PCa) according to the EAU guidelines, treated with radical prostatectomy and ePLND. METHODS We retrospectively evaluated 554 consecutive Pts with clinically localized, intermediate-high risk PCa, treated with open radical prostatectomy and ePLND between 2009 and 2015 at a single institution by multiple experienced surgeons. The ePLND always consisted of the external iliac, obturator, internal iliac, presacral and common iliac nodal site up to the ureteric crossing. Specimens from each anatomic site were sent in separate packets. RESULTS The median number of removed nodes was 22 (range 9-61). Positive nodes (LN+) were found in 119 patients (21.4%). The mean and median number of positive nodes were 2.9 and 1 (range: 1-18), respectively. The median number of removed nodes was 6, 8, 5, 2, and 1 for external iliac, obturator, internal iliac, common iliac, and presacral site, respectively. Out of the 119 Pts, nodal metastases were found in 54 (45.4%), 50 (42%), 56 (47.1%), 12 (10.1%) and 15 (12.6%) in the external iliac, obturator, internal iliac, common iliac, and presacral sites, respectively. However, when analyzing the presence of positive nodes only in a single anatomic area, nodal metastases were present in 19 (16%), 18 (15.1%), 25 (21%), 0, and 3 (2%) in the external iliac, obturator, internal iliac, common iliac, and presacral site, respectively. A limited LND would have correctly staged 92 (77%) Pts and would have removed all LN+ in 37 (31%) Pts. An extended LND would have correctly staged 116 (97%) Pts but removed all LN+ in only 93 (78%) Pts. CONCLUSIONS Internal iliac and presacral nodes harbored metastases in more than 60% of cases, and positive nodes were present only in these areas in 23% of cases. On the contrary, metastases at common iliac nodes were always associated with concomitant involvement of external iliac, obturator and/or internal iliac nodes. An extended LND would have correctly staged 116 (97%) Pts but removed all LN+ in only 93 (78%) Pts. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e632 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Marco Roscigno More articles by this author Maria Nicolai More articles by this author Richard LJ Naspro More articles by this author Federico Pellucchi More articles by this author Laura B Cornaghi More articles by this author Daniela Chinaglia More articles by this author Antonino Saccà More articles by this author Luigi F Da Pozzo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A study on uterine lymphatic anatomy for standardization of pelvic sentinel lymph node detection in endometrial cancer

ObjectiveTo describe the anatomy of uterine lymphatic drainage following cervical or fundal tracer injection to enable standardization of a pelvic sentinel lymph node (SLN) concept in endometrial cancer (EC). MethodsA prospective consecutive study of women with EC was conducted. A fluorescent dye (Indocyanine green) was injected into the cervix (n=60) or the uterine fundus (n=30). A systematic trans- and retroperitoneal mapping of uterine lymphatic drainage was performed. Positions of the pelvic SLNs, defined by afferent lymph vessels, and lymph node metastases were compared. ResultsTwo consistent lymphatic pathways with pelvic SLNs were identified irrespective of injection site; an upper paracervical pathway (UPP) with draining medial external and/or obturator lymph nodes and a lower paracervical pathway (LPP) with draining internal iliac and/or presacral lymph nodes. Bilateral display of at least one pelvic pathway following cervical and fundal injection occurred in 98% and 80% respectively (p=0.005). Bilateral display of both pelvic pathways occurred in 30% and 20% respectively (p=0.6) as the LPP was less often displayed. Nearly one third of the 19% node positive patients had metastases along the LPP. No false negative SLNs were identified. ConclusionsBased on uterine lymphatic anatomy a bilateral detection of at least one SLN in both the UPP and LPP should be aimed for. Absence of display of the LPP may warrant a full presacral lymphadenectomy. Although pelvic pathways and positions of SLNs are independent of the tracer injection site, cervical injection is preferable due to a higher technical success rate.

The minimum number of lymph nodes needed to be resected during radical cystectomy

Objective To evaluate the minimum number of lymph nodes(LN)required for optimal staging at radical cystectomy specimens analysis from patients with bladder cancer and to analyze the frequency of LN metastases among different anatomic regions. Methods From Jan. 2008 to Jan. 2015, a total of 197 patients underwent super-extended pelvic lymph nodes dissection were recruited, and their clinical data were reviewed, icluding 53cases(47male and 3 female patients) with positive LN . The super-extended pelvic lymph nodes dissection were divided into 10 regions as well as 6 groups according to the anatomic sites, including the external iliac, internal iliac, obturator and bilateral common lilac lymph nodes, the presacral lymph nodes and above the aortic bifurcation lymph nodes. Particular attention was paid to the total number of LN examined, the number and location of LN with metastases (positive LN), lymph node metastasis rate and lymph nodes density in the cystectomy specimen. According to the lymph node density(LND) of lymph node metastasis cases, minimum removal of lymph node number is 1/LND. The recurrence and survival was followed up. Results A total of 197 radical cystectomies with 8 513 LN were reviewed, including 53(26.9 %) LNs positive cases, with 244 positive LN out of the 1 528 LNs (16.0%). The average number of LN examined in each case was 29.4±11.9, and the average number of positive LNs identified in each case was 4.7±3.9. Among all of the LNs, the internal iliac /obturator LN were the most commonly submitted (23.8%/19.7%) and the external iliac /obturator LN were the highest number of positive LNs (20.9%/27.5%). On average, for cases staged N1 and N2, there was one positive LN per 18(1/0.056)and 11(1/0.195×2)LN examined from the primary drainage LN, respectively. For N3 cases, one out of 5 (1/0.211)secondary drainage LN was found to be positive. Similarly, one out of 4(1/0.251)distant LN was found to be positive in cases with M1 staging . On average, 23 LN(at least 16LN) including 18(at least 11) primary drainage LN and five secondary drainage LN should be submitted for optimal N staging. For adequate M1 staging, an average of four distal LN should be evaluated. One hundred and twenty-nine cases were followed up for an average of 37.7 months, with tumor recurrence was 33 cases (25.6%), overall survival 87.6% (113/129). Conclusion A minimum of 20 and 27 LNs should be examined in radical cystectomy specimens in order to achieve accurate N and M staging. Key words: Urothelial carcinoma; Bladder; Lymphnode; Pathologic staging

Détermination des marges du volume cible anatomoclinique au volume cible prévisionnel pour la radiothérapie des cancers du canal anal

There are very few data on the expansion from the clinical target volume (CTV) to the planning target volume (PTV) in the anal cancer treatment. This article aims to collect the different elements needed for the construction of a PTV from scientific data based on a literature analysis. We reviewed the articles published in the medical literature from the last 20years. They concerned setup errors and internal organ mobility of the different volumes of patients treated by conformational radiotherapy and intensity-modulated radiotherapy (anal canal, meso-rectum, common, intern and extern, inguinal and pre-sacral lymph nodes). CTV to PTV margins admitted in the guidelines and atlas of consensus groups (SFRO, RTOG, AGITG) are from 0.7 to 1cm in all directions, based on expert's opinions but not on scientific data. There are no specific studies on the canal anal mobility. Most of the data are from other pelvis cancers (gynecologic, rectum and prostate). Setup errors can be reduced by daily imaging. Patient repositioning and immobilization modalities are mostly local habits rather than scientific consensus. A three-dimensional 1cm margin is generally admitted. Margins reduction must be careful and has to be assessed.

Robot-assisted Salvage Lymph Node Dissection for Clinically Recurrent Prostate Cancer

BackgroundSalvage lymph node dissection has been described as a feasible treatment for the management of prostate cancer patients with nodal recurrence after primary treatment. ObjectiveTo report perioperative, pathologic, and oncologic outcomes of robot-assisted salvage nodal dissection (RASND) in patients with nodal recurrence after radical prostatectomy (RP). Design, setting, and participantsWe retrospectively evaluated 16 patients affected by nodal recurrence following RP documented by positive positron emission tomography/computed tomography scan. Surgical procedureSurgery was performed using DaVinci Si and Xi systems. A pelvic nodal dissection that included lymphatic stations overlying the external, internal, and common iliac vessels, the obturator fossa, and the presacral nodes was performed. In 13 (81.3%) patients a retroperitoneal lymph node dissection that included all nodal tissue located between the aortic bifurcation and the renal vessels was performed. MeasurementsPerioperative outcomes consisted of operative time, blood loss, length of hospital stay, and complications occurred within 30 d after surgery. Biochemical response (BR) was defined as a prostate-specific antigen level <0.2 ng/ml at 40 d after RASND. Results and limitationsMedian operative time, blood loss, and length of hospital stay were 210min, 250ml, and 3.5 d. The median number of nodes removed was 16.5. Positive lymph nodes were detected in 11 (68.8%) patients. Overall, four (25.0%) and five (31.2%) patients experienced intraoperative and postoperative complications, respectively. Overall, one (6.3%) and four (25.0%) patients had Clavien I and II complications within 30 d after RASND, respectively. Overall, five (33.3%) patients experienced BR after surgery. Our study is limited by the small cohort of patients evaluated and by the follow-up duration. ConclusionsRASND represents a feasible procedure in patients with nodal recurrence after RP and provides acceptable short-term oncologic outcomes, where one out of three patients experience BR immediately after surgery. Long-term data are needed to confirm the effectiveness of this approach. Patient summaryWe report our initial experience with robot-assisted salvage nodal dissection for the management of patients with lymph node recurrence after radical prostatectomy. This technique represents a feasible and effective approach, where no high-grade complications were recorded and one out of three patients experienced biochemical response at 40 d after surgery.

Patterns of lymph node metastasis in locally advanced cervical cancer.

The aim of this study was to investigate patterns and locations of lymph node metastasis in locally advanced cervical cancers.A total of 244 consecutive patients with stage IIb cervical cancer were retrospectively evaluated. Contrast-enhanced CT scans were used for lymph node grading. Lymph nodes with the shortest axis (>1 cm) were categorized as positive and those between 0.5 and 1 cm were categorized as suspicious. All lymph nodes (LNs) were also classified by their anatomic locations.Nine hundred thirty-one LNs (136 positive and 795 suspicious) were identified. Sixty-three (25.8%) patients had positive LNs, and 153 (62.7%) patients had only suspicious LNs. The metastatic pattern was predictable traveling from level 1 (external iliac, internal iliac, obturator, and mesorectum groups) through level 2 (common iliac and presacral groups) to level 3 (para-aortic groups). In most groups, LNs were located within 1.0 cm of main blood vessels. Our novel findings were: presacral LNs metastases were rare (2/244, 0.82%); the left common iliac group (LCI) had significantly more enlarged nodes than the right common iliac group (P = 0.00); the LCI and left down-para-aortic group were further away from blood vessels than expected (1.2 cm and 1.4 cm, respectively); no additional margin was needed in anterolateral direction for external iliac groups.The lymph node metastatic patterns are relatively predicable. Different expansions from vessels should be used to include LNs for different groups. Presacral nodes metastases are rare, and further study is warranted to see whether this region can be excluded from nodal CTV.

Laparoscopic extraperitoneal lumboaortic lymphadenectomy in 10 steps – Let's make it easier!

ObjectiveLaparoscopic extraperitoneal lymphadenectomy has both advantages of minimally invasive approach and retroperitoneal access. Although procedure is described for more than two decades there is a lack of diffusion of the technique. Standardization and simple description of the technique is main objective of this video. We described this procedure in 10 logical steps which could help to understand and perform this procedure. MethodsThis video presents systematic approach to extraperitoneal lumboaortic lymphadenectomy which was clearly divided in ten steps ordered in a counter-clockwise direction. ResultsStep 1:Retroperitoneal access and introduction of trocarsStep 2:Creating of a space for subsequent lymphadenectomy and identification of anatomical landmarksStep 3:Left common iliac lymph nodes dissectionStep 4:Latero-aortal lymph nodes dissectionStep 5:Aorto-caval lymph nodes dissectionStep 6:Latero-caval lymph nodes dissectionStep 7:Right common iliac lymph nodes dissectionStep 8:Presacral lymph nodes dissectionStep 9:Fenestration of peritoneumStep 10:Extraction of bags with specimens ConclusionsLaparoscopic extraperitoneal access to lumboaortic lymph nodes is an effective method of lymphadenectomy which may bring benefits to a patient and physician. Presented ten steps help to perform each part of surgery in logical sequence making procedure ergonomic, easier to adopt and learn. Prior development of operative area in the extraperitoneal space followed by identification of anatomical landmarks is an important step which should precede lymph node dissection. Standardization of laparoscopic techniques could help to reduce learning curve.

Limited versus extended pelvic lymphadenectomy in patients with bladder cancer undergoing radical cystectomy: Survival results from a prospective, randomized trial (LEA AUO AB 25/02).

4503Background: The extent of pelvic lymph node dissection (PLND) in bladder cancer patients (pts.) undergoing radical cystectomy may affect survival according to retrospective studies. The German Urologic Oncology Group (AUO) reports mature data of the first prospective, randomized clinical trial to evaluate the impact of a limited versus an extended PLND. Methods: Pts. with high-grade T1 or invasive urothelial bladder cancer (cT2-T4a) from 16 German centers were randomized 1:1 to receive a limited versus an extended PLND at the time of radical cystectomy. Limited PLND included 6 fields (bilateral obturator, internal and external iliac nodes) and extended PLND defined 14 fields (in addition bilateral deep obturator fossa, presacral, paracaval, interaortocaval and paraaortal nodes up to the inferior mesenteric artery). Pts. with neoadjuvant chemo- or radiotherapy were excluded, adjuvant chemotherapy was allowed. The primary endpoint was recurrence-free survival (RFS). Cancer-specific survival (CSS) was a ...

Mesorectal node metastasis from gynecological cancer in the era of 3D conformal pelvic radiation therapy and intensity modulated radiation therapy

Whole pelvic radiation therapy (WPRT) is an integral part of treatment for locally advanced cervical and vaginal cancer prior to brachytherapy. The most common beam arrangements for WPRT are opposed anteroposterior/ posteroanterior beams and the 4-field box. The lateral fields of the 4-field box spare small bowel and a portion of the rectum from radiation. Intensity modulated radiation therapy (IMRT) is increasingly used for gynecologic (GYN) cancers to improve dose conformity. Before the availability of computed tomography (CT), the portals used for WPRTwere determined solely based on bony anatomy. Because fluoroscopy-based planning risks geometric miss,1,2 CT-based planning is now considered standard. Conventional WPRT portals are designed to include the primary tumor, uterus, upper vagina, and regional lymphatics (common, external and internal iliac, and presacral lymph nodes). However, the mesorectum is not consistently contoured as a target volume. The advent of fluorine-18 fludeoxyglucose (FDG) positron emission tomography (PET)/CT scan has increased

AB045. Extended lymphadenectomy versus non-extended lymphadenectomy in radical cystectomy for bladder cancer: a meta-analysis

ObjectiveBladder cancer (BCa) is the most common tumor of male urinary reproductive system. Radical cystectomy (RC) with pelvic lymph node dissection (PLND) is the standard treatment for muscle invasive and high-risk non-muscle invasive bladder cancer. But the 5-year overall survival is only about 50%, the majority of the death causes are the tumor local recurrence and metastasis. Local residual micro-lesions and lymph node metastasis are the most important factors of tumor local recurrence and metastasis. At present, radical cystectomy with pelvic lymph node dissection is a necessary step and an important part of radical cystectomy to remove lymph node metastases, an effective means to accurately determine the clinical stage, and is also effective in reducing tumor recurrence and improve the disease-free survival. At present, the extent of lymph node dissection for radical cystectomy remains controversial and has not formed a conclusion. Now the common extent of lymph node dissection including local pelvic lymph node dissection (lPLND, including the obturator and internal iliac lymph nodes), standard pelvic lymph node dissection (sPLND, including the obturator, internal iliac and external iliac lymph nodes), and extended pelvic lymph node dissection (ePLND, including the obturator, internal iliac, external iliac, common iliac, presacral and para-aortic lymph nodes to the inferior mesenteric artery lymph nodes). That lPLND is inaccurate for clinical staging, tumor cured and recurrence rate. sPLND is the most often used clinical technique. In recent years, a growing number of studies have shown that ePLND not only able to provide more accurate tumor clinical staging, but also may complete removal of lymph node metastasis, and the micrometastases can not be detected, thereby reducing the local recurrence, distant metastasis and improve survival, especially non-organ confirmed, and even the patients with lymph node metastasis. However, with extended the extent of lymph node dissection, operative difficulty, operative time, blood loss and surgical complications are bound to increase too far. In pursuing a thorough lymph node dissection may affect the recovery of postoperative urinary control and sexual function. Surgical complications and postoperative lower quality of life, which also will affect the patients received the confidence and motivation for further treatment. Moreover, there is no large sample of multi-center prospective randomized controlled study confirms the cure effect of EL arm is better than the non-EL arm.MethodsA comprehensive literature search was performed in electronic databases including PubMed, EMBASE and the Cochrane Library (last search March 2012). There were no restrictions to publication time or language. Radical cystectomy with EL was the trial arm (extended lymphadenectomy, EL group), and radical cystectomy with non-EL (standard or local lymph node dissection, non-EL group) was the control arm. The software of RevMan5.1 and Stata11 were used for this meta-analysis (MTA). Data including 5-year overall survival (5-year OS), and 5-year recurrence-free survival (5-year RFS) and total recurrence (TR) were extracted from the EL arm and non-EL arm respectively. Useing the index of hazards ratio (HR), odds ratio (odds ratio, OR) or the weighted mean difference (WMD) to express the result for the categorical variable.ResultsTen studies published from 1998 to 2012 fulfilled the inclusion criteria and were included in the meta-analysis. There was one prospective non-randomized controlled study, and the remaining studies were retrospective. Analysis was performed on 1865 patients in the EL arm and 1,524 in the non-EL arm. The results show that the lymph node numbers (LNs) increased significantly, and there were significant differences (WMD16.79, 95% CI, 11.14–22.43; P<0.00001); lymph node density (LD) were no significant differences (OR 1.39, 95% CI, 0.97–2.01; P=0.07); There were no significant differences in 5-year overall survival (HR 0.84,95% CI, 0.66–1.08; P=0.17); 5-year recurrence-free survival were higher in EL arm (HR 0.81, 95% CI, 0.68–0.98; P=0.03); There were no significant differences in total recurrence (OR 0.89, 95% CI, 0.75–1.05; P=0.17). There was no significant difference in peri-operative complication (P=0.08).ConclusionsThis study showed that radical cystectomy with extended lymph node dissection can improve the patient’s 5-year recurrence-free survival, but no sufficient evidence can improve the 5-year overall survival and reduce the overall recurrence. Extended lymph node dissection does not increase peri-operative morbidity and mortality.