Role Of Lymphadenectomy Research Articles

Comparative effectiveness research in gynecologic oncology.

The field of gynecologic oncology is faced with a number of challenges including how to incorporate new drugs and procedures into practice, how to balance therapeutic efficacy and toxicity of treatment, how to individualize therapy to particular patients or groups of patients, and how to contain the rapidly rising costs associated with oncologic care. In this chapter we examine three common and highly debated clinical scenarios in gynecologic oncology: the initial management of ovarian cancer, the role of lymphadenectomy in the treatment of endometrial cancer, and the choice of adjuvant therapy for ovarian cancer.

Contemporary Management and Trends in the Treatment of Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) represents only 5% of all urothelial cancers. The 5-year cancer-specific survival in the United States is roughly 75%, with grade and stage being the most powerful predictors of survival. Nephroureterectomy with excision of the ipsilateral ureteral orifice and bladder cuff en bloc remains the gold standard treatment of the upper urinary tract urothelial cancers. However, endoscopic and laparoscopic approaches are rapidly evolving as reasonable alternatives of care depending on grade and stage of disease. A critical review of the current literature and various guidelines regarding tumor management in UTUC was undertaken, with a focus on surgical options. Topics reviewed include percutaneous and endoscopic approaches, laparoscopic nephroureterectomy (LNU), options regarding the management of the distal ureter, the role of lymphadenectomy, and the emerging role of chemotherapy in the treatment of UTUC. Both National Comprehensive Cancer Network (NCCN) and European Association of Urology (EAU) current guidelines are reviewed. Limited recommendations are provided by the American Urological Association (AUA). Scant level 1 or grade A evidence was noted in the establishment of the various guidelines. There is debate regarding how to best manage UTUC. With the current trend towards minimally invasive, localized, and precise surgical treatments for all solid malignancies, we must evaluate this movement as it applies to UTUC. Nephron sparing surgery is the preferred option, when feasible, in the management of other renal malignancies. This, too, must be considered when managing UTUC. Higher quality research is needed to better establish evidence-based guidelines. However, this is a challenging prospect given the low incidence of UTUC and the difficulties encountered in creating appropriate protocols. World J Nephrol Urol. 2015;4(2):189-200 doi: http://dx.doi.org/10.14740/wjnu200w

In-transit melanoma metastases: incidence, prognosis, and the role of lymphadenectomy.

In-transit melanoma metastases: incidence, prognosis, and the role of lymphadenectomy.

In-transit melanoma metastases: incidence, prognosis, and the role of lymphadenectomy.

To analyze a large, single-institution database to further understanding of melanoma in-transit metastases (ITM) with regard to incidence, prognosis, and the role of lymphadenectomy. A total of 11,614 patients with single primary cutaneous melanomas were treated at Melanoma Institute Australia between January 1994 and December 2009. Of these, 505 developed ITM. Clinicopathologic characteristics, sentinel node (SN) status, patterns of disease progression, and outcomes were analyzed. In the 505 patients with ITM, the median primary tumor thickness was 2.95mm, and 39.4% were ulcerated. The ITM rates for patients with primary melanomas <1 or ≥1mm in size and in those who underwent sentinel node biopsy were 0.4, 7.8, and 7.2%, respectively. The ITM rates for SN-positive and SN-negative patients were 21.6 and 4.7%, respectively. The median time from primary diagnosis to the development of ITM was 17.9months. After ITM diagnosis, the median survival time was 19.9months, 5-year survival was 32.8%, and 10-year survival was 27.5%. After ITM diagnosis, primary tumor site (head/neck, trunk) and ulceration were predictors of poorer survival. Five-year survival from the time of ITM ranged from 47.9% for nonulcerated limb primary lesions to only 13.6% for ulcerated trunk primary lesions. Elective lymph node dissection in clinically node-negative patients with ITM did not significantly alter overall survival. This large study demonstrates that the diagnosis of melanoma ITM carries serious adverse prognostic implications and will assist in improving the accuracy of staging and prognostic estimates as well as treatment in these patients.

What is the role of lymph nodal metastases and lymphadenectomy in the surgical treatment and prognosis of thymic carcinomas and carcinoids?

A best evidence topic in thoracic surgery was written according to a structured protocol. We looked at the clinical relevance of lymph node involvement and nodal (N) stage, in thymomas, thymic carcinomas and carcinoids. The possible role of lymphadenectomy in addition to thymectomy was also evaluated. A total of 605 papers were found, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. In the Yamakawa-Masaoka classification, based on 226 patients, lymph nodes were classified as anterior mediastinal (N1), defined as nodes surrounding the thymus gland; intrathoracic (N2), all nodes within the thorax excluding N1; and extrathoracic nodes (N3). Kondo validated the Yamakawa-Masaoka classification in a multicentric cohort of 1320 patients. Thymomas presented nodal involvement in 1.8% of cases, carcinomas in 27% of cases, and carcinoids in 28% of cases. The role of nodal status in defining the stage was even more emphasized in the staging system developed by Tsuchiya for thymic carcinomas. In the Istituto Nazionale Tumori classification, thymomas with N1 or N2 were considered as locally advanced disease with a 95-month disease-free survival rate for locally advanced disease of 46.9 vs 98.6% for locally restricted disease (absence of nodal involvement). Weissferdt and Moran, on a series of 65 thymic carcinomas, underlined the clinical relevance of nodal involvement. Positive lymph nodes were associated with significantly worse survival (P = 0.01070). Okuma, in a series of 68 advanced stage thymic carcinomas, showed that curative-intent surgical treatment was related to prolonged survival (P = 0.03). In particular, IVb tumours due to node-only involvement had better survival when radical resection was achieved when compared with IVb due to distant metastases (P = 0.03). Sung et al. showed the importance of harvesting 10 or more lymph nodes and dissecting intrathoracic lymph nodes to ensure a more complete stadiation of thymic carcinomas. The results underline the clinical relevance and prognostic value of nodal involvement in thymic carcinomas and carcinoids. In these cases, lymphadenectomy is desirable to allow the real definition of N status.

77IN - Do Minimal Access and Robotic Surgery Bring Benefit to Neuroendocrine Tumours?

ABSTRACT Minimally invasive surgery has become a well-accepted modality in the management of neuroendocrine tumors (NETs). Laparoscopic approach is the treatment of choice for colorectal NET and it represents a crucial tool for establishing the localization of a lesion after noninvasive studies failed to identify the site of the neoplasm. On the other hand, there is no general consensus regarding the indications for and limitations of laparoscopic surgery for pancreatic NETs. Several studies demonstrated that laparoscopic distal pancreatic resection for NET is safe and feasible providing long-term results comparable with those achieved in open surgery. The main advantage of minimally invasive approach is to reduce the length of hospital stay and to lower significantly blood loss. Several experiences have also reported a significant decrease in the overall complication rate. Laparoscopic pancreaticoduodenectomy is not widely performed due to the associated technical difficulties. However, many studies have shown the effectiveness and safety of this procedure, when performed by expert laparoscopic surgeons. Robotic surgery can overcome the technical difficulties of traditional laparoscopic surgery by restoring three-dimensional vision, enhancing surgeon dexterity and eliminating tremor. Although the role of lymphadenectomy in pancreatic NET has not well established, a robot assisted distal pancreatic resection seems to be associated with a higher median number of resected lymph nodes. Nevertheless, a robotic approach is still limited to highly selected patients and there are many concerns regarding cost-effectiveness of these operations. Conclusions: Laparoscopic surgery is a valid option for NETs. This technique has been widely demonstrated to be safe and feasible with all the advantages of a minimally invasive approach in terms of pain, cosmetic results, length of stay and overall complications. These promising results have to be confirmed by future prospective randomized trials. Disclosure: All authors have declared no conflicts of interest.

The role of lymphadenectomy in the management of renal cell carcinoma.

The role of lymphadenectomy in the management of renal cell carcinoma has been established in staging but is less well defined as a therapeutic maneuver. Level one evidence suggests no survival benefit or increased complication rate with lymphadenectomy when performed concurrently with radical nephrectomy. However, several retrospective studies have identified a survival benefit when patients with increased risk of micrometastatic lymph node disease undergo lymphadenectomy. We perform a selective review of the literature and present the historical basis, risk assessment, use and development of nodal templates, and therapeutic benefits associated with the use of lymphadenectomy in the management of renal cell carcinoma.

Ovary and uterus-sparing procedures for low-grade endometrial stromal sarcoma: A retrospective study of 153 cases

ObjectiveTo discuss the optimal treatment options for low grade endometrial stromal sarcoma (LG-ESS). MethodsMedical records of consecutive patients with LG-ESS in our institute were collected. The pertinent data, including clinicopathological characteristics, treatment and prognostic information were evaluated. ResultsA total of 153 cases of LG-ESS were included. The 5-year relapse free survival (RFS), overall survival (OS) and survival after relapse (SAR) rates were 66.1%, 95.8% and 82.9%, respectively. Ovary-sparing procedures, positive resection-margins, and myomectomy were the independent adverse factors for relapse (P<0.0001, =0.0041, and =0.0075, respectively). Post-menopause, cervical involvement, and positive lymphovascular space involvement were significantly associated with survival (P<0.0001, =0.0020, and =0.0163, respectively). Distance recurrence and macroscopically residual tumors negatively affected SAR (P=0.0137 and =0.0004, respectively). No benefit was found for lymphadenectomy in terms of both RFS and OS (P=0.1187 and =0.5138, respectively). Initial ovary-sparing procedures and myomectomy had no impact on OS (P=0.0810 and =0.8845, respectively). Adjuvant treatment had a slightly beneficial effect both on OS and SAR. ConclusionHysterectomy with bilateral salpingo-oophorectomy and complete resection of the macroscopic lesion should be treated as the initial and salvage mainstay treatments for LG-ESS patients. Ovary-sparing procedures could be considered for young women without cervical involvement; however, long-term follow-up should be mandatory. Myomectomy should only be conserved for young patients with a strong desire for future fertility, with fully informed consent; hysterectomy was recommended after the completion of pregnancy and delivery. However, the roles of lymphadenectomy and adjuvant treatment deserve further investigation.

Is there any clinical significance of compression of left common iliac vein?

Deep venous thrombosis (DVT) has been noted to occur as much as 60% more frequently in the left lower extremity than in the right extremity [1]. Virchow first suggested this disparity in 1851 when he observed that iliofemoral vein thrombosis was five times more likely to occur in the left leg than in the right leg [2]. In 1957, May and Thurner [3] pathologic changes at the points where the right common iliac artery crosses over the left common iliac artery. They found that the right iliac artery compressed the left iliac vein against the fifth lumbar vertebra in 22% of 430 cadavers. A recent large number of study using computed tomography showed that mean percentage of compression was 36.6%: 29.7% (66/222) of greater than 50% compression and 7.2% (16/222) of greater than 70% compression [4]. They concluded that increasing levels of percentage compression were not associated with left-sided DVT up to 70%; however, greater than 70% compression might be associated with left DVT. The results of this study are consistent with those of previous smaller studies on iliac vein compression [5,6]. However, Kibbe et al. [7] reported that hemodynamically significant left common iliac vein compression is a frequent anatomic variant in asymptomatic individuals. Hence, they concluded that compression of the left iliac vein might represent a normal anatomic pattern that has thus far been thought as a pathologic condition. Several studies have demonstrated that therapeutic roles of lymphadenectomy in endometrial cancer and cervical cancer [8-10]. Moreover, extended systematic lymph node dissection resulted in high regional tumor control and high metastatic lymph node rate in cervical cancer [11,12]. To perform the extended systematic lymphadenectomy, it is important to know the exact anatomy of major retroperitoneal vascular structure. Kose et al. [13] demonstrated that prevalence of major retroperitoneal vascular structure anomalies was 17% and common iliac artery and/or vein anomalies was 1.8%. Presence of these anomalies may lead to devastating complications resulting in organ loss or death. However, a few data on anomalies of common iliac vessels are available. Cancer patients are at increased risk of venous thromboembolism and pulmonary embolism. For prediction of venous thromboembolism, several biomarkers were introduced including blood count analysis (elevated leukocyte and platelet count and decreased hemoglobin), D-dimer, prothrombin fragment, soluble P-selectin, and clotting factor VII [14]. Furthermore, risk assessment models were developed that include clinical and laboratory markers. From a clinical perspective, it would be helpful to have biomarkers that enable early identification of cancer patients at risk of venous thromboembolism and to target anticoagulation for primary prevention of venous thormboembolism based on risk stratification. In summary, severe compression of the common iliac vein may be associated with left-sided DVT. We should be concerned about the degree of compression to the common iliac vein during systematic para-aortic and pelvic lymphadenectomy for the treatment of gynecologic cancer patients. To prevent life threatening bleeding during systematic lymphadenectomy, it is important to know the exact anatomy of major retroperitoneal vascular structure including common iliac vessels [15]. Thromboprophylaxis is considered to reduce venous thromoembolism using several biomarkers and clinical parameters.

State of the art of surgery in advanced epithelial ovarian cancer

State of the art of surgery in advanced epithelial ovarian cancer

Total Oesophagectomy for Squamous Cell Carcinoma With or Without Standard Two Field Node Dissection - A Prospective Study

Cancer of the esophagus and gastroesophageal junction (GEJ) is notorious for its advanced stage at the time of diagnosis with transmural invasion and early lymphatic spread in the majority of the patients. R0 resection is the aim of surgery with curative intent. Regarding the role of lymphadenectomy, as in any other solid organ cancer, there are opposing views. Some surgeons argue that the presence of lymph node involvement equals systemic disease and that survival remains unchanged despite removal of these lymph nodes. For others the presence of lymph node involvement, even at a distance from the primary tumor, justifies an aggressive approach with radical esophagectomy combined with lymphadenectomy. The purpose of this article is to compare standard two field lymph node dissection versus non formal lymph node dissection in carcinoma esophagus. The conclusions are based on the experience with 60 cases of carcinoma esophagus over 2 years. In our opinion total esophagectomy with 2-field lymphadenectomy is the standard surgery for resectable squamous cell carcinoma of esophagus. It improves the lymphnode yield thereby ensuring adequate staging of the disease. It can be performed with acceptable morbidity and mortality as the nonformal lymphadenectomy procedure. Locoregional recurrence following 2 field lymphadenectomy is significantly low as compared to nonformal lymphadenectomy procedure though the distant recurrence rate is same. 2 year disease free survival in this study shows advantage of 2 field lymphadenectomy compared to non formal lymphadenectomy procedure.

The Role of Lymphadenectomy in Cervical Cancer Patients: The Significance of the Number and the Status of Lymph Nodes Removed in 526 Cases Treated in a Single Institution

To investigate whether the total number of removed lymph nodes (LNs) and the number of metastatic LNs would prove to be independent prognostic factors for survival in patients with cervical cancer (CC). Data from patients with CC who underwent radical surgery between March 1980 and September 2009 were reviewed. A total of 526 patients were included in the statistical analysis. Full pathologic evaluation was performed. The total number of examined LNs and their histopathological status were analyzed for their prognostic effect on survival by means of multivariable Cox proportional hazard regression models. The median number (interquartile range) of total, pelvic, and para-aortic nodes removed was 37 (29-47), 34 (27-42), and 19 (14-24), respectively. Positive pelvic nodes were found in 102 of 526 (19%) patients. All 8 patients with para-aortic metastases had also pelvic node metastases. At multivariable analysis, vaginal involvement, type of lymphadenectomy and LN status all significantly negatively affected disease-free survival and overall survival, whereas the number of total LNs removed did not affect survival. LN metastasis and number of LN metastases confer an independent risk for worse survival in patients with CC. Pelvic lymphadenectomy is important for staging and regional disease control when LNs are involved. If a standardized complete lymphadenectomy is performed, the number of LNs is not a significant factor per se.

Renal Lymph Nodes for Tumor Staging: Appraisal of 871 Nephrectomies With Examination of Hilar Fat

Despite decades of research, the role of lymphadenectomy in the management of renal cell carcinoma (RCC) is still not clearly defined. Before the implementation of targeted therapies, lymph node metastases were considered to be a portent of markedly decreased survival, regardless of the tumor stage. However, the role of lymphadenectomy and the relative benefit of retroperitoneal lymph node dissection in the context of modern adjunctive therapies have not been conclusively addressed in the clinical literature. The current pathologic literature does not offer clear recommendations with regard to the minimum number of lymph nodes that should be examined in order to accurately stage the pN in renal cell carcinoma. Although gross examination of the hilar fat to assess the nodal status is performed routinely, it has not yet been determined whether this approach is adequate. To evaluate the status of lymph nodes and their rate of identification in the pathologic examination of nephrectomy specimens in adult renal malignancies. We reviewed the operative and pathology reports of 871 patients with renal malignancies treated by nephrectomy. All tumors were classified according to the seventh edition of the Tumor-Nodes-Metastasis classification. Patients were divided into 3 groups: Nx, no lymph nodes recovered; N0, negative; and N1, with positive lymph nodes. Grossly visible lymph nodes were submitted separately; as per grossing protocol, hilar fatty tissue was submitted for microscopic examination. We evaluated the factors that affected the number of lymph nodes identified and the variables that allowed the prediction of nodal involvement. Lymph nodes were recovered in 333 of 871 patients (38%): hilar in 125 patients, nonhilar in 137 patients, and hilar and nonhilar in 71 patients. Patients with positive lymph nodes (n = 87) were younger, had larger primary tumors, and had lymph nodes of average size, as well as a higher pT stage, nuclear grade, and rate of metastases. Metastases were seen only in grossly identified lymph nodes (65% hilar, 16% nonhilar); all microscopic nodes were negative. Even with the microscopic examination of fat, hilar lymph nodes were recovered in only 22.5% of patients. A nonhilar route of node metastasis was suspected in 40 patients. Only grossly identifiable lymph nodes, both hilar and nonhilar, were positive for metastases. Although microscopic examination of the hilar fat increased the number of lymph nodes recovered, the identification rate of these nodes was low (22.5%), and such microscopic nodes were invariably negative. Hence, microscopic examination of the hilar fat may be unnecessary.

895 ROLE FOR PULMONARY METASTASECTOMY WITH A CURATIVE INTENT IN PATIENTS WITH METASTATIC UROTHELIAL CARCINOMA

INTRODUCTION AND OBJECTIVES: Recent studies showed therapeutic benefit from lymphadenectomy in advanced stage urothelial carcinoma of the upper urinary tract (UCUUT). However, there is still a lack of prospective studies and standardization of the extent of lymphadenectomy. We conducted this multi-institutional prospective study to further examine the role of lymphadenectomy in UCUUT. METHODS: From January 2005, we performed lymphadenectomy in 82 patients at the time of radical nephroureterectomy for curative purposes as a prospective study in both institutes. These lymphadenectomies were performed in all patients except those with severe co-morbidity by exactly following the anatomical template determined from the mapping study (Pros-CompLND). These results were compared with those from 203 patients who underwent curative surgery except for Pros-CompLND in Tokyo Womenufs Medical University. We classified these patients into three groups: the patients in whom all regional sites were dissected before 2005 (Retro-CompLND), those in whom lymphadenectomy did not include all regional sites (IncompLND), and those without lymphadenectomy (No-LND). This study protocol was approved by the institutional review board of each institute. RESULTS: Mean follow-up period was 26.8 19.3 months in 82 Pros-CompLND patients, 99.7 62.4 months in 40 Retro-CompLND, 73.4 64.5 months in 45 IncompLND, and 48.5 49.1 months in 118 No-LND patients. The number of lymph nodes was significantly higher in Pros-CompLND (14.5 6.6) than in Retro-CompLND (8.5 5.6) and IncompLND (4.6 2.8) (p 0.001). We examined cancer-specific survival (CSS) in the non-metastatic patients with pT2 or higher. In 121 patients with renal pelvic cancer, 3-year CSS was 87.9% in ProsCompLND, 90.8% in Retro-CompLND, 68.9% in IncompLND, and 64.7% in No-LND. CSS of Pros-CompLND and Retro-CompLND was significantly better than that of No-LND (p 0.04, p 0.01). In contrast, CSS of 69 patients with ureteral cancer was not significantly different between Pros-CompLND, Retro-CompLND, and No-LND. CONCLUSIONS: This multi-institutional study further supports the therapeutic role of template-based lymphadenectomy in patients with advanced stage renal pelvic cancer. Source of Funding: None

Redefining classification of central neck dissection in differentiated thyroid cancer

Therapeutic central neck dissection for differentiated thyroid cancer is recommended in the setting of clinically positive disease. The role of lymphadenectomy in patients with clinically negative disease is a matter of controversy and therefore extent of surgery varies. The boundaries of the central neck are variably described, as are the components of a central neck dissection. Patients with aggressive disease are managed with a comprehensive dissection, yet there is no classification system to distinguish this from a less rigorous operation. Therefore, there is variability in reporting and difficulty in the interpretation of results in the published literature. Here we propose a novel classification system for central neck dissection in thyroid cancer that allows accurate reporting of extent of surgery. The objectives are to reduce ambivalence and allow documentation of extent of lymphadenectomy, such that comparisons can be made between the varied strategies in the management of the central compartment.

Defining the role of lymphadenectomy in gynaecological oncology

Defining the role of lymphadenectomy in gynaecological oncology

Surgical Staging for Endometrial Cancer in the Elderly—Is There a Role for Lymphadenectomy?

AbstractMost gynecologic oncologists believe that use of lymphadenectomy (LND) after hysterectomy in women with advanced-stage endometrial cancer improves the 5-year disease-specific survival (DSS). At present, the role of postsurgical LND in the management of women with early-stage endometrial canc

IJU this issue

This issue consists of one Perspective, two Review Articles, seven Original Articles, two Short Communications, two Procedures and two other reports. The contents of these studies focus on various topics from the fields of basic science to clinical urology. Therefore, I believe that this issue may provide useful information to a wide variety of readers of International Journal of Urology. This issue starts with a perspective on photodynamic diagnosis of urothelial cancer by Matsuyama (Ube, Japan). In this interesting article, the author emphasized that false positive mucosa by photodynamic diagnosis might be a potential reason for exploring the mechanism of oncogenesis in urothelial cancer. This issue then includes two Review Articles describing clinically relevant topics. One is by Low and Sahi (Edmonton, Canada) overviewing the progress on the imaging of functional adrenal neoplasms. The authors clearly presented the key radiological observations of each type of these neoplasms using multimodality images, and concluded that familiarity with the imaging features of these neoplasms could contribute to facilitating appropriate decision-making and patient management. The other Review Article by Kondo and Tanabe (Tokyo, Japan) described the role of lymphadenectomy in the management of urothelial carcinoma. In this review, the authors asserted based on their own data that lymphadenectomy for urothelial cancer might have a potential role in not only staging, but also improving the oncological outcomes. Seven excellent articles are subsequently provided. Takeshita et al. (Tokyo, Japan) reported the impact of renal function on cardiovascular events in patients undergoing radical nephrectomy. The content of this article is a very hot topic, which might affect the selection of the surgical approach for patients with renal cell carcinoma. The authors of this article showed that postoperative renal dysfunction was a significant risk factor for cardiovascular events after radical nephrectomy in addition to age and history of cardiovascular disease. Soga et al. (Tsu, Japan) assessed the incidence of benign renal lesions in resected suspicious renal masses. In this article, the authors reported that the incidence of benign lesions ≥2 cm (3.5%) was significantly lower than that of masses <2 cm (16.2%), and identified female sex and small mass size (≥2 cm) as independent predictors for benign lesions. In the remaining five articles, Chen et al. (Taichung, Taiwan) described the malfunctions of the da Vinci robotic system in the field of urological surgery, Moreira et al. (Durham, USA) analyzed the association between prostate-specific antigen doubling time and cancer in men diagnosed by repeat prostate biopsy, Liu et al. (Oslo, Norway) investigated the significance of a highly proliferative immune-evasive B7-H3-expressing cell population in the malignant phenotype of prostate cancer, Lin et al. (Chongqing, China) characterized the features of resveratrol-induced apoptotic cell death in bladder cancer with respect to mitochondrial dysfunction, and Kaneko et al. (Sagamihara, Japan) carried out the comparative study of matrix proteins in different types of urinary stone by proteomic analysis with liquid chromatography-tandem mass spectrometry. This issue also included two Short Communications and two Procedures assessing important topics. Veeratterapillay et al. (Newcastle Upon Tyne, UK) assessed whether the Kattan nomogram still accurately predict prognosis in renal cell carcinoma using the revised 2010 tumor–nodes–metastasis reclassification. Okegawa et al. (Mitaka, Japan) reported their initial experience with single-port retroperitoneal laparoscopic nephrectomy and concluded that this surgical procedure is equally efficacious as conventional laparoscopic nephrectomy. Brunocilla et al. (Bologna, Italy) described the surgical technique regarding the preservation of the smooth muscular internal sphincter and the proximal urethra during retropubic radical prostatectomy, which resulted in improved postoperative functional outcomes. Shen and Chiang (Kaohsiung, Taiwan) reported their preliminary experience with the penoscrotal approach for artificial sphincter implantation in male urinary incontinence. None declared.

The Role of Lymphadenectomy in the Surgical Treatment of Esophageal and Gastric Cancer

The carotid body tumors (CBTs) are relatively rare neoplasms and may present into benign or life threatening malignant forms. Matrix metalloproteinases (MMPs) are often involved in vascular and cancer diseases. Objective of this study is to study the relationship between CBTs and MMPs.We performed a multicenter study on 14 patients with CBTs. All tumors were resected. For each patient, we evaluated the MMPs' levels in both plasma (enzyme-linked immunosorbent assay [ELISA] test) and tissue samples (Western blot analysis). These MMPs' plasma levels were compared with the MMPs' plasma levels of healthy patients.Eleven patients had benign CBTs, whereas 3 patients had malignant CBTs. ELISA findings revealed significant higher levels (P < 0.01) of MMP-1, -2, -3, -8, and -9 in patients with paraganglioma with respect to healthy patients. Patients with malignant CBTs showed significantly higher levels (P < 0.01) of MMP-1, -2, and -3 compared with patients with benign CBTs.Because this is an exploratory study, the experience on this casuistry showed that MMPs' evaluation may help clinicians and surgeons to formulate a more rapid and clear diagnosis on CBTs' behavior. However, other studies on a large group of patients may be useful to validate these observations.

Surgical staging for endometrial cancer in the elderly — Is there a role for lymphadenectomy?

ObjectivesWe sought to evaluate the effect of systematic lymphadenectomy (LND) on endometrial cancer-specific survival in an elderly population. MethodsData were obtained from the Surveillance, Epidemiology, and End Results (SEER) program from 1988 to 2006. Women who underwent primary hysterectomy for non-serous, non-clear cell endometrial carcinoma were included. Women were stratified by age (<70, 70–79, and ≥80) and disease-specific survival (DSS) was analyzed via the Kaplan–Meier method and stratified by postoperative grade. Cohorts were compared using the log-rank test. In a simulated population, the disease-specific survival of women with pre-operative grade 1 endometrial carcinoma was calculated using a weighted average survival accounting for those upgraded at final pathology. ResultsEndometrial cancer was identified in 5759 women ≥80years old. Disease specific survival at 5years for the LND and no LND groups was 93.4% and 94.5% (p=0.36) for grade 1, 84.4% and 85% (p=0.97) for grade 2, and 65.9% and 60.9% (p=0.002) for grade 3. In the simulated pre-operative grade 1 group, 5year disease-specific survival (DSS) was 91% in the LND group and 92% in the no LND group. ConclusionIn women older than 80, systematic lymphadenectomy is associated with improved DSS for high grade, but similar DSS for low grade endometrial cancer, consistent with what is seen with younger women. As there is no clear survival benefit to lymphadenectomy in elderly women presenting with low grade disease, the surgeon should carefully weigh the surgical risks and benefits in this patient population, which may be at higher risk for morbidity.