Role Of Lymphadenectomy Research Articles

The role of lymphadenectomy in endometrial cancer: Was the ASTEC trial doomed by design and are we destined to repeat that mistake?

ObjectiveThis study examines the design of previous and future trials of lymph node dissection in endometrial cancer. MethodsData from previous trials were used to construct a decision analysis modeling the risk of lymphatic spread and the effects of treatment on patients with endometrial cancer. This model was then applied to previous trials as well as other future trial designs that might be used to address this subject. ResultsComparing the predicted and actual results in the ASTEC trial, the model closely mimics the survival results with and without lymph node dissection for the low and high risk groups. The model suggests a survival difference of less than 2% between the experimental and control arms of the ASTEC trial under all circumstances. Sensitivity analyses reveal that these conclusions are robust. Future trial designs were also modeled with hysterectomy only, hysterectomy with radiation in intermediate risk patients, and staging with radiation only with node positive patients. Predicted outcomes for these approaches yield survival rates of 88%, 90%, and 93% in clinical stage I patients who have a risk of pelvic node involvement of approximately 7%. These estimates were 78%, 82%, and 89% in intermediate risk patients who have a risk of nodal spread of approximately 15%. ConclusionsThis model accurately predicts the outcome of previous trials and demonstrates that even if lymph node dissection was therapeutic, these trials would have been negative due to study design. Furthermore, future trial designs that are being considered would need to be conducted in high-intermediate risk patients to detect any difference.

Role of lymphadenectomy in the management of urothelial carcinoma of the bladder and the upper urinary tract

The role of lymphadenectomy has been controversial in urological malignancies. Urothelial carcinoma of the bladder and upper urinary tract has a high potential to spread through the lymphatic network compared with other malignancies, including renal cell carcinoma or prostate cancer. In urothelial carcinoma of the bladder, lymphadenectomy of pelvic nodes had been considered as the standard procedure when radical cystectomy was carried out. Recently, many investigators have examined the influence of its extent, and the majority of the studies have supported the beneficial role of extended lymphadenectomy in accurate staging or in improving patient survival. Although randomized controlled trials are required to establish a greater level of evidence, more urological surgeons have already noticed the necessity for extended lymphadenectomy in bladder cancer. In contrast to bladder cancer, there have been far fewer studies on urothelial carcinoma of the upper urinary tract. This might be because of the smaller number of the patients with urothelial carcinoma of the upper urinary tract and the lack of understanding of regional nodes. However, studies of lymph node mapping and the retrospective analyses with respect to the benefit of lymphadenectomy have been carried out in urothelial carcinoma of the upper urinary tract by some investigators, although the results are still controversial. However, the results from multi-institutional studies by high volume centers have supported the beneficial role of lymphadenectomy in urothelial carcinoma of the upper urinary tract, as it has been proposed in bladder cancer. Thus, lymphadenectomy for urothelial carcinoma of the bladder and the upper urinary tract might have a potential role in staging and improving the oncological outcomes.

Endometrial stromal sarcoma: A review of the literature.

Endometrial stromal sarcomas are rare malignant tumors of the uterus, and most of the information available in literature is based on small series or case reports. A proper preoperative diagnosis is difficult and in most cases the diagnosis is confirmed after hysterectomy for a presumed benign disease. Endometrial sampling, ultrasound, and magnetic resonance imaging can provide diagnostic clues. Total hysterectomy with bilateral salpingo-oopherectomy is the main line of management and for early disease complete cure is a reality. Ovarian conservation may be possible in young women with early stage disease and the role of lymphadenectomy is controversial. Adjuvant hormone therapy in the form of progesterone, gonadotropin releasing hormone analogues, and aromatase inhibitors are found to be effective in preventing recurrences. Hormone therapy, radiotherapy and surgical excision of the metastasis are recommended for recurrences.

The role of lymphadenectomy in endometrial cancer: Was the ASTEC trial doomed by design and are we destined to repeat that mistake?

The role of lymphadenectomy in endometrial cancer: Was the ASTEC trial doomed by design and are we destined to repeat that mistake?

Role of Lymphadenectomy in Endometrial Cancer

Endometrial cancer is the most frequent gynaecological carcinoma with an increasing incidence. However, this tumour is usually identified in its early stages due to its symptomatology appearing fairly soon. This fact allows for a diagnosis in early stages in most patients, thus providing a good prognosis with an overall survival rate at 5 years higher than 95%. The classical management has been hysterectomy with bilateral salpingo-oophorectomy and pelvic-aortic lymphadenectomy, but we know that many patients in early stages may be treated with only hysterectomy plus salpingooophorectomy. The role of lymphadenectomy in the surgical treatment of these patients is a controversial issue. Assessment of regional nodes varies from elective omission to sampling (selective assessment) to systematic pelvic and para-aortic lymphadenectomy. In order to prevent under or overtreatment, some authors also propose pelvic lymphadenectomy and, in case of it being positive proceed to an aortic lymphadenectomy. At present this technical procedure seems to be useful only in high-risk patients since low-risk patients would not obtain real benefits. Taking into account that in endometrial cancer the drainage is through the pelvic and para-aortic lymph nodes, lymphadenectomy should include all the nodal regions mentioned. Lymphadenectomy allows for a selection of high-risk patients candidates for adjuvant therapy. Keywords: Endometrial cancer, lymphadenectomy, survival, node, gynaecological carcinoma, tumour, hysterectomy, salpingo-oophorectomy, para-aortic lymphadenectomy, para-aortic lymph nodes

Risk Factors for Node Affectation and Recurrence in Endometrial Cancer

Endometrial cancer is the most common gynecologic malignancy in western countries. In United States, 42000 estimated new cases were diagnosed in 2009, approximately 7780 women died from this cancer last year. This malignancy has a five year survival rate around 80%, thanks to its early diagnosis. The surgical management of endometrial cancer includes hysterectomy as main surgical procedure. The role of lymphadenectomy, pelvic and para aortic is still controversial. The authors discuss in this article the risk factors for lymph node metastases and recurrence for endometrial cancer by reviewing the international literature. Conclusions: Lymphadenectomy is a crucial surgical procedure for an adequate staging of endometrial cancer. It is necessary a to evaluate the prognostic factors of this disease in order to properly select the most adequate adjuvant therapy. Since last trials on lymphadenectomy in endometrial cancer have not been convincing, further studies are warranted.

Endometrial cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Endometrial cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

The Role of Lymphadenectomy in Endometrial Cancer

The role of lymphadenectomy in the management of endometrial cancer is rapidly evolving. Although retrospective reports have suggested that lymphadenectomy is associated with a therapeutic benefit, recent prospective trials have questioned the therapeutic effect of lymphadenectomy. Lymphadenectomy remains the gold standard for detecting metastatic disease to the regional nodes. In this review, we discuss the controversies surrounding lymphadenectomy for endometrial cancer.

The role of lymphadenectomy for upper tract urothelial carcinoma

Regional lymphadenectomy, with both its diagnostic and therapeutic roles, serves as an integral component of the management of many malignancies. Extended pelvic lymph node dissection (LND) is the standard of care for urothelial carcinoma of the bladder, with the extent of lymphadenectomy correlating positively with cancer-related outcomes. Given their histologic similarities with bladder cancer, it is reasonable to hypothesize that a similar relationship exists for upper tract urothelial carcinomas (UTUCs). However, the data published to date have failed to consistently demonstrate a therapeutic benefit of regional LND for UTUC. As a consequence, utilization of regional lymphadenectomy remains at the discretion of the surgeon, the extent of LND lacks standardization, and its clinical utility continues to be debated. In order to better clarify the existing data, we present a review of the role of regional lymphadenectomy in patients with UTUC.

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

Objective: Data suggesting a survival advantage for surgical staging in the elderly may be subject to selection bias based on a woman's overall health. We sought to evaluate the effect on endometrial cancer-specific survival of the inclusion or omission of a lymphadenectomy during hysterectomy in an elderly population.

The role of lymphadenectomy in endometrial cancer: Was the ASTEC trial doomed by design and are we destined to repeat that mistake?

The role of lymphadenectomy in endometrial cancer: Was the ASTEC trial doomed by design and are we destined to repeat that mistake?

Identification of High Risk Pathological Node Positive Penile Carcinoma: Value of Preoperative Computerized Tomography Imaging

Patients with penile carcinoma, and 3 or more histopathologically proven unilateral metastatic inguinal nodes, and/or extranodal extension, and/or pelvic metastasis are considered a subgroup with prognostically unfavorable parameters for disease specific death and local recurrence after inguinal lymphadenectomy. We established radiographic criteria for the preoperative identification of such patients. Preoperative diagnostic computerized tomography studies of 30 patients with penile carcinoma with proven unilateral or bilateral lymph node metastasis were reviewed independently by 2 radiologists blinded for patient data. All computerized tomography images were analyzed per side (60). Several radiographic criteria were assessed for regional lymph nodes with short-axis diameter 8 mm or greater and/or central nodal necrosis. Sides were characterized as high risk if histopathology revealed 3 or more metastatic inguinal nodes and/or extranodal extension and/or pelvic nodal involvement. Histopathological nodal involvement was found in 38 sides (63%) including 22 sides (37%) defined as high risk. The presence of central nodal necrosis and/or irregular nodal border of the regional lymph nodes on the preoperative computerized tomography identified the high risk subgroup with a sensitivity of 95% (21 of 22) and a specificity of 82% (31 of 38). All 7 sides falsely designated as high risk harbored inguinal metastases but they were classified as low risk. The interobserver agreement of each radiographic parameter was almost perfect. The presence of central nodal necrosis and/or an irregular nodal border of the regional lymph nodes on preoperative computerized tomography images are accurate and reproducible criteria to identify high risk pathological node positive penile cancer. These criteria can be used for risk stratification and patient counseling.

The Role of Lymphadenectomy in Surgical Staging of Endometrial Cancer

Surgical staging, including lymph node sampling, for endometrial cancer was adopted by the International Federation of Gynecology and Obstetrics (FIGO) in 1988 based on reports demonstrating diagnostic and therapeutic advantages. This review focuses on the incidence of lymph node metastasis, risk factors for lymph node involvement, the effect of lymph node metastasis on prognosis, the therapeutic effect and diagnostic usefulness of lymphadenectomy, risks of lymph node dissection, and future directions in surgical staging of endometrial cancer. Surgical staging identifies most patients with extrauterine disease as well as uterine risk factors for recurrence, thereby allowing for a more informed approach to postoperative adjuvant therapy. Lymphadenectomy as a part of surgical staging is not required in patients assessed intraoperatively to be at low risk for lymph node metastasis (<2 cm grade 1 tumors with superficial myometrial invasion), however, a systematic lymph node dissection should be performed in most other patients with endometrial cancer. In the future, molecular markers may be useful to predict preoperatively tumor aggressiveness and lymph node metastasis. It is hoped that an approach of surgical staging with selective lymph node dissection will improve survival and spare patients additional surgical complications or unnecessary postoperative exposure to radiation and/or chemotherapy.

Lymphadenectomy in uterine low-grade endometrial stromal sarcoma: an analysis of 19 cases and a literature review.

The role of lymphadenectomy in low-grade endometrial stromal sarcoma (ESS) is controversial. The risk of nodal metastases ranges from 0% to 44%, but data are inconclusive. The objective of this study and of the literature review was to investigate the incidence of nodal involvement in macroscopically early-stage tumors. All consecutive patients with histologically proven uterine low-grade ESS who underwent surgery in our institution were considered eligible for the analysis. Until July 2006, pelvic systematic lymphadenectomy was performed based on the physician's choice, whereas after July 2006, all women with apparent early-stage tumor underwent systematic pelvic nodes dissection. From January 1985 to March 2009, 64 women were surgically treated and 19 underwent bilateral systematic pelvic lymphadenectomy. The median count of nodes removed was 20 (range, 11-30). Nodal involvement was depicted in 3 of 19 women but only in 1 in 16 (5%) women with apparent early-stage disease. Specifically, we did not find nodal metastases in 9 women with macroscopically early-stage tumors treated after July 2006. According to the literature review, the risk of nodal metastases is 5% (range, 0%-16%) in early-stage disease. There is no indication to offer a systematic lymphadenectomy in apparent early-stage low-grade ESS according to our analysis and to the literature review. Retroperitoneal surgery should be limited in case of bulky nodal disease or in case of nodal recurrences.

The role of lymphadenectomy in uterine carcinosarcomas (malignant mixed mullerian tumours): a critical literature review

Uterine carcinosarcomas are rare and highly aggressive tumours. Although surgery is the cornerstone of treatment, the extent of the procedure remains controversial. We sought to evaluate the available literature data regarding the rationale of lymphadenectomy and its possible impact on survival. A systematic Medline, PubMed and Scopus search with special focus on the publications of the last decade. Carcinosarcomas have similar clinical characteristics and behaviour with grade 3 endometrioid or aggressive variants of uterine adenocarcinoma. All studies have demonstrated that the FIGO stage of disease is the most important prognostic factor, followed by the depth of myometrial invasion, extra-uterine spread and positive peritoneal cytology. Moreover, lymph node involvement will be found in 14-38% of patients undergoing lymphadenectomy. This figure is similar to the one reported for endometrial carcinoma. Therefore, lymphadenectomy is mandatory for staging purposes. Regarding its impact on survival, the majority of studies confirm a significant survival benefit. The possible mechanisms for the improvement of survival from lymphadenectomy include removal of micro-metastatic foci, reduction of recurrence risk (removal of "target tissue") and mechanical circumvallate of the disease. Given that 5-38% of the patients will experience local recurrence and 30-83% distant metastases, lymphadenectomy reduces the risk of the first and identifies patients in advanced stage that may benefit from adjuvant chemotherapy, aiming to reduce the second and ultimately improve overall survival. Our review data fully justifies the rationale of lymphadenectomy, which beyond staging information seems to offer a measurable survival benefit.

Biochemical Recurrence After Radical Prostatectomy: Multiplicative Interaction Between Surgical Margin Status and Pathological Stage

A positive surgical margin after radical prostatectomy is considered an adverse prognostic feature. However, few groups have explored the potential interaction between surgical margin status and other cancer characteristics, specifically pathological stage. We addressed the first degree of interaction between positive surgical margins and other established adverse predictors of biochemical recurrence after radical prostatectomy. We used univariate and multivariate analysis to test the effect of surgical margin status on biochemical recurrence in 4,490 patients treated at a single institution between 1992 and 2008. We systematically tested all first-degree interactions between surgical margin status, and pretreatment prostate specific antigen, pT and pN stage, and radical prostatectomy Gleason sum. If interactions were significant, we quantified the effect on the biochemical recurrence rate. Overall 850 patients (18.9%) had positive surgical margins. In those with negative vs positive surgical margins the 5-year biochemical recurrence-free survival rate was 95% vs 83%, 74% vs 62% and 47% vs 29% for pT2, pT3a and pT3b disease, respectively. In multivariate models only the pT stage-surgical margin status interaction achieved independent predictor status (p = 0.003). Negative vs positive surgical margin multivariate HRs were 1 vs 2.9, 2.3 vs 4.3 and 4.1 vs 5.6 in pT2, pT3a and pT3b cases, respectively. Compared to negative surgical margins, positive surgical margins increase the absolute biochemical recurrence 5-year rate by 12% to 18%. More importantly, positive surgical margins may substantially worsen the prognosis beyond that of the original pathological disease stage.

The Role of Lymphadenectomy in Minimally Invasive Urologic Oncology

Growing data suggest that lymphadenectomy is a critical component of the surgical management of urologic malignancies with both diagnostic and therapeutic benefit. The increased use of minimally invasive approaches for the management of urologic malignancies may be in conflict with the need for more extensive lymphadenectomy with these procedures. The purpose of this review is to summarize the current evidence for lymphadenectomy as a staging and/or therapeutic procedure for urologic oncology procedures, summarize the feasibility of lymphadenectomy for these disease processes using a minimally invasive approach, and make recommendations regarding management of these disease processes using minimally invasive approaches. A literature review using MESH terms to identify literature on lymphadenectomy in urologic oncology (including minimally invasive urologic oncology procedures) was performed. This literature was the summarized by disease process and by its relation to minimally invasive procedures. The literature demonstrates that lymphadenectomy can successfully duplicate that performed for open urologic oncology procedures. The application of minimally invasive approaches, however, requires advanced skills to be able to accomplish this.

Indications and approach to surgical resection of lung metastases

Pulmonary metastasectomy is a curative option for selected patients with cancer spread to the lungs. Complete surgical removal of pulmonary metastases can improve survival and is recommended under certain criteria. Specific issues that require consideration in a multidisciplinary setting when planning pulmonary metastasectomy include: adherence to established indications for resection, the surgical strategy including the use of minimally invasive techniques, pulmonary parenchyma preservation, and the role of lymphadenectomy.

The role of lymphadenectomy in uterine leiomyosarcoma: review of the literature and recommendations for the standard surgical procedure

Uterine sarcomas are rare and aggressive gynaecologic malignancies with poor prognosis, arising from myometrial or endometrial tissue. These rare cancers can be aggressive, and account for a greatly disproportionate amount of deaths from uterine cancers. The histological uterine sarcomas classification includes carcinosarcomas (malignant mesodermal mixed tumors), accounting for 40% of cases, leiomyosarcomas (40%) and endometrial stromal sarcomas (10-15%). Each group of these tumors presents differences in diagnosis, prognostic factors, treatment, and outcome. Uterine leiomyosarcomas typically affects women in their sixth decade of life, presenting with atypical symptoms such as abnormal uterine bleeding and abdominal pain. The optimal treatment of uterine leiomyosarcomas is surgery, including total abdominal hysterectomy and bilateral salpingooophorectomy. The aim of this study was to conduct a systematic review of the literature regarding the standard surgical procedure of uterine leiomyosarcomas and investigate whether lymphadenectomy affects the 5-year DSS, as well as other relevant clinical outcomes, in women with uterine leiomyosarcomas. For this purpose, MEDLINE, EMBASE, and the Cochrane Library databases were reviewed, and a critical account of the management strategies of these tumors is presented.

Prognostic role of lymph node status in primary advanced ovarian cancer after complete resection or residual disease less than 1 cm: Results of a meta-analysis of the AGO-OVAR meta-database.

5048 Background: The role of lymphadenectomy (LNE) in advanced ovarian cancer is still under discussion and actual randomised trials (LION) are ongoing. Positive lymph node status is a poor prognos...