Systematic Lymphadenectomy In Patients Research Articles

Role of systematic lymphadenectomy in patients with intermediate to high-risk early stage endometrial cancer.

To determine the clinical significance of systematic lymph node dissection (LND) and to better define the relevant extent of LND in intermediate- to high-risk early stage endometrial cancer (EC). Patients who received surgery as a primary treatment of histologically confirmed EC and preoperatively considered as uterus-confined early stage disease were included in the study population. The rates of lymph node metastasis (LNM) according to the risk groups and anatomic sites were assessed. Univariate and multivariate analyses were performed to evaluate risk factors for recurrence. A total of 804 patients were included in the study analysis. The rates of LNM were significantly different according to the risk group; 1.2% in low-risk, 20.1% in intermediate-risk, and 30.0% in high-risk group. When assessing the rates of LNM in individual anatomic sites, positive LNs were evenly distributed throughout the pelvic and para-aortic regions. In the intermediate to high-risk EC cases, the rates of para-aortic LNM below and above inferior mesenteric artery (IMA) were 11.1% and 12.5%, respectively. On multivariate analysis, LNM was the only independent risk factor for recurrence in the intermediate to high-risk EC (hazard ratio=2.63, 95% confidence interval=1.01-6.82, p=0.047). LNM was frequently observed in intermediate- and high-risk early stage EC and it served as an independent risk factor for recurrence. When considering the similar rates of LNM between below and above IMA, nodal assessment needs to be performed up to the infra-renal level, especially for the staging purpose in high-risk EC.

Therapeutic Benefit of Systematic Lymphadenectomy in Node-Negative Uterine-Confined Endometrioid Endometrial Carcinoma: Omission of Adjuvant Therapy

Simple SummaryEndometrial cancer is the most common gynecological tract malignancy in developed countries. Extrauterine disease, in particular lymph node metastasis, is an important prognostic factor. Nevertheless, pelvic lymphadenectomy is not considered to have a therapeutic benefit, as it did not improve survival in randomized studies. However, lymphadenectomy may have a therapeutic benefit if adjuvant therapy can be omitted without decreasing oncological outcomes, as the long-term quality of life is maintained by avoiding morbidities associated with adjuvant therapy. In intermediate- and high-risk endometrioid endometrial carcinomas, adjuvant therapy may be safely omitted without decreasing long-term survival by open surgery including systematic pelvic and para-aortic lymphadenectomy when patients are node-negative. Systematic lymphadenectomy may remove undetectable low-volume lymph node metastasis in both pelvic and para-aortic regions, and open surgery may reduce vaginal recurrence even without vaginal brachytherapy. However, lymphadenectomy may not improve survival in elderly patients and patients with p53-mutant tumors.Endometrial cancer is the most common gynecological tract malignancy in developed countries, and its incidence has been increasing globally with rising obesity rates and longer life expectancy. In endometrial cancer, extrauterine disease, in particular lymph node metastasis, is an important prognostic factor. Nevertheless, pelvic lymphadenectomy is not considered to have a therapeutic benefit, as it did not improve survival in randomized studies. However, lymphadenectomy may have a therapeutic benefit if adjuvant therapy can be omitted without decreasing oncological outcomes, as the long-term quality of life is maintained by avoiding morbidities associated with adjuvant therapy. In intermediate- and high-risk endometrioid endometrial carcinomas, adjuvant therapy may be safely omitted without decreasing long-term survival by open surgery including systematic pelvic and para-aortic lymphadenectomy when patients are node-negative. Systematic lymphadenectomy may remove undetectable low-volume lymph node metastasis in both pelvic and para-aortic regions, and open surgery may reduce vaginal recurrence even without vaginal brachytherapy. However, lymphadenectomy may not improve survival in elderly patients and patients with p53-mutant tumors. In this review, I discuss the characteristics of lymph node metastasis, the methods of lymph node assessment, and the therapeutic benefits of systematic lymphadenectomy in patients with intermediate- and high-risk endometrioid endometrial carcinoma.

Sentinel lymph node biopsy compared with systematic lymphadenectomy in patients with uterine carcinosarcoma (536)

<b>Objectives:</b> To assess survival among patients with newly diagnosed uterine carcinosarcoma undergoing sentinel lymph node biopsy (SLN) alone and those undergoing systematic lymphadenectomy (LND). <b>Methods:</b> We identified all patients with newly diagnosed uterine carcinosarcoma who underwent primary surgical management at our institution from January 1996 to December 2019. Patients with gross extrauterine disease of any type were excluded. The SLN cohort underwent SLN biopsy alone, with bilateral SLNs identified. The systematic LND cohort did not undergo SLN biopsy. Progression-free survival (PFS) and overall survival (OS) were defined from the date of surgery to the event. Appropriate statistical testing was performed. <b>Results:</b> We identified 99 SLN and 100 LND patients. Median age and BMI were not different between the groups. Minimally invasive surgery was the approach in 56 (56.6%) SLN (56.6%) and 47 (47%) LND patients (p=0.2). There was no significant difference between cohorts with respect to the degree of myoinvasion (<50%, >50%), presence of lymphovascular space invasion (LVSI), stage, or positive washings. The median total node count was four (range: 1-13) for SLN and 19 (range: 2-50) for LN (p<0.001). Nodal metastasis was noted in 26 (26%) SLN and 21 (21%) LND (p=0.4). Postoperative therapy was given to 91 (92%) SLN and 87 (87%) LND (p=0.3). The type of postoperative therapy administered was as follows: none in eight (8%) SLN and 14 (14%) LND; chemotherapy with or without radiation (RT) in 86 (87%) SLN and 71 (71%) LND; RT alone in five (5%) SLN and 15 (15%) LND (p=0.02). Median follow-up was 51.3 months (range: 0.9-211.1) for the SLN cohort compared with 40.8 months (range: 0.5-269.1) for the LND cohort (p=0.3). The 4-year PFS was 62.4% (SE 5.3%) for SLN and 47.7% (SE 5.5%) for LND (p=0.07). The 4-year OS was 72.4% (SE 4.9%) for SLN and 62.2% (SE 4.2%) for LND (p=0.2). There was no difference in PFS or OS when adjusted for the type of postoperative therapy (chemotherapy with or without RT vs none/RT). An isolated nodal recurrence occurred in two (2%) SLN and four (4%) LND patients (p=0.2). <b>Conclusions:</b> There is no difference in PFS or OS among patients who have uterine carcinosarcoma and undergo SLN biopsy versus systematic LND. SLN biopsy adequately detects the presence of nodal metastasis in these patients. SLN biopsy alone does not compromise oncologic outcomes, and systematic LND is unnecessary in the setting of successful bilateral SLN mapping.

Complete Lymphadenectomy for Clinical Stage I Lepidic Adenocarcinoma of the Lung: Is it justified?

The role of a systematic lymphadenectomy in patients undergoing surgery for clinical stage I lung lepidic adenocarcinoma is still unclear. In the last years, some authors have advocated the possibility to avoid a complete lymph-node dissection in this setting. Results of patients who received systematic hilar-mediastinal nodal dissection for this oncologic condition are here reported. Between 2012 and March 2019, 135 consecutive patients underwent lung resection for clinical stage I lepidic adenocarcinoma, at our institution. Only patients (n = 98) undergoing lobectomy or sublobar resection associated with systematic hilar-mediastinal nodal dissection were retrospectively enrolled in the study. Patients' mean age was 67.8 ± 8.7 years (range 37-84). Three were 52 females and 46 males. Resection was lobectomy in 77.6% (n = 76) and sublobar in 22.4% (n = 22). All the resections were complete (R0). Histology was lepidic predominant adenocarcinoma in 85 cases and minimally invasive adenocarcinoma in 13 cases. At pathologic examination, N0 was confirmed in 78 patients (79.6%), while N+ was found in 20 cases (20.4%), (N1 in 12, 12.2% and N2 in 8, 8.2%). No mortality occurred. Complication rate was 8.2%. At a median follow-up of 45.5 months, recurrence rate was 26.5%. Disease-free 5-year survival was 98.6% for stage I, 75% for stage II and 45% for stage III, p < 0.001. A complete nodal dissection can reveal occult nodal metastases in lepidic adenocarcinoma patients and can increase the accuracy of pathologic staging. N1/N2 disease is a negative prognostic factor for this histology. A systematic lymph-node dissection should be considered even in this setting.

Sentinel lymph node biopsy alone compared to systematic lymphadenectomy in patients with uterine carcinosarcoma

ObjectiveTo assess survival among patients diagnosed with uterine carcinosarcoma (CS) who underwent sentinel lymph node (SLN) biopsy alone vs. systematic lymph node dissection (LND). MethodsWe identified newly diagnosed CS patients who underwent primary surgical management from January 1996–December 2019. The SLN cohort underwent SLN biopsy alone with bilateral SLNs identified. The systematic LND cohort did not undergo SLN biopsy. ResultsNinety-nine patients underwent SLN biopsy, and 100 patients underwent systematic LND. There was no difference by age, stage, body mass index, myoinvasion (<50%, ≥50%), lymphovascular space invasion, or positive washings. Eighty-five SLN (85.9%) and 15 LND (15%) underwent minimally invasive surgery (P < 0.001). The median total node count was four (range, 1–13) for SLN and 19 (range, 2–50) for LND (P < 0.001). Nodal metastasis occurred in 23 (23.2%) SLN and in 22 (22%) LND (P = 0.4). Postoperative therapy was administered to 85 (85.9%) SLN and 71 (71%) LND (P = 0.02). Median follow-up was 33 months (range, 1–205) for SLN and 55.3 months (range, 1–269) for LND (P = 0.001). The three-year progression-free survival (PFS) was 62.9% (SE 5.2%) for SLN and 52.3% (SE 5.3%) for LND (P = 0.13). The three-year overall survival (OS) was 72.1% (SE 5.1%) for SLN and 71.6% (SE 4.6%) for LND (P = 0.68). An isolated nodal recurrence occurred in two (2%) SLN and four (4%) LND (P = 0.26). ConclusionsThere is no difference in PFS or OS among CS patients who undergo SLN biopsy vs. systematic LND. SLN biopsy detects nodal metastasis without compromising oncologic outcomes.

Factors associated with the involvement of lymph nodes in low‐grade serous ovarian cancer

Evaluating nodal metastases in low-grade serous ovarian cancer (LGSOC) patients. Women with LGSOC who had undergone primary cytoreductive surgery comprising systematic pelvic-paraaortic lymphadenectomy were included. Data were obtained retrospectively from 12 oncology centers. One hundred and forty-eight women with LGSOC who had undergone comprehensive surgical staging were included. Seventy-one (48.0%) patients had metastatic lymph nodes. Preoperative serum CA-125 levels of ≥170 U/ml (odds ratio [OR]: 3.84; 95% confidence interval [CI]: 1.22-12.07; p = 0.021) and presence of lymphovascular space invasion (LVSI) (OR: 13.72; 95% CI: 3.36-55.93; p < 0.001) were independent predictors of nodal metastasis in LGSOC. Sixty (40.5%) patients were classified to have apparently limited disease to the ovary/ovaries. Twenty (33.3%) of them were upstaged after surgical staging. Twelve (20.0%) had metastatic lymph nodes. Presence of LVSI (OR: 12.96; 95% CI: 1.14-146.43; p = 0.038) and preoperative serum CA-125 of ≥180 U/ml (OR: 7.19; 95% CI: 1.35-38.12; p = 0.02) were independent predictors of lymph node metastases in apparent Stage Ⅰ disease. Clinicians may consider to perform a reoperation comprising systematic lymphadenectomy in patients who had apparently limited disease to the ovary/ovaries and had not undergone lymphadenectomy initially. Reoperation may be considered particularly in patients whose preoperative serum CA-125 is ≥180 U/ml and/or whose pathological assessment reported the presence of LVSI.

Is there any therapeutic role of pelvic and para-aortic lymphadenectomy in apparent early stage epithelial ovarian cancer?

ObjectiveThe therapeutic role of pelvic and para-aortic lymphadenectomy in surgical staging of apparent early-stage epithelial ovarian cancer (eEOC) is still under debate. The aim of this study was to evaluate the potential therapeutic role of systematic lymphadenectomy in patients with eEOC. MethodsMulti-center retrospective cohort study, comparing women with apparent eEOC who underwent comprehensive bilateral pelvic and para-aortic lymphadenectomy (defined as ≥20 lymph nodes) versus patients receiving no lymphadenectomy or lymph node sampling, from 05/1985 to 12/2016. Patients with bulky nodes at CT-scan and those without complete intra-peritoneal surgical staging were excluded. Only patients who received at least 3 cycles of platinum-based adjuvant chemotherapy were included. ResultsOut of 2559 patients with FIGO stage IA-IIIA1 ovarian cancer, 639 (25.0%) met inclusion criteria. 360 (56.3%) underwent comprehensive lymphadenectomy, 150 (23.5%) lymph node sampling and 129 (20.2%) no lymphadenectomy. Patients who underwent comprehensive lymphadenectomy were younger (p < 0.001), experienced a higher number of severe post-operative complications (p = 0.008) and had a longer time to start chemotherapy (p = 0.034). There was no difference in intra-operative complications. Median follow-up was 63 months (range, 5–342). The 5-year disease-free survival (DFS) was 79.7% vs. 76.5% vs. 68.3% (p = 0.006), and 5-year overall survival (OS) was 92.3% vs. 94.5% vs. 89.8% (p = 0.165) in women who received comprehensive lymphadenectomy vs. lymph node sampling vs. no lymphadenectomy, respectively. Lymphadenectomy represented an independent factor for DFS improvement, HR 0.52 (95%CI 0.37–0.73) (p < 0.001). ConclusionPelvic and para-aortic lymphadenectomy in surgical staging of eEOC improves DFS for the price of increasing post-operative complications and time to chemotherapy but does not affect OS. Better understanding of tumor biology may help to identify those patients in whom lymphadenectomy should still play a role.

Can lymphadenectomy be omitted in advanced ovarian cancer?-a brief review.

The indication of systematic lymphadenectomy in advanced ovarian cancer without apparent macroscopic lymph node involvement has been controversial over the past three decades, and the recommendation to perform it or not has been based on multiple retrospective studies, small cohort studies, and few randomized studies with several biases; however, it seems that this controversy has come to an end after the recent publication of a randomized clinical trial. The study of lymph node disease in ovarian cancer has intensified in the last two decades, so far that it was part of the changes of the last update of the International Federation of Gynecology and Obstetrics (FIGO) staging; In this review, a search was made of the available literature to understand the evolution of knowledge about the implications of the realization or not of lymphadenectomy in two scenarios of advanced ovarian cancer (namely, the presence or not of lymph node disease macroscopic), without losing the landscape of the importance of peritoneal disease in these stages, which, as we will see throughout the review, the complete cytoreduction of the tumor remains an integral part of the treatment, since residual disease is one of the most relevant prognostic factors. Nowadays, we can confidently state that systematic lymphadenectomy in patients with advanced ovarian cancer without clinically apparent nodal disease is not necessary, and the presence of macroscopic retroperitoneal lymph node disease should be resected as part of cytoreductive surgery since it will be this and the residual disease that determine the prognosis of the patients.

The value of systematic lymphadenectomy during debulking surgery in the treatment of ovarian cancer: a meta-analysis of randomized controlled trials

BackgroundThe therapeutic value of systematic lymphadenectomy during debulking surgery for ovarian cancer remains controversial. We conduct this meta-analysis to evaluate the significance of systematic lymphadenectomy in patients treated with optimal cytoreduction for ovarian cancer.MethodThe PubMed, Medline, Embase, Cochrane Library and Web of Science databases were searched up to October 2019. Only English-language publications of randomized controlled trials (RCTs) that investigated the role of systematic lymphadenectomy in patients with ovarian cancer were selected for this analysis. For overall survival (OS) and progression-free survival (PFS), pooled hazard ratios (HR) with 95% confidence intervals (CIs) were calculated; for complications rate, we calculated pooled risk ratio (RR) with 95% confidence interval (CI). Statistical heterogeneity was assessed using both the I2 and chi-square tests. In cases of I2 being larger than 50%, a random-effect model was used, otherwise a fixed-effect model was used.ResultsFour RCTs involving 1607 patients were included in the present analysis. There was no difference in OS between systematic lymphadenectomy and unsystematic lymphadenectomy (HR = 1.00; 95% CI = 0.94, 1.07; p = 0.90). Similarly, no significant difference was observed in PFS between these two groups (HR = 0.97; 95% CI = 0.87, 1.08; p = 0.62). And postoperative complications occurred more frequently in the systematic lymphadenectomy group (RR = 1.50; 95% CI = 1.34, 1.68; p < 0.00001).ConclusionSystematic lymphadenectomy in patients with optimally cytoreduced ovarian cancer was not associated with longer overall or progression-free survival than unsystematic lymphadenectomy and was associated with a higher incidence of postoperative complications.

Prognostic Significance of Systematic Lymphadenectomy in Patients With Optimally Debulked Advanced Ovarian Cancer: A Meta-Analysis

Background: The effect of systematic lymphadenectomy (SL) on survival in patients with optimally debulked advanced ovarian cancer remains unclear. We evaluated the therapeutic value of SL in advanced ovarian cancer patients who underwent primary optimal debulking surgery.Methods: A meta-analysis was carried out using articles retrieved from the PubMed, Embase, and Cochrane databases. Overall survival (OS) and progression-free survival (PFS) were compared between patients who underwent SL and those who underwent unsystematic lymphadenectomy (USL).Results: Seven studies that included 2,425 patients with advanced ovarian cancer were included in the meta-analysis. The overall analyses indicated significantly improved OS [hazard ratio (HR) = 0.64, 95% confidence interval (CI): 0.49–0.84, P < 0.01] but not PFS (HR = 0.89, 95% CI: 0.69–1.15, P = 0.38) in patients who underwent SL compared to those who underwent USL. Subgroup analyses based on study type, study quality, total numbers of patients, and International Federation of Gynecology and Obstetrics (FIGO) stage provided similar results. However, subgroup analysis of patients with no residual tumor revealed that SL was not associated with improved OS (HR = 0.81, 95% CI: 0.66–1.00, P = 0.05) or PFS (HR = 1.09, 95% CI: 0.91–1.30, P = 0.33).Conclusions: In patients with optimally debulked advanced ovarian cancer, SL may improve OS but not PFS. However, SL does not provide a survival advantage when macroscopically complete resection of all visible tumors is achieved.

Survival implication of lymphadenectomy in patients surgically treated for apparent early-stage uterine serous carcinoma.

ObjectiveUterine serous carcinoma (USC) is a rare highly aggressive disease. In the present study, we aimed to investigate the survival implication of the systematic lymphadenectomy in patients who underwent surgery for apparent early-stage USC.MethodsConsecutive patients with apparent early-stage USC surgically treated at six Italian referral cancer centers were analyzed. A comparison was made between patients who underwent retroperitoneal staging including at least pelvic lymphadenectomy “LND” vs. those who underwent hysterectomy alone “NO-LND”. Baseline, surgical and oncological outcomes were analyzed. Kaplan- Meier curves were calculated for disease-free survival (DFS) and disease-specific survival (DSS). Associations were evaluated with Cox proportional hazard regression and summarized using hazard ratio (HR).ResultsOne hundred forty patients were analyzed, 106 LND and 34 NO-LND. NO-LND group (compared to LND group) included older patients (median age, 73 vs.67 years) and with higher comorbidities (median Charlson Comorbidity Index, 6 vs. 5) (p<0.001). No differences in terms of recurrence rate (LND vs. NO-LND, 33.1% vs. 41.4%; p=0.240) were observed. At Cox regression analysis lymphadenectomy did not significantly influence DFS (HR=0.59; 95% confidence interval [CI]=0.32–1.08; p=0.09), and DSS (HR=0.14; 95% CI=0.02–1.21; multivariable analysis p=0.07). Positive node was independently associated with worse DFS (HR=6.22; 95% CI=3.08–12.60; p<0.001) and DSS (HR=5.51; 95% CI=2.31–13.10; p<0.001), while adjuvant chemotherapy was associated with improved DFS (HR=0.38; 95% CI=0.17–0.86; p=0.02) and age was independently associated with worse DSS (HR=1.07; 95% CI=1.02–1.13; p<0.001).ConclusionsAlthough lymphadenectomy did not show survival benefits in patients who underwent surgery for apparent early-stage USC, the presence of lymph node metastasis was the main adverse prognostic factors, supporting the prognostic role of the retroperitoneal staging also in this histological subtype.

Sentinel node navigation surgery in cervical and endometrial cancer: a review.

Pelvic lymphadenectomy is generally performed to treat early-stage cervical cancer, and pelvic ± para-aortic lymphadenectomy is performed in patients with endometrial cancer confined to the uterus. However, systematic lymphadenectomy is frequently associated with sequelae including lymphocele, lymphedema and cellulitis. The sentinel lymph node concept has been recently applied in the management of patients with gynecological cancer, with the goal of avoiding systematic lymphadenectomy and its associated postoperative complications. In this review, we examine and summarize the recently expanding body of literature and discuss sentinel lymph node navigation during surgery in patients with cervical and endometrial cancer. Current data suggest that sentinel node navigation surgery (SNNS) appears to be feasible for detecting lymph node metastasis compared with systematic lymphadenectomy in patients with early-stage cervical or endometrial cancer. The non-inferiority of long-term prognosis through omission of systematic lymphadenectomy has not been proven by randomized trial, but SNNS decreases lymphatic complications related to systematic lymphadenectomy. Further studies are needed to clarify the necessity of additional systematic lymphadenectomy and/or adjuvant therapy in cases with isolated tumor cells or micrometastasis in SLNs.

Subserosal uterine injection of blue dye for the identification of the sentinel node in patients with endometrial cancer: a feasibility study.

To define the detection rate, sensitivity, and negative predictive value (NPV) of the sentinel node technique in patients with endometrial cancer. Patients with endometrial cancer after informed consent underwent subserosal injection of blue dye during hysterectomy in a tertiary gynae/oncology department between 2010 and 2014. The procedure was performed in all cases by the same team including two gynae/oncologist consultants and one trainee. All relevant perioperative clinicopathological characteristics of the population were recorded prospectively. The identified sentinel nodes were removed separately and a completion bilateral pelvic lymphadenectomy followed in all cases. Simple statistics were used to calculate the sensitivity and NPV of the method on per patient basis. Fifty-four patients were included in this study. At least one sentinel node was mapped in 46 patients yielding a detection rate of 85.2%. Bilateral detection of sentinel nodes was accomplished in only 31 patients (57.4%). The mean number of sentinel nodes was 2.6 per patient and the commonest site of identification was the external iliac artery and vein area (66%). Six patients (11%) had a positive lymph node, and in five of them, this was the sentinel one yielding a sensitivity of 83.3% and an NPV of 97.5%. The overall detection rate improved significantly after the first 15 cases; however, this was not the case for the bilateral detection rate. Our study is in accordance with previous studies of sentinel node in endometrial cancer and further demonstrates and enhances the confidence in the technique. In the current era of an ongoing debate on whether a systematic lymphadenectomy in patients with endometrial cancer is still necessary, we believe that the sentinel node is an acceptable alternative and should be applied routinely in tertiary centres following a strict algorithm.

Prognostic risk factors for lymph node involvement in patients with endometrial cancer.

Objective:We aimed to analyze variables affecting lymph node (LN) involvement and to assess the need for systematic lymphadenectomy in patients with endometrial cancer (EC).Materials and Methods:A single centre retrospective analysis was conducted in a total of 128 consecutive patients with EC who underwent systematic pelvic or combined pelvic and paraaortic lymphadenectomy between 2009 and 2012. Mann-Whitney U, chi-square, and Fisher’s exact test were used for univariate analyses when appropriate. Variables with a p value <0.05 in the univariate analysis were included into a multivariate logistic regression analysis. The effects of variables on LN involvement are reported using adjusted odds ratios (ORs) and 95% confidence intervals (CI).Results:In univariate analysis, grade 2-3, tumor size ≥3 cm, deep (≥50%) myometrial invasion, presence of cervical, adnexal or omental involvement, positive peritoneal cytology, open surgical approach (laparotomy), combined pelvic and paraaortic lymphadenectomy and number of total LNs removed (>30) were found associated with LN involvement. However, the number of total LNs removed (>30) was the only independent variable that predict LN involvement in multivariate analysis [OR: 15.08; 95% CI: (1.28-177.59); p=0.03].Conclusion:This study demonstrates that the more LNs removed during staging of EC, the greater the probability of finding LN metastasis.

The therapeutic and prognostic significance of systematic lymphadenectomy in patients with advanced ovarian cancer at the time of interval debulking surgery after neoadjuvant chemotherapy

The therapeutic and prognostic significance of systematic lymphadenectomy in patients with advanced ovarian cancer at the time of interval debulking surgery after neoadjuvant chemotherapy

Relationship between removal of circumflex iliac nodes distal to the external iliac nodes and postoperative lower-extremity lymphedema in uterine cervical cancer

ObjectiveThis study aimed to determine if there is a causal relationship between removal of the circumflex iliac nodes distal to the external iliac nodes (CINDEIN) and postoperative lower-extremity lymphedema (POLEL) after systematic lymphadenectomy in patients with cervical cancer. MethodsA retrospective chart review was performed for all living cervical cancer patients who underwent lymphadenectomy and were managed at Hokkaido Cancer Center between 1993 and 2013. The type of lymphadenectomy gradually shifted from lymphadenectomy with removal of CINDEIN to without CINDEIN dissection during this period. The study period was divided into two phases: from 1993–2007 (first phase) and from 2008–2013 (second phase). We identified patients with POLEL. Logistic regression analysis was used to select the risk factors for POLEL. ResultsImplementation of CINDEIN-dissection lymphadenectomy (94.0% vs. 20.6%, p<0.0001) and adjuvant radiotherapy (26.1% vs. 4.5%, p<0.0001) was significantly higher in the first phase than in the second phase. Of 398 patients evaluated, POLEL was noted in medical records of 80 (20.1%) patients with a median follow-up period of 78.0months. The occurrence rate of POLEL was significantly higher in the first phase than in the second phase (32.2% vs. 8.0%, p<0.0001), despite no change in the number of dissected lymph nodes between the two phases. Multivariate analysis showed that adjuvant radiation therapy (odds ratio=2.6, 95% confidence interval=1.4–4.8) and removal of CINDEIN (odds ratio=4.6, 95% confidence interval=2.4–9.0) were independent risk factors for POLEL. ConclusionElimination of CINDEIN dissection is helpful for reducing the incidence of POLEL.

Close relationship between removal of circumflex iliac nodes to distal external iliac nodes and postoperative lower-extremity lymphedema in uterine corpus malignant tumors

ObjectiveThe aim of this study was to confirm a causal relationship between removal of circumflex iliac nodes to the distal external iliac nodes (CINDEIN) and lower-extremity lymphedema after systematic lymphadenectomy in patients with uterine corpus malignancies. MethodsA retrospective chart review was carried out for all patients with uterine corpus malignant tumor managed at Hokkaido Cancer Center between 1991 and 2013. All 318 patients underwent CINDEIN dissection as a part of initial surgery and 217 patients did not. Patients had undergone hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy and their medical records were reviewed. The type of lymphadenectomy gradually shifted from pelvic lymphadenectomy with removal of CINDEIN to full lymphadenectomy without CINDEIN dissection during this period. We identified patients with postoperative lower-extremity lymphedema (POLEL). Logistic regression analysis was used to select the risk factors for POLEL. ResultsOf 535 patients evaluated, POLEL was noted in the medical records of 126 patients (23.6%), with median follow-up of 71months. The occurrence of POLEL was significantly higher in the CINDEIN-dissection group than in the CINDEIN-sparing group (34.3% vs. 7.8%, P<0.0001). Multivariate analysis confirmed that adjuvant radiation therapy [odds ratio (OR)=6.3, 95% confidence interval (CI)=2.6–14.9], resection of more than 31 lymph nodes (OR=2.0, 95% CI=1.2–3.5), and removal of CINDEIN (OR=5.4, 95% CI=3.1–9.3) were independent risk factors for POLEL. ConclusionsElimination of CINDEIN dissection can be helpful in reducing the incidence of POLEL.

MRI prior to systematic lymphadenectomy in patients with locally advanced cervical cancer.

5042 Background: Surgical evaluation of lymph node (LN) metastases has served as the gold standard for comparison of imaging modalities in locally advanced cervical cancers. It has been suggested that contemporary techniques such as MRI be relied upon for treatment planning and, specifically, extended-field radiation (EFRT) without pathologic confirmation. Methods: As part of a prospective, multicenter clinical trial conducted by ACRIN/GOG, patients (pts) with histologically confirmed, stage IB2, IIA≥4 cm, or IIB-IVA) cervical carcinoma underwent MRI prior to systematic pelvic (PLN) and abdominal (PALN) lymphadenectomy. LNs ≤ 1 cm were bisected while those > 1 cm were serially sectioned into 5 mm sections and a slide was made from each section. For positive & negative predictive values (PPV & NPV) of PALN on MRI, patients were grouped into those with MRI reports of both (+) PLN & PALN (G1), (+) PLN but (-)PALN (G2), and those with both (-) PLN & PALN (G3). Results: 33 pts are included in this analysis. Stage distribution was 12 1B2, 3 2A, 15 2B, 3 3B. 29 were squamous, 3 adeno, and 1 rhabdomyosarcoma. 94 (+) and 659 (-) LNs were removed. (+) LNs were found in the PALN in 12 (36%) and in the PLN in 22 (67%) pts. Two pts had PALN but not PLN metastases. The mean size of the long axis of the largest (+) (N=60) and (-) (N=209) LNs removed did not differ (18.7±9.3 vs. 18.7±11.6 mm; p=0.47). The size of the largest focus of metastasis within a LN ranged from 2-50 mm and was statistically larger in PLN compared to PALN (18 vs. 14 mm; p=0.02). The mean number of LNs counted by pathology was greater than the number reported on MRI (p <0.0001). For the above defined groups, the PPV for PALN in G1 was 0.61 (95% CI 0.48-0.73), the NPV for PALN in G2 was 0.66 (95% CI 0.55-0.75), and the NPV for PALNs in G3 was 0.86 (95% CI 0.76-0.92). Conclusions: PALN metastases are common in locally advanced cervical cancer. The NPV of MRI for PALN among pts reported to have negative PLN & PA LN on MRI is high enough that surgical evaluation and EFRT is not necessary. For all others, the PPV & NPV of MRI is too low to determine the need for EFRT without first performing surgical evaluation. This study was supported by NCI funding to the GOG (grants CA 27469 and CA 37517) and to ACRIN (grants U01 CA079778 and U01 CA080098).

Hilar Lymph Node Involvement in Colorectal Cancer Liver Metastases ? An Overview

Hepatectomy is the only possible option for cure in any treatment strategy of colorectal liver metastases, and several studies have shown good results, with five-year survival rates ranging from 27 to 56%. Several clinical and pathological predictive factors for survival after liver resection have been studied and the metastatic involvement of the hepatic hilum lymph nodes indicates a poor long-term prognosis. Despite variable results, some authors have reported a not-insignificant improvement in survival rate in liver-metastasis patients with hilar-lymph-node involvement who undergo combined liver resection and lymphadenectomy. Due to the low rates of morbidity and mortality for liverresection surgery, several specialized centers perform liver resections combined with lymphadenectomy in selected cases. It should be noted that the therapeutic value of systemic lymphadenectomy is not yet entirely understood, and only controlled studies comparing groups with and without lymphadenectomy can fully resolve the issue. In any case, hilar lymph node dissection has been shown to be a useful tool for improving the accuracy of extrahepatic disease staging, regardless of its impact on survival. The authors review the incidence and the clinical impact of hilar lymph node metastases, and analyses the possible beneficial role of systematic lymphadenectomy in patients who have undergone liver resection for colorectal-cancer metastases.

Risk factors for postoperative lower-extremity lymphedema in endometrial cancer survivors who had treatment including lymphadenectomy

Objective The aim of this study was to determine the incidence rate of lower-extremity lymphedema after systematic lymphadenectomy in patients with uterine corpus malignancies and to elucidate risk factors for this type of lymphedema. Methods A retrospective chart review was carried out for all patients with uterine corpus malignant tumor managed at Hokkaido Cancer Center between 1991 and 2007. Patients who did not undergo lymphadenectomy as a treatment or died of cancer/intercurrent disease were excluded from this study. All living patients included in this study had hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy and their medical records were reviewed. We identified patients with postoperative lower-extremity lymphedema (POLEL). Logistic regression analysis was used to select the risk factors for POLEL. Results Of 286 patients evaluated, 103 (37.8%) had POLEL. Multivariate analysis confirmed that adjuvant radiation therapy (OR = 5.2, 95% CI = 2.1–12.7), resection of more than 31 lymph nodes (OR = 2.6, 95% CI = 1.4–4.9), and removal of circumflex iliac nodes to the distal external iliac nodes (CINDEIN) (OR = 6.1, 95% CI = 1.3–28.2) were independent risk factors for POLEL. Conclusion Adjuvant radiation therapy should be avoided in patients who undergo systematic lymphadenectomy if an alternative postoperative strategy is possible. Although reducing the number of resected lymph nodes is not appropriate from a therapeutical point of view, elimination of CINDEIN dissection may be helpful in reducing the incidence of POLEL. The clinical significance of CINDEIN dissection needs to be investigated by a randomized controlled trial.