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European Journal of Obstetrics,... Jun 2023To investigate whether systematic pelvic and para-aortic lymphadenectomy offers superior survival rates in patients with advanced epithelial ovarian cancer (EOC), tubal,... (Meta-Analysis)
Meta-Analysis Review
The role of systematic pelvic and para-aortic lymphadenectomy in the management of patients with advanced epithelial ovarian, tubal, and peritoneal cancer: A systematic review and meta-analysis.
OBJECTIVE
To investigate whether systematic pelvic and para-aortic lymphadenectomy offers superior survival rates in patients with advanced epithelial ovarian cancer (EOC), tubal, or peritoneal cancer.
METHODS
We searched the electronic databases PubMed (from 1996), Cochrane Central Register of Controlled trials (from 1996), and Scopus (from 2004) to September 2021. We considered randomised controlled trials (RCTs) comparing systematic pelvic and para-aortic lymphadenectomy with no lymphadenectomy in patients with advanced EOC. Primary outcomes were overall survival and progression-free survival. Secondary outcomes were peri-operative morbidity and operative mortality. The revised Cochrane tool for randomised trials (RoB 2 tool) was utilised for the risk of bias assessment in the included studies. We performed time-to-event and standard pairwise meta-analyses, as appropriate.
RESULTS
Two RCTs with a total of 1074 patients were included in our review. Meta-analysis demonstrated similar overall survival (HR = 1.03, 95% CI [0.85-1.24]; low certainty) and progression-free survival (HR = 0.92, 95% CI [0.63-1.35]; very low certainty). Regarding peri-operative morbidity, systematic lymphadenectomy was associated with higher rates of lymphoedema and lymphocysts formation (RR = 7.31, 95% CI [1.89-28.20]; moderate certainty) and need for blood transfusion (RR = 1.17, 95% CI [1.06-1.29]; moderate certainty). No statistically significant differences were observed in regard to other peri-operative adverse events between the two arms.
CONCLUSIONS
Systematic pelvic and para-aortic lymphadenectomy is likely associated with similar overall survival and progression-free survival compared to no lymphadenectomy in optimally debulked patients with advanced EOC. Systematic lymphadenectomy is also associated with an increased risk for certain peri-operative adverse events. Further research needs to be conducted on whether we should abandon systematic lymphadenectomy in completely debulked patients during primary debulking surgery.
Topics: Female; Humans; Lymph Node Excision; Carcinoma, Ovarian Epithelial; Progression-Free Survival; Peritoneal Neoplasms; Ovarian Neoplasms
PubMed: 37149928
DOI: 10.1016/j.ejogrb.2023.04.020 -
American Journal of Obstetrics and... Apr 2024This study aimed to provide procedure-specific estimates of the risk of symptomatic venous thromboembolism and major bleeding in the absence of thromboprophylaxis,... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
This study aimed to provide procedure-specific estimates of the risk of symptomatic venous thromboembolism and major bleeding in the absence of thromboprophylaxis, following gynecologic cancer surgery.
DATA SOURCES
We conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar for observational studies. We also reviewed reference lists of eligible studies and review articles. We performed separate searches for randomized trials addressing effects of thromboprophylaxis and conducted a web-based survey on thromboprophylaxis practice.
STUDY ELIGIBILITY CRITERIA
Observational studies enrolling ≥50 adult patients undergoing gynecologic cancer surgery procedures reporting absolute incidence for at least 1 of the following were included: symptomatic pulmonary embolism, symptomatic deep vein thrombosis, symptomatic venous thromboembolism, bleeding requiring reintervention (including reexploration and angioembolization), bleeding leading to transfusion, or postoperative hemoglobin <70 g/L.
METHODS
Two reviewers independently assessed eligibility, performed data extraction, and evaluated risk of bias of eligible articles. We adjusted the reported estimates for thromboprophylaxis and length of follow-up and used the median value from studies to determine cumulative incidence at 4 weeks postsurgery stratified by patient venous thromboembolism risk factors. The GRADE approach was applied to rate evidence certainty.
RESULTS
We included 188 studies (398,167 patients) reporting on 37 gynecologic cancer surgery procedures. The evidence certainty was generally low to very low. Median symptomatic venous thromboembolism risk (in the absence of prophylaxis) was <1% in 13 of 37 (35%) procedures, 1% to 2% in 11 of 37 (30%), and >2.0% in 13 of 37 (35%). The risks of venous thromboembolism varied from 0.1% in low venous thromboembolism risk patients undergoing cervical conization to 33.5% in high venous thromboembolism risk patients undergoing pelvic exenteration. Estimates of bleeding requiring reintervention varied from <0.1% to 1.3%. Median risks of bleeding requiring reintervention were <1% in 22 of 29 (76%) and 1% to 2% in 7 of 29 (24%) procedures.
CONCLUSION
Venous thromboembolism reduction with thromboprophylaxis likely outweighs the increase in bleeding requiring reintervention in many gynecologic cancer procedures (eg, open surgery for ovarian cancer and pelvic exenteration). In some procedures (eg, laparoscopic total hysterectomy without lymphadenectomy), thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding venous thromboembolism and bleeding.
Topics: Adult; Humans; Female; Anticoagulants; Venous Thromboembolism; Postoperative Complications; Hemorrhage; Thrombosis; Neoplasms
PubMed: 37827272
DOI: 10.1016/j.ajog.2023.10.006 -
Journal of Endourology Apr 2020To perform a systematic review and meta-analysis and to assess the clinical benefit of prophylactic pelvic drain (PD) placement after robot-assisted laparoscopic... (Meta-Analysis)
Meta-Analysis
To perform a systematic review and meta-analysis and to assess the clinical benefit of prophylactic pelvic drain (PD) placement after robot-assisted laparoscopic prostatectomy (RALP) with pelvic lymph node dissection (PLND) in patients with localized prostate cancer. An electronic search of databases, including Scopus, Medline, and EMbase, was conducted for articles that considered postoperative outcomes with PD placement and without PD (no drain) placement after RALP. The primary outcome was rate of symptomatic lymphocele (requiring intervention) and secondary outcomes were complications as described by the Clavien-Dindo classification system. Quality assessment was performed using the Modified Cochrane Risk of Bias Tool for Quality Assessment. Six relevant articles comprising 1783 patients (PD = 1253; ND = 530) were included. Use of PD conferred no difference in symptomatic lymphocoele rate (risk difference 0.01; 95% confidence interval [CI] -0.007 to 0.027), with an overall incidence of 2.2% (95% CI 0.013-0.032). No difference in low-grade (I-II; risk difference 0.035, 95% CI -0.065 to 0.148) or high-grade (III-V; risk difference -0.003, 95% CI -0.05 to 0.044) complications was observed between PD and ND groups. Low-grade (I-II) complications were 11.8% (95% CI 0-0.42) and 7.3% (95% CI 0-0.26), with similar rates of high-grade (III-V) complications, being 4.1% (95% CI 0.008-0.084) and 4.3% (95% CI 0.007-0.067) for PD and ND groups, respectively. PD insertion after RALP with extended PLND did not confer significant benefits in prevention of symptomatic lymphocoele or postoperative complications. Based on these results, PD insertion may be safely omitted in uncomplicated cases after consideration of clinical factors.
Topics: Humans; Lymph Node Excision; Male; Pelvis; Prostatectomy; Prostatic Neoplasms; Robotic Surgical Procedures; Robotics
PubMed: 32037859
DOI: 10.1089/end.2019.0554 -
The Cochrane Database of Systematic... Sep 2015This is an update of a previous Cochrane review published in Issue 1, 2010. The role of lymphadenectomy in surgical management of endometrial cancer remains... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This is an update of a previous Cochrane review published in Issue 1, 2010. The role of lymphadenectomy in surgical management of endometrial cancer remains controversial. Lymph node metastases can be found in approximately 10% of women who clinically before surgery have cancer confined to the womb. Removal of all pelvic and para-aortic lymph nodes (lymphadenectomy) at initial surgery has been widely advocated, and pelvic and para-aortic lymphadenectomy remains part of the FIGO (International Federation of Gynaecology and Obstetrics) staging system for endometrial cancer. This recommendation is based on data from studies that suggested improvement in survival following pelvic and para-aortic lymphadenectomy. However, these studies were not randomised controlled trials (RCTs), and treatment of pelvic lymph nodes may not confer a direct therapeutic benefit, other than allocating women to poorer prognosis groups. Furthermore, the Cochrane review and meta-analysis of RCTs of routine adjuvant radiotherapy to treat possible lymph node metastases in women with early-stage endometrial cancer found no survival advantage. Surgical removal of pelvic and para-aortic lymph nodes has serious potential short-term and long-term sequelae. Therefore it is important to investigate the clinical value of this treatment.
OBJECTIVES
To evaluate the effectiveness and safety of lymphadenectomy for the management of endometrial cancer.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Gynaecological Cancer Review Group Trials Register, MEDLINE and EMBASE to June 2009 for the original review and extended the search to June 2015 for this version of the review. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies, and we contacted experts in the field.
SELECTION CRITERIA
RCTs and quasi-RCTs that compared lymphadenectomy versus no lymphadenectomy in adult women diagnosed with endometrial cancer.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data and assessed risk of bias. Hazard ratios (HRs) for overall and progression-free survival and risk ratios (RRs) comparing adverse events in women who received lymphadenectomy versus those with no lymphadenectomy were pooled in random-effects meta-analyses. We assessed the quality of the evidence using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.
MAIN RESULTS
Three RCTs met the inclusion criteria; for one small RCT, data were insufficient for inclusion in the meta-analysis. The two RCTs included in the analysis randomly assigned 1945 women, reported HRs for survival adjusted for prognostic factors and based on 1851 women and had an overall low risk of bias, as they satisfied four of the assessment criteria. The third study had an overall unclear risk of bias, as information provided was not adequate concerning random sequence generation, allocation concealment, blinding or completeness of outcome reporting.Results of the meta-analysis remain unchanged from the previous version of this review and indicate no differences in overall and recurrence-free survival between women who underwent lymphadenectomy and those who did not undergo lymphadenectomy (pooled HR 1.07, 95% CI 0.81 to 1.43; HR 1.23, 95% CI 0.96 to 1.58 for overall and recurrence-free survival, respectively) (1851 participants, two studies; moderate-quality evidence).We found no difference in risk of direct surgical morbidity between women who underwent lymphadenectomy and those who did not undergo lymphadenectomy. However, women who underwent lymphadenectomy had a significantly higher risk of surgery-related systemic morbidity and lymphoedema/lymphocyst formation than those who did not undergo lymphadenectomy (RR 3.72, 95% CI 1.04 to 13.27; RR 8.39, 95% CI 4.06 to 17.33 for risk of surgery-related systemic morbidity and lymphoedema/lymphocyst formation, respectively) (1922 participants, two studies; high-quality evidence).
AUTHORS' CONCLUSIONS
This review found no evidence that lymphadenectomy decreases risk of death or disease recurrence compared with no lymphadenectomy in women with presumed stage I disease. Evidence on serious adverse events suggests that women who undergo lymphadenectomy are more likely to experience surgery-related systemic morbidity or lymphoedema/lymphocyst formation. Currently, no RCT evidence shows the impact of lymphadenectomy in women with higher-stage disease and in those at high risk of disease recurrence.
Topics: Adult; Disease-Free Survival; Endometrial Neoplasms; Female; Humans; Lymph Node Excision; Lymphatic Metastasis; Lymphedema; Lymphocele; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 26387863
DOI: 10.1002/14651858.CD007585.pub3 -
International Journal of Colorectal... Nov 2021The role of lateral lymph node dissection (LLND) during total mesorectal excision (TME) for rectal cancer is still controversial. Many reviews were published on... (Meta-Analysis)
Meta-Analysis Review
UNLABELLED
The role of lateral lymph node dissection (LLND) during total mesorectal excision (TME) for rectal cancer is still controversial. Many reviews were published on prophylactic LLND in rectal cancer surgery, some biased by heterogeneity of overall associated treatments. The aim of this systematic review and meta-analysis is to perform a timeline analysis of different treatments associated to prophylactic LLND vs no-LLND during TME for rectal cancer.
METHODS
A literature search was performed in PubMed, SCOPUS and WOS for publications up to 1 September 2020. We considered RCTs and CCTs comparing oncologic and functional outcomes of TME with or without LLND in patients with rectal cancer.
RESULTS
Thirty-four included articles and 29 studies enrolled 11,606 patients. No difference in 5-year local recurrence (in every subgroup analysis including preoperative neoadjuvant chemoradiotherapy), 5-year distant and overall recurrence, 5-year overall survival and 5-year disease-free survival was found between LLND group and non LLND group. The analysis of post-operative functional outcomes reported hindered quality of life (urinary, evacuatory and sexual dysfunction) in LLND patients when compared to non LLND.
CONCLUSION
Our publication does not demonstrate that TME with LLND has any oncological advantage when compared to TME alone, showing that with the advent of neoadjuvant therapy, the advantage of LLND is lost. In this review, the most important bias is the heterogeneous characteristics of patients, cancer staging, different neoadjuvant therapy, different radiotherapy techniques and fractionation used in different studies. Higher rate of functional post-operative complications does not support routinely use of LLND.
Topics: Humans; Lymph Node Excision; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Neoplasm Staging; Quality of Life; Rectal Neoplasms; Treatment Outcome
PubMed: 34125269
DOI: 10.1007/s00384-021-03946-2 -
Anticancer Research Jan 2017The aim of this study was to review the current literature on the role of minimally invasive lymphadenectomy in the treatment of cervical cancer. (Review)
Review
BACKGROUND/AIM
The aim of this study was to review the current literature on the role of minimally invasive lymphadenectomy in the treatment of cervical cancer.
MATERIALS AND METHODS
Non-randomized control trials published between January 2007 to May 2016 were identified by searching the Pubmed, EMBASE and Cochrane Library databases. Primary endpoints included operative outcomes (operative time, intraoperative blood loss, number of transfused patients and conversion rates), postoperative outcomes (length of postoperative hospital stay, postoperative morbidity and postoperative in-hospital mortality), and oncological outcomes (number of harvested lymph nodes, tumor recurrence, disease-free rates and overall survival rates).
RESULTS
A total of 17 studies with a total of 1,676 patients were included in the review. Compared to the open approach, minimally invasive lymphadenectomy demonstrated a significantly larger number of harvested lymph nodes, longer operative time, lower intraoperative blood loss and shorter postoperative hospital stay. No significant differences were observed between groups treated with an open, laparoscopic or robotic approach for the following criteria: lymph node metastasis, postoperative morbidity, tumor recurrence and postoperative mortality.
CONCLUSION
Although a technically demanding and time-consuming procedure, minimally invasive lymphadenectomy appears to be safe and feasible and may offer an alternative approach in staging and treatment of cervical cancer. Multicentre randomized controlled trials investigating its long-term oncological outcomes and its cost-effectiveness are required to determine the advantages of this procedure over the open approach in cervical cancer.
Topics: Female; Humans; Laparoscopy; Lymph Node Excision; Pelvis; Robotics; Treatment Outcome; Uterine Cervical Neoplasms
PubMed: 28011511
DOI: 10.21873/anticanres.11326 -
International Journal of Clinical... Aug 2022Sentinel node navigation surgery (SNNS) is used in clinical practice for the treatment of cervical cancer. This study aimed to elucidate the appropriate sentinel lymph... (Meta-Analysis)
Meta-Analysis Review
Sentinel node navigation surgery (SNNS) is used in clinical practice for the treatment of cervical cancer. This study aimed to elucidate the appropriate sentinel lymph node (SLN) mapping method and assess the safety and benefits of SNNS. We searched the PubMed, Ichushi, and Cochrane Library databases for randomized controlled trials (RCT) and studies on SLN in cervical cancer from January 2012 to December 2020. Two authors independently assessed study quality and extracted data. We quantitatively analyzed the detection rate, sensitivity/specificity, and complications and reviewed information, including the survival data of SLN biopsy (SLNB) without pelvic lymphadenectomy (PLND). The detection rate of SLN mapping in the unilateral pelvis was median 95.7% and 100% and in the bilateral pelvis was median 80.4% and 90% for technetium-99 m (Tc) with/without blue dye (Tc w/wo BD) and indocyanine green (ICG) alone, respectively. The sensitivity and specificity of each tracer were high; the area under the curve of each tracer was 0.988 (Tc w/wo BD), 0.931 (BD w/wo Tc), 0.966 (ICG), and 0.977 (carbon nanoparticle). Morbidities including lymphedema, neurological symptoms and blood loss were associated with PLND. One RCT and five studies all showed SNNS without systematic PLND does not impair recurrence or survival in early-stage cervical cancer with a tumor size ≤ 2-4 cm. Both Tc w/wo BD and ICG are appropriate SLN tracers. SNNS can reduce the morbidities associated with PLND without affecting disease progression in early-stage cervical cancer.
Topics: Coloring Agents; Female; Humans; Indocyanine Green; Retrospective Studies; Sentinel Lymph Node; Sentinel Lymph Node Biopsy; Uterine Cervical Neoplasms
PubMed: 35612720
DOI: 10.1007/s10147-022-02178-w -
The Journal of Urology Jun 2017In penile cancer, the optimal diagnostics and management of metastatic lymph nodes are not clear. Advances in minimally invasive staging, including dynamic sentinel...
PURPOSE
In penile cancer, the optimal diagnostics and management of metastatic lymph nodes are not clear. Advances in minimally invasive staging, including dynamic sentinel lymph node biopsy, have widened the diagnostic repertoire of the urologist. We aimed to provide an objective update of the recent trends in the management of penile squamous cell carcinoma, and inguinal and pelvic lymph node metastases.
MATERIALS AND METHODS
We systematically reviewed several medical databases, including the Web of Science® (with MEDLINE®), Embase® and Cochrane databases, according to PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines. The search terms used were penile cancer, lymph node, sentinel node, minimally invasive, surgery and outcomes, alone and in combination. Articles pertaining to the management of lymph nodes in penile cancer were reviewed, including original research, reviews and clinical guidelines published between 1980 and 2016.
RESULTS
Accurate and minimally invasive lymph node staging is of the utmost importance in the surgical management of penile squamous cell carcinoma. In patients with clinically node negative disease, a growing body of evidence supports the use of sentinel lymph node biopsies. Dynamic sentinel lymph node biopsy exposes the patient to minimal risk, and results in superior sensitivity and specificity profiles compared to alternate nodal staging techniques. In the presence of locoregional disease, improvements in inguinal or pelvic lymphadenectomy have reduced morbidity and improved oncologic outcomes. A multimodal approach of chemotherapy and surgery has demonstrated a survival benefit for patients with advanced disease.
CONCLUSIONS
Recent developments in lymph node management have occurred in penile cancer, such as minimally invasive lymph node diagnosis and intervention strategies. These advances have been met with a degree of controversy in the contemporary literature. Current data suggest that dynamic sentinel lymph node biopsy provides excellent sensitivity and specificity for detecting lymph node metastases. More robust long-term data on multicenter patient cohorts are required to determine the optimal management of lymph nodes in penile cancer.
Topics: Carcinoma, Squamous Cell; Humans; Inguinal Canal; Lymphatic Metastasis; Male; Pelvis; Penile Neoplasms; Sentinel Lymph Node Biopsy
PubMed: 28115191
DOI: 10.1016/j.juro.2017.01.059 -
Minerva Urologica E Nefrologica = the... Apr 2016Non-urothelial bladder cancer patients represent a rare and challenging group. Advances in bladder cancer to date have largely been driven by studies investigating... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Non-urothelial bladder cancer patients represent a rare and challenging group. Advances in bladder cancer to date have largely been driven by studies investigating common urothelial bladder tumors. New evidence is emerging supporting lymphadenectomy in standard surgical management of muscle invasive bladder cancer. We aim to explore the utility of lymphadenectomy in non-urothelial bladder cancer.
EVIDENCE ACQUISITION
A systematic review of the available peer-reviewed literature on PubMed was performed using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) search strategy. Tumors included in our analysis were squamous cell carcinomas, adenocarcinomas, paragangliomas, melanomas and sarcomas.
EVIDENCE SYNTHESIS
Our search strategy identified 8168 unique records and we included 135 full text articles in our final qualitative analysis. No comparative studies comparing lymphadenectomy outcomes in non-urothelial bladder tumors were identified. Practice of lymphadenectomy in combination with partial or radical cystectomy in the treatment of non-urothelial bladder cancer is relatively common. Pelvic recurrence following radical or partial cystectomy of non-urothelial tumors was more commonly reported in non-lymphadenectomy cohorts. The exception to this observation was the adenocarcinoma cohort.
CONCLUSIONS
Current evidence supporting lymphadenectomy in the surgical management of bladder cancer is largely based on studies limited to urothelial cancer. Despite this, the practice of lymphadenectomy in non-urothelial cancer is common. We support lymphadenectomy in non-urothelial bladder cancer given the minimal risk associated with the procedure and the potential for improved survival.
Topics: Combined Modality Therapy; Cystectomy; Humans; Lymph Node Excision; Urinary Bladder Neoplasms
PubMed: 26684181
DOI: No ID Found -
European Urology Mar 2024Lymph node (LN) involvement in penile cancer is associated with poor survival. Early diagnosis and management significantly impact survival, with multimodal treatment...
CONTEXT
Lymph node (LN) involvement in penile cancer is associated with poor survival. Early diagnosis and management significantly impact survival, with multimodal treatment approaches often considered in advanced disease.
OBJECTIVE
To assess the clinical effectiveness of treatment options available for the management of inguinal and pelvic lymphadenopathy in men with penile cancer.
EVIDENCE ACQUISITION
EMBASE, MEDLINE, the Cochrane Database of Systematic Reviews, and other databases were searched from 1990 to July 2022. Randomised controlled trials (RCTs), nonrandomised comparative studies (NRCSs), and case series (CSs) were included.
EVIDENCE SYNTHESIS
We identified 107 studies, involving 9582 patients from two RCTs, 28 NRCSs, and 77 CSs. The quality of evidence is considered poor. Surgery is the mainstay of LN disease management, with early inguinal LN dissection (ILND) associated with better outcomes. Videoendoscopic ILND may offer comparable survival outcomes to open ILND with lower wound-related morbidity. Ipsilateral pelvic LN dissection (PLND) in N2-3 cases improves overall survival in comparison to no pelvic surgery. Neoadjuvant chemotherapy in N2-3 disease showed a pathological complete response rate of 13% and an objective response rate of 51%. Adjuvant radiotherapy may benefit pN2-3 but not pN1 disease. Adjuvant chemoradiotherapy may provide a small survival benefit in N3 disease. Adjuvant radiotherapy and chemotherapy improve outcomes after PLND for pelvic LN metastases.
CONCLUSIONS
Early LND improves survival in nodal disease in penile cancer. Multimodal treatments may provide additional benefit in pN2-3 cases; however, data are limited. Therefore, individualised management of patients with nodal disease should be discussed in a multidisciplinary team setting.
PATIENT SUMMARY
Spread of penile cancer to the lymph nodes is best managed with surgery, which improves survival and has curative potential. Supplementary treatment, including the use of chemotherapy and/or radiotherapy, may further improve survival in advanced disease. Patients with penile cancer with lymph node involvement should be treated by a multidisciplinary team.
Topics: Humans; Male; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Neoplasm Staging; Penile Neoplasms
PubMed: 37208237
DOI: 10.1016/j.eururo.2023.04.018