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Journal of Gynecologic Oncology Sep 2023Since sentinel lymph node mapping in endometrial cancer is becoming more widely used, the need of standardizing surgical technique is growing [1, 2]. The objective of...
Since sentinel lymph node mapping in endometrial cancer is becoming more widely used, the need of standardizing surgical technique is growing [1, 2]. The objective of this surgical video is to describe the procedure of two-step pelvic and para-aortic sentinel lymph node mapping using indocyanine green and fluorescent camera in endometrial cancer, in three versions of surgical modality of laparoscopic, robotic, and open laparotomy. The patients in the surgical video are diagnosed with biopsy-proven endometrial cancer in its early stage determined by the preoperative imaging study. After collecting washing cytology, bilateral salpinges were clamped with Endo Clip™ to minimize tumor spillage. Gauze packing in posterior cul-de-sac was done to minimize the spillage of indocyanine green dye during paraaortic sentinel lymph node mapping. Indocyanine green dye was injected in bilateral uterine fundus, to detect isolated paraaortic sentinel lymph node pathway. After bilateral paraaortic sentinel lymph node was sampled, cervical injection of Indocyanine green dye was done in 3 o'clock and 9 o'clock directions, both superficially and deeply, 2 mL in each side. After dissecting off the obliterated umbilical ligament, para-vesical and para-rectal spaces were developed. The ureter, uterine artery, and internal and external iliac vessels were identified before bilateral pelvic sentinel lymph nodes were sampled. Asan Medical Center's Institutional Review Board exempted this project. Sentinel paraaortic and pelvic lymph nodes were successfully harvested by two-step method of sentinel lymph node mapping through laparoscopic, robotic, and open laparotomy methods. This surgical video provides specific steps of pelvic and para-aortic sentinel lymph node mapping.
Topics: Female; Humans; Sentinel Lymph Node; Sentinel Lymph Node Biopsy; Indocyanine Green; Robotic Surgical Procedures; Lymph Nodes; Coloring Agents; Lymph Node Excision; Endometrial Neoplasms; Laparoscopy
PubMed: 37170729
DOI: 10.3802/jgo.2023.34.e67 -
Journal of Cancer Research and Clinical... Sep 2023Depiction of pelvic lymph node metastasis (LNM) sites among patients with cervical cancer facilitates accurate determination of the extent of dissection and radiotherapy...
PURPOSE
Depiction of pelvic lymph node metastasis (LNM) sites among patients with cervical cancer facilitates accurate determination of the extent of dissection and radiotherapy regimens.
METHODS
A retrospective study of 1182 cervical cancer patients who underwent radical hysterectomy and pelvic lymph node dissection between 2008 and 2018 was performed. The number of removed pelvic lymph nodes and metastasis status in different anatomical regions was analyzed. The prognostic difference of patients with lymph node involvement stratified by various factors was analyzed by Kaplan-Meier method.
RESULTS
The median number of pelvic lymph nodes detected was 22, mainly from obturator (29.54%) and inguinal (21.14%) sites. Metastatic pelvic lymph nodes were found in 192 patients, with obturator accounting for the highest percentage (42.86%). The patients with lymph node involvement in single site had better prognosis that those in multiple sites. The overall- (P = 0.021) (OS) and progression-free (P < 0.001) survival (PFS) curves of patients with inguinal lymph node metastases were worse compared to those with obturator site. There was no difference in the OS and PFS among patients with 2 and more than 2 lymph nodes involvement.
CONCLUSION
An explicit map of LNM in patients with cervical cancer was presented in this study. Obturator lymph nodes tended to be involved. The prognosis of patients with inguinal lymph node involvement was poor in contrast to that with obturator LNM. In patients with inguinal lymph node metastases, clinical staging needs to be reconsidered and extended radiotherapy to the inguinal region needs to be strengthened.
Topics: Female; Humans; Lymphatic Metastasis; Retrospective Studies; Uterine Cervical Neoplasms; Neoplasm Staging; Lymph Nodes; Lymph Node Excision
PubMed: 37237167
DOI: 10.1007/s00432-023-04810-2 -
Gynecologic Oncology Reports Aug 2024Cervical cancer management often relies on surgical interventions, among which open total mesometrial resection (TMMR) has gained prominence. This abstract gives an...
INTRODUCTION
Cervical cancer management often relies on surgical interventions, among which open total mesometrial resection (TMMR) has gained prominence. This abstract gives an insight into the technique of TMMR in the surgical treatment of cervical cancer. TMMR involves precise dissection of the mesometrium surrounding the cervix, aiming for optimal oncological outcomes while minimizing surgical morbidity.
METHODS OR TECHNIQUE
TMMR entails meticulous dissection of the mesometrium surrounding the cervix, following embryonic planes to ensure complete removal of the primary tumour and associated lymphadenectomy. Access to the abdomen is achieved through either a muscle-cutting transverse or midline abdominal incision. The procedure emphasizes meticulous dissection and removal of the tumour-containing area, with careful attention to preserving vital structures such as the ureters and pelvic autonomic nerves to minimize postoperative complications. Extensive lymphadenectomy, including first and second echelon nodal groups, and in selected cases, third echelon nodes such as lower paraaortic nodes, is performed.
CONCLUSION
TMMR offers several advantages, including precise identification and preservation of vital structures, thorough lymphadenectomy, and favourable oncological outcomes with improved survival rates. Importantly, TMMR allows for the avoidance of radiation therapy in the majority of operable cervical cancer cases. In conclusion, TMMR represents a cornerstone in the surgical management of cervical cancer, striking a balance between oncological efficacy, radiation avoidance, and preservation of patients' quality of life.
PubMed: 38873088
DOI: 10.1016/j.gore.2024.101410 -
The Journal of Urology Jul 2023Bilateral extended pelvic lymph node dissection at the time of radical prostatectomy is the current standard of care if pelvic lymph node dissection is indicated; often,...
PURPOSE
Bilateral extended pelvic lymph node dissection at the time of radical prostatectomy is the current standard of care if pelvic lymph node dissection is indicated; often, however, pelvic lymph node dissection is performed in pN0 disease. With the more accurate staging achieved with magnetic resonance imaging-targeted biopsies for prostate cancer diagnosis, the indication for bilateral extended pelvic lymph node dissection may be revised We aimed to assess the feasibility of unilateral extended pelvic lymph node dissection in the era of modern prostate cancer imaging.
MATERIALS AND METHODS
We analyzed a multi-institutional data set of men with cN0 disease diagnosed by magnetic resonance imaging-targeted biopsy who underwent prostatectomy and bilateral extended pelvic lymph node dissection. The outcome of the study was lymph node invasion contralateral to the prostatic lobe with worse disease features, ie, dominant lobe. Logistic regression to predict lymph node invasion contralateral to the dominant lobe was generated and internally validated.
RESULTS
Overall, data from 2,253 patients were considered. Lymph node invasion was documented in 302 (13%) patients; 83 (4%) patients had lymph node invasion contralateral to the dominant prostatic lobe. A model including prostate-specific antigen, maximum diameter of the index lesion, seminal vesicle invasion on magnetic resonance imaging, International Society of Urological Pathology grade in the nondominant side, and percentage of positive cores in the nondominant side achieved an area under the curve of 84% after internal validation. With a cutoff of contralateral lymph node invasion of 1%, 602 (27%) contralateral pelvic lymph node dissections would be omitted with only 1 (1.2%) lymph node invasion missed.
CONCLUSIONS
Pelvic lymph node dissection could be omitted contralateral to the prostate lobe with worse disease features in selected patients. We propose a model that can help avoid contralateral pelvic lymph node dissection in almost one-third of cases.
Topics: Male; Humans; Prostatic Neoplasms; Lymph Node Excision; Lymph Nodes; Biopsy; Prostatectomy; Magnetic Resonance Imaging
PubMed: 37052480
DOI: 10.1097/JU.0000000000003442 -
The Journal of Obstetrics and... Oct 2023Some studies have reported that the prognosis of total laparoscopic hysterectomy (TLH) for early-stage cervical cancer (CC) is worse than that of open surgery. And this...
Comparison of the efficacy and safety of total laparoscopic hysterectomy without and with uterine manipulator combined with pelvic lymphadenectomy for early cervical cancer.
OBJECTIVE
Some studies have reported that the prognosis of total laparoscopic hysterectomy (TLH) for early-stage cervical cancer (CC) is worse than that of open surgery. And this was associated with the use of uterine manipulator or not. Therefore, this study retrospectively analyzes the efficacy and safety of TLH without uterine manipulator combined with pelvic lymphadenectomy for early-stage CC.
METHODS
Fifty-eight patients with CC (stage IB1-IIA1) who received radical hysterectomy from September 2019 to January 2020 were divided into no uterine manipulator (n = 26) and uterine manipulator group (n = 32). Then, clinical characteristics were collected and intraoperative/postoperative related indicators were compared.
RESULTS
Patients in the no uterine manipulator group had significantly higher operation time and blood loss than in the uterine manipulator group. Notably, there was no significant difference in hemoglobin change, blood transfusion rate, number of pelvic nodules, anal exhaust time, complications and recurrence rate between the two groups. Additionally, patients in the uterine manipulator group were prone to urinary retention (15.6%) and lymphocyst (12.5%), while the no uterine manipulator group exhibited high probability of bladder dysfunction (23.1%) and urinary retention (15.4%). Furthermore, the 1-year disease-free survival rate and the 1-year overall survival rate were not significantly different between the two groups.
CONCLUSION
There was no significant difference in the efficacy and safety of TLH with or without uterine manipulator combined with pelvic lymphadenectomy in the treatment of patients with early-stage CC. However, the latter requires consideration of the negative effects of high operation time and blood loss.
Topics: Female; Humans; Hysterectomy; Laparoscopy; Lymph Node Excision; Neoplasm Staging; Retrospective Studies; Urinary Retention; Uterine Cervical Neoplasms
PubMed: 37488971
DOI: 10.1111/jog.15749 -
BJU International Mar 2024To determine the oncological impact of extended pelvic lymph node dissection (ePLND) vs standard PLND (sPLND) during radical cystectomy (RC) in clinically lymph...
OBJECTIVE
To determine the oncological impact of extended pelvic lymph node dissection (ePLND) vs standard PLND (sPLND) during radical cystectomy (RC) in clinically lymph node-positive (cN+) bladder cancer (BCa).
PATIENTS AND METHODS
In this retrospective, multicentre study we included 969 patients who underwent RC with sPLND (internal/external iliac and obturator lymph nodes) or ePLND (sPLND plus common iliac and presacral nodes) with or without platin-based peri-operative chemotherapy for cTany N1-3 M0 BCa between 1991 and 2022. We assessed the impact of ePLND on recurrence-free survival (RFS) and the distribution of recurrences (locoregional and distant recurrences). The secondary endpoint was overall survival (OS). We performed propensity-score matching using covariates associated with the extent of PLND in univariable logistic regression analysis. The association of the extent of PLND with RFS and OS was investigated using Cox regression models.
RESULTS
Of 969 cN+ patients, 510 were 1:1 matched on propensity scores. The median (interquartile range [IQR]) time to recurrence was 8 (4-16) months, and median (IQR) follow-up of alive patients was 30 (13-51) months. Disease recurrence was observed in 104 patients in the ePLND and 107 in the sPLND group. Of these, 136 (27%), 47 (9.2%) and 19 patients (3.7%) experienced distant, locoregional, or both distant and locoregional disease recurrence, respectively. When stratified by the extent of PLND, we did not find a difference in recurrence patterns (P > 0.05). ePLND improved neither RFS (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.70-1.19; P = 0.5) nor OS (HR 0.78, 95% CI 0.60-1.01; P = 0.06) compared to sPLND. Stratification by induction chemotherapy did not change outcomes.
CONCLUSION
Performing an ePLND at the time of RC in cN+ patients improved neither RFS nor OS compared to sPLND, regardless of induction chemotherapy status. Pretreatment risk stratification is paramount to identify ideal candidates for RC with ePLND as part of a multimodal treatment approach.
Topics: Humans; Retrospective Studies; Neoplasm Recurrence, Local; Lymph Node Excision; Urinary Bladder Neoplasms; Lymph Nodes; Cystectomy
PubMed: 37904652
DOI: 10.1111/bju.16210 -
Journal of Clinical Medicine Dec 2023Cervical cancer (CC) continues to be a significant global public health concern, even with preventive measures in place. In women with early-stage CC, the status of... (Review)
Review
Cervical cancer (CC) continues to be a significant global public health concern, even with preventive measures in place. In women with early-stage CC, the status of lymph nodes is of paramount importance, not only for the final prognosis but also for determining the best therapeutic strategy. According to main international guidelines, pelvic full lymphadenectomy (PLND) is recommended for lymph node staging. However, in these early stages of CC, sentinel lymph node biopsy (SLNB) has emerged as a precise technique for evaluating lymph node involvement, improving its morbidity profile. We performed a literature review through PubMed articles about progress on the application of SLNB in women with early-stage CC focusing on the comparison with PET/CT and PLND in terms of oncological outcomes and diagnostic accuracy. While the superiority of SLNB is clear compared to radiologic modalities, it demonstrates no clear oncologic inferiority over PLND, given the higher detection rate of positive lymph nodes and predominance of no lymph node recurrences. However, due to a lack of prospective evidence, particularly concerning long-term oncological safety, SLNB is not the current gold standard. With careful patient selection and adherence to straightforward protocols, a low false-negative rate can be ensured. The aim of the ongoing prospective trials is to address these issues.
PubMed: 38202034
DOI: 10.3390/jcm13010027 -
Journal of Minimally Invasive Gynecology Jun 2024To evaluate the effectiveness of using vascular clips to seal targeted lymphatics in gynecological malignancies for the prevention of postoperative pelvic lymphocele and...
STUDY OBJECTIVE
To evaluate the effectiveness of using vascular clips to seal targeted lymphatics in gynecological malignancies for the prevention of postoperative pelvic lymphocele and symptomatic lymphocele after laparoscopic pelvic lymphadenectomy.
DESIGN
Retrospective analysis.
SETTING
Single-center academic hospital.
PATIENTS
In total, 217 patients with gynecological malignancies were included.
INTERVENTIONS
Patients were classified into two groups: group 1 (vascular clips were used to seal the targeted lymphatics) and group 2 (electrothermal instruments were used to seal the targeted lymphatics). The patients were followed up 4-6 weeks after surgery to evaluate the incidence of lymphoceles by ultrasound or CT. Symptomatic lymphoceles are defined as those that cause infection, deep vein thrombosis with or without swelling of the extremities, edema (swelling) of the extremities or perineum, hydronephrosis and/or moderate to severe pain.
MEASUREMENT AND MAIN RESULTS
One hundred and thirteen patients were enrolled in group 1, and 104 patients were enrolled in group 2. Lymphoceles were observed in 46 (21.2%) patients. Fewer lymphoceles occurred in group 1 than in group 2 [8 (7.1%) vs. 38 (36.5%), p < 0.001]. The percentage of significantly sized lymphoceles was lower in group 1 than that in group 2 [4 (3.5%) vs. 30 (28.8%), p < 0.001]. Symptomatic lymphoceles occurred in 18 patients (8.3%), and only one (1.0%) occurred in group 1, while 17 (16.3%) occurred in group 2 (p < 0.001). A multivariate analysis revealed that vascular clips were the only independent factor for preventing lymphocele (OR = 7.65, 95% CI = [3.30, 17.13], p < 0.001) and symptomatic lymphocele (OR = 22.03, 95% CI = [2.84, 170.63], p = 0.003).
CONCLUSIONS
The results indicate that the use of vascular clips may be useful for the prevention of the development of lymphocele and symptomatic lymphocele secondary to pelvic lymphadenectomy performed via laparoscopy.
PubMed: 38944337
DOI: 10.1016/j.jmig.2024.06.011 -
Clinics in Colon and Rectal Surgery Mar 2024This article discusses the management of isolated metastatic lymph nodes for colon and rectal cancer. There are traditionally significant differences in how certain... (Review)
Review
This article discusses the management of isolated metastatic lymph nodes for colon and rectal cancer. There are traditionally significant differences in how certain regions of lymph nodes for colon and rectal cancer are managed in the East and West. This has led to the development of the lateral lymph node dissection for rectal cancer and extended lymphadenectomy techniques for colon cancer. This article will evaluate the literature on these techniques and what the surgical and oncological outcomes are at this time. In addition, colon and rectal cancers can occasionally have isolated distant lymph node metastases. These would traditionally be treated as systemic disease with chemotherapy. There is consideration though that these could be treated as similar to isolated liver or lung metastases which have been shown to be able to be treated surgically with good oncological results. The literature for these isolated distant lymph node metastases will be reviewed and treatment options available will be discussed.
PubMed: 38322601
DOI: 10.1055/s-0043-1761474 -
BMC Cancer Dec 2023Up to the present time, there has remained a lack of strong evidence as to whether sentinel lymph node biopsy can replace lymphadenectomy for early endometrial cancer....
A multicenter noninferior randomized controlled study of sentinel lymph node biopsy alone versus sentinel lymph node biopsy plus lymphadenectomy for patients with stage I endometrial cancer, INSEC trial concept.
BACKGROUND
Up to the present time, there has remained a lack of strong evidence as to whether sentinel lymph node biopsy can replace lymphadenectomy for early endometrial cancer. The traditional surgery for endometrial cancer includes pelvic lymphadenectomy and paraaortic lymph node resection, but complications often seriously affect patients' quality of life. Two randomized controlled trials with large samples have proved that lymphadenectomy does not improve the overall recurrence rate and survival rate of patients. On the contrary, it increases the incidence of complications and even mortality. The current trial is designed to clarify whether sentinel lymph node biopsy can replace lymphadenectomy for early endometrial cancer patients with negative lymph nodes.
METHODS
This study is a randomized, open-label, multicenter and non-inferiority controlled clinical trial in China. Potential participants will be patients with pathologically confirmed endometrial cancer at the Zhejiang Cancer Hospital, Jiaxing Maternity and Child Health Care Hospital, and the First Hospital of Jiaxing in China. The total sample size for this study is 722. Patients will be randomly assigned in a 1:1 ratio to two groups. Patients in one group will undergo sentinel lymph node biopsy + total hysterectomy + bilateral salpingo-oophorectomy ± paraaortic lymph node resection. Patients in the other group will undergo sentinel lymph node biopsy + total hysterectomy + bilateral salpingo-oophorectomy + pelvic lymphadenectomy ± paraaortic lymph node resection. The 3-year disease-free survival rate, overall survival rate, quality of life (use EORTC QLQ-C30 + QLQ-CX24), and perioperative related indexes of the two groups will be compared.
RESULTS
We expect to find that for patients with early endometrial cancer, the 3-year disease-free survival rate following sentinel lymph node biopsy with indocyanine green combined with near-infrared fluorescence imaging is similar to that following lymphadenectomy. The operation time, as well as incidence of pelvic lymphocyst, lymphedema of lower limb, and edema of vulva in patients who only undergo sentinel lymph node biopsy are expected to be significantly lower than in patients who undergo lymphadenectomy. The quality of life of patients who undergo sentinel lymph node biopsy alone will be significantly better than that of patients who undergo lymph node dissection.
CONCLUSION
This will prove that the prognosis of sentinel lymph node biopsy alone with indocyanine green combined with near-infrared fluorescence imaging is not inferior to that of sentinel lymph node biopsy plus lymphadenectomy for early stage endometrial cancer with negative nodal assessment intraoperatively. In addition, sentinel lymph node biopsy alone with indocyanine green combined with near-infrared fluorescence imaging results in fewer surgical complications and gives patients better quality of life.
TRIAL REGISTRATION
chictr.org.cn, ChiCTR1900023161. Registered 14 May 2019, http://www.chictr.org.cn/edit.aspx?pid=38659&htm=4 .
Topics: Pregnancy; Child; Humans; Female; Sentinel Lymph Node Biopsy; Indocyanine Green; Quality of Life; Sentinel Lymph Node; Lymph Node Excision; Lymph Nodes; Endometrial Neoplasms; Randomized Controlled Trials as Topic
PubMed: 38041023
DOI: 10.1186/s12885-023-11226-1