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International Journal of Gynecological... Apr 2024The purpose of this study was to establish a consensus on the surgical technique for sentinel lymph node (SLN) dissection in cervical cancer.
OBJECTIVE
The purpose of this study was to establish a consensus on the surgical technique for sentinel lymph node (SLN) dissection in cervical cancer.
METHODS
A 26 question survey was emailed to international expert gynecological oncology surgeons. A two-step modified Delphi method was used to establish consensus. After a first round of online survey, the questions were amended and a second round, along with semistructured interviews was performed. Consensus was defined using a 70% cut-off for agreement.
RESULTS
Twenty-five of 38 (65.8%) experts responded to the first and second rounds of the online survey. Agreement ≥70% was reached for 13 (50.0%) questions in the first round and for 15 (57.7%) in the final round. Consensus agreement identified 15 recommended, three optional, and five not recommended steps. Experts agreed on the following recommended procedures: use of indocyanine green as a tracer; superficial (with or without deep) injection at 3 and 9 o'clock; injection at the margins of uninvolved mucosa avoiding vaginal fornices; grasping the cervix with forceps only in part of the cervix is free of tumor; use of a minimally invasive approach for SLN biopsy in the case of simple trachelectomy/conization; identification of the ureter, obliterated umbilical artery, and external iliac vessels before SLN excision; commencing the dissection at the level of the uterine artery and continuing laterally; and completing dissection in one hemi-pelvis before proceeding to the contralateral side. Consensus was also reached in recommending against injection at 6 and 12 o'clock, and injection directly into the tumor in cases of the tumor completely replacing the cervix; against removal of nodes through port without protective maneuvers; absence of an ultrastaging protocol; and against modifying tracer concentration at the time of re-injection after mapping failure.
CONCLUSION
Recommended, optional, and not recommended steps of SLN dissection in cervical cancer have been identified based on consensus among international experts. These represent a surgical guide that may be used by surgeons in clinical trials and for quality assurance in routine practice.
Topics: Female; Humans; Uterine Cervical Neoplasms; Lymphatic Metastasis; Consensus; Lymph Node Excision; Sentinel Lymph Node Biopsy; Indocyanine Green; Lymph Nodes
PubMed: 38378695
DOI: 10.1136/ijgc-2023-005151 -
PloS One 2023Radiomics extracted from prostate-specific membrane antigen (PSMA)-PET modeled with machine learning (ML) may be used for prediction of disease risk. However, validation...
INTRODUCTION
Radiomics extracted from prostate-specific membrane antigen (PSMA)-PET modeled with machine learning (ML) may be used for prediction of disease risk. However, validation of previously proposed approaches is lacking. We aimed to optimize and validate ML models based on 18F-DCFPyL-PET radiomics for the prediction of lymph-node involvement (LNI), extracapsular extension (ECE), and postoperative Gleason score (GS) in primary prostate cancer (PCa) patients.
METHODS
Patients with intermediate- to high-risk PCa who underwent 18F-DCFPyL-PET/CT before radical prostatectomy with pelvic lymph-node dissection were evaluated. The training dataset included 72 patients, the internal validation dataset 24 patients, and the external validation dataset 27 patients. PSMA-avid intra-prostatic lesions were delineated semi-automatically on PET and 480 radiomics features were extracted. Conventional PET-metrics were derived for comparative analysis. Segmentation, preprocessing, and ML methods were optimized in repeated 5-fold cross-validation (CV) on the training dataset. The trained models were tested on the combined validation dataset. Combat harmonization was applied to external radiomics data. Model performance was assessed using the receiver-operating-characteristics curve (AUC).
RESULTS
The CV-AUCs in the training dataset were 0.88, 0.79 and 0.84 for LNI, ECE, and GS, respectively. In the combined validation dataset, the ML models could significantly predict GS with an AUC of 0.78 (p<0.05). However, validation AUCs for LNI and ECE prediction were not significant (0.57 and 0.63, respectively). Conventional PET metrics-based models had comparable AUCs for LNI (0.59, p>0.05) and ECE (0.66, p>0.05), but a lower AUC for GS (0.73, p<0.05). In general, Combat harmonization improved external validation AUCs (-0.03 to +0.18).
CONCLUSION
In internal and external validation, 18F-DCFPyL-PET radiomics-based ML models predicted high postoperative GS but not LNI or ECE in intermediate- to high-risk PCa. Therefore, the clinical benefit seems to be limited. These results underline the need for external and/or multicenter validation of PET radiomics-based ML model analyses to assess their generalizability.
Topics: Male; Humans; Prostatic Neoplasms; Positron Emission Tomography Computed Tomography; Prostate; Lymph Nodes; Lymph Node Excision; Retrospective Studies
PubMed: 37943772
DOI: 10.1371/journal.pone.0293672 -
World Journal of Surgical Oncology Feb 2024Pelvic lymph node dissection (PLND) is commonly performed alongside radical prostatectomy. Its primary objective is to determine the lymphatic staging of prostate tumors... (Review)
Review
Pelvic lymph node dissection (PLND) is commonly performed alongside radical prostatectomy. Its primary objective is to determine the lymphatic staging of prostate tumors by removing lymph nodes involved in lymphatic drainage. This aids in guiding subsequent treatment and removing metastatic foci, potentially offering significant therapeutic benefits. Despite varying recommendations from clinical practice guidelines across countries, the actual implementation of PLND is inconsistent, partly due to debates over its therapeutic value. While high-quality evidence supporting the superiority of PLND in oncological outcomes is lacking, its role in increasing surgical time and risk of complications is well-recognized. Despite these concerns, PLND remains the gold standard for lymph node staging in prostate cancer, providing invaluable staging information unattainable by other techniques. This article reviews PLND's scope, guideline perspectives, implementation status, oncologic and non-oncologic outcomes, alternatives, and future research needs.
Topics: Male; Humans; Pelvis; Lymphatic Metastasis; Lymph Node Excision; Lymph Nodes; Prostatic Neoplasms; Prostatectomy
PubMed: 38403658
DOI: 10.1186/s12957-024-03344-2 -
Journal of Surgical Case Reports Dec 2023Large-cell undifferentiated carcinoma of the urinary bladder is an extremely rare and aggressive neoplasm. We present a unique case of painless gross hematuria and a...
Large-cell undifferentiated carcinoma of the urinary bladder is an extremely rare and aggressive neoplasm. We present a unique case of painless gross hematuria and a past surgical history of cystolithotomy. The patient underwent transurethral resection of the bladder tumor, which revealed high-grade urothelial cell carcinoma with lamina propria involvement. Subsequent radical cystoprostatectomy with orthotopic neobladder urinary diversion and pelvic lymphadenectomy was performed, and the postoperative pathologic examination indicated large-cell undifferentiated. This case report highlights the importance of accurate diagnosis and management for this rare malignancy and adds to the limited existing literature on Large-cell undifferentiated carcinoma.
PubMed: 38076314
DOI: 10.1093/jscr/rjad656 -
Contrast Media & Molecular Imaging 2024Ovarian cancer in the early stage requires a complete surgical staging, including radical lymphadenectomy, implying subsequent risk of morbidity and complications....
PURPOSE
Ovarian cancer in the early stage requires a complete surgical staging, including radical lymphadenectomy, implying subsequent risk of morbidity and complications. Sentinel lymph node (SLN) mapping is a procedure that attempts to reduce radical lymphadenectomy-related complications and morbidities. Our study evaluates the feasibility of SLN mapping in patients with ovarian tumors by the use of intraoperative Technetium-99m-Phytate (Tc-99m-Phytate) and postoperative lymphoscintigraphy using tomographic (single-photon emission computed tomography/computed tomography (SPECT/CT)) acquisition.
MATERIALS AND METHODS
Thirty-two patients with ovarian mass participated in this study. Intraoperative injection of the radiopharmaceutical was performed just after laparotomy and before the removal of tumor in utero-ovarian and suspensory ligaments of the ovary just beneath the peritoneum. Subsequently, pelvic and para-aortic lymphadenectomy was performed for malignant masses, and the presence of tumor in the lymph nodes was assessed through histopathological examination. Conversely, lymphadenectomy was not performed in patients with benign lesions or borderline ovarian tumors. Lymphoscintigraphy was performed within 24 hr using tomographic acquisition (SPECT/CT) of the abdomen and pelvis.
RESULTS
Final pathological examination showed 19 patients with benign pathology, 5 with borderline tumors, and 6 with malignant ovarian tumors. SPECT/CT identified SLNs in para-aortic-only areas in 6 (20%), pelvic/para-aortic areas in 14 (47%), and pelvic-only areas in 7 (23%) cases. Notably, additional unusual SLN locations were revealed in perirenal, intergluteal, and posterior to psoas muscle regions in three patients. We were not able to calculate the false negative rate due to the absence of patients with involved lymph nodes.
CONCLUSION
SLN mapping using intraoperative injection of radiotracers is safe and feasible. Larger studies with more malignant cases are needed to better evaluate the sensitivity of this method for lymphatic staging of ovarian malignancies.
Topics: Female; Humans; Lymphoscintigraphy; Ovarian Neoplasms; Tomography, Emission-Computed, Single-Photon; Tomography, X-Ray Computed
PubMed: 38435483
DOI: 10.1155/2024/5453692 -
World Journal of Clinical Oncology Apr 2024In this editorial, we proceed to comment on the article by Chua , addressing the management of metastatic lateral pelvic lymph nodes (mLLN) in stage II/III rectal cancer...
In this editorial, we proceed to comment on the article by Chua , addressing the management of metastatic lateral pelvic lymph nodes (mLLN) in stage II/III rectal cancer patients below the peritoneal reflection. The treatment of this nodal area sparks significant controversy due to the strategic differences followed by Eastern and Western physicians, albeit with a higher degree of convergence in recent years. The dissection of lateral pelvic lymph nodes without neoadjuvant therapy is a standard practice in Eastern countries. In contrast, in the West, preference leans towards opting for neoadjuvant therapy with chemoradiotherapy or radiotherapy, that would cover the treatment of this area without the need to add the dissection of these nodes to the total mesorectal excision. In the presence of high-risk nodal characteristics for mLLN related to radiological imaging and lack of response to neoadjuvant therapy, the risk of lateral local recurrence increases, suggesting the appropriate selection of strategies to reduce the risk of recurrence in each patient profile. Despite the heterogeneous and retrospective nature of studies addressing this area, an international consensus is necessary to approach this clinical scenario uniformly.
PubMed: 38689627
DOI: 10.5306/wjco.v15.i4.472 -
Obstetrics & Gynecology Science Nov 2023The first-line treatment for early ovarian cancer typically involves primary debulking surgery aimed at maximal cytoreduction, alongside adjuvant chemotherapy if...
The first-line treatment for early ovarian cancer typically involves primary debulking surgery aimed at maximal cytoreduction, alongside adjuvant chemotherapy if clinically indicated. Nodal assessment involving pelvic and para-aortic lymph node dissection is typically performed during the primary debulking surgery. However, the survival benefit of lymphadenectomy in patients with early ovarian cancer has not been well established, and the procedure is associated with longer operation time and higher perioperative complications. With the emergence of minimally invasive surgery as a potential alternative to laparotomy for early ovarian cancer, sentinel lymph node biopsy has been evaluated in this setting. In this review, we summarized the current literature regarding sentinel lymph node biopsy in patients with early ovarian cancer, focusing on the clinical relevance of this method, including its detection rate and diagnostic accuracy. Additionally, we discuss the current status of clinical trials investigating sentinel lymph node biopsy in early ovarian cancer cases.
PubMed: 37821093
DOI: 10.5468/ogs.23114 -
Urologic Oncology Sep 2023Guideline recommendations disagree on template boundaries for pelvic lymph node dissection (PLND) in conventional urothelial carcinoma. Less is known about PLND in...
OBJECTIVE
Guideline recommendations disagree on template boundaries for pelvic lymph node dissection (PLND) in conventional urothelial carcinoma. Less is known about PLND in variant histology. We aimed to analyze the role of LND in plasmacytoid urothelial carcinoma (PUC).
METHODS
A retrospective review of patients with cTanyNanyM0 PUC who underwent radical cystectomy (RC) with PLND was performed from 2012 to 2022. Lymph node count (LNC) was a surrogate for extent of lymph node dissection and dichotomized based on maximally selected rank statistics. Multivariable cox hazard regression analysis (MVA) for overall survival (OS) corrected for age, perioperative chemotherapy, soft tissue margin status, and stage ≥pT3 and/or pN+ was performed. Disease free survival (DFS) and OS were estimated using Kaplan-Meier (KM) analysis.
RESULTS
Sixty-seven patients with median age of 71, who were 79.1% male were included. Neoadjuvant and adjuvant chemotherapy were administered in 61.2% and 19.4% of patients, respectively. At RC, 70.1% were ≥pT3. Median LNC was 22 (IQR 14-27) with 43.3% of patients being pN+. Calculated optimal-LNC cut point for DFS and OS was 19. Grouping by optimal (≥20) vs. suboptimal-LNC (<20), no significant clinicodemographic differences were found. Optimal-LNC provided improved DFS (P = 0.05) and OS (P = 0.02). Optimal-LNC (HR 0.47, 0.24-0.93 CI 95%, P = 0.03) and negative soft tissue margin (HR 0.38, 0.19-0.76 CI 95%, P = 0.01) was associated with improved OS on MVA. Receipt of perioperative chemotherapy did not improve OS (P = 0.46).
CONCLUSION
In PUC, complete surgical extirpation achieving negative soft tissue margins and removing ≥20 lymph should be prioritized if operative intervention is pursued.
Topics: Humans; Male; Female; Carcinoma, Transitional Cell; Urinary Bladder Neoplasms; Margins of Excision; Lymph Node Excision; Lymph Nodes; Retrospective Studies; Cystectomy
PubMed: 36959058
DOI: 10.1016/j.urolonc.2023.02.003 -
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 -
Advanced Biomedical Research 2024Yolk sac tumors make up 14% to 20% of all malignant ovarian germ cell tumors. Serum alpha-fetoprotein (AFP) levels are elevated in a significant number of patients and...
Yolk sac tumors make up 14% to 20% of all malignant ovarian germ cell tumors. Serum alpha-fetoprotein (AFP) levels are elevated in a significant number of patients and are useful for monitoring the response to treatment and for post-treatment surveillance. Surgery is required for diagnosis, staging, and treatment. The first case is a 12-year-old girl presented with abdominal pain. The ultrasonography (US) showed a huge pelvic tumor. AFP level was high (1000 mg/ml). Right salpingo-oophorectomy and pelvic lymphadenectomy were done. Histopathology reported yolk sac tumor of ovary. She received 3 courses of bleomycin, etoposide, cisplatin (BEP). The second case is a 25-year-old G1AB1 presented with pelvic pain and distension. The US showed a huge pelvic tumor in the right abdominopelvic region. AFP level was high (1000 mg/ml). Right salpingo-oophorectomy, omentectomy, and appendectomy were done. Histopathology reported yolk sac tumor of ovary. The patient received four cycles of BEP protocol; AFP level decreased to 10 mg/ml after the four cycles of chemotherapy. The third case is a 21-year-old girl presented with abdominal pain. The US showed a huge pelvic tumor in the right adnexa. AFP level was high (8700 mg/ml). Right salpingo-oophorectomy and pelvic lymphadenectomy were done. Yolk sac tumor is rare in children and it could be cured usually. In this study, we described three patients with ovarian yolk sac tumors and their fertility preservation treatments.These cases has reminded that in young age with high AFP levels and rapidly growing ovarian mass, diagnosis of the yolk sac tumor has to be kept in mind.
PubMed: 38525405
DOI: 10.4103/abr.abr_112_21