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Archives of Gynecology and Obstetrics Jan 2022The value of pelvic lymphadenectomy (LAE) has been subject of discussions since the 1980s. This is mainly due to the fact that the relation between lymph node...
BACKGROUND
The value of pelvic lymphadenectomy (LAE) has been subject of discussions since the 1980s. This is mainly due to the fact that the relation between lymph node involvement of the groin and pelvis is poorly understood and therewith the need for pelvic treatment in general.
PATIENTS AND METHODS
N = 514 patients with primary vulvar squamous cell cancer (VSCC) FIGO stage ≥ IB were treated at the University Medical Center Hamburg-Eppendorf between 1996 and 2018. In this analysis, patients with pelvic LAE (n = 21) were analyzed with regard to prognosis and the relation of groin and pelvic lymph node involvement.
RESULTS
The majority had T1b/T2 tumors (n = 15, 78.9%) with a median diameter of 40 mm (11-110 mm). 17/21 patients showed positive inguinal nodes. Pelvic nodal involvement without groin metastases was not observed. 6/17 node-positive patients with positive groin nodes also had pelvic nodal metastases (35.3%; median number of affected pelvic nodes 2.5 (1-8)). These 6 patients were highly node positive with median 4.5 (2-9) affected groin nodes. With regard to the metastatic spread between groins and pelvis, no contralateral spread was observed. Five recurrences were observed after a median follow-up of 33.5 months. No pelvic recurrences were observed in the pelvic nodal positive group. Patients with pelvic metastasis at first diagnosis had a median progression-free survival of only 9.9 months and overall-survival of 31.1 months.
CONCLUSION
A relevant risk for pelvic nodal involvement only seems to be present in highly node-positive disease, therefore pelvic staging (and radiotherapy) is probably unnecessary in the majority of patients with node-positive VSCC.
Topics: Female; Groin; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Neoplasm Staging; Prognosis; Retrospective Studies; Vulvar Neoplasms
PubMed: 34387725
DOI: 10.1007/s00404-021-06156-x -
Gynecologic Oncology Reports May 2021Robot-assisted extraperitoneal -aortic lymphadenectomy has been reported to be feasible option for the surgical management of gynecologic malignancy previously (Narducci...
Robot-assisted extraperitoneal -aortic lymphadenectomy has been reported to be feasible option for the surgical management of gynecologic malignancy previously (Narducci et al., 2009) (Hudry et al., 2019). We have reported the feasibility of laparoscopic extraperitoneal total -aortic and pelvic lymphadenectomy (Andou, 2016). This article aims to show the safety of robot-assisted extraperitoneal "total -aortic and pelvic" lymphadenectomy. The video is the staging surgery for 67-year-old woman suspected clinical stage IA ovarian clear cell carcinoma after abdominal hysterectomy and salpingo-oophorectomy. As abdominal adhesion was predicted, she was treated using robot-assisted extraperitoneal total -aortic and pelvic lymphadenectomy. The patient was placed in the supine position and tilted 7 degrees to the right. Three robot arms were docked at the patient's left side. The center port was used for the scope. The bipolar cutting method was performed using the surgeon's right hand. An AirSeal® port (ConMed, Utica, NY, USA) was placed on the side near the assistant. After the extraperitoneal space was expanded, lymphadenectomy was performed up to the renal veins and below to the obturator muscles using the bipolar cutting method. This was followed by omentectomy. The operative time were 189 min, and the estimated blood loss was 75 ml. A total of 56 lymph nodes were harvested (22 -aortic lymph nodes and 34 pelvic lymph nodes). Total extraperitoneal lymphadenectomy by robot-assisted surgery was a feasible procedure for this patient. The procedure, which does not require the Trendelenburg position and is not obstructed by bowel, may be suitable for patients with hypertension, glaucoma, obesity or abdominal adhesion.
PubMed: 34026997
DOI: 10.1016/j.gore.2021.100768 -
Best Practice & Research. Clinical... Jan 2022Endometrial cancer (EC) usually presented as a localized disease at diagnosis (67%), 20% of patients diagnosed with regional spread, and distant metastasis accounted for... (Review)
Review
Endometrial cancer (EC) usually presented as a localized disease at diagnosis (67%), 20% of patients diagnosed with regional spread, and distant metastasis accounted for 9%. The standard treatments include hysterectomy, bilateral salpingo-oophorectomy, and pelvic with/without paraaortic lymph node dissection/biopsy. Adjuvant therapy is arranged according to risk factors and stages. Risk group classification varied among different guidelines and studies and evolved with time. Adjuvant modalities include chemotherapy, radiotherapy, chemoradiotherapy, antiangiogenesis agents, immune checkpoint inhibitors, and multi-target agents. We review the recent literature to incorporate important advances in trial results, real-world big data, and knowledge in biomarkers of EC to update appropriate adjuvant therapy and post-surgical treatment of EC patients.
Topics: Chemotherapy, Adjuvant; Endometrial Neoplasms; Female; Humans; Hysterectomy; Lymph Node Excision; Lymphatic Metastasis; Neoplasm Staging; Radiotherapy, Adjuvant; Retrospective Studies
PubMed: 34420863
DOI: 10.1016/j.bpobgyn.2021.06.002 -
Diagnostics (Basel, Switzerland) Jan 2021Pelvic lymphadenectomy is a common surgical procedure in gynecologic oncology. Pelvic lymph node dissection is performed for all types of gynecological malignancies to... (Review)
Review
Pelvic lymphadenectomy is a common surgical procedure in gynecologic oncology. Pelvic lymph node dissection is performed for all types of gynecological malignancies to evaluate the extent of a disease and facilitate further treatment planning. Most studies examine the lymphatic spread, the prognostic, and therapeutic significance of the lymph nodes. However, there are very few studies describing the possible surgical approaches and the anatomical variations. Moreover, a correlation between anatomical variations and lymphadenectomy in the pelvic region has never been discussed in medical literature. The present article aims to expand the limited knowledge of the anatomical variations in the pelvis. Anatomical variations of the ureters, pelvic vessels, and nerves and their significance to pelvic lymphadenectomy are summarized, explained, and illustrated. Surgeons should be familiar with pelvic anatomy and its variations to safely perform a pelvic lymphadenectomy. Learning the proper lymphadenectomy technique relating to anatomical landmarks and variations may decrease morbidity and mortality. Furthermore, accurate description and analysis of the majority of pelvic anatomical variations may impact not only gynecological surgery, but also spinal surgery, urology, and orthopedics.
PubMed: 33430363
DOI: 10.3390/diagnostics11010089 -
Annals of Coloproctology Dec 2023In Western countries, the gold-standard therapeutic strategy for rectal cancer is preoperative chemoradiotherapy (CRT) following total mesorectal excision (TME), without... (Review)
Review
In Western countries, the gold-standard therapeutic strategy for rectal cancer is preoperative chemoradiotherapy (CRT) following total mesorectal excision (TME), without lateral lymph node dissection (LLND). However, preoperative CRT has recently been reported to be insufficient to control lateral lymph node recurrence in cases of enlarged lateral lymph nodes before CRT, and LLND is considered necessary in such cases. We performed a literature review on aspects of pelvic anatomy associated with rectal surgery and LLND, and then combined this information with our experience and knowledge of pelvic anatomy. In this review, drawing upon research using a 3-dimensional anatomical model and actual operative views, we aimed to clarify the essential anatomy for LLND. The LLND procedure was developed in Asian countries and can now be safely performed in terms of functional preservation. Nonetheless, the longer operative time, hemorrhage, and higher complication rates with TME accompanied by LLND than with TME alone indicate that LLND is still a challenging procedure. Laparoscopic or robotic LLND has been shown to be useful and is widely performed; however, without a sufficient understanding of anatomical landmarks, misrecognition of vessels and nerves often occurs. To perform safe and accurate LLND, understanding the landmarks of LLND is essential.
PubMed: 38062625
DOI: 10.3393/ac.2023.00164.0023 -
Archives of Pathology & Laboratory... Nov 2021Endosalpingiosis is a benign Müllerian inclusion that can mimic metastatic low-grade mammary carcinoma, particularly when encountered in axillary lymph nodes excised...
CONTEXT.—
Endosalpingiosis is a benign Müllerian inclusion that can mimic metastatic low-grade mammary carcinoma, particularly when encountered in axillary lymph nodes excised for breast cancer staging. Immunohistochemistry can be useful in histologically ambiguous cases, and a targeted immunopanel should include a marker of gynecologic tract origin and a marker of mammary origin. GATA3 is a sensitive immunomarker for breast carcinoma, but the immunoreactivity of GATA3 in endosalpingiosis has not been systematically evaluated.
OBJECTIVE.—
To evaluate whether GATA3 immunohistochemistry could be used to differentiate endosalpingiosis from metastatic mammary carcinoma.
DESIGN.—
Whole slide sections of 15 cases of endosalpingiosis involving nonneoplastic tissues were subjected to GATA3 immunohistochemistry. Nuclear GATA3 labeling was scored as percentage and intensity labeling, with any labeling considered positive; GATA3 labeling was recorded in all cells present in the sections.
RESULTS.—
Half (47%, n = 7 of 15) of the endosalpingiosis cases involved lymph nodes (2 axillary, 5 pelvic) and half (53%, n = 8 of 15) involved pelvic organs or soft tissue (3 myometrial, 2 paratubal, 2 periadnexal soft tissue, and 1 pelvic sidewall). GATA3 immunohistochemistry was negative in all cases of endosalpingiosis, with intact, positive control labeling in lymphocytes. The benign fallopian tube epithelium present on the sections of paratubal endosalpingiosis displayed focal (<5%), weak labeling for GATA3, specifically within the ciliated and secretory cells.
CONCLUSIONS.—
These findings support the diagnostic utility of GATA3 immunohistochemistry and its use in a targeted immunopanel to resolve the differential diagnosis of metastatic low-grade mammary carcinoma (GATA3+) and nodal endosalpingiosis (GATA3-).
Topics: Biomarkers, Tumor; Biopsy; Breast Neoplasms; Carcinoma; Diagnosis, Differential; Female; GATA3 Transcription Factor; Humans; Immunohistochemistry; Lymph Node Excision; Lymph Nodes; Lymphatic Diseases; Lymphatic Metastasis; Predictive Value of Tests
PubMed: 33571371
DOI: 10.5858/arpa.2020-0359-OA -
Current Oncology (Toronto, Ont.) Feb 2022Sentinel lymph node (SLN) mapping is becoming an acceptable alternative to full lymphadenectomy for evaluating lymphatic spread in clinical stage I endometrial cancer... (Review)
Review
Sentinel lymph node (SLN) mapping is becoming an acceptable alternative to full lymphadenectomy for evaluating lymphatic spread in clinical stage I endometrial cancer (EC). While the assessment of pelvic and para-aortic lymph nodes is part of the surgical staging of EC, there is a long-standing debate over the therapeutic value of full lymphadenectomy in this setting. Although lymphadenectomy offers critical information on lymphatic spread and prognosis, most patients will not derive oncologic benefit from this procedure as the majority of patients do not have lymph node involvement. SLN mapping offers prognostic information while simultaneously avoiding the morbidity associated with an extensive and often unnecessary lymphadenectomy. A key factor in the decision making when planning for EC surgery is the histologic subtype. Since the risk of lymphatic spread is less than 5% in low-grade EC, these patients might not benefit from lymph node assessment. Nonetheless, in high-grade EC, the risk for lymph node metastases is much higher (20-30%); therefore, it is crucial to determine the spread of disease both for determining prognosis and for tailoring the appropriate adjuvant treatment. Studies on the accuracy of SLN mapping in high-grade EC have shown a detection rate of over 90%. The available evidence supports adopting the SLN approach as an accurate method for surgical staging. However, there is a paucity of prospective data on the long-term oncologic outcome for patients undergoing SLN mapping in high-grade EC, and more trials are warranted to answer this question.
Topics: Endometrial Neoplasms; Female; Humans; Neoplasm Staging; Prospective Studies; Sentinel Lymph Node; Sentinel Lymph Node Biopsy
PubMed: 35200595
DOI: 10.3390/curroncol29020096 -
Annals of Coloproctology Dec 2021Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to... (Review)
Review
Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.
PubMed: 34961303
DOI: 10.3393/ac.2021.00927.0132 -
Journal of B.U.ON. : Official Journal... 2021Indocyanine green (ICG) is being used more and more in Urology along with advances in minimal invasive surgery, guiding excision and reconstruction, highlighting...
PURPOSE
Indocyanine green (ICG) is being used more and more in Urology along with advances in minimal invasive surgery, guiding excision and reconstruction, highlighting anatomic structures and functional features with oncologic guidance still being debatable. The purpose of this paper was to explore ICG use in urologic procedures.
METHODS
We present our experience (37 cases) of using ICG fluorescence guidance in urologic operations performed using 3D laparoscopy and FireFly® fluorescence imaging mode of Da Vinci X robot. The operations were the following: pelvic lymphadenectomy in radical prostatectomy, totally intracorporeal orthotopic ileal neobladder reconstruction, vesicovaginal fistula repair, partial nephrectomy and pyeloplasty. Barnard's test was used to compare postoperative complications (digestive fistula, ureteral stricture) for totally intracorporeal ileal neobladders performed with (group e, 27 cases) vs. without (group 2, 28 cases) ICG guidance.
RESULTS
ICG under near-infrared fluorescence offered a precise identification of ischemic structures- vaginal wall, distal ureteral end, ileal loop, along with vascularized tissues allowing an optimal pyeloplasty and nephron sparing surgery with partial unclamping. It also allowed the identification of a lymph node during radical prostatectomy that otherwise would not have been excised during the routinely performed pelvic lymphadenectomy. There were no complications of ICG usage and the complication rate (digestive fistula, ureteral strictures) was significantly lower (p=0.002716) for group 1 compared with group 2.
CONCLUSIONS
ICG facilitates the identification of key elements (anatomy and pathological structures) in the laparoscopic and robotic treatment of both malignant and benign urologic diseases, with possible impact on perioperative complications, along with oncologic and functional postoperative outcomes.
Topics: Aged; Female; Humans; Indocyanine Green; Male; Middle Aged; Urology
PubMed: 33721461
DOI: No ID Found -
World Journal of Surgical Oncology Jun 2023Cervical cancer (CC) is one of the most common gynaecologic malignancies. The prognosis of stage IIIC1p cervical cancer patients treated by surgery is heterogeneous....
BACKGROUND
Cervical cancer (CC) is one of the most common gynaecologic malignancies. The prognosis of stage IIIC1p cervical cancer patients treated by surgery is heterogeneous. Therefore, the aim of this study was to analyse the factors influencing the prognosis in such patients.
METHODS
From January 2012 to December 2017, 102 patients with cervical cancer who underwent surgical treatment in the Department of Gynaecology and Tumours, Changzhou Maternal and Child Health Hospital, and had pelvic lymph node metastasis confirmed by pathology were analysed retrospectively. All patients underwent radical hysterectomy with/without oophorectomy with pelvic lymphadenectomy with/without para-aortic lymphadenectomy. Clinical data was collected including age, surgical method, ovarian status, intraoperative blood loss, perioperative complications, tumour size, pathological type, depth of stromal invasion (DSI), whether the lymphatic vascular space was infiltrated, number of pelvic lymph node metastases, location of pelvic lymph node metastases, total number of lymph nodes resected, lymph node ratio (LNR), nature of vaginal margin, whether parametrium was involved, postoperative adjuvant therapy, preoperative neutrophil-lymphocyte ratio (NLR) and prognostic information of patients. Survival curves for overall survival (OS) and disease-free survival (DFS) were plotted using the Kaplan-Meier method, and the difference between the survival curves was tested using the log-rank test. Univariate and multivariate COX regression models were used to assess the factors associated with overall survival and disease-free survival in patients with stage IIIC1p cervical cancer. Nomogram plots were constructed to predict OS and DFS, and the predictive accuracy of the nomograms was measured by Harrell's C-index and calibration curves.
RESULTS
A total of 102 patients with stage IIIC1p cervical cancer were included in the study, and the median follow-up time was 63 months (range from 6 to 130 months). The 5-year OS was 64.7%, and the 5-year DFS was 62.7%. Multivariate analysis showed that no postoperative adjuvant therapy, LNR > 0.3 and NLR > 3.8 were independent risk factors for OS and DFS in patients with stage IIIC1p cervical cancer.
CONCLUSIONS
Patients with stage IIIC1p cervical cancer have a poor prognosis. Lower OS and DFS were associated with no postoperative adjuvant therapy, LNR > 0.3 and NLR > 3.8.
Topics: Female; Child; Humans; Prognosis; Retrospective Studies; Uterine Cervical Neoplasms; Lymphatic Metastasis; Neoplasm Staging; Lymph Node Excision; Lymph Nodes; Hysterectomy
PubMed: 37344912
DOI: 10.1186/s12957-023-03076-9