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American Society of Clinical Oncology... Jan 2024Prostate cancer (PCa) is the second most commonly diagnosed cancer in men with around 1.4 million new cases every year. In patients with localized disease, management...
Prostate cancer (PCa) is the second most commonly diagnosed cancer in men with around 1.4 million new cases every year. In patients with localized disease, management options include active surveillance (AS), radical prostatectomy (RP; with or without pelvic lymph node dissection), or radiotherapy to the prostate (with or without pelvic irradiation) with or without hormonotherapy. In advanced disease, treatment options include systemic treatment(s) and/or treatment to primary tumour and/or metastasis-directed therapies (MDTs). Specifically, in advanced stage, the current trend is earlier intensification of treatment such as dual or triple combination systemic treatments or adding treatment to primary and MDT to systemic treatment. However, earlier treatment intensification comes with the cost of increased morbidity and mortality resulting from drug-/treatment-related side effects. The main goal is and should be to provide the best possible care and oncologic outcomes with minimum possible side effects. This chapter will explore emerging possibilities to de-escalate treatment in PCa driven by enhanced insights into disease biology and the natural course of PCa such as AS in intermediate-risk disease or salvage versus adjuvant radiotherapy in post-RP patients. Considerations arising from advancements in PCa imaging and technological advancements in surgical and radiation therapy techniques including omitting pelvic lymph node dissection in the era of prostate-specific membrane antigen positron emitting tomography, the potential of MDT to delay/omit systemic treatment in metachronous oligorecurrence, and the efficacy of hypofractionation schemes compared with conventional fractionated radiotherapy will be discussed.
Topics: Male; Humans; Prostatic Neoplasms; Drug-Related Side Effects and Adverse Reactions; Lymph Node Excision; Medical Oncology; Neoplasms, Second Primary
PubMed: 38206291
DOI: 10.1200/EDBK_430466 -
Chinese Clinical Oncology Apr 2021Pelvic and para-aortic lymphadenectomy are associated with increased risk of complications and are responsible for a significant proportion of morbidity and impaired... (Review)
Review
Pelvic and para-aortic lymphadenectomy are associated with increased risk of complications and are responsible for a significant proportion of morbidity and impaired quality of life following surgical management of pelvic malignancies. Sentinel lymph node (SLN) was developed as a trade-off between systematic and no lymphadenectomy to limit morbidity while conserving good oncological staging and outcomes. In this comprehensive review, we aimed to synthetize the anatomical basis of the SLN procedure in patients with pelvic malignancies from a surgical perspective. The reliability of the SLN procedure is based on the knowledge of the dissemination pathways for each type of tumors. The most recent understanding of the uterine lymphatic anatomy defined three consistent channels: an upper paracervical pathway (UPP) with draining medial external and/or obturator lymph nodes; a lower paracervical pathway (LPP) with draining internal iliac and/or presacral lymph nodes and the infundibulo-pelvic pathway (IPP) with a course along the fallopian tube and upper broad ligament via the infundibulo-pelvic ligament to its origin. In patients with endometrial cancer, most SLNs are located on the UPP pathway: obturator and external iliac whereas 80% of the SLNs in patients with cervical cancer are located in the external iliac, interiliac and obturator area. Surgical training is a key step toward improving detection rates and exhaustiveness of SLN research while reducing overall morbidity. This is all the more important that the indications for performing complete lymphadenectomy are becoming increasingly rare.
Topics: Endometrial Neoplasms; Female; Humans; Lymph Nodes; Neoplasm Staging; Quality of Life; Reproducibility of Results; Sentinel Lymph Node Biopsy; Uterine Cervical Neoplasms
PubMed: 33548983
DOI: 10.21037/cco-20-228 -
Minerva Urology and Nephrology Dec 2022Prostate cancer and bladder cancer accounts for approximately 13.5% and 3% of all male cancers and all newly diagnosed cancers (regardless sex), respectively. Thus,... (Review)
Review
Prostate cancer and bladder cancer accounts for approximately 13.5% and 3% of all male cancers and all newly diagnosed cancers (regardless sex), respectively. Thus, these cancers represent a major health and economic burden globally. The knowledge of lymph node status is an integral part of the management of any solid tumor. In the urological field, pelvic lymph node dissection (PLND) is of paramount importance in the diagnosis, management, and prognosis of prostate and bladder cancers. However, PLND may be associated with several comorbidities. In this narrative review, the most recent updates concerning the patterns and incidence of lymph node metastasis, the role of different imaging studies and nomograms in determining patients' eligibility for PLND, and the anatomical templates of PLND in urologic patients with bladder or prostate cancer will be discussed.
Topics: Humans; Male; Prostate; Lymph Node Excision; Prostatic Neoplasms; Urinary Bladder Neoplasms; Pelvis
PubMed: 36197698
DOI: 10.23736/S2724-6051.22.04904-7 -
International Angiology : a Journal of... Apr 2021The aim of this study was to investigate the effect of maintaining opened distal lymphatic vessels of external iliac lymph nodes on lymphedema and lymphocyst formation... (Observational Study)
Observational Study
BACKGROUND
The aim of this study was to investigate the effect of maintaining opened distal lymphatic vessels of external iliac lymph nodes on lymphedema and lymphocyst formation of lower limbs after pelvic lymphadenectomy.
METHODS
Prospective single center observational study was carried out in 83 patients with gynecological malignancies who underwent pelvic lymphadenectomy. During the operation, the distal lymphatic vessels of the external iliac lymph nodes were cut off by an ultrasound scalpel or scissors, and the proximal end was closed by bipolar coagulation. The patients were re-examined by a physical examination, ultrasound examination and inquiry of the symptoms within 2 years after the operation to check whether they had lower limb lymphedema and to analyze the presence of lymphedema and lymphocyst of lower limbs and the risk.
RESULTS
The incidence of lower limb lymphedema (LLL) was 21.6% (18/83). Among the patients with LLL, 5.5% (1/18) was diagnosed with stage 0 according to the criteria of International Society of Lymphology, 83.3% (15/18) with stage 1, and 11.1% (2/18) with stage 2. Presently, there was no lymphedema diagnosed at stage 3. The incidence of lymphocyst was 7.2% (6/83). Among the patients with lymphocyst, 3.6% (3/83) occurred 1 month after operation, 2.4% (2/83) occurred 3 months after operation and 1.2% (1/83) occurred 6 months after operation. Patients with radiotherapy and abdominal infection were more likely to suffer from LLL (P<0.05).
CONCLUSIONS
Maintaining opened distal lymphatic vessels of external iliac lymph nodes during pelvic lymphadenectomy is feasible, safe and with a 21.6% and 7.2% of potential lymphedema and lymphocists, respectively.
Topics: Humans; Lower Extremity; Lymph Node Excision; Lymph Nodes; Lymphedema; Prospective Studies
PubMed: 33300763
DOI: 10.23736/S0392-9590.20.04486-7 -
World Journal of Surgical Oncology Nov 2022The debate surrounding systematic lymphadenectomy in the epithelial cancers of the ovary (EOC) was temporarily put to rest by the LION trial. However, there was a... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The debate surrounding systematic lymphadenectomy in the epithelial cancers of the ovary (EOC) was temporarily put to rest by the LION trial. However, there was a glaring disparity between the number of patients registered and the number of patients randomized suggesting inadvertent selection. A subsequent meta-analysis after this trial included all types of studies in the literature (randomized, non-randomized, case series, and, retrospective cohort), thus diluting the results.
METHODS
We conducted a meta-analysis of hazard ratios of randomized controlled trials, to study the role of systematic para-aortic and pelvic lymph node dissection in the EOC. A detailed search of MEDLINE, Cochrane, and Embase databases was done to look for the published randomized controlled trials (RCT) comparing lymphadenectomy versus no lymphadenectomy in EOC. A meta-analysis of hazard ratios (HR) was performed for overall survival (OS) and progression-free survival (PFS) using fixed and random effect models. The quality of the RCTs was evaluated on Jadad's score, and the risk of bias was estimated by the Cochrane tool.
RESULTS
A total of 1342 patients with EOC were included for quantitative analysis. On meta-analysis, HR for PFS was 0.9 (95% CI 0.79-1.04) favoring lymphadenectomy. HR for OS was 1 (95% CI 0.84-1.18) signifying no benefit of systematic lymphadenectomy.
CONCLUSION
The results show a trend towards increased PFS which did not reach statistical significance nor translate into any meaningful benefit in OS. There is still a need for a greater number of well-conducted, suitably powered trials to convincingly answer this question.
Topics: Female; Humans; Randomized Controlled Trials as Topic; Lymph Node Excision; Proportional Hazards Models; Ovarian Neoplasms; Progression-Free Survival
PubMed: 36419077
DOI: 10.1186/s12957-022-02835-4 -
European Journal of Cancer (Oxford,... Dec 2023The aim of this study was to assess the disease-free survival (DFS) and overall survival (OS) of patients with grade 1-2 endometrioid ovarian carcinoma apparently... (Observational Study)
Observational Study
OBJECTIVE
The aim of this study was to assess the disease-free survival (DFS) and overall survival (OS) of patients with grade 1-2 endometrioid ovarian carcinoma apparently confined to the ovary, according to surgical staging.
METHODS
Multicenter, retrospective, observational cohort study. Patients with endometrioid ovarian carcinoma, surgical procedure performed between May 1985 and December 2019, stage pT1 N0/N1/Nx, grade 1-2 were included. Patients were stratified according to lymphadenectomy (defined as removal of any lymph node versus no lymph node assessment), and subgroup analyses according to tumor grade were performed. Kaplan-Meier curves and cox regression analyses were used to perform survival analyses.
RESULTS
298 patients were included. 199 (66.8 %) patients underwent lymph node assessment. Of these, 166 (83.4 %) had unilateral/bilateral pelvic and para-aortic/caval lymphadenectomy. Eleven (5.5 %) patients of those who underwent lymph node assessment showed pathologic metastatic lymph nodes (FIGO stage IIIA1). Twenty-seven patients (9.1 %) had synchronous endometrioid endometrial cancer. After a median follow up of 45 months (95 %CI:37.5-52.5), 5-year DFS and OS of the entire cohort were 89.8 % and 96.2 %, respectively. Age ≤ 51 years (HR=0.24, 95 %CI:0.06-0.91; p = 0.036) and performance of lymphadenectomy (HR=0.25, 95 %CI: 0.07-0.82; p = 0.022) represented independent protective factors toward risk of death. Patients undergoing lymphadenectomy had better 5-year DFS and OS compared to those not receiving lymphadenectomy, 92.0 % versus 85.6 % (p = 0.016) and 97.7 % versus 92.8 % (p = 0.013), respectively. This result was confirmed after exclusion of node-positive patients. When stratifying according to tumor grade (node-positive excluded), patients with grade 2 who underwent lymphadenectomy had better 5-year DFS and OS than those without lymphadenectomy (93.0 % versus 83.1 %, p = 0.040 % and 96.5 % versus 90.6 %, p = 0.037, respectively).
CONCLUSION
Staging lymphadenectomy in grade 2 endometrioid ovarian carcinoma patients was associated with improved DFS and OS. Grade 1 and grade 2 might be considered as two different entities, which could benefit from different approach in terms of surgical staging. Prospective studies, including molecular profiles are needed to confirm the survival drivers in this rare setting.
Topics: Female; Humans; Middle Aged; Retrospective Studies; Prospective Studies; Neoplasm Staging; Lymph Nodes; Carcinoma, Endometrioid; Lymph Node Excision; Carcinoma, Ovarian Epithelial; Ovarian Neoplasms; Endometrial Neoplasms
PubMed: 37890354
DOI: 10.1016/j.ejca.2023.113398 -
Seminars in Oncology 2020The incidence of endometrial cancer, the most common gynecological malignancy, is increasing as life expectancy and obesity both rise. Lymph node status is the most... (Review)
Review
The incidence of endometrial cancer, the most common gynecological malignancy, is increasing as life expectancy and obesity both rise. Lymph node status is the most important predictor for outcome, yet routine lymphadenectomy does not confer a survival benefit and is associated with substantial surgical morbidity. In the last decade, sentinel lymph node (SLN) mapping has emerged as a feasible and accurate alternative to full lymphadenectomy. Yet, SLN has introduced a distinction between micro- and macrometastasis, and the entity of non-SLN involvement with their attendant impact on outcome. Included among the raised issues is the question of whether positive sentinel nodes should be followed by pelvic and/or para-aortic lymphadenectomy dependent on the presence of macrometastasis at frozen section or other criteria. Moreover, the proper adjuvant treatment for individual cases with micrometastasis and/or isolated tumor cells is unclear. Recently published data on this topic are summarized in order to optimize the current treatment algorithm as it relates to the results of SLN assessment in endometrial cancer.
Topics: Algorithms; Endometrial Neoplasms; Female; Humans; Lymphatic Metastasis; Neoplasm Staging; Sentinel Lymph Node; Sentinel Lymph Node Biopsy
PubMed: 32513418
DOI: 10.1053/j.seminoncol.2020.04.006 -
Fertility and Sterility Sep 2021Iatrogenic causes of male infertility can include medications, chemotherapy, radiation, and surgery. In this review, we discuss commonly performed urologic cancer... (Review)
Review
Iatrogenic causes of male infertility can include medications, chemotherapy, radiation, and surgery. In this review, we discuss commonly performed urologic cancer surgeries and nonurologic surgeries that harbor a high risk of iatrogenic infertility. These include radical prostatectomy, radical cystectomy, retroperitoneal lymph node dissection, pelvic colon surgery, and anterior spine surgery. In addition, we review the anatomy and surgical strategies that help to reduce the risks of infertility. With an increase in life expectancy and improvements in fertility preservation, it is important to properly counsel patients about the risks of infertility and provide options for fertility preservation before surgery.
Topics: Azoospermia; Colectomy; Cystectomy; Ejaculation; Fertility; Fertility Preservation; Humans; Iatrogenic Disease; Infertility, Male; Lumbar Vertebrae; Lymph Node Excision; Male; Neoplasms; Orthopedic Procedures; Prostatectomy; Risk Factors
PubMed: 34462097
DOI: 10.1016/j.fertnstert.2021.07.1200 -
Folia Morphologica 2023Anatomical variations are defined as atypical morphologic and positional presentations of anatomical entities. Pelvic anatomical variations encountered during abdominal... (Review)
Review
BACKGROUND
Anatomical variations are defined as atypical morphologic and positional presentations of anatomical entities. Pelvic anatomical variations encountered during abdominal hysterectomy can be of clinical interest, given that misidentification of certain structures can lead to iatrogenic injuries and postoperative sequelae. The aim of the present study was to detect and highlight the anatomical structures of interest and their variations to the surgeon performing abdominal hysterectomy for benign conditions.
MATERIALS AND METHODS
A narrative review of the literature was performed including reports of anatomical variations encountered in cadavers, by surgeons during abdominal hysterectomy and radiologists on computed tomography angiography, searching within a 10-year span on PubMed database. Studies regarding the treatment of malignant conditions requiring lymphadenectomy and different modes of surgical approach were reviewed with regards to the aspects relevant to benign conditions. The search was extended to the reference lists of all retrieved articles.
RESULTS
Ureters and the uterine arteries, due to anatomical variations, are the anatomical structures most vulnerable during abdominal hysterectomy. Specifically, the ureters can present multiplications, retroiliac positionings and ureteric diverticula, whereas, the uterine arteries can present notable variability in their origins. Such variations can be detected preoperatively or intraoperatively.
CONCLUSIONS
Although rare, the presence of anatomical variations of the uterine arteries and ureters can increase the possibility of complications should they escape detection. Intraoperative misidentification could lead to improper dissection or ligation of the affected structures. Knowledge of these variations, coupled with extensive preoperative investigation and intraoperative vigilance can minimise the risk of complications.
Topics: Female; Humans; Hysterectomy; Pelvis; Ureter
PubMed: 36254107
DOI: 10.5603/FM.a2022.0089 -
Medicina (Kaunas, Lithuania) Nov 2022: We aimed to evaluate Progression Free Survival (PFS), Overall Survival (OS), and relapse rate in women affected by endometrioid ovarian cancer and synchronous...
Progression Free Survival, Overall Survival, and Relapse Rate in Endometrioid Ovarian Cancer and Synchronous Endometrial-Ovarian Endometrioid Cancer (SEO-EC): Results from a Large Retrospective Analysis.
: We aimed to evaluate Progression Free Survival (PFS), Overall Survival (OS), and relapse rate in women affected by endometrioid ovarian cancer and synchronous endometrial-ovarian endometrioid cancer (SEO-EC). As secondary outcome, we assessed whether systematic pelvic and para-aortic lymphadenectomy could be considered a determinant of relapse rate in this population. : We performed a retrospective analysis of women with diagnosis of endometrioid ovarian cancer or SEO-EC between January 2010 to September 2020, and calculated PFS, OS and relapse rate. : In almost all the patients (97.6%) who underwent systematic pelvic and para-aortic lymphadenectomy, there were no lymph node metastases confirmed by histology. We did not find a significant difference ( = 0.6570) for the rate of relapse in the group of women who underwent systematic pelvic and para-aortic lymphadenectomy (4/42; 9.5%) compared with the group of women who did not undergo the same procedure (1/21; 4.8%). During a median follow-up was 23 months, both PFS and OS were excellent. : Women affected by early-stage low-grade endometrioid cancer and SEO-EC without apparent lymph node involvement at pre-operative imaging showed a very low rate of lymph node metastasis and similar relapse rate with or without lymphadenectomy.
Topics: Humans; Female; Retrospective Studies; Progression-Free Survival; Endometrial Neoplasms; Neoplasm Staging; Carcinoma, Endometrioid; Lymph Node Excision; Carcinoma, Ovarian Epithelial; Ovarian Neoplasms; Recurrence; Survival Rate
PubMed: 36556908
DOI: 10.3390/medicina58121706