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The Indian Journal of Medical Research Aug 2021Locally advanced cervical cancer with the involvement of para-aortic lymph nodes (PALN) is a common occurrence in low-income and low-middle-income countries. With the... (Review)
Review
Locally advanced cervical cancer with the involvement of para-aortic lymph nodes (PALN) is a common occurrence in low-income and low-middle-income countries. With the incorporation of PALN in the recent FIGO staging, therapeutic management becomes crucial. There are varied presentations of this group which may range from microscopic involvement to extensive lymphadenopathy. Various imaging modalities have been studied to accurately diagnose PALN metastases without surgical intervention, while some investigators have studied the survival benefit of para-aortic lymph node dissection for accurate staging and guiding extent of radiation. With recent advances in radiation therapy, its application to treat bulky nodal metastases and the role of prophylactic irradiation have been reported. In this review, the available evidence and the scope of further interventions is presented.
Topics: Female; Humans; Lymph Nodes; Neoplasm Staging; Uterine Cervical Neoplasms
PubMed: 35295007
DOI: 10.4103/ijmr.IJMR_4183_20 -
European Journal of Cancer (Oxford,... Jul 2019To prospectively assess the diagnostic accuracy of a pelvic sentinel lymph node (SLN) algorithm in high-risk endometrial cancer (HREC). (Clinical Trial)
Clinical Trial
STUDY AIMS
To prospectively assess the diagnostic accuracy of a pelvic sentinel lymph node (SLN) algorithm in high-risk endometrial cancer (HREC).
PATIENTS AND METHODS
Consecutive women with presumed FIGO stage I-II HREC underwent robotic surgery at two academic centres by five accredited surgeons. An anatomically based algorithm was adhered to, following cervical injection of indocyanine green (ICG), with reinjection of tracer in case of non-display of predefined lymphatic pathways. After removal of SLNs, a pelvic and infrarenal para-aortic lymphadenectomy was performed. Primary end-point was sensitivity of the SLN-ICG algorithm. Secondary end-points were sensitivity of the overall SLN algorithm (including macroscopically suspect nodes as SLNs), SLN mapping rates and morbidity of the SLN procedure.
RESULTS
Two hundred fifty-seven women were analysed; 54 had pelvic lymph node metastases (LNMs), and 52 of those were correctly identified by the SLN-ICG algorithm. In two women (one with false-negative ICG-SLNs and one non-mapped woman), the pelvic LNMs were identified by the overall SLN algorithm. The SLN-ICG algorithm had a sensitivity of 98% (95% confidence interval [CI] 89-100) and a negative predictive value of 99.5% (95% CI 97-100). The sensitivity of the overall SLN algorithm was 100% (95% CI 92-100) and the negative predictive value was 100% (95% CI 98-100). The bilateral mapping rate was 95%. Two women (1%) had isolated para-aortic metastases. No adverse events occurred during the SLN procedure.
CONCLUSION
With a complete sensitivity to detect pelvic LNMs, the described pelvic SLN algorithm can, in the hands of experienced surgeons, exclude overall nodal involvement in 99% and thereby safely replace a full lymphadenectomy in HREC.
Topics: Adult; Aged; Aged, 80 and over; Algorithms; Endometrial Neoplasms; Female; Humans; Lymphatic Metastasis; Middle Aged; Neoplasm Staging; Pelvis; Robotic Surgical Procedures; Sensitivity and Specificity; Sentinel Lymph Node Biopsy; Surgery, Computer-Assisted
PubMed: 31181536
DOI: 10.1016/j.ejca.2019.04.025 -
Gynecologic Oncology Mar 2022Accurate staging of para-aortic nodal status in cervical cancer is of great importance for individualizing treatment and impacting outcomes. Three-dimensional imaging... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Accurate staging of para-aortic nodal status in cervical cancer is of great importance for individualizing treatment and impacting outcomes. Three-dimensional imaging (i.e. PET, CT, MRI) may miss para-aortic lymph node (PALN) metastases. The aim of this study was to systematically review and meta-analyze the proportion of upstaging by PALN dissection in patients with locally advanced cervical cancer without suspicious PALNs on imaging.
METHODS
PubMed/MEDLINE and Embase were systematically searched. The analysis included diagnostic studies that reported on 3D imaging and pre-therapeutic surgical assessment of PALN status in patients with cervical cancer. An overall pooled upstaging rate was calculated using a random-effects model.
RESULTS
The search identified 16 eligible studies including 18 cohorts with a total of 1530 patients. Pooling of 12 cohorts demonstrated an upstaging rate of 12% (95% confidence interval [CI] 10-15%) by PALN dissection after negative PET or PET-CT. Pooling of 6 cohorts demonstrated a pooled upstaging rate of 11% (95% CI: 8-16%) by PALN dissection after negative MRI or CT. No significant heterogeneity in upstaging proportions across cohorts was observed (I = 0% and 27%, respectively). In 7 cohorts including only patients with pelvic nodal metastases on imaging (but no suspicion of PALN involvement) a pooled upstaging rate by PALN dissection of 21% (95% CI: 17-26%) was found (I = 0%).
CONCLUSIONS
This meta-analysis demonstrates that in case of no suspicious PALN on PET-CT or MRI, PALN dissection still identifies lymph node metastases in a considerable amount of patients with locally advanced cervical cancer and especially in those patients with confirmed pelvic nodal metastases.
Topics: Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Neoplasm Staging; Positron Emission Tomography Computed Tomography; Uterine Cervical Neoplasms
PubMed: 34969533
DOI: 10.1016/j.ygyno.2021.12.026 -
Journal of Cancer Research and... 2019This study investigated potential preoperative predictors of pelvic lymph node (PLN) and para-aortic LN (PaLN) involvement in cervical cancer (CC).
AIM
This study investigated potential preoperative predictors of pelvic lymph node (PLN) and para-aortic LN (PaLN) involvement in cervical cancer (CC).
MATERIALS AND METHODS
This study retrospectively analyzed 283 patients diagnosed with early (stage IA1-IIA) CC who underwent retroperitoneal LN dissection between January 1992 and February 2015. Several risk factors that are believed to influence PLN and PaLN involvement in CC were analyzed as follows: age >50 years, lymphovascular space invasion (LVSI), tumor size ≥2 cm, hemoglobin <12 g/dL, and nonsquamous cell histologic type.
RESULTS
LVSI (odds ratio [OR] = 11.3, 95% confidence interval [CI] = 5.2-24.3) and tumor size (OR = 3.2, 95% CI = 1.4-7.2) were independent predictors of PLN involvement. None of the factors predicted PaLN involvement in a regression analysis. However, all nine patients who had PaLN involvement also had PLN involvement.
CONCLUSION
LVSI and tumor size independently increase the risk of PLN involvement.
Topics: Adult; Clinical Decision-Making; Combined Modality Therapy; Disease Management; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Middle Aged; Neoplasm Invasiveness; Neoplasm Staging; Pelvis; Preoperative Period; Treatment Outcome; Tumor Burden; Uterine Cervical Neoplasms
PubMed: 31898653
DOI: 10.4103/jcrt.JCRT_467_17 -
European Journal of Nuclear Medicine... Jul 2023To develop machine learning models to predict para-aortic lymph node (PALN) involvement in patients with locally advanced cervical cancer (LACC) before chemoradiotherapy...
PURPOSE
To develop machine learning models to predict para-aortic lymph node (PALN) involvement in patients with locally advanced cervical cancer (LACC) before chemoradiotherapy (CRT) using F-FDG PET/CT and MRI radiomics combined with clinical parameters.
METHODS
We retrospectively collected 178 patients (60% for training and 40% for testing) in 2 centers and 61 patients corresponding to 2 further external testing cohorts with LACC between 2010 to 2022 and who had undergone pretreatment analog or digital F-FDG PET/CT, pelvic MRI and surgical PALN staging. Only primary tumor volumes were delineated. Radiomics features were extracted using the Radiomics toolbox®. The ComBat harmonization method was applied to reduce the batch effect between centers. Different prediction models were trained using a neural network approach with either clinical, radiomics or combined models. They were then evaluated on the testing and external validation sets and compared.
RESULTS
In the training set (n = 102), the clinical model achieved a good prediction of the risk of PALN involvement with a C-statistic of 0.80 (95% CI 0.71, 0.87). However, it performed in the testing (n = 76) and external testing sets (n = 30 and n = 31) with C-statistics of only 0.57 to 0.67 (95% CI 0.36, 0.83). The ComBat-radiomic (GLDZM_HISDE_PET_FBN64 and Shape_maxDiameter2D3_PET_FBW0.25) and ComBat-combined (FIGO 2018 and same radiomics features) models achieved very high predictive ability in the training set and both models kept the same performance in the testing sets, with C-statistics from 0.88 to 0.96 (95% CI 0.76, 1.00) and 0.85 to 0.92 (95% CI 0.75, 0.99), respectively.
CONCLUSIONS
Radiomic features extracted from pre-CRT analog and digital F-FDG PET/CT outperform clinical parameters in the decision to perform a para-aortic node staging or an extended field irradiation to PALN. Prospective validation of our models should now be carried out.
Topics: Female; Humans; Positron Emission Tomography Computed Tomography; Fluorodeoxyglucose F18; Uterine Cervical Neoplasms; Retrospective Studies; Lymph Nodes; Magnetic Resonance Imaging
PubMed: 36892667
DOI: 10.1007/s00259-023-06180-w -
Clinical and Translational Radiation... Jul 2022Patients with locally advanced cervical cancer without para-aortic lymph node metastases (PAO-LNM) at diagnosis who undergo concurrent chemoradiotherapy are at 4-11%... (Review)
Review
BACKGROUND
Patients with locally advanced cervical cancer without para-aortic lymph node metastases (PAO-LNM) at diagnosis who undergo concurrent chemoradiotherapy are at 4-11% risk of developing PAO-LNM during follow-up. Some studies suggest a beneficial influence of elective para-aortic radiotherapy (PAO-RT) on disease-free survival (DFS) in these patients. The aim of this study was to systematically review and meta-analyse literature on the impact of PAO-RT on DFS in cervical cancer patients.
METHODS
A systematic search of PubMed/MEDLINE and EMBASE databases was performed. The analysis included intervention studies that reported on DFS in patients with cervical cancer who received chemotherapy and pelvic radiotherapy with or without PAO-RT. From each included study, relevant study characteristics and outcome data including the hazard ratio (HR) adjusted for potential confounders were extracted. An overall pooled adjusted hazard ratio (aHR) for DFS after PAO-RT versus no PAO-RT was calculated using a random-effects model.
RESULTS
A total of 2,016 articles were evaluated. Eleven articles were included in the systematic review, of which 3 were appropriate for quantitative meta-analysis. Pooling of these 3 cohorts (including 1,113 patients) demonstrated a statistically significant association between PAO-RT and DFS (pooled aHR 0.87, 95% confidence interval: 0.79-0.97). No significant heterogeneity among reported aHRs was observed (I = 0.0%).
CONCLUSIONS
This meta-analysis suggests a modest but significant beneficial impact of elective para-aortic radiotherapy on DFS in patients with locally advanced cervical cancer who undergo concurrent chemoradiotherapy. This finding based on non-randomized studies provides an imperative for further investigation in prospective controlled trials.
PubMed: 35669003
DOI: 10.1016/j.ctro.2022.05.006 -
Surgical Oncology May 2022Para-aortic lymph node (PALN) metastases in pancreatic ductal adenocarcinoma (PDAC) correlates with poor prognosis. The role of PALN in invasive intraductal papillary...
Prognostic impact of para-aortic lymph node status in resected pancreatic ductal adenocarcinoma and invasive intraductal papillary mucinous neoplasm - Time to consider a reclassification?
BACKGROUND
Para-aortic lymph node (PALN) metastases in pancreatic ductal adenocarcinoma (PDAC) correlates with poor prognosis. The role of PALN in invasive intraductal papillary mucinous neoplasms (inv-IPMN) has not been well explored. The present study investigated the rate of metastatic PALN, lymph node ratio (LNR) and the overall nodal (N) status as prognostic factors in PDAC and inv-IPMN.
METHODS
This consecutive single-center series included patients with PDAC or inv-IPMN in the pancreatic head who underwent pancreatoduodenectomy or total pancreatectomy, including PALN resection between 2009 and 2018. Median overall survival (mOS) and impact of clinicopathological factors, including PALN status on survival, were evaluated.
RESULTS
403 patients were included, 314 had PDAC and 89 inv-IPMN. PALN were metastatic in 16% of PDAC and 17% of inv-IPMN. N0 status was present in 6% of the patients with PDAC and 16% of inv-IPMN patients (p = 0.007). LNR >15% was more common in PDAC (52%) than in inv-IPMN (34%) (p = 0.004). mOS was 12.7 months in the presence of PALN metastases and 22.7 months without (p < 0.0001). Age >70 years, CA19-9 >200 U/mL, PDAC and N2 status were significantly associated with worse survival in a multivariable analysis. PALN status and LNR were not independent prognostic factors. In N2 status mOS was similar regardless the presence of PALN metastases.
CONCLUSION
The frequency of PALN metastases was similar in PDAC and inv-IPMN. Although PALN positive status entailed a shorter mOS, it was not an independent risk factor for death, and did not influence survival in N2-staged disease. The M1-status for PALN positivity may need reconsideration.
Topics: Adenocarcinoma, Mucinous; Aged; Carcinoma, Pancreatic Ductal; Humans; Lymph Nodes; Pancreatectomy; Pancreatic Intraductal Neoplasms; Pancreatic Neoplasms; Prognosis; Retrospective Studies
PubMed: 35287096
DOI: 10.1016/j.suronc.2022.101735 -
Frontiers in Medicine 2021To systematically evaluate lymph node metastasis (LNM) patterns in patients with endometrial cancer (EC) who underwent complete surgical staging, which included...
To systematically evaluate lymph node metastasis (LNM) patterns in patients with endometrial cancer (EC) who underwent complete surgical staging, which included systematic pelvic and para-aortic lymphadenectomy. Four thousand and one patients who underwent complete surgical staging including systematic pelvic and para-aortic lymphadenectomy for EC were enrolled from 30 centers in China from 2001 to 2019. We systematically displayed the clinical and prognostic characteristics of patients with various LNM patterns, especially the PLN-PAN+ [para-aortic lymph node (PAN) metastasis without pelvic lymph node (PLN) metastasis]. The efficacy of PAN+ (para-aortic lymph node metastasis) prediction with clinical and pathological features was evaluated. Overall, 431 of the 4,001 patients (10.8%) showed definite LNM according to pathological diagnosis. The PAN+ showed the highest frequency (6.6%) among all metastatic sites. One hundred fourteen cases (26.5%) were PLN-PAN+ (PAN metastasis without PLN metastasis), 167 cases (38.7%) showed PLN+PAN-(PLN metastasis without PAN metastasis), and 150 cases (34.8%) showed metastasis to both regions (PLN+PAN+). There was also 1.9% (51/2,660) of low-risk patients who had PLN-PAN+. There are no statistical differences in relapse-free survival (RFS) and disease-specific survival (DSS) among PLN+PAN-, PLN-PAN+, and PLN+PAN+. The sensitivity of gross PLNs, gross PANs, and lymphovascular space involvement (LVSI) to predict PAN+ was 53.8 [95% confidence interval (CI): 47.6-59.9], 74.2 95% CI: 65.6-81.4), and 45.8% (95% CI: 38.7-53.2), respectively. Over one-fourth of EC patients with LMN metastases were PLN-PAN+. PLN-PAN+ shares approximate survival outcomes (RFS and DSS) with other LNM patterns. No effective clinical methods were achieved for predicting PAN+. Thus, PLN-PAN+ is a non-negligible LNM pattern that cannot be underestimated in EC, even in low-risk patients.
PubMed: 34746191
DOI: 10.3389/fmed.2021.754890 -
BMC Women's Health Apr 2022Endometriosis is a common benign gynecological disease characterized by growing-functioning endometrial tissue outside the uterus. Extra-pelvic endometriosis, which... (Review)
Review
BACKGROUND
Endometriosis is a common benign gynecological disease characterized by growing-functioning endometrial tissue outside the uterus. Extra-pelvic endometriosis, which accounts for approximately 12% of endometriosis, is more challenging to diagnose because of its distance from the pelvic organs. Halban's theory of benign metastasis indicates that endometrial cells can appear in extra-pelvic organs via lymphatic and blood vessels, but endometrial lymph node metastasis cases are still rare. We report a case of endometriosis in a para-aortic lymph node whose clinical behavior mimicked a malignancy.
CASE PRESENTATION
A 52-year-old perimenopausal woman underwent laparoscopic hysterectomy plus bilateral salpingectomy (the patient insisted on the preservation of her ovaries) at a local hospital 2 years earlier because of adenomyosis. The patient presented with a complaint of low back pain to the gastrointestinal outpatient department of our hospital. The carbohydrate antigen 125 (CA125) was abnormally elevated at 5280.20 U/ml, human epididymis 4 (HE4) was 86.0 pmol/L, while other tumor markers were normal. Serum female hormone results were in the postmenopausal range, and her gastroenteroscopy showed no abnormalities. Moreover, both enhanced magnetic resonance imaging and positron emission tomography-computed tomography showed a high possibility of a retroperitoneal malignant lymph node (metastasis possible, primary site unknown). One week after admission, she underwent laparoscopic exploratory surgery, during which we observed normal shape and size of both ovaries while the left ovary was cystic-solid. After opening the retroperitoneal space, an enlarged lymph node-like tissue measuring 8 × 4 × 3 cm was found near the abdominal aorta. When the surrounding adhesions were separated, lymph node-like tissue was poorly demarcated from the abdominal aorta and renal artery. Some lymph node samples and left ovary were sent for intraoperative frozen section, which revealed benign lesions, similar to endometrial tissue. The lymph node tissue was then excised as much as possible, and the second set of intraoperative frozen sections showed high probability of endometrial tissue. The final histopathology and immunohistochemistry staining reached a diagnosis of para-aortic lymph node endometriosis. Gonadotropin-releasing hormone antigen treatment was recommended every 28 days because of the high preoperative CA125 and imaging-based suspicion of malignancy. The serum CA125 subsequently decreased to normal levels, and no para-aortic lesions were detected on abdominal enhancement CT. She is being followed up regularly.
CONCLUSION
It is known that the incidence of lymph node metastasis in pelvic endometriosis is relatively rare. Our report shows that endometriotic tissue can metastasize via the lymphatic route and suggests that endometriotic tissue has the characteristics of invasion and metastasis.
Topics: Endometrial Neoplasms; Endometriosis; Female; Humans; Lymph Nodes; Lymphatic Metastasis; Magnetic Resonance Imaging; Male; Middle Aged
PubMed: 35379213
DOI: 10.1186/s12905-022-01659-4 -
Therapeutic Advances in Medical Oncology 2020The aim of this study was to clarify the features and prognostic significance of isolated para-aortic lymphatic metastasis of endometrial cancer.
BACKGROUND
The aim of this study was to clarify the features and prognostic significance of isolated para-aortic lymphatic metastasis of endometrial cancer.
METHODS
A retrospective study of patients with stage IIIC endometrial cancer was performed based on the Surveillance, Epidemiology, and End Results (SEER) database. A total of 2767 patients were divided into three groups according to the lymphatic metastasis patterns: isolated pelvic lymphatic metastasis, isolated para-aortic lymphatic metastasis and dual lymphatic metastasis. The clinic-pathological characteristics and prognosis of patients were compared among the three groups.
RESULT
The proportion of patients with isolated para-aortic lymphatic metastasis was 13.70%. Patients with isolated pelvic lymphatic metastasis or isolated para-aortic lymphatic metastasis shared similar histological characteristics, except that patients with isolated para-aortic lymphatic metastasis had a lower proportion of tumors over 5 cm in diameter than patients with isolated pelvic lymphatic metastasis (35.1% 45.7%, = 0.001). Compared with patients with dual lymphatic metastasis, isolated para-aortic lymphatic metastasis was more common in patients with endometrioid tumors (78.6% 67.3%, < 0.001), grade 1-2 cancers (53.3% 36.3%, < 0.001) and negative peritoneal cytology (76.2% 61.1%, < 0.001). Dual lymphatic metastasis was an independent predictive factor for the poor outcomes of patients at stage IIIC. However, in stage IIIC endometrioid tumors, patients with isolated pelvic lymphatic metastasis and those with isolated para-aortic lymphatic metastasis shared similar prognosis. Patients at stage IIIC with nonendometrioid tumors and patients at stage IV could not be further divided into subgroups according to lymphatic metastasis patterns in terms of prognosis.
CONCLUSION
Endometrioid patients with isolated pelvic lymphatic metastasis and isolated para-aortic lymphatic metastasis share similar clinical pathological characteristics and prognoses.
PubMed: 32587635
DOI: 10.1177/1758835920933036