Surgery without radiotherapy for primary treatment of endometrial cancer

Objective: To analyze the role of surgery alone, including pelvic and para-aortic lymphadenectomy, in patients with endometrial cancer who did not receive radiotherapy.Methods: Between August 1987 and January 1997, 225 women with disease clinically confined to the uterus were staged surgically by a standard protocol that included pelvic and para-aortic lymphadenectomy in women with high risk factors. No radiation was administered before or after surgery.Results: The combination of preoperative endometrial biopsy grade and gross depth of myometrial invasion identified 123 (55%) high-risk patients who had lymphadenectomy and 102 (45%) low-risk patients who did not. Eighteen (15%) high-risk patients had lymph node metastases and received postoperative systemic therapy. Three low-risk, eight high-risk-node-negative, and no high-risk-node-positive patients were diagnosed with recurrent cancer, corresponding to 5-year recurrence-free proportions of 0.95, 0.89, and 1.00, respectively. Although sample sizes and limited follow-up limit conclusions, the experience to date suggests a high rate of survival in all three groups.Conclusion: Our preliminary experience indicates that even high-risk patients have an excellent prognosis when treated with surgery, including pelvic and para-aortic lymphadenectomy, without radiotherapy.     

Pelvic and para-aortic lymphadenectomy for surgical staging of endometrial cancer: morbidity and mortality.

This analysis compared retrospectively the morbidity and mortality of patients with endometrial cancer who had total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH/BSO) alone or with pelvic and para-aortic lymphadenectomy performed by the same surgeon at one private institution. Between August 1987 and March 1991, 77 women with endometrial cancer were staged surgically by a standard protocol without preoperative radiotherapy. Thirty-five patients (45%) had TAH/BSO alone and 42 (55%) had TAH/BSO with pelvic and para-aortic lymphadenectomy. The median number of lymph nodes removed was 18. Patients having lymphadenectomy had an increased mean (+/- standard deviation) operative time (129 +/- 29 versus 87 +/- 26 minutes; P less than .0001), increased mean estimated blood loss (391 +/- 192 versus 272 +/- 219 mL; P = .013), and a longer postoperative hospital stay (P = .017) compared with patients having TAH/BSO alone. However, there was no difference in transfusion rate, febrile morbidity, postoperative complications, or mortality. We conclude that pelvic and para-aortic lymphadenectomy can be added to TAH/BSO in patients with endometrial cancer without a clinically significant increase in morbidity or mortality.     

Robot assisted laparoscopic transperitoneal para-aortic lymphadenectomy in the management of advanced cervical carcinoma

ObjectivesAdequate staging of advanced cervical cancer is essential in order to optimally treat the patient. FIGO clinical staging, imaging techniques such as CT scan, MRI and PET sometimes underestimate the extension of tumors. The presence of para-aortic lymph node metastases in advanced cervical cancer identifies patients with poor prognosis who need to be treated aggressively. Laparoscopic para-aortic lymph node dissection is now proposed as a diagnostic tool in many guidelines. We evaluated the feasibility and safety of a robot assisted laparoscopic transperitoneal approach to para-aortic lymph node dissection.Study designEight patients with advanced cervical carcinoma who were eligible for primary pelvic radiotherapy combined with concurrent cisplatin chemotherapy or pelvic exenteration underwent a pre-treatment robot assisted transperitoneal laparoscopic para-aortic lymphadenectomy.ResultsWe isolated from 1 to 38 para-aortic nodes per patient and had one para-aortic node positive patient who was treated with extended doses of pelvic radiotherapy. We did not encounter any major complications and post-operative morbidity was low.ConclusionsRobot assisted transperitoneal laparoscopic para-aortic lymphadenectomy is feasible and provides the surgeon with greater precision than classical laparoscopy. Larger prospective multicentric trials are needed to validate the generalised usefulness of this technique.     

腹主动脉旁淋巴结切除在子宫内膜癌手术治疗中的意义

目的:探讨腹主动脉旁淋巴结切除对子宫内膜癌手术病理分期及预后的影响。方法:回顾性分析我院行系统性盆腔及腹主动脉旁淋巴结切除的68例子宫内膜癌患者的临床病理资料。结果:15例(22.1%)发生淋巴结转移的患者中,12例(17.6%)发生盆腔淋巴结转移,7例(10.3%)发生腹主动脉旁淋巴结转移,其中4例(5.9%)患者同时出现盆腔及腹主动脉旁淋巴结转移,3例(4.4%)为单纯腹主动脉旁淋巴结转移。临床分期与手术病理分期不符合率为22.1%。术后随访6～57个月,平均26个月,获访率100%,1例复发,1例复发并死亡。结论:系统性盆腔及腹主动脉旁淋巴结切除术不仅对进行准确的手术病理分期,指导术后辅助治疗有重要意义,而且能提供预后相关信息。     

腹主动脉旁淋巴结切除术在子宫内膜癌治疗中的临床意义

目的探讨子宫内膜癌患者腹主动脉旁淋巴结切除范围及其临床意义。方法回顾四川大学华西第二医院709例患者的临床-病理资料,随访217例行腹主动脉旁淋巴结切除患者的生存情况。结果多因素分析发现：淋巴脉管浸润及盆腔淋巴结转移是发生腹主动脉旁淋巴结转移的独立高危因素（P〈0.05）。腹主动脉旁淋巴结取样组,切除至肠系膜下血管水平组以及肾血管水平组术后10月生存率分别为：98.6%,94.3%和100.0%。结论中低分化、淋巴脉管转移、特殊病理类型、以及晚期子宫内膜癌患者建议切除腹主动脉旁淋巴结,其切除范围应至肾血管水平。     

Randomized study comparing two techniques of conization: cold knife versus loop excision

OBJECTIVE: The aim of this study was to analyze the prognostic significance of DNA ploidy in patients with endometrial cancer. METHODS: Between October 1988 and January 1997, DNA ploidy was determined prospectively in 208 women who were staged surgically by a standard protocol that included pelvic and para-aortic lymphadenectomy. Median follow-up was 48 months. RESULTS: Diploid tumors were identified in 154 (74%) patients and aneuploid tumors in 54 (26%). Patients with aneuploid tumors had a significantly higher prevalence of metastases to the cervix, adnexa, and omentum, malignant pelvic cytology, and advanced surgical stage. Patients with aneuploid tumors had a 4.5 times higher prevalence of pelvic lymph node metastases and a 5.8 times higher prevalence of para-aortic lymph node metastases. A significantly higher proportion of patients with aneuploid tumors was diagnosed with recurrent or progressive endometrial cancer (22.2 versus 6.5%, P = 0.002). Patients with aneuploid tumors had a significantly lower rate of survival from cancer death (P = 0.038) with 83% versus 94% surviving 5 years. CONCLUSION: Patients with aneuploid tumors are at high risk for lymph node metastases and should be surgically staged, including pelvic and para-aortic lymphadenectomy. Aneuploidy confers a risk for endometrial cancer death and these patients should be candidates for clinical trials evaluating treatment following surgery.     

Feasibility of extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy

OBJECTIVE: The aim of this study is to evaluate the feasibility of extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy for cervical and endometrial carcinoma. METHODS: Seventy-six patients underwent extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy between February 1999 and September 2005. The lymph nodes dissected with the laparoscopic procedure included the inframesenteric para-aortic lymph nodes, the sacral lymph nodes, and the bilateral common iliac lymph nodes. The extraperitoneal laparoscopic operation was performed with pelvic open surgery using Lap Disc to ensure the safety of patients. RESULTS: The number of patients with cervical and endometrial carcinoma was 36 and 40, respectively. The median age of patients was 51 years (range 24-75 years). Conversion to open surgery was necessary in 8 patients. These include 3 patients who encountered blood loss of 400, 136 and 128 ml; 2 extremely obese women; and 3 patients who had peritoneal tears causing CO2 gas leakage. Among the remaining 68 patients, the median operating time for extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy was 75 min (range 45-145 min), and the median estimated blood loss was 5 ml (range 5-138 ml). The median total number of resected nodes was 14 (range 2-31), and 4 patients had lymph node metastasis. No patient encountered postoperative complications attributable to extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy. CONCLUSIONS: Extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy with pelvic open surgery using Lap Disc is a feasible procedure, particularly in the surgeons learning phase.     

盆腔淋巴清扫术对子宫内膜癌预后的影响

目的　探讨子宫内膜癌盆腔淋巴转移的相关因素及盆腔淋巴清扫术对子宫内膜癌预后的影响。方法　选择 1981年 1月至 2 0 0 2年 12月行子宫内膜癌盆腔淋巴清扫术患者 90例 ,淋巴结取样活检术患者 12例 ,分析这 10 2例患者淋巴转移与各临床病理指标的关系。随机选取同期未行淋巴清扫术的 90例患者作为对照与行淋巴清扫术的 90例患者进行比较 ,寿命表法计算两者的生存率。结果　 10 2例患者中 ,低分化、深肌层浸润、宫颈浸润、腹腔冲洗液细胞学检查阳性、附件浸润、远处转移者 ,盆腔淋巴转移的发生率升高 ,分别为 46%、42 %、44%、52 %、75%、10 0 %。盆腔淋巴转移患者的 5年累计生存率 (3 7% )低于无淋巴转移者 (89% ,P <0 0 1)。 90例行盆腔淋巴清扫术患者与对照者的 5年累计生存率分别为 78%和 72 % ,两者比较 ,差异无显著性 (P >0 0 5)。COX逐步回归分析显示 ,盆腔淋巴清扫术不是影响患者预后的独立因素。结论　低分化、深肌层浸润、宫颈浸润、腹腔冲洗液细胞学检查阳性、附件浸润、远处转移是子宫内膜癌盆腔淋巴转移的高危因素 ,有盆腔淋巴转移的患者预后差 ,但盆腔淋巴清扫术并不改善患者预后     

冰冻病理诊断预测子宫内膜癌淋巴转移的临床价值研究

目的:研究影响子宫内膜癌患者淋巴结转移的因素,评价术中冰冻病理预测淋巴结转移的作用。方法:回顾分析1996年7月至2008年1月在上海交通大学医学院附属仁济医院和2008年9月至2011年9月在同济大学附属第一妇婴保健院收治的共389例子宫内膜癌患者的临床资料,195例患者实施了盆腔淋巴结切除,其中43例同时行腹主动脉旁淋巴结切除。分析患者淋巴结转移的临床相关因素,评价冰冻病理结果在预测淋巴结转移中的价值。结果:盆腔淋巴结转移率为12.8%(25/195),腹主动脉旁淋巴结转移率为11.6%(5/43)。深肌层浸润(P<0.001)、宫颈累及(P<0.001)、ER阴性(P=0.001)与盆腔淋巴结转移显著相关。肿瘤细胞级别升高、病理类型(Ⅰ型、Ⅱ型)与盆腔淋巴结转移无显著相关性。低风险子宫内膜癌(排除G3和肌层深度≥1/2)患者的盆腔淋巴转移率为4.5%(3/67)。按冰冻结果制定4种预测模型,G1+限于内膜组,淋巴结阳性率为0;G1+<1/2肌层组,盆腔和腹主淋巴结阳性率均为2.4%;G2+<1/2肌层组,盆腔和腹主淋巴结阳性率分别为4.8%、0;未发现G2+限于内膜的病例。淋巴结切除组的生存率高于未切除组(79.5%vs 75.9%),但无统计学差异(P=0.086)。结论:冰冻病理用于预测淋巴结转移的作用有限,建议对除G1限于内膜的子宫内膜样腺癌患者,其余均应实施全面的分期手术。     

盆腹腔淋巴取样术在子宫内膜癌手术中的临床意义

目的探讨盆腹腔淋巴取样术在子宫内膜癌的临床意义。方法分析2000年1月-2007年12月上海同济大学附属第一妇婴保健院手术治疗的213例子宫内膜癌患者,其中,86例行盆腹腔淋巴取样术,127例行淋巴结切除术。手术方式根据手术切除淋巴结的情况分为两组。①取样组：淋巴取样术,筋膜外全子宫双附件切除/次广泛子宫切除术＋盆腔/腹主动脉旁淋巴结取样术86例;②切除组：次广泛/广泛子宫切除术＋盆腔淋巴结切除/腹主动脉旁淋巴结切除术127例。结果取样组：切除淋巴结中位数18枚,淋巴结的转移10例。切除组：切除淋巴结中位数32枚,淋巴结转移11例。5年生存率分别为94.2%和94.5%。取样组无病发症发生,淋巴结切除组中有9例,分别是1例术中大出血（〉2000ml）,淋巴囊肿感染6例,淋巴漏2例。结论在子宫内膜癌中淋巴结取样术可准确了解淋巴结的转移情况,适宜手术分期,并不影响生存率,是避免过度手术减少并发症发生的有效方法。     

Chemoradiation with adjuvant hysterectomy for stage IB-2 cervical cancer: a 10-year experience

To review outcomes of patients with stage IB-2 cervical carcinoma treated with chemoradiation therapy (CRT) followed by total abdominal hysterectomy (TAH), common iliac and para-aortic lymphadenectomy (PAL). A retrospective review of patients with stage IB-2 cervical cancer treated with CRT followed by TAH/PAL from 1999 to 2009 was performed. Brachytherapy was limited to 1,500–1,800?cGy. Sixty-nine patients were identified. The mean age was 46.7?years, tumor diameter 5.4?cm, and all patients had complete clinical response to CRT. The mean follow-up was 61.7?months. There were no central pelvic relapses and two pelvic sidewall failures (97% pelvic control). The mean time to progression was 31.6?months, and 5-year disease-specific survival was 81%. Three (4.3%) patients developed symptomatic vaginal stenosis. CRT plus adjuvant hysterectomy for stage IB-2 cervical cancer resulted in excellent pelvic control and 5-year survival. Vaginal stenosis was rare.     

Is aortic lymphadenectomy necessary in the management of endometrial carcinoma?

OBJECTIVE: To evaluate the role of aortic lymphadenectomy in the management of endometrial carcinoma. METHODS: Clinical notes of 163 patients with endometrial carcinoma were reviewed. All patients had peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy with or without aortic lymphadenectomy. RESULTS: Seventy-five (46.0%) patients had pelvic lymphadenectomy alone whereas 88 (54.0%) had both pelvic and aortic lymphadenectomy. Thirty-five (21.5%) patients had nodal metastases with positive pelvic and aortic nodes in 26 (16.0%) and 24 (27.3%) patients, respectively. Isolated aortic metastases were found in 17 cases (19.3%). Among 35 patients with nodal metastases, recurrence developed in 15 (42.9%) patients and all except one died within five to 50 months. The remaining patients had a median disease-free period of 55 months (13-93 months). The recurrence rate was higher (63.6%) among patients with upper aortic lymph node metastases, and all those who recurred died of disease within seven to 28 months. CONCLUSIONS: Our data suggest that aortic lymphadenectomy provides both diagnostic and therapeutic value in the management of endometrial carcinoma with high metastatic risk. After surgical removal and adjuvant radiotherapy, patients with nodal metastases achieved a better survival chance.     

Is there any therapeutic role of pelvic and para-aortic lymphadenectomy in apparent early stage epithelial ovarian cancer?

ObjectiveThe therapeutic role of pelvic and para-aortic lymphadenectomy in surgical staging of apparent early-stage epithelial ovarian cancer (eEOC) is still under debate. The aim of this study was to evaluate the potential therapeutic role of systematic lymphadenectomy in patients with eEOC.MethodsMulti-center retrospective cohort study, comparing women with apparent eEOC who underwent comprehensive bilateral pelvic and para-aortic lymphadenectomy (defined as ≥20 lymph nodes) versus patients receiving no lymphadenectomy or lymph node sampling, from 05/1985 to 12/2016. Patients with bulky nodes at CT-scan and those without complete intra-peritoneal surgical staging were excluded. Only patients who received at least 3 cycles of platinum-based adjuvant chemotherapy were included.ResultsOut of 2559 patients with FIGO stage IA-IIIA1 ovarian cancer, 639 (25.0%) met inclusion criteria. 360 (56.3%) underwent comprehensive lymphadenectomy, 150 (23.5%) lymph node sampling and 129 (20.2%) no lymphadenectomy. Patients who underwent comprehensive lymphadenectomy were younger (p < 0.001), experienced a higher number of severe post-operative complications (p = 0.008) and had a longer time to start chemotherapy (p = 0.034). There was no difference in intra-operative complications. Median follow-up was 63 months (range, 5–342). The 5-year disease-free survival (DFS) was 79.7% vs. 76.5% vs. 68.3% (p = 0.006), and 5-year overall survival (OS) was 92.3% vs. 94.5% vs. 89.8% (p = 0.165) in women who received comprehensive lymphadenectomy vs. lymph node sampling vs. no lymphadenectomy, respectively. Lymphadenectomy represented an independent factor for DFS improvement, HR 0.52 (95%CI 0.37–0.73) (p < 0.001).ConclusionPelvic and para-aortic lymphadenectomy in surgical staging of eEOC improves DFS for the price of increasing post-operative complications and time to chemotherapy but does not affect OS. Better understanding of tumor biology may help to identify those patients in whom lymphadenectomy should still play a role.     

The role of laparoscopic lymphadenectomy in the management of cervical carcinoma.

Laparoscopic lymphadenectomy was performed on 18 patients with invasive carcinoma of the cervix prior to definitive radiation therapy and/or radical hysterectomy. Ten patients underwent pelvic and para-aortic lymphadenectomies prior to planned radiotherapy. Two of these patients had grossly positive pelvic nodes, and one had a microscopically positive para-aortic node. Eight patients with early disease were considered candidates for radical hysterectomy and underwent laparoscopic lymphadenectomy. Three of these patients were found to have positive pelvic lymph nodes and the hysterectomy was abandoned. Five patients underwent radical hysterectomies immediately following their laparoscopic procedures. The average number of lymph nodes removed laparoscopically in these patients was 31.4; the average number of additional lymph nodes resected at laparotomy with the radical hysterectomy was 2.8. A single microscopically positive parametrial lymph node was found on permanent section in 1 patient with radical hysterectomy. No significant complications were associated with the laparoscopic lymphadenectomies. Nine of the 13 patients who underwent laparoscopic procedures only were discharged on Postoperative Day 1. The ability to perform pelvic and para-aortic lymphadenectomy allows for complete surgical staging of carcinoma of the cervix laparoscopically.     

Pattern and clinical predictors of lymph node metastases in epithelial ovarian cancer

Para-aortic lymphadenectomy is part of staging in early epithelial ovarian cancer (EOC) and could be part of therapy in advanced EOC. However, only a minority of patients receive therapy according to guidelines or have attendance to a specialized unit. We analyzed pattern of lymphatic spread of EOC and evaluated if clinical factors and intraoperative findings reliably could predict lymph node involvement, in order to evaluate if patients could be identified in whom lymphadenectomy could be omitted and who should not be referred to a center with capacity of performing extensive gynecological operations. Retrospective analysis was carried out of all patients with EOC who had systematic pelvic and para-aortic lymphadenectomy during primary cytoreductive surgery. One hundred ninety-five patients underwent systematic pelvic and para-aortic lymphadenectomy. Histologic lymph node metastases were found in 53%. The highest frequency was found in the upper left para-aortic region (32% of all patients) and between vena cava inferior and abdominal aorta (36%). Neither intraoperative clinical diagnosis nor frozen section of pelvic nodes could reliably predict para-aortic lymph node metastasis. The pathologic diagnosis of the pelvic nodes, if used as diagnostic tool for para-aortic lymph nodes, showed a sensitivity of only 50% in ovarian cancer confined to the pelvis and 73% in more advanced disease. We could not detect any intraoperative tool that could reliably predict pathologic status of para-aortic lymph nodes. Systematic pelvic and para-aortic lymphadenectomy remains part of staging in EOC. Patients with EOC should be offered the opportunity to receive state-of-the-art treatment including surgery.     

Is lymphadenectomy useful in the treatment of endometrial carcinoma?

In our institution endometrial carcinoma stages I and II is treated with uterovaginal brachytherapy and radical hysterectomy with pelvic lymphadenectomy. We have made a retrospective analysis of the results of lymphadenectomy to determine its place in the treatment strategy. Between 1976 and 1986, 155 patients were treated with these modalities (107 were stage I, 48 were stage II). The mean age was 60.2 years. Brachytherapy delivered 60 Gy, and then radical hysterectomy with pelvic lymphadenectomy was performed. Twenty-six patients received pelvic external-beam irradiation because of lymph node involvement and or deep tumor invasion into the myometrium. Fourteen patients (9%) had lymph node involvement. External iliac lymph nodes were involved in 78.5% of these cases. The lymph node involvement rate was higher for patients with stage II disease, patients with grade 3 tumors, and patients in whom there was deep tumor invasion into the myometrium. Pelvic failure rate was 12% for node-negative patients and 36% for node-positive patients. The 5-year actuarial survival rates were 83% for node-negative and 41% for node-positive patients. We administer pelvic external-beam radiotherapy to all stage II patients, grade 2 or 3 patients, and patients in whom there is deep tumor invasion into the myometrium. We do not perform lymphadenectomy on these patients. We perform only external iliac sampling for patients with stage I, grade 1 tumor without deep tumor invasion.     

Combined use of magnetic resonance imaging,CA 125 assay,histologic type,and histologic grade in the prediction of lymph node metastasis in endometrial carcinoma

OBJECTIVE: The aim of this study was to predict retroperitoneal lymph node metastasis during the preoperative examination of patients with endometrial carcinoma and to determine whether lymphadenectomy must be performed. STUDY DESIGN: This study was carried out on 214 patients with endometrial carcinoma. Preoperative evaluators were volume index, depth of myometrial invasion (as assessed by magnetic resonance imaging), serum CA 125 level, histologic type, and histologic grade. With the use of receiver operating characteristic curves, cutoff values of volume index and serum CA 125 levels were determined. The relationships of these evaluators with pelvic lymph node metastasis were investigated by multivariate analysis with a logistic regression model. The relationships of these evaluators with para-aortic lymph node metastasis were investigated in the same way. RESULTS: Histologic type, volume index, histologic grade, and serum CA 125 level were found to be independent risk factors for pelvic lymph node metastasis; serum CA 125 level and volume index were found to be independent risk factors for para-aortic lymph node metastasis. Among 110 cases with no risk factors for pelvic lymph node metastasis, pelvic lymph node metastasis was observed in 4 cases (3.6%). On the other hand, only 1 case of 128 cases (0.7%) with no risk factors for para-aortic lymph node metastasis actually had metastasis. CONCLUSION: Careful consideration of the possibility of the elimination of the requirement of retroperitoneal lymphadenectomy is needed in cases with no risk factors for lymph node metastasis. However, our results suggest that para-aortic lymphadenectomy may not be necessary in cases with no risk factors for para-aortic lymph node metastasis.     

FIGO stage IIIC endometrial carcinoma with metastases confined to pelvic lymph nodes: analysis of treatment outcomes, prognostic variables, and failure patterns following adjuvant radiation therapy.

OBJECTIVES: This study was undertaken to evaluate the prognostic significance of isolated positive pelvic lymph nodes on survival and to analyze other prognostic variables, overall survival, and failure patterns in surgically staged endometrial carcinoma patients with positive pelvic lymph nodes and negative para-aortic lymph nodes following radiation therapy (RT). METHODS: Between January 1, 1987, and December 31, 1997, 782 women underwent primary treatment for uterine cancer at Indiana University Medical Center. Through a review of the medical records, we identified 58 patients with pathologic stage IIIA, 27 patients with pathologic stage IIIB, and 77 patients with pathologic stage IIIC endometrial carcinoma. Patients with pathologically positive or unsampled para-aortic lymph nodes and patients who received preoperative radiation therapy were excluded, leaving a study group of 17 patients with nodal metastases confined to pelvic lymph nodes. Thirteen patients received adjuvant pelvic RT using AP-PA or four-field technique. A median dose of 5040 cGy was delivered. Four patients received whole abdominal irradiation (WAI) delivering a median dose of 3000 cGy. Two patients received vaginal cuff boosts of 1000 and 3560 cGy to 0.5 cm from the vaginal surface mucosa via Cs-137 brachytherapy. Two patients also received adjuvant chemotherapy (cis-platinum and doxorubicin) and/or hormonal therapy (megestrol acetate). Disease-free and overall survivals were estimated using the Kaplan-Meier method of statistical analysis and prognostic variables were analyzed using the log-rank test. RESULTS: With a median follow-up of 51 months the actuarial 5-year disease-free survival was 81% and the actuarial 2-year and 5-year overall survival rates were 81 and 72%, respectively. Univariate analysis revealed that positive peritoneal cytology in conjunction with positive pelvic lymph nodes imparts a greater risk of recurrence and decreased overall survival. There were no pelvic and/or upper abdominal failures, but there were recurrences in the para-aortic lymph nodes (two patients) and distantly (two patients). CONCLUSION: Surgery followed by postoperative pelvic RT is a viable treatment option for pathologically staged stage IIIC endometrial carcinoma with disease confined to the pelvic lymph nodes. Failures in the para-aortic region suggest a possible role for extended-field RT. Patients with positive peritoneal cytology in conjunction with nodal metastasis fared poorly with pelvic RT. Studies evaluating the efficacy of WAI are ongoing. Finally, substages within FIGO stage IIIC are recommended in an effort to better understand and define treatment strategies which might be appropriate for these patients.     

Laparoscopic management of occult cervical cancer discovered after simple hysterectomy

OBJECTIVES: To assess the feasibility and morbidity of surgical management by combined laparoscopic and vaginal approach after cervical cancer diagnosed at the time of simple hysterectomy. PATIENTS AND METHODS: From 2000 to 2005, 10 patients were referred with occult cervical cancer discovered after simple hysterectomy. All these patients had laparoscopy for surgical staging. RESULTS: Eight on ten patients had complete laparoscopic staging: pelvic lymphadenectomy (N=8), radical colpectomy (N=5). Operative time, pelvic lymph nodes resected, postoperative stay were respectively 261.3 minutes (200-400), 27 (23-38), 4.4 days. There were 2 symptomatic lymphocysts. Pelvic lymph nodes were positive for 1 patient with negative paraaortic nodes. Residual disease was present in 2 cases: 1 parametrial and vaginal involvement, 1 ovarian metastasis. 5 patients had adjuvant treatment: 2 combined pelvic external radiotherapy and brachytherapy, 1 pelvic external radiotherapy, 1 pelvic concurrent chemoradiation and 1 brachytherapy only. Two on ten patients needed a laparoconversion, one for ovarian involvement and one for technical failure. With a median follow-up of 29.7 months (4-63), 3 patients recurred. 3 patients recurred above 5 patients with pelvic lymphadenectomy but without parametrectomy versus no recurrence above 5 patients with pelvic lymphadenectomy and parametrectomy. DISCUSSION AND CONCLUSION: Surgical staging of occult cervical cancer discovered after simple hysterectomy is necessary for indication of adjuvant treatment. Laparoscopy combined with vaginal surgery is feasible and safe, inducing fewer adhesions which is important for adjuvant radiotherapy. The realization of a radical parametrectomy seems to offer a local control of the disease and a decrease in the risk of recurrence, which need to be confirmed by conducting a study with more patients. This emphasize the necessity of creating a national record to register all women managed for occult cervical cancer.     

Residual pelvic lymph node involvement after concomitant chemoradiation for locally advanced cervical cancer

OBJECTIVE: Concomitant chemoradiation (and brachytherapy) has become the standard treatment for locally advanced cervical cancers (FIGO stage IB2 to IVA). Adjuvant surgery is optional. The aim of this study was to evaluate the rate of residual positive pelvic lymph nodes after chemoradiation. METHODS: From February 1988 to August 2004, 113 patients with locally advanced cervical cancer have been treated by chemoradiation followed by an adjuvant surgery with a pelvic lymphadenectomy performed (study group). A para-aortic lymphadenectomy had also been performed in 85 of them. RESULTS: The mean age of the patients was 48.4 years (27-74). FIGO stage was: IB2 in 17.7% (20/113), II in 44.2% (50/113), III in 21.2% (24/113) and IVA in 16.8% of the patients (19/113). The mean number of removed nodes was 11.5 (median 11) in pelvic, and 7.5 (median 7) in para-aortic basins. A pelvic lymph node involvement was present in 15.9% (18/113) of the patients after chemoradiation. In 11 patients, only one node was positive. 11.7% (10/85) of the patients had a para-aortic lymph node involvement. A residual pelvic lymph node disease has been observed in 6.3% (4/63) of the cases with no residual cervical disease (or microscopic) versus 26.5% (13/49) of the cases with macroscopic residual cervical tumor (P = 0.003). CONCLUSIONS: Our experience shows that a pelvic lymph node involvement persists in about 16% of the patients after chemoradiation. We can make the assumption that performing a pelvic lymphadenectomy along with the removal of the primary tumor after chemoradiation could reduce the rate of latero-pelvic recurrences, whatever the para-aortic lymph node status.