Usefulness of (18)F-fluorodeoxyglucose positron emission tomography to detect para-aortic lymph nodal metastasis in advanced cervical cancer with negative computed tomography findings

OBJECTIVE: In advanced cervical cancer, it has been reported that progression-free survival is significantly related to para-aortic lymph node metastasis. Computed tomography (CT) has been widely used for clinical staging, but its sensitivity for lymph nodal metastasis is low. Therefore, this prospective study was undertaken to evaluate (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in detecting para-aortic lymph nodal metastasis in patients with locally advanced cervical carcinoma when CT findings were negative. METHODS: Fifty women with advanced cervical cancer confined to the pelvis with negative abdominal CT findings were included in this study. After 10 mCi of FDG was administered intravenously, the abdomens were scanned by PET. Para-aortic lymph node metastases were diagnosed as present or absent according to a standardized staging procedure. RESULTS: Retroperitoneal surgical exploration revealed 14 patients with para-aortic lymph nodal metastasis. Two patients had false-negative FDG-PET findings and the other two patients had false-positive FDG-PET findings. CONCLUSION: Overall, FDG-PET imaging had a sensitivity of 85.7%, a specificity of 94.4%, and an accuracy of 92%. When abdominal CT findings are negative, the use of FDG-PET can accurately detect para-aortic lymph nodal metastatis in patients with advanced cervical cancer.     

根治性同步放化疗前淋巴结清扫在局部晚期宫颈癌诊疗中的意义

宫颈癌是威胁女性健康的第四大肿瘤,分期主要基于临床检查。2018年10月国际妇产科联盟(FIGO对宫颈癌分期进行了修改,强调了盆腔及腹主动脉旁淋巴结的转移情况。对于根治性同步放化疗的患者,淋巴结转移与放疗肿瘤控制率密切相关。由于腹主动脉旁淋巴结转移的情况决定了是否扩大放疗照射野,放疗对于较大的淋巴结控制效果不理想,因此在根治性放化疗前手术评估淋巴结情况、切除增大的淋巴结,有助于分期及减瘤,进行个体化的治疗。但手术分期为有创操作,存在相关风险,可能推迟放疗起始时间,缺乏前瞻性的随机对照研究,此治疗方式并未被广泛认可。综述根治性放化疗前手术清扫淋巴结分期的相关文献。     

The impact of pre-therapy extraperitoneal surgical staging on the evaluation and treatment of patients with locally advanced cervical cancer.

OBJECTIVE: The use of extraperitoneal surgical staging prior to treatment in patients with bulky or locally advanced cervical cancer allows the detection and treatment of disease beyond the standard pelvic radiation fields. This study was conducted to evaluate the impact of extraperitoneal surgical staging in the treatment and outcome of patients with locally advanced cervical cancer. METHODS: 51 patients with locally advanced cervical cancer treated between 1985 and 1998 were retrospectively reviewed. Information on morbidity, usefulness, and results of surgery and patterns of disease recurrence were obtained. Survival distributions were calculated by the Kaplan-Meier product limit method and compared with the log-rank test. RESULTS: All 51 women were surgically staged by an extra-peritoneal approach. Preoperative CT scans (n=27) when compared with surgical findings showed sensitivity for pelvic and para-aortic lymph node metastasis of 39%, specificity of 88%, positive predictive value of 39% and negative predictive value of 88%. Lymph node metastases were found in 30/51 patients (59%). There were no significant treatment delays or surgical morbidity as a result of extra-peritoneal surgical staging. In 21 patients (41%), the highest level of involved nodes was in the pelvis and they were treated with pelvic radiation. The para-aortic nodes were involved in nine patients (18%) and were treated with extended field radiation. All patients also received concurrent radiosensitization with chemotherapy. The estimated survival for the entire group was 60% at 5 years. For node negative patients, estimated 5-year survival was 67% while it was 54% for all node positive patients (p=0.17). Analysis according to anatomic site of involved nodes showed that the estimated 2-year and 5-year survival for those with pelvic nodal involvement was 81% and 64%, respectively. However, in the group of nine patients with para-aortic nodal disease, the estimated 2-year survival was 44%. Five (56%) were dead of disease with a median time to death of 16.0 months and four patients (44%) were alive with a median duration of follow up of 16.1 months. There was a statistically significant difference in survival for the group of patients with positive pelvic nodes only compared to the group with positive para-aortic nodes (p=0.03). The estimated 5-year survival by FIGO stage was 80%, 70% and 51% for stages Ib, II, III, disease, respectively. Factors that did not significantly affect survival included age, histology and type of chemotherapy. CONCLUSIONS: Pre-therapy extra-peritoneal surgical staging resulted in treatment modification in 18% of patients with locally advanced cervical cancer. The morbidity from surgery and subsequent radiation therapy was acceptable. The procedure is recommended to allow for individualization of treatment in patients with local-regional cervical cancer.     

Laparoscopic surgical staging of locally advanced cervix cancer (IB2 to IVA): initial experience

Introduction and objectives

Cervical cancer incidence worldwide is about 500,000 new cases per year with most of them being detected at a locally advanced stage. Many studies have shown the need to look for extra-pelvic disease when planning appropriate therapy. We performed surgical staging by laparoscopy in 43 cases of cervical cancer at stages IB2 to IVa and evaluated our initial results.

Materials and methods

Between February 2008 and May 2010, we selected 43 patients with histologically confirmed cervical cancer at stages IB2 to IVA with a Karnosfsky index > 70. We classified the tumors according to the FIGO (International Federation of Gynecology and Obstetrics) stage and performed tomographic evaluations of the abdomen to select patients without signs of peritoneal or para-aortic tumor spread. We performed a laparoscopic evaluation of the peritoneal cavity and para-aortic lymph nodes by an extra-peritoneal route. We did not use tweezers or disposable energy seals.

Results

The mean surgical time was 130.8 min. The mean blood loss was 111.5 ml. There was no conversion to laparotomy for any case. We describe a case with peritoneal implants that was classified as IVB.We removed an average of 16.4 lymph nodes; nine cases had para-aortic lymph node metastases.

Conclusion

Laparoscopic surgical staging diagnosed 23.3% of cases with peritoneal spread of the tumor or extra-pelvic lymph node metastases. In this study, we could better define the lymph node status through laparoscopic surgical staging and could therefore recommend more suitable adjuvant therapy for patients with locally advanced cervical cancer.     

Laparoscopic Debulking of Enlarged Pelvic Nodes during Surgical Para-aortic Staging in Locally Advanced Cervical Cancer: A Retrospective Comparative Cohort Study

Study ObjectiveTo evaluate laparoscopic pelvic lymph node debulking during extraperitoneal aortic lymphadenectomy in diagnosis, therapeutic planning, and prognosis of patients with locally advanced cervical cancer and enlarged lymph nodes on imaging before chemoradiotherapy.DesignRetrospective, multicenter, comparative cohort study.SettingThe study was carried out at 11 hospitals with specialized gynecologic oncology units in Spain.PatientsTotal of 381 women with locally advanced cervical cancer and International Federation of Gynecology and Obstetrics 2018 stage IIIC 1r (radiologic) and higher who received primary treatment with chemoradiotherapy.InterventionsPatients underwent pelvic lymph node debulking and para-aortic lymphadenectomy (group 1), only para-aortic lymphadenectomy (group 2), or no lymph node surgical staging (group 3). On the basis of pelvic node histology, group 1 was subdivided as negative (group 1A) or positive (group 1B).Measurements and Main ResultsFalse positives and negatives of imaging tests, disease-free survival, overall survival, and postoperative complications were evaluated.In group 1, pelvic lymph node involvement was 43.3% (71 of 164), and aortic involvement was 24.4% (40 of 164). In group 2, aortic nodes were positive in 29.7% (33 of 111). Disease-free survival and overall survival were similar in the 3 groups (p = .95) and in groups 1A and 1B (p = .25). No differences were found between groups 1 and 2 in intraoperative (3.7% vs 2.7%, p = .744), early postoperative (8.0% vs 6.3%, p = .776), or late postoperative complications (6.1% vs 2.7%, p = .252). Fewer early and late complications were attributed to radiotherapy in group 1A than in the others (p = .022).ConclusionLaparoscopic pelvic lymph node debulking during para-aortic staging surgery in patients with locally advanced cervical cancer with suspicious nodes allows for the confirmation of metastatic lymph nodes without affecting survival or increasing surgical complications. This information improves the selection of patients requiring boost irradiation, thus avoiding overtreatment of patients with negative nodes.     

Chylous ascites following treatment for gynecologic malignancies

BACKGROUND: Chylous ascites is a rare complication following abdominal radiation or para-aortic lymph node dissection in the management of gynecologic malignancies. Treatment options include dietary restriction with addition of medium-chain triglycerides, serial paracenteses, total parenteral nutrition, and somatostatin. Current opinion advocates that surgical exploration and peritoneo-venous shunts be reserved for refractory cases. CASES: Two patients developed chylous ascites, one after completion of surgical staging and chemoradiation for stage IIB squamous carcinoma of the cervix and one following para-aortic lymph node dissection for recurrent malignant mixed mullerian tumor of the endometrium. In both cases resolution of the chylous ascites followed placement of a peritoneo-venous shunt. CONCLUSIONS: Chylous ascites should be considered in the differential diagnosis of ascites in patients with gynecologic malignancy treated with radiation or para-aortic lymph node dissection.     

Stadification ganglionnaire des cancers du col utérin avancé

Lymph node staging in patients with locally advanced cervical cancer is the most important prognostic factor and also leads to adjuvant treatment choice. Because of the lymphadenectomy associated morbidity and delay in the beginning of adjuvant therapy, noninvasive approaches were developed during the last decennia. Recently, positron emission tomography employing a glucose analogue (FDG-PET) has been shown to be more sensitive and more specific than magnetic resonance imaging or than computed tomography usually used in diagnosis of pelvic and para-aortic lymph node metastases. Even if recent studies have reported promising results, surgical pelvic and para-aortic staging remains actually the most accurate procedure for evaluating lymph node metastases. This procedure should be accomplished by transperitoneal or extraperitoneal laparoscopy, with the benefits of minimal morbidity, shorter length of hospital stay and no significant increase of complications comparing to laparotomy approach. Laparoscopy also allows an early start of adjuvant treatment, this delay constituting an important prognostic factor for patients with locally advanced cancer. However, the survival benefit of lymph node dissection is still controversial and should be proved in randomised studies.     

Surgical and radiographic staging in patients with cervical cancer

PURPOSE OF REVIEW: The most recent data on surgical and radiographic staging in patients with cervical cancer are analysed. RECENT FINDINGS: Laparoscopic staging of retro and intraperitoneal disease is feasible. Morbidity is low, but the impact on survival has still to be shown. The sentinel lymph node concept is valid in patients with cervical cancer. Sensitivity and negative predictive value, however, have to be improved before the concept can be integrated into clinical practice. The majority of most recent radiographic studies evaluate the value of positron emission tomography. Accuracy of detection of extracervical disease is high and the response to chemoradiation can be measured by positron emission tomography using various scoring systems. Positron emission tomography seems to be the most accurate technique for detecting early recurrence. SUMMARY: Surgical staging is less invasive by laparoscopy, and radiographic staging becomes more accurate by positron emission tomography. Prospective evaluations have to show the impact of these new techniques on survival of patients diagnosed with cervical cancer.     

Early-stage cervical adenocarcinoma treated by surgical intent: the role of para-aortic lymph node dissection.

OBJECTIVE: Previous reports suggest that cervical adenocarcinomas have a unique pattern of spread and are more apt to metastasize to para-aortic lymph nodes. The purpose of this study was to further define the node of para-aortic lymph node dissection in early-stage cervical adenocarcinoma treated by surgical intent. METHODS: Institutional review board approval was obtained to perform a computerized search of the data of all women diagnosed with cervical adenocarcinoma between 1982 and 2000. Hospital charts were retrospectively reviewed. Follow-up was obtained from the tumor registry, medical records, and correspondence with health care providers. RESULTS: Three hundred (87%) of 345 early-stage (FIGO IA(1)-IIA) cervical adenocarcinoma patients were primarily treated by surgical intent. Two hundred seventy-six underwent pelvic and para-aortic node dissection (n = 69) or pelvic node dissection only (n = 207); 24 had no lymph node dissection. The median number of lymph nodes removed was 13 pelvic (range, 1-58) and 3 para-aortic (range, 1-17). Three (4%) of 69 patients had para-aortic nodal metastases. Each had either grossly evident para-aortic adenopathy (n = 2) or an adnexal metastasis. Thirty-six of 40 women developing recurrent disease had at least some component of pelvic recurrence; 4 had only extrapelvic disease. Three patients undergoing para-aortic node dissection developed an isolated extrapelvic recurrence despite originally negative para-aortic nodes (n = 2) or treatment by extended-field radiation for para-aortic metastases. One woman undergoing only pelvic node dissection had an isolated extrapelvic recurrence despite originally negative nodes. CONCLUSIONS: Early-stage cervical adenocarcinoma primarily treated by surgical intent has a very low risk of para-aortic metastases. These were detected only when there was gross evidence of nodal or adnexal disease.     

磁共振成像检查对早期宫颈癌分期价值研究

目的探讨磁共振成像(MRI)在评估早期宫颈癌患者宫旁浸润、阴道受侵、淋巴结转移方面的价值。方法选取2010-10-01至2013-01-31辽宁省肿瘤医院收治的48例因宫颈癌为病因首次就诊患者,以术后病理结果为金标准比较MRI、术前妇科三合诊、术中探查和剖视标本3种诊断方法在宫旁浸润、阴道受侵、淋巴结转移3个方面的价值,并以手术-病理分期为金标准对MRI分期及术前临床分期的准确度进行对比。结果 MRI在早期宫颈癌术前淋巴结转移诊断方面的敏感度、特异度、阳性预测值、阴性预测值、准确度分别为65%、94%、85%、83%、83%,在宫旁浸润方面分别为50%、91%、33%、95%、88%,在阴道受侵方面分别为50%、78%、43%、82%、71%。妇科三合诊在早期宫颈癌宫旁浸润方面的敏感度、特异度、阳性预测值、阴性预测值、准确度分别为0、100%、0、92%、92%、阴道受侵方面分别为75%、100%、100%、92%、94%。临床分期的整体准确度为81%,MRI分期的整体准确度为67%,临床-MRI分期的整体准确度为92%。结论 MRI在早期宫颈癌术前淋巴结转移诊断方面有良好的价值;在宫旁浸润、阴道受侵方面有较好的阴性预测值和特异度;将临床-MRI结合所得分期较单独运用两种诊断方法分期准确度有所提高。     

Lymph node metastasis in stage I epithelial ovarian cancer

OBJECTIVES: A relatively high incidence of para-aortic and pelvic lymph node metastasis is found in epithelial ovarian cancer. This paper investigates the clinicomorphological features of intra-abdominal stage I epithelial ovarian cancer that may predict the occurrence of lymph node metastasis and the prognosis of patients in whom lymph node metastases are identified. METHODS: From November 1988 to December 1997 we performed systematic para-aortic and pelvic lymphadenectomy as primary surgery in 47 patients with intra-abdominal stage I epithelial ovarian cancer. The incidence of lymph node metastasis in these patients and the clinicomorphological features of the patients with lymph node involvement were examined. RESULTS: Five patients (10.6%) were metastasis positive (IC: four; IA: one), of whom four had serous adenocarcinoma. Serous adenocarcinoma was associated with a significantly higher incidence of metastases than other histological types (P < 0.05). The number of positive lymph nodes was one in four patients and two in one patient, and the metastatic sites ranged from the para-aortic to the suprainguinal lymph nodes. All five metastasis-positive patients were alive and disease free at the time of this report (survival 28-85 months: median 59 months). CONCLUSION: This clinical study suggests that serous adenocarcinoma carries a high risk of lymph node metastasis, requiring systematic lymphadenectomy for accurate staging in intra-abdominal stage I epithelial ovarian cancer.     

Intra-operative frozen section analysis of common iliac lymph nodes in patients with stage IB1 and IIA1 cervical cancer

Introduction  

To evaluate frozen section analysis of common iliac lymph nodes for developing the accuracy of para-aortic lymphadenectomy and detection of para-aortic lymph node metastasis in patients with stage IB1 and IIA1 cervical cancer treated by surgical intent.     

Widespread lymph node metastases in a young woman with FIGO stage IA1 squamous cervical cancer

BACKGROUND: Lymphatic and hematologic metastases are rare in microinvasive cervical cancers (FIGO stage IA1), supporting a role for conservative treatment. Cervical conization followed by prolonged surveillance is an accepted treatment in patients with low-risk features and negative surgical margins. This option is particularly appealing for younger or nulliparous patients, in whom fertility may be highly desired. CASE: We report a case of a 22-year-old, HIV-negative female with stage IA1 squamous cell cervical carcinoma who was found to have bilateral lymph node metastases in both pelvic and para-aortic distributions after electing to undergo hysterectomy. CONCLUSION: Clinicians treating patients with microinvasive cervical cancer conservatively must be aware of the possibility of lymph node involvement and should consider radiological imaging to look for metastatic disease.     

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.     

Endometrium- und Zervixkarzinom

Laparoscopic management of gynaecologic cancer has been controversial for decades. Much technical progress has however been achieved, enabling experienced endoscopic surgeons to perform most gynaeco-oncologic procedures such as hysterectomy, omentectomy, and pelvic and para-aortic lymph node dissection. Although the oncologic value of laparoscopy with respect to safety and patient outcome has not yet been shown in prospective randomized clinical trials, many studies with thousands of patients have revealed similar oncologic results and its feasibility when compared to laparotomy. Especially the lymph node yield has been shown to be similar with both laparoscopic and open surgical methods. This approach has therefore become well accepted for cervical and endometrial carcinomas, especially in early stages. In addition, a staging laparoscopy including pelvic and paraaortic lymph node sampling and debulking contributes to accurately stage advanced cervical cancer cases in order to achieve the adequate treatment.     

Transperitoneal Versus Extraperitoneal Para-Aortic Lymphadenectomy in Patients with Cervical Cancer

Cervical carcinoma is clinically staged according to the International Federation of Gynecology and Obstetrics system; however, this staging system is frequently inaccurate, particularly with advancing stage. Imaging modalities are often used in guiding therapeutic decisions for advanced cervical cancer. However, despite technologic radiographic advances, imaging results correlate variably with the histopathology of surgical specimens. The transperitoneal laparoscopic lymphadenectomy approach offers less morbidity than the traditional laparotomy approach to surgical staging, and the retroperitoneal laparoscopic approach has been demonstrated to decrease the risk of bowel injury and reduce abdominal adhesion formation, and prior abdominal surgery does not appear to be a factor. Further prospective clinical trials are necessary to better define the role of retroperitoneal laparoscopic surgery in the management of gynecologic malignancies.Key words: Cervical cancer, surgical staging; Transperitoneal para-aortic lymphadenectomy; Extraperitoneal para-aortic lymphadenectomyDespite the declining death rate of cervical carcinoma, the American Cancer Society estimated almost 4000 deaths and more than 11,000 new diagnoses in 2008.¹ Cervical carcinoma is clinically staged according to the International Federation of Gynecology and Obstetrics (FIGO) system; however, this staging system is frequently inaccurate, particularly with advancing stage. Clinical staging correlates poorly with the true extent of disease. Inaccuracies in staging occur in as many as 25% of patients categorized as FIGO stages I and II and in up to 65% to 90% in FIGO stage III.² Cervical carcinoma metastasizes predominantly by the lymphatic system in an orderly fashion: initially to the pelvic lymph nodes then to the para-aortic lymph nodes. Previous studies have demonstrated a strong correlation between the incidence of nodal metastasis with tumor volume and clinical stage.³Imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) are often used in guiding therapeutic decisions for advanced cervical cancer. However, despite these technologic radiographic advances, imaging results correlate variably with the histopathology of surgical specimens.⁴ In particular, CT and MRI are poor at detecting small volume disease in patients’ para-aortic metastases.⁵ Currently, positron emission tomography (PET) imaging is being evaluated as a method for detecting cervical cancer metastases prior to initiating therapy and for post-treatment surveillance to assess for recurrence. In early studies, PET scan has shown superior sensitivity (52%–85.7%) and specificity (94.4%) compared with CT and MRI in the detection of para-aortic node metastases.⁵Knowing the extent of disease in patients with cervical cancer is important as it helps guide treatment. Lymphadenectomy offers the opportunity of learning whether there is involvement of the lymph nodes, not only in the pelvis, but also along the chain of lymph nodes around the aorta. Initially, lymph nodes were sampled through a traditional transperitoneal laparotomy; however, due to high complication rates, a retroperitoneal approach was developed. Dargent and colleagues⁶ demonstrated the feasibility and benefits of the retroperitoneal approach. The advancement of endoscopic equipment and surgical techniques in minimally invasive surgery over the past decade has decreased the morbidity associated with laparotomy. In multiple studies, staging by laparoscopy compared with laparotomy has resulted in less blood loss, shorter hospital stay, less postoperative adhesion formation, and equivalent assessment of lymph node status.⁷     

Prospective evaluation of FDG-PET for detecting pelvic and para-aortic lymph node metastasis in uterine corpus cancer

OBJECTIVES: To estimate the sensitivity and specificity of positron emission tomography (PET) with 2-[(18)F]fluoro-2-deoxy-d-glucose (FDG) for detecting pelvic and para-aortic lymph node metastasis in patients with uterine corpus carcinoma before surgical staging. METHODS: Patients with newly diagnosed FIGO grade 2 or 3 endometrioid, papillary serous, or clear cell adenocarcinoma or uterine corpus sarcoma scheduled for surgical staging, including bilateral pelvic and para-aortic lymphadenectomy, were eligible. PET was performed within 30 days of surgery and interpreted independently by two nuclear medicine physicians. The imaging, operative, and pathologic findings for each patient and each nodal site were compared, and the sensitivity and specificity of FDG-PET in predicting nodal metastasis were determined. RESULTS: Twenty patients underwent FDG-PET before surgical staging. One patient found to have ovarian carcinoma on final pathology was excluded. Of the 19 primary intrauterine tumors, 16 (84%) exhibited increased FDG uptake. One patient did not undergo lymphadenectomy; her chest CT was suspicious for metastatic disease and FDG-PET showed uptake in multiple nodal and pulmonary foci. Metastatic disease was confirmed by percutaneous nodal biopsy. A total of three pathologically positive nodes were found in 2 of the 18 patients (11%). FDG-PET predicted that 3 patients would have positive lymph nodes (2 true positive and 1 false positive). Analyzed by lymph node regions, FDG-PET had 60% sensitivity and 98% specificity. The sensitivity and specificity by individual patient were 67% and 94%, respectively. CONCLUSIONS: FDG-PET is only moderately sensitive in predicting lymph node metastasis pre-operatively in patients with endometrial cancer. This imaging modality should not replace lymphadenectomy, but may be helpful for patients in whom lymphadenectomy cannot be, or was not, performed.     

Extraperitoneal laparoscopic para-aortic lymphadenectomy for lymph node recurrence of fallopian tube carcinoma

The endoscopic retroperitoneal approach is a minimally invasive method for surgical staging of cervical cancer. A 57-year-old woman had an intraoperative diagnosis of carcinoma of the left fallopian tube and undergone a retroperitoneal pelvic and para-aortic lymphadenectomy with no peritonization during surgical staging. Small suspicious nodes in the serous membrane of the sigmoid colon and peritoneal washings were positive for malignancy. A total of 12 nodes were obtained, all of which were negative. She received six cycles of paclitaxel and platinum-based chemotherapy and showed a complete clinical response. Thirty-two months after surgery, the abdominal computed tomography scan showed a left para-aortic lymph node, 19 mm in diameter, which was successfully removed through an extraperitoneal laparoscopic approach. The extraperitoneal laparoscopic approach of the para-aortic region is a feasible procedure after previous transperitoneal lymphadenectomy and chemotherapy.     

Sentinel lymph node procedure and uterine cancers

Lymph node metastases in cervical and endometrial cancer are major prognostic factors. Lymph-nodal involvement determines adjuvant therapy. As imagery is not reliable to diagnose lymph node status, pelvic +/- para-aortic lymphadenectomy remains the gold standard. These surgical procedures are, however, responsible for specific morbidity: lymphocele and lymphedema. Sentinel lymph node procedure could avoid lymphadenectomy and their complications in cervical and endometrial cancer with good negative predictive values. We present actual indications, procedure and results of sentinel lymph node procedures in cervical and endometrial cancer.     

Evaluation of the scalene lymph nodes in primary and recurrent cervical carcinoma

Open biopsy of the left scalene lymph nodes has been utilized to identify distant spread of cervical carcinoma in selected groups of patients who do not have other clinical evidence of disseminated disease. Twenty-one patients with primary cervical carcinoma and histologically proven para-aortic lymph node metastases and 10 patients with centrally recurrent tumors underwent scalene lymph node biopsy at Walter Reed Army Medical Center or the Naval Hospital, Bethesda, Maryland, between July 1, 1979 and June 30, 1985. All patients undergoing scalene node biopsy had clinically negative physical examinations. There were no surgical complications. All 31 biopsies were negative for metastatic tumor. Combined with previously reported data from this institution, 3 of 28 patients (11%) with primary cervical carcinoma and involved para-aortic nodes, and 6 of 35 patients (17%) with centrally recurrent disease had subclinical scalene node metastases. Patients with clinically suspicious scalene lymphadenopathy had fine needle aspiration cytology performed to document metastatic disease. The success of this technique has eliminated the need for open biopsy in these patients. Scalene node biopsy provides valuable prognostic information in patients with cervical cancer who have positive para-aortic lymph nodes. It also obviates surgical exploration in some patients felt to have resectable recurrent disease who actually have subclinical distant spread.