Pelvic and para-aortic lymphatic involvement in tubal carcinoma: topography and surgical implications

OBJECTIVE: The purpose of this study is to determine the topography of pelvic and para-aortic node involvement in Fallopian tube carcinoma (PFTC). This will help us to recommend appropriate surgical treatment options to the related patients. PATIENTS AND METHOD: A retrospective study was performed on 19 women with PFTC who underwent a systematic bilateral pelvic and para-aortic lymphadenectomy. RESULTS: The overall frequency of lymph node involvement was 47% (9/19). The frequency of pelvic and para-aortic metastases was 21% (4/19) and 42% (8/19) respectively. The frequency of lymph node metastases according to the stage of the disease (stage I, II and III) was : 29% (2/7), 50% (1/2) and 60% (6/10) respectively. The left para-aortic chain above the level of the inferior mesenteric artery was the site most frequently involved (75%) when para-aortic nodes were involved. DISCUSSION AND CONCLUSIONS: In patients with primary tubal carcinoma, the left para-aortic chain above the level of the inferior mesenteric artery is the most frequently involved. A complete lymphadenectomy (including all pelvic and para-aortic chains up to the level of the left renal vein) should be performed in patients with primary tubal carcinoma, even in patients with stage I disease.     

Lymphatic spread in stage Ib and II cervical carcinoma: Anatomy and surgical implications

Objective: To determine the frequency and topography of pelvic and para-aortic node involvement in cervical carcinoma and to identify the appropriate level for resection of the lymphatic chains.Methods: Between 1985 and 1994, 421 women with stage Ib or II cervical carcinoma were treated by surgery in combination with irradiation. Each underwent a radical hysterectomy with systematic pelvic and para-aortic lymphadenectomy.Results: A median of 34 lymph nodes were removed per patient. The overall frequency of lymph node involvement was 26%, and the frequency of para-aortic metastases was 8%. The frequency of lymph node metastasis was associated significantly with stage (χ² = 7.8; P < .02), tumor size (χ² = 14.8; P < .001), and patient age (χ² = 5.9; P < .05). The frequency of para-aortic involvement was below 3% in patients with small tumors (under 2 cm). When pelvic nodes were involved, the obturator group was concerned in 76 cases (18%) and the external iliac group in 48 patients (11%). When para-aortic nodes were involved, the left para-aortic chain was the most frequently concerned (23 patients [5%]). In eight of these patients, nodal involvement was found only above the level of the inferior mesenteric artery. Among 106 patients with pelvic positive nodes, 28 (26%) also had para-aortic metastatic nodes.Conclusion: Para-aortic lymphadenectomy should remove all of the left para-aortic chain (inframesenteric and supramesenteric) and so should be performed up to the level of the left renal vein. According to the low frequency of para-aortic involvement when tumor size is below 2 cm, such a procedure could be avoided in patients with small tumors.     

Are nodal metastases in ovarian cancer chemoresistant lesions? Analysis of nodal involvement in 105 patients treated with preoperative chemotherapy

BACKGROUND: To report the rates of nodal involvement in epithelial ovarian cancer (EOC) in patients who underwent initial lymphadenectomy (before chemotherapy) and patients who underwent lymphadenectomy after chemotherapy. STUDY DESIGN: The rates of nodal involvement in 205 patients with EOC who underwent complete bilateral pelvic and para-aortic lympadenectomy between 1985 and 2001 were analyzed: 100 women underwent this surgical procedure before chemotherapy (initial surgery) and 105 at the end of chemotherapy (second-look surgery for 77 patients with 6 courses of a platinum-based regimen) or during chemotherapy (interval debulking surgery for 28 patients with 3 courses of a platinum-based regimen containing paclitaxel). RESULTS: The overall frequency of lymph-node involvement was 35% (35/100) in patients treated with initial surgery, 54% (15/28) in the interval debulking surgery group and 36% (28/77) in the second-look surgery group. In patients with Stage III disease, the rates of nodal involvement in patients treated with initial surgery, interval debulking surgery (with paclitaxel-based regimen) and second-look surgery were respectively: 53% (15/28), 58% (15/26) and 48% (20/42). The rates of nodal involvement in patients who underwent lymphadenectomy prior to or after chemotherapy were not statistically different whatever the stage of the disease. Adding paclitaxel to the platinum-based regimen does not seem to improve node sterilization rates. CONCLUSIONS: The rates of nodal involvement seem to be similar in patients treated before or after chemotherapy. Such results suggest that nodal metastases are not as chemosensitive as peritoneal lesions. However, further studies are needed to evaluate the therapeutic value of lymphadenectomy in patients with nodal involvement.     

Lymph node involvement in primary carcinoma of the fallopian tube

Although the bad prognosis of primary fallopian tube carcinoma has been mostly ascribed to early lymphogenous dissemination, precise information regarding the characteristics of retroperitoneal spread are still missing. Our study was designed to evaluate the incidence and clinical significance of lymph node metastases in 33 patients with primary carcinoma of the fallopian tube. During primary surgery nine patients (27%) were submitted to systematic pelvic and para-aortic lymphadenectomy, whereas 24 received lymph node sampling. The clinicopathologic characteristics of the patients (intraperitoneal spread, grading, peritoneal cytology, depth of tubal infiltration and residual disease after primary surgery) were compared with lymphnodal status.
Overall 15 patients (45%) had positive nodes, that is, invaded by tumor; whereas 18 (55%) showed no lymphatic spread. Six patients (40%) had exclusively positive para-aortic lymph nodes; five (33%) had only tumor metastases in pelvic lymph nodes, three (20%) manifested simultaneously pelvic and para-aortic spread, and one patient with pure primary squamous cell carcinoma had a massive groin node metastasis as presenting sign of the tumor. The rate of lymphogenous metastases was not significantly related to progressive intra-abdominal dissemination, histologic grade or depth of tubal infiltration. On the other hand, the presence of residual disease after primary surgery and positive peritoneal cytology significantly increased the risk of nodal metastases. Patients with lymph node metastasis had a significantly ( P = 0.02) worse prognosis compared with patients without nodal involvement (median survival 39 vs 58 months).
Considering the high incidence of lymph node metastasis, correct staging of tubal carcinoma should include a thorough surgical evaluation of both pelvic and para-aortic lymph nodes. The role of systematic lymph node dissection in the treatment of tubal carcinoma remains controversial.     

Lymph node metastasis in ovarian cancer: difference between serous and non-serous primary tumors

OBJECTIVE: To investigate the lymph node sites most susceptible to involvement relative to primary tumor histology in ovarian cancer. METHODS: The locations of metastatic lymph nodes were investigated in 208 patients with primary ovarian cancer who underwent systemic lymphadenectomy covering both the pelvic and para-aortic regions. RESULTS: Lymph node metastasis was present in 12.8% (20/156) of patients with stage I (pT1M0), 48.6% (18/37) with stage II (pT2M0), and 60% (9/15) with stage III (pT3M0) disease, thus in 22.6% (47/208) of all study patients. Isolated para-aortic nodal involvement was present in 23.3% (14/60) of patients with serous tumor and 4.1% (6/148) of those with non-serous tumor (P = 0.00002). In an analysis of 35 positive nodes from 25 patients with up to 3 positive nodes, 86.4% (19/22) of metastatic lymph nodes from patients with serous tumor were found in the para-aortic region, with 14 positive nodes located above the inferior mesenteric artery (IMA) and 5 below it, whereas metastasis to para-aortic lymph nodes accounted for 53.8% (7/13) of metastatic lymph nodes from patients with non-serous tumor (P = 0.0334). CONCLUSIONS: The locations of metastatic lymph nodes in ovarian cancer depend upon the histologic type of the primary cancer. In cases of serous tumor, the para-aortic region, particularly above the IMA, is the prime site for the earliest lymph node metastasis. However, the likelihood of pelvic node involvement is almost equal to that of para-aortic node involvement in cases of non-serous tumor.     

Impact of Surgical Staging in Women with Locally Advanced Cervical Cancer

OBJECTIVE: The aim of this study was to evaluate the impact of surgical staging in the treatment and outcome of women with locally advanced cervical cancer. METHODS: Ninety-eight women with locally advanced cervical cancer treated between 1993 and 1997 were retrospectively reviewed. Survival probabilities were calculated by the Kaplan-Meier product limit method and compared with the log-rank test. RESULTS: Of the 98 women treated over the 5-year period, 86 were surgically staged: 61 by a retroperitoneal approach, 18 by laparoscopy, and 7 by laparotomy. Median blood loss was 120 cc and median length of hospitalization was 3 days. Preoperative CT scans (n = 55), when compared with surgical findings, missed macroscopic nodal disease in 20% and microscopic disease in 15% and overcalled disease in 10% of cases. Lymph node metastases were found in 45/86 patients (52%): 12 microscopic and 33 macroscopic. The highest level of nodes found to be involved was pelvic in 23, common iliac nodes in 3, para-aortic nodes in 14, and scalene nodes in 5 cases. Of the 86 patients, 49 received pelvic radiation, 27 received extended field radiation, and 10 were identified for palliative treatment only (5 scalene node metastasis, 5 extensive intraperitoneal disease). For node-negative patients, 5-year survival was 74%; for microscopic nodal involvement it was 58%; and for macroscopic involvement it was 39% (P = 0.007). Five-year survival for women with para-aortic node involvement was 52%. Number of nodes involved was a significant prognostic variable (P = 0.008). Patients who received chemotherapy had a 5-year survival of 68% compared to 35% for those who did not (P = 0.06). Factors which did not affect survival included age, histology, type of surgery, stage, and type of radiation (pelvic vs extended). CONCLUSION: Surgical staging of women with locally advanced cervical cancer can be performed with acceptable morbidity and it provided more accurate information than CT scans and resulted in a modification of the standard pelvic radiation field for 43% of our patients. The information obtained from surgical staging allows better individualization of therapy, which may improve overall clinical outcome.     

Para-aortic lymphadenectomy for primary fallopian tube cancer

Objective

To investigate the topography of lymph node spread and the need for para-aortic lymphadenectomy in primary fallopian tube cancer (PFTC).

Methods

Twenty-six women were diagnosed with PFTC at Cheil General Hospital and Women's Healthcare Center, Seoul, Korea, between March 1992 and November 2009. Of the 26 patients, we retrospectively analyzed 15 patients who underwent complete staging surgery, including bilateral pelvic and para-aortic lymphadenectomy.

Results

The median follow-up period was 57.9 months (range, 3-185 months) and the 5-year survival rate was 86.3%. Five (33.3%) patients were diagnosed with FIGO stage I, 1 (6.7%) with stage II, and 9 (60%) with stage III cancer. The median number of lymph nodes removed was 53.8 (range, 18-106 nodes). Four (26.7%) patients had nodal involvement: 2 patients with para-aortic lymph node involvement and 2 patients with both pelvic and para-aortic lymph node involvement. None of the patients was positive for pelvic lymph nodes alone.

Conclusion

A comprehensive para-aortic lymphadenectomy was necessary for accurate staging in PFTC.     

Endometrial disorders in patients with peritoneal serous papillary carcinoma

BACKGROUND: The purpose of this study was to evaluate the incidence rate of endometrial disease, particularly endometrial carcinoma, in patients with primary peritoneal serous papillary carcinoma (PSPC). METHODS: Retrospective review of clinical and histological data from 32 women undergoing surgery (with hysterectomy) for stage III or IV PSPC. RESULTS: Six patients underwent primary debulking surgery and 26 underwent interval debulking surgery after 3 or 4 courses of platinum-based chemotherapy. Six patients (18%) had endometrial disease (hyperplasia in four). Two patients had endometrioid adenocarcinoma of the uterine body (stage IA grade 1 in one case, and stage IB grade 1 in the other) associated with the PSPC. CONCLUSIONS: Endometrial carcinoma of the uterine body may be associated with PSPC (6% cases in the present series). This result suggests that systematic hysterectomy should be performed at the time of debulking surgery in PSPC, even in the absence of peritoneal spread within pelvic cavity.     

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.     

Para-aortic node sampling in small (3-cm or less) stage IB invasive cervical cancer.

Only 2 of 125 patients with FIGO stage IB invasive squamous or adenocarcinoma of the cervix 3 cm or less in diameter who underwent exploration for radical hysterectomy, bilateral pelvic lymphadenectomy, and para-aortic node sampling had metastases to the para-aortic nodes. No patient had gross para-aortic nodal involvement, and both patients with microscopic para-aortic nodal metastases had grossly positive pelvic nodal involvement. Para-aortic node sampling in patients with small stage IB cervical cancers undergoing radical hysterectomy may be restricted to patients with suspicious pelvic or para-aortic nodes.     

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.     

Interstitial thermoradiotherapy in recurrent gynecologic malignancies

In patients with ovarian carcinoma, the presence of metastatic disease in a retroperitoneal lymph node is indicative of a poor prognosis. Although a “staging laparotomy” is required for proper treatment, definitive information concerning para-aortic and pelvic lymph node metastasis often is not available. To determine the incidence of retroperitoneal lymph node metastases in untreated cases of ovarian carcinoma, a prospective study by selective nodal biopsy was undertaken in 61 unselected patients with the following distribution: Stage I, 11; Stage II, 10; Stage III, 31; and Stage IV, 9. The incidence of para-aortic node metastasis overall was 37.7% and of pelvic node metastasis, 14.8%. Of 23 patients with positive para-aortic nodes, 30.4% had no concomitant pelvic node involvement. Direct relationships between nodal metastasis and clinical stage, tumor grade, and histologic type of tumor were demonstrated. The incidence of positive para-aortic nodes in Stage I disease was 18.2%; in Stage II, 20.0%; in Stage III, 41.9%; and in Stage IV, 66.7%. The corresponding incidence of pelvic node metastasis was 9.1% in Stage I, 10.0% in Stage II, 12.9% in Stage III, and 33.3% in Stage IV. Grade 3 tumors were associated most frequently with nodal involvement, with an incidence of positive para-aortic nodes of 52.5% and of positive pelvic nodes of 15.5%. In patients with a serous type of malignancy, the frequencies of positive para-aortic/pelvic nodes were 44.4%/16.7%, respectively; in the undifferentiated type, 50.0%/10.0%; in the clear cell type, 25.0%/25.0%; and in the mucinous type, 14.3%/ 14.3%. In this small series, 32 patients (52.5%) had positive retroperitoneal nodal involvement. It is concluded that selective biopsies of the para-aortic and pelvic lymph nodes should be part of any “staging laparotomy” for ovarian carcinoma, and that the true incidence of nodal involvement in these patients awaits further investigation.     

Are nodal metastases in ovarian cancer chemoresistant lesions? Comparative study of initial lymphadenectomy or after chemotherapy

OBJECTIVE: The aim of this study is to compare the rates of nodal involvement in epithelial ovarian cancer (EOC) in patients who underwent initial lymphadenectomy (before chemotherapy/group 1) and patients who underwent lymphadenectomy after chemotherapy (during interval debulking surgery/group 2 or second-look surgery/group 3). PATIENTS AND METHODS: The rates of nodal involvement in 205 patients with EOC who underwent complete pelvic and paraaortic lympadenectomy were compared. One hundred and five patients underwent this surgical procedure at the end of chemotherapy (group 3) or during chemotherapy (group 2) for 28 patients (with three courses of a platinum-based regimen containing paclitaxel) and were compared to 100 patients who underwent initial lymphadenectomy (group 1). RESULTS: In patients with stage I and II disease the rate of nodal involvement in group 1 and 3 were similar (respectively 19% vs. 21% and 50% vs. 33% in stage I or II disease-NS). In patients with stage III disease, the rates of nodal involvement in patients treated with initial surgery, interval debulking surgery (with paclitaxel-based regimen) and second-look surgery were respectively: 53%, 58% and 48% (NS). Adding to the platinum-based regimen does not seem to improve node sterilization rates. DISCUSSION AND CONCLUSIONS: The rates of nodal involvement seem to be similar in patients treated before or after chemotherapy but the comparison of groups is difficult because the presence of several bias (particularly in early stage disease). Such results suggest that nodal metastases are not totally sterilized by chemotherapy. However, further studies are needed to evaluate the therapeutic value of lymphadenectomy in patients with nodal involvement.     

Para-aortic node biopsy in cervical and endometrial cancers: does it affect survival?

Two hundred ten patients with endometrial and cervical carcinoma had para-aortic node biopsies. Nineteen of the 210 patients (9.0%) had positive para-aortic nodes. These 19 patients received pelvic irradiation, and 18 patients received para-aortic irradiation. The incidence of para-aortic nodal involvement in cervical carcinoma was directly related to the stage of the disease. Eleven of the 12 patients with cervical carcinoma and positive para-aortic nodes received both pelvic and para-aortic irradiation. Three of these patients are alive without disease, resulting in a survival rate of 25%. These patients are surviving for 16, 30, and 41 months. The incidence of positive para-aortic nodes in endometrial adenocarcinoma was related to the uterine length and the histologic grade. The survival rate for patients with endometrial adenocarcinoma and positive para-aortic nodes in this study was 57.1%. Four patients have survived for 1, 30, 60, and 71 months. There were no surgical deaths or radiation therapy complications directly attributable to para-aortic biopsy or irradiation.     

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.     

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.     

Patterns of pelvic and paraaortic lymph node involvement in ovarian cancer

One hundred eighty patients with ovarian cancer underwent complete pelvic lymphadenectomy (n = 75) or pelvic and paraaortic lymphadenectomy (n = 105). Twenty-one patients underwent a preoperative biopsy of the scalene lymph nodes. The incidence of positive lymph nodes was 24% in stage I (n = 37), 50% in stage II (n = 14), 74% in stage III (n = 114), and 73% in stage IV (n = 15). Of the 105 patients who underwent pelvic and paraaortic lymphadenectomy, 13 (12%) had positive pelvic and negative paraaortic nodes and 10 (9%) had positive paraaortic and negative pelvic nodes. Positive scalene nodes were found in four patients (19%) later shown to have stage IV disease. One hundred forty patients were studied for number of involved nodes and node groups, size of nodal metastases, residual tumor, and survival. Of the 81 patients with positive nodes, most had only one or two positive node groups or one to three positive individual nodes. A few patients had seven to eight involved node groups with up to 44 positive nodes. Greater numbers of positive nodes were found in stage III than stage IV. The size of the largest nodal metastasis was not related to the clinical stage or survival, but did correlate with the number of positive nodes. Stage III patients with no residual tumor had a significantly lower rate of lymph node involvement than those with tumor residual (P less than 0.01). Actuarial 5-year survival rates of patients with stage III disease and no, one, or more than one positive nodes were 69, 58, and 28%, respectively.     

Pelvic and para-aortic lymphadenectomy in patients with endometrioid adenocarcinoma of the endometrium.

BACKGROUND: The purpose is to determine the rate of lymph node metastases in women with endometrioid adenocarcinoma of the endometrium (EAE) undergoing systematic lymphadenectomy. METHODS: Patients (349) underwent a complete pelvic and para-aortic lymphadenectomy from caudal to the median circumflex to the level of the renal vessels. RESULTS: Grade 1 tumors accounted for 32.7% of the tumors and 31.0% of the positive nodes, grade 2 accounted for 47.3% of the tumors (37.9% of positive nodes), and grade 3 accounted for 20.1% of the tumors and 31.0% of the positive nodes (P>0.05). Positive nodes were found in 15.8% of grade 1 tumors, 13.3% of grade 2 tumors and 25.7% of grade 3 tumors (P>0.05). Isolated para-aortic involvement without pelvic nodal involvement occurred in 29% of patients with positive nodes. CONCLUSIONS: When complete lymphadenectomies are performed in EAE, positive lymph nodes (including isolated para-aortic lymph nodes) are common in all grades.     

Is there a place for a less extensive radical surgery in locally advanced cervical cancer patients?

OBJECTIVE: The aim of this study was to assess the association among the pathological status of different lymph node groups and parametrium in a single institutional population of 103 locally advanced cervical cancer (LACC) cases who underwent surgery after a neoadjuvant approach. A series of 29 early cervical cancer patients was also included in the analysis. METHODS: Eighty-two LACC patients with documented clinical response to neoadjuvant treatment and 29 early stage cases underwent radical surgery. The operative technique consisted of a type II-V radical hysterectomy and systematic pelvic lymphadenectomy (median number of lymph nodes removed 46; range 5-140). Sixty-four cases were submitted to para-aortic lymphadenectomy up to the level of the inferior mesenteric artery (median number of lymph nodes removed 13; range 1-37). RESULTS: Two subgroups of lymph nodes were defined: lower pelvic lymph nodes (LPN), including obturator and external iliac nodes, and upper pelvic nodes (UPN) including common iliac, presacral, and internal iliac nodes. Metastatic UPN involvement showed a strict association with LPN involvement: in LACC cases, 6 of 7 (86%) positive UPN cases had tumor disease at the LPN level. The single positive UPN case with negative LPN was intraoperatively identified by palpation and frozen section. Similarly, in early cervical cancer patients, 100% of positive UPN cases showed metastatic involvement at the LPN level. Sixty-three of 70 (90%) LACC patients with negative histological parametrium had negative LPN. Among 12 cases with metastatic involvement of parametrium, 5 cases (41.7%) had positive LPN. In early stage cervical cancer, 23 of 27 (85%) cases with negative parametrium showed no lymph nodal involvement. Intraoperative palpation of the parametrium could identify all cases with parametrial involvement not predicted by LPN status. CONCLUSIONS: These data offer the basis for tailoring the extent of radical surgery in LACC patients, through the selection of those lymph node stations likely to provide reliable information on the pathological status of UPN and parametrium.     

Correlation between clinical and histopathologic risk factors and lymph node metastases in early endometrial cancer (a multivariate analysis of 183 cases)

This study includes 183 patients with clinical stage I endometrial cancer subjected to peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymphadenectomy and omental biopsy during a 12-year period in a single institution. The factors analyzed were age, menopausal state, cell type, grade, mitotic activity, myometrial invasion, lymphovascular space invasion, cervical involvement, microscopic vaginal metastases, adnexal metastases, peritoneal cytology, presence of concomitant endometrial hyperplasia and lymph node status. The overall incidences of pelvic and para-aortic lymph node metastases were found to be 15.3% (28/183) and 9.3% (17/183), respectively. In five of 17 patients (29.4%) with para-aortic nodal metastases, pelvic nodes were free of tumor. The most significant prognostic factors for positive pelvic and/or para-aortic nodes were found to be the depth of myometrial invasion, grade of tumor and age.