Nodal distribution and its significance in FIGO stage IIIc endometrial cancer

OBJECTIVE: The aim of this study was to describe the distribution of nodal disease in FIGO Stage IIIc endometrial cancer (EC) and to evaluate whether nodal distribution is related to recurrence and survival. METHODS: Charts from EC patients with FIGO Stage IIIc disease from 1989 to 1998 were abstracted for clinicopathologic data, pelvic (PLN) and para-aortic (PALN) nodal involvement, number of positive/removed nodes, and extranodal disease spread. Patterns of nodal distribution were evaluated for site of first recurrence and survival. Associations between variables were tested by chi(2) and Wilcoxon rank sums. Survival analyses were performed by the Kaplan-Meier method. RESULTS: Of 607 EC patients evaluated, 47 were identified with FIGO Stage IIIc disease. All 47 patients underwent hysterectomy and PLN sampling, and 42/47 had PALN sampling. The median number of PLN removed was 16 (range 2-35), and the median number of PALN was 7 (0-18). Stage IIIc disease was defined by positive PLN alone in 43%, positive PLN and PALN in 40%, and positive PALN alone in 17%. Positive peritoneal cytology and/or adnexal metastasis were present in 12 patients. Only 1/12 of these patients had isolated positive PLN whereas 11/12 had positive PALN (P = 0.007). An increasing number of positive PLN was associated with PALN metastasis (P = 0.0001), and of the 10 patients with bilateral PLN involvement, 9/10 also had positive PALN (P = 0.001). Sites of first recurrence were similar regardless of whether PALN were positive. At a median follow-up of 37 months, the 3-year survival estimate was 70% for patients with positive PALN versus 87% for those with isolated PLN disease (P = 0.22). For all patients neither the total number of positive PLN nor the total number of PLN or PALN removed was associated with survival. CONCLUSIONS: PALN involvement is common in patients with FIGO Stage IIIc endometrial cancer, suggesting that PLN sampling alone may result in underdiagnosis of disease. Patients with positive PALN had more extensive disease, but survival and patterns of failure were not significantly different from those with disease confined to PLN, suggesting that lymph node dissection may have a therapeutic role.     

子宫内膜癌腹膜后淋巴结转移相关因素分析

目的:探讨预测子宫内膜癌腹膜后淋巴结转移的指标,以期为确定子宫内膜癌手术范围提供参考。方法:回顾分析1997年1月至2006年12月初治为手术治疗的641例子宫内膜癌患者的临床与病理资料,单因素分析用χ2检验和Fish确切概率法,多因素分析用Logistic回归模型。结果:经多因素分析显示,病理分级G3、深肌层浸润、附件转移对预测子宫内膜癌盆腔淋巴结(pelvic lymph node,PLN)转移具有统计学意义;盆腔淋巴结转移与腹主动脉旁淋巴结(para-aortic lymph node,PALN)转移显著相关。结论:病理分级G3、深肌层浸润、附件转移是子宫内膜癌盆腔淋巴结转移的重要预测因素;盆腔淋巴结转移对预测腹主动脉旁淋巴结转移具有重要意义。病理分级G3、深肌层浸润、附件转移的子宫内膜癌患者应行盆腔淋巴结清扫术,并根据术中患者的盆腔淋巴结状况决定是否行腹主动脉旁淋巴结清扫术。     

Thrombospondin-1 expression in epithelial ovarian carcinoma: association with p53 status, tumor angiogenesis, and survival in platinum-treated patients

OBJECTIVE: The aim of this study was to analyze FIGO Stage IIIc endometrial cancer (EC) patients to better define clinicopathologic associations, patterns of failure, and survival. METHODS: Charts were abstracted from EC patients with lymph node metastasis from 1989 to 1998. Data on clinicopathologic variables, adjuvant treatment, site of first recurrence, and survival were collected. Associations between variables were tested by chi(2) and Wilcoxon rank sums. Survival analyses were performed by the Kaplan-Meier method, and multiple regression analysis was done by the Cox proportional hazards model. RESULTS: From 607 EC patients evaluated, 47 (8%) were identified with FIGO Stage IIIc disease. All 47 underwent hysterectomy and pelvic lymph node (PLN) sampling, and 42/47 had para-aortic lymph node (PALN) sampling. Stage IIIc disease was defined by positive PLN alone in 38%, positive PLN and PALN in 41%, and positive PALN alone in 17%. Twelve of 47 also had positive peritoneal cytology and/or adnexal metastases. Grade III tumors were present in 56% and >50% myometrial invasion in 61%. No association between depth of invasion (DOI) and grade was seen, however. Nearly 1/3 of cases had papillary serous or clear cell histology. Postoperative adjuvant treatment included whole abdominal radiation (36%), pelvic radiation with (19%) and without (17%) extended field, chemotherapy (17%), and oral progestins (11%). The 3-year and 5-year survival estimates for all patients were 77 and 65%, respectively. At a median follow-up of 37 months, 5 patients are alive with disease, and 10 are dead of disease. A distant site of first recurrence was most common (21%), followed by pelvic failure (9%). Only 1 patient has had an abdominal recurrence. Univariate predictors of survival included age, DOI, and extranodal disease, but not grade, histology, or PALN involvement. For the 12 patients with nodal disease and positive cytology and/or adnexa, 3-year survival was 39% versus 93% for those patients without evidence of extranodal disease. In a multivariate analysis only DOI was an independent predictor of survival (P = 0.03). CONCLUSIONS: Once lymph node involvement occurs, the importance of additional extranodal disease increases. Consideration of substaging Stage IIIc patients based on positive adnexa or cytology is supported by the data. The extent which adjuvant treatments contributed to the 77% 3-year survival remains to be defined. The patterns of failure suggest a possible role for combined modalities in future treatments.     

Lymph node pathway in the spread of endometrial carcinoma

OBJECTIVE: To elucidate the sentinel nodes of endometrial carcinoma, the spread pathway was clarified. The correlation between lymph node spread and other clinicopathological variables was also analyzed. METHODS: Dissected lymph node samples in 342 patients who underwent pelvic and selective paraaortic lymphadenectomy were reviewed. Pelvic and paraaortic node (PLN and PAN) status was compared with clinicopathological parameters. RESULTS: Lymph node metastasis was demonstrated in 52 patients, including 46 cases with PLN metastasis and six patients with independent PAN metastasis. The metastatic sites were most frequent in the obturator and internal iliac nodes. Eleven of 49 patients who underwent PAN dissection were positive for metastasis. Sixteen of 23 cases with parametrial metastasis also metastasized in the retroperitoneal lymph node. CONCLUSION: The lymph node spread pathway in endometrial carcinoma consists of a major route via the obturator node or internal iliac node with or without parametrial involvement, and rarely a direct PAN pathway.     

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。     

Is it possible to predict para-aortic lymph node metastasis in endometrial cancer?

Objective

The purpose of this study was to determine the histopathologic risk factors for pelvic lymph node (PLN) and para-aortic lymph node (PALN) metastasis in endometrial cancer (EC) and to identify in which patients PALN dissection should be performed.

Study design

A total of 204 consecutive patients, with EC and underwent systematic pelvic and para-aortic lymphadenectomy extending to the renal vessels, were studied retrospectively. Statistical significance between risk factors was examined using multivariant logistic regression analysis.

Results

Cell type, depth of myometrial invasion and tumor size were found to be independently related to PLN metastasis. PLN metastasis in any site and lymphovascular invasion (LVSI) were independent prognostic factors for predicting PALN metastasis. The sensitivity, specificity and the NPV of PLN metastasis for detecting PALN metastasis were 80.8%, 89.3% and 97%, respectively. Furthermore, the 204 patients were divided into two groups according to the presence of one of these following factors: (1) non-endometrioid cell type, (2) PLN metastasis, (3) LVSI, (4) adnexal metastasis and (5) serosal involvement. Among these 204 patients, 104 had one or more of these factors (group A), and 100 patients had none of these factors (group B). PALN metastasis was significantly greater in group A, compared to group B. The sensitivity and the NPV of these combined prognostic factors for predicting PALN metastasis were 96.2% and 99%, respectively.

Conclusions

Presence of non-endometrioid cell type, PLN metastasis, LVSI, adnexal metastasis or serosal involvement diagnosed by frozen section (FS) seem to be poor prognostic factor for PALN metastasis in EC. Also, PALN dissection should be extended to the level of the renal vessels in all patients who will undergo PALN dissection, due to frequent involvement of the supramesenterial region.     

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.     

Indispensability of Pelvic and Paraaortic Lymphadenectomy in Endometrial Cancers

The purposes of this study were to analyze the relationship between retroperitoneal lymph node (RLN) metastasis and clinical and pathologic risk factors in endometrial cancers, and to clarify the correlation between RLN metastasis and survival of patients with the disease. This analysis included 63 patients with endometrial cancer who underwent simultaneous pelvic lymph node (PLN) and paraaortic lymph node (PAN) dissection between April 1988 and December 1995. Patients with stage Ia grade 1 and stage IV disease were excluded from this analysis. Both PLN and PAN metastases were found in 10.0% (4/40) of patients with stage I (FIGO, 1988) disease. Of 14 cases with PLN metastases, 8 (57.1%) had PAN metastases simultaneously, whereas 4 (8.2%) of 49 cases without PLN metastases had PAN metastases. There was no significant relationship between the sites or numbers of positive PLN and PAN metastases. Multivariate analysis revealed that poor grade and deep myometrial invasion had an independent relationship with PAN metastases, whereas vascular space invasion and cervical invasion were independently associated with PLN metastases. When divided into the groups of stage I–II and stage III, the prognosis of patients with RLN metastases was significantly poorer than that of patients without RLN metastases in each stage. Furthermore, survival of patients with PAN metastases was significantly worse compared with that of patients with only PLN metastases (44.4 and 80.0%, respectively,P< 0.05). These results reveal that PLN and PAN metastases occur frequently even in early-stage endometrial cancer, and that RLN metastases, especially PAN metastases, have a serious impact on patient survival. In conclusion, systemically simultaneous pelvic and paraaortic lymphadenectomy is essential for all the patients with endometrial cancer except those with stage Ia grade 1 and stage IV to provide prognostic information and select suitable postoperative treatment as well as to perform accurate FIGO staging, provided the condition of the patient permits.     

Sister Joseph umbilical nodule coexisting with endometriosis from endometrial carcinoma

A 58-year-old woman was diagnosed with endometrial carcinoma. Total hysterectomy, bilateral salpingo-oophorectomy and paraaortic and a pelvic lymph node dissection were performed. The cytology of peritoneal fluid was negative. There was no peritoneal dissemination except umbilical nodule. A peritoneal 2.0×1.5 cm umbilical nodule was also resected. The nodule was identified as a metastasis from endometrial cancer with endometriosis. The pelvic lymph nodes also showed metastatic lesion with endometriosis. Our case showed that endometriosis coexisted with umbilical and pelvic lymph nodal metastatic lesions from endometrial cancer. This fact suggests that the mode of metastasis to the umbilicus via lymph flow from endometrial cancer is the same as that for endometriosis.     

Carcinoma IB of the endometrium: spread and prognostic factors

The prognostic factors and their intercorrelation in 47 patients with IB endometrial cancer are presented. The data reveal the particular behaviour of the lymphatic involvement: five patients (10.6%) showed metastases to pelvic lymph nodes and six patients (12.8%) had paraaortic node metastases; altogether two women (4.2%) had histological evidence of involvement of pelvic and paraaortic nodes. Both histological grade and depth of myometrial invasion showed a characteristic relationship with the lymphatic spread: the percentage of lymph node metastases seems to bear relation to progression of myometrial penetration (M2-M3) and to histological differentiation (G2-G3).     

Long-term results of maximally aggressive trimodality therapy in a high-risk subset of early-stage cervical cancer patients

OBJECTIVE: To evaluate the long-term survival and treatment-related morbidity associated with treating patients who have early-stage cervical carcinoma metastatic to the paraaortic lymph nodes with radical hysterectomy, pelvic and paraaortic lymphadenectomy, and adjuvant, extended field chemoradiation with cisplatin and 5-fluorouracil (5-FU). STUDY DESIGN: From 1988 to 1997, 14 consecutive patients referred to Radiological Associates of Sacramento following radical hysterectomy and pelvic and paraaortic lymphadenectomy with findings of clinical stage IB or IIA cervical cancer and histologically confirmed lymph node metastasis to the common iliac or paraaortic distributions were treated with adjuvant, extended field chemoradiation utilizing prolonged infusion 5-FU and bolus cisplatin. Retrospective chart review was performed, and survival and morbidity information were analyzed. Recurrence was assessed among patients based on age, race, total number of nodes involved, gross vs. microscopic nodal involvement, squamous vs. nonsquamous tumor histology, time to initiation of adjuvant treatment and time required to complete that treatment. Calculated 5-year survival, mean survival, morbidity type and incidence are reported for the group as a whole. RESULTS: Calculated 5-year survival of patients in this series was 38% by life table analysis. Median survival was 4.4 years; 50% of patients had a recurrence. None of the examined parameters were significant predictors of recurrence. There was 1 treatment-related death and a second case of severe treatment-related morbidity (radiation enteritis requiring colostomy and bilateral ureteral stenosis requiring bilateral nephrostomies). There were 6 cases of minor treatment-related toxicity occurring in 5 of 14 (36%) treated patients. CONCLUSION: In general, survival in the current series of patients was akin to that in clinically similar patients treated with chemoradiation alone. Morbidity among our patients was significant. In the presence of positive paraaortic lymph nodes there were no independent predictors of recurrence among the pathologic or treatment parameters examined.     

Lymphatic mapping and sentinel node identification as related to the primary sites of lymph node metastasis in early stage ovarian cancer

OBJECTIVE: We evaluated the primary sites of lymph node (LN) metastasis in patients during the early stage of ovarian cancer. METHODS: Study 1: patients with clinical stage I and II common epithelial ovarian carcinoma (n = 150) underwent systematic retroperitoneal LN dissection of the pelvic and paraaortic areas. The relationship between the incidence and location of LN metastasis and clinical and histological characteristics was examined. Study 2: we studied 11 women with endometrial or fallopian tube tumors. At laparotomy, activated charcoal solution was injected into the unilateral cortex of the ovary. Ten minutes later, the retroperitoneal spaces were opened and charcoal uptake within the pelvic lymph node (PLN) and paraaortic node (PAN) as far as the level of renal vein was examined. RESULTS: Study 1: The incidence of LN metastasis by stage was 6.5% (8/123) in stage I and 40.7% (11/27) in stage II. Among 19 patients with LN metastasis, 14 had only PAN, 2 had only pelvic LN, and 3 had both PAN and PLN metastases. Metastasis was limited to the ipsilateral side in 12 (63%) patients, but was bilateral in 5 (26%) and contralateral to the neoplastic ovary in 2 (11%). Positive peritoneal cytology was significantly (P < 0.05) correlated with lymph node metastasis. Study 2: Lymphatic channels along the ovarian vessels were identified in all injected ovaries. Charcoal was deposited in the LN of all patients. The locations of these nodes included PAN in all patients, common iliac node in three, and external iliac node in one. CONCLUSION: PAN is the primary site of LN metastasis in ovarian cancer. Bilateral PAN dissections are necessary to determine the extent of tumors even in stage I ovarian carcinoma.     

The incidence and clinical significance of paraaortic lymph node metastases in patients with uterine cervical cancer

Paraaortic lymph node dissection was performed in the treatment of patients with carcinoma of the cervix who were subjected to radical hysterectomy between June, 1982 and March, 1988 at the Department of Obstetrics and Gynecology, Hokkaido University Hospital, Sapporo, Japan. Thirteen out of 246 (5.3%) patients had metastases in the paraaortic lymph node. Of the patients with stage I carcinoma of the cervix, 1.0 per cent had positive paraaortic lymph node. Of the patients with stage II carcinoma, 4.9 per cent had metastases in the paraaortic lymph nodes, and of the stage III patients, 16.7 per cent had positive paraaortic lymph nodes. The incidence of paraaortic node involvement increased along with the advance of the disease. Of the patients with squamous cell carcinoma of the cervix, 4.6 per cent had paraaortic lymph node metastases. Of the patients with adenocarcinoma of the cervix including mixed carcinoma, 6.8 per cent had positive paraaortic node. All the patients with positive paraaortic lymph nodes had metastatic diseases in the pelvic nodes. In addition, the number of groups of positive pelvic nodes in the patients with positive paraaortic lymph nodes was significantly larger than that in those with negative paraaortic nodes. At the time of reporting, seven out of 13 patients with positive paraaortic lymph node have died of the disease. The mean survival period of those seven patients was 14.9 +/- 12.2 (mean +/- SD) months. Of the remaining six surviving patients, three have been doing well for more than three years.(ABSTRACT TRUNCATED AT 250 WORDS)     

卵巢癌腹主动脉旁淋巴结清除术与生存率的关系

目的:探讨上皮性卵巢癌患者行腹主动脉旁淋巴结清除术与其生存预后的关系。方法:回顾分析卵巢癌肿瘤细胞减灭术的80例患者,将其中行腹主动脉旁淋巴结(PAN)+盆腔淋巴结(PLN)清除术分为A组(30例),仅行PLN清除术者分为B组(50例),分析PAN清除与患者生存预后的相关性。结果:行卵巢肿瘤细胞减灭术的80例患者中,32例(40.0%)发生淋巴结转移。A组中19例发生淋巴结转移,其中仅PAN阳性7例,仅PLN阳性3例,PAN和PLN均阳性9例;B组中13例发生PLN转移。A与B组患者的淋巴结转移与临床分期、肿瘤细胞分化程度和组织学类型显著相关(P0.05)。A组中淋巴结转移部位以PAN最多16例,其余依次为髂内、闭孔、髂总、腹股沟及髂外淋巴结。A组患者的3年、5年生存率分别为77.9%和46.7%,均高于B组(69.0%和39.2%),但无显著差异(P0.05)。A与B组患者中转移至PLN者的3年生存率分别是68.5%和41.4%,5年生存率是49.7%和26.4%,两组比较差异显著(P=0.044)。A组患者中淋巴结阳性与阴性患者3年生存率分别为43.5%和72.7%,5年生存率是27.2%和58.5%,差异显著(P=0.048)。Cox模型单因素分析提示,淋巴结状态对患者的生存率有影响(P0.01),而且是死亡风险因素。结论:腹主动脉旁淋巴结的清除对改善卵巢癌患者预后起着重要作用。     

Significance of pathologic patterns of pelvic lymph node metastases in endometrial cancer

OBJECTIVE: The aim of this study was to correlate the pathologic characteristics of pelvic lymph node metastases with survival, recurrence, and patterns of recurrence in endometrial cancer. METHODS: Sixty patients with epithelial endometrial cancer and pelvic node metastasis were managed surgically between 1984 and 1993 at the Mayo Clinic. The mean number of nodes harvested was 16.7 and the mean number of nodes positive was 3.0. Mean follow-up was 45.5 months. The pathologic patterns of lymph node metastases were characterized. RESULTS: Outcome was related to pathologic patterns of pelvic node metastasis. Both diameter of lymph node metastasis (P < 0.01) and capsular integrity (P < or = 0.01) influenced 5-year disease-related survival and 5-year progression-free survival. The percentage of biopsied pelvic lymph nodes harboring metastatic disease and the proportion of the involved lymph nodes occupied by tumor significantly influenced death rates and recurrence rates (P < 0.05). The immune response and the absolute number of positive pelvic nodes did not impact recurrence or survival. The above characteristics of pelvic node metastasis correlated also with patterns of recurrence. Regression analysis indicated that capsular integrity (RR = 2.97; P = 0.005) and proportion of positive pelvic nodes biopsied (RR = 3.84; P = 0.01) were significant predictors of recurrence, whereas diameter of metastasis (RR = 3.68; P = 0.02) and proportion of positive pelvic nodes biopsied (RR = 4.04; P = 0.02) were most predictive of survival. CONCLUSIONS: The pathologic patterns of pelvic node metastasis appear to be significantly related to survival, recurrence, and patterns of recurrence.     

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.     

Maylard incision for radical hysterectomy and pelvic and para-aortic lymph node dissection

Angioli R, Koechli OR, Sevin B-U. Maylard incision for radical hysterectomy and pelvic and para-aortic lymph node dissection. Int J Gynecol Cancer 1998; 8 : 274–278.
Although the transverse, muscle-splitting technique for abdominal incision (Maylard incision) has been described for radical hysterectomy and for lymph node dissection of the pelvis and para-aortic area, the adequacy of the procedure performed through this incision has not been assessed. From 1991 to 1994, 205 patients underwent radical hysterectomy with pelvic lymph node (PLN) and para-aortic lymph node (PALN) dissection at the Division of Gynecologic Oncology, Jackson Memorial Hospital/University of Miami School of Medicine. Twenty-four patients with cervical cancer stage IB-IIA underwent radical hysterectomy, pelvic lymph node and para-aortic lymph node dissection through a Maylard incision. Three patients had panniculectomy performed at the same time. Duration of surgery, estimated blood loss, number of pelvic and para-aortic lymph nodes removed and duration of hospital stay were within acceptable ranges. Postoperative and intraoperative complications were minimal. Excellent cosmetic results were obtained. In conclusion, the Maylard incision offers good exposure to the pelvic and para-aortic area for lymph node dissection, good cosmetic result, and can be performed in association with abdominoplasty. Complications are similar to those observed with a vertical skin incision. This type of incision should be considered in selected young patients with early cervical cancer and in obese patients desiring abdominoplasty.     

Predicting pelvic lymph node metastasis in endometrial carcinoma

BACKGROUND: To determine the possibility of individualizing the pelvic lymph node dissection in patients with endometrial cancer, the relationship between pelvic lymph node (PLN) metastasis and various prognostic factors was retrospectively investigated. METHODS: From 1979 to 1994, 175 patients with endometrial carcinoma were treated with either total or radical hysterectomy combined with a PLN dissection as initial therapy. The prognostic factors examined included clinical stage, patient age, histological grade, the microscopic degree of myometrial invasion (DMI), cervical invasion, adnexal metastasis, and macroscopic tumor diameter (TD). RESULTS: Of the 175 patients undergoing PLN dissection, 24 (14%) had PLN metastasis. An endometrial cancer with PLN metastasis had a significantly longer diameter than those without PLN metastasis. The frequency of PLN metastasis increased along with increases in tumor diameter. A logistic regression analysis revealed DMI and TD to be independently correlated with PLN metastasis. The formula based on the coefficients of TD and DMI obtained from the analysis also showed a good correlation, which allowed us to estimate the probability of patients having PLN metastasis. CONCLUSIONS: DMI and TD could accurately estimate the status of PLN in endometrial carcinoma patients.     

Is systematic scalene node biopsy in pretreatment evaluation of locally advanced cervical carcinoma necessary? Systematic dissection and histopathology of left scalene node biopsies in patients with locally advanced cervical carcinoma

OBJECTIVE: Cervical carcinomas mainly spread via lymphatics, stepwise from pelvic to aortic and scalenic lymph nodes. Metastatic nodes are the major prognostic factor in this disease. When scalenic nodes are involved, cervical cancer is considered to be disseminated. Since there is a major discrepancy in reported percentages of metastatic scalene nodes in the literature (0 to 50%), we proceeded to systematic pretreatment scalene node biopsy and then evaluated the validity of this procedure. METHODS: From January 1998 to May 2003, 72 patients with locally advanced cervical carcinoma and no suspicious paraaortic or scalenic nodes (respectively on magnetic resonance imaging and clinically) had a systematic surgical pretreatment lymph node evaluation (retroperitoneal laparoscopic infrarenal paraaortic lymph node dissection and left scalenic lymph node biopsy). Scalene biopsy was examined using hematoxylin/eosin stain and immunohistochemistry (KL1 antibodies). RESULTS: Among the 72 patients, 20 were stage IB2, 4 were IIA, 14 were IIB, 4 were IIIA, 27 were IIIB, 1 was IVA and 2 had a recurrent cervical carcinoma. Fourteen women had histologically confirmed paraaortic metastases (11 macroscopic, 3 microscopic). No metastatic involvement of the scalene nodes was detected. Fifteen patients developed a recurrence within 12 months (3 to 19 months). None of the patients developed scalenic recurrence. CONCLUSION: Left scalene node biopsy does not appear to be mandatory in routine pretherapeutic lymph node evaluation of patients with advanced cervical carcinoma and no clinical suspicious nodes. It may be useful to prove disseminated disease in patients with suspicious clinical nodes or hot spots on PET-scan, if fine needle biopsy is unconclusive.     

Panniculectomy: improving lymph node yield in morbidly obese patients with endometrial neoplasms

OBJECTIVE: Panniculectomy has been used to facilitate pelvic surgery in obese women. The goal of this study was to determine the effect of panniculectomy on staging adequacy and lymph node yield in obese women with endometrial carcinoma undergoing staging laparotomy. METHODS: A retrospective review of patients with endometrial neoplasms who underwent panniculectomy at the time of hysterectomy was performed. For each subject, two control patients were matched by body mass index (BMI). RESULTS: Twenty-seven endometrial cancer patients who underwent panniculectomy at the time of staging were identified. Panniculectomy was successfully performed in all 27 patients. While the mean number of pelvic nodes was statistically similar between the two groups (16.2 vs. 13.7) (P = 0.199), the paraaortic node count was higher in patients who underwent panniculectomy (4.3 vs. 2.9) (P = 0.032). A paraaortic node dissection was not feasible in 3 (11.1%) of the panniculectomy patients and in 11 (20.4%) of the controls (P = 0.365). There were no differences in intraoperative or postoperative complications or in survival between the two groups. CONCLUSION: Among obese women with endometrial cancer, panniculectomy is well tolerated, feasible, and associated with acceptable morbidity. While the clinical significance of an increased paraaortic node count is uncertain, our findings suggest that panniculectomy may enhance operative exposure and facilitate endometrial cancer staging.