Laparoscopic pelvic lymphadenectomy in the staging of early carcinoma of the cervix.

Laparoscopic pelvic lymphadenectomy was performed in 39 patients. An incision of the peritoneum between the round and infundibulo-pelvic ligament on each side gave access to the retroperitoneal space. Subsequently, laparoscopic surgery allowed precise dissection of external and internal iliac vessels, umbilical artery, and obturator nerve. The peritoneum was left open, and the lymph was drained into the peritoneal cavity. No lymphocele was observed. Three to 22 (mean, 8.7) nodes were removed, and there was no significant morbidity. Sensitivity and specificity were 100% in this preliminary experience. It is thus possible to remove the first-line regional lymph nodes of the cervix for pathologic examination. Because "skip" metastases are quite rare in early cervical carcinoma, the risk of missing a positive node is low. Brachytherapy alone, vaginal surgery, or, in microinvasive carcinoma, conization alone can be applied safely without the need of a staging laparotomy in cases with negative nodes.     

Laparoscopic findings, management, histopathology, and outcome of 25 women with cyclic leg pain

STUDY OBJECTIVE: To determine pelvic findings, histopathology, and clinical outcome in women with chronic pelvic pain and cyclic sciatica-like pain after laparoscopic surgery. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: University-affiliated teaching hospital. PATIENTS: Of 2115 women with chronic pelvic pain, 25 also complained of cyclic pain radiating to the leg (right 15, left 9, both 1), pain over buttocks, and paresthesia of the thighs and/or knees, exacerbated during menses. INTERVENTION: Laparoscopy. MEASUREMENTS AND MAIN RESULTS: Laparoscopic findings were endometriosis nodules (5 patients), peritoneal pockets and/or peritoneal endometriosis (19), and inflammatory peritoneum (1). Associated pelvic endometriosis was identified and confirmed in 17 women (68%). No additional lesions other than peritoneal pockets were found in eight (32%). All nodules, peritoneal pockets, and abnormal peritoneum were excised with a combination of hydrodissection and carbon dioxide laser. Peritoneum over resultant deep defects was sutured with one to three 2-0 nonabsorbable sutures in accordance with the surgeon's practice and experience. Endometriosis was confirmed in all five nodules, and histology of excised pockets showed endometriosis in nine (60.0%), endosalpingiosis in two (13.3%), chronic inflammation in one (6.7%), and normal tissue in three (20.0%). After laparoscopic excision sciatic symptoms were eliminated in 19, markedly improved in 4, remained the same in 2, and recurred in 3 patients after 2 years. CONCLUSION: Cyclic leg signs and symptoms were associated with pelvic peritoneal pockets, endometriosis nodules, or surface endometriosis of the posterolateral pelvic peritoneum. We hypothesize that the pain associated with these lesions is more likely referred pain originating from pelvic peritoneum than direct irritation of the lumbosacral plexus of the sciatic nerve.     

Endosalpingiosis in association with ovarian surface papillary tumor of borderline malignancy.

A 40-year-old woman underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic/paraaortic lymphadenectomy, and omentectomy for Stage IA ovarian surface papillary tumor of borderline malignancy. Microscopic examination revealed endosalpingiosis of ovaries, the peritoneum of uterus, pelvic lymph nodes, and omentum. There was no evidence of disseminated peritoneal malignancy. The several proposed theories of the pathogenesis of endosalpingiosis are reviewed, but that involving metaplasia of the multipotential peritoneal cells is presented as the most acceptable.     

Mesorectal lymph node involvement and prognostic implications at total pelvic exenteration for gynecologic malignancies

OBJECTIVES: To determine the incidence and prognostic implications of positive mesorectal lymph nodes in patients undergoing total pelvic exenteration for recurrent gynecologic malignancies. METHODS: We performed a retrospective chart review of all patients who had undergone total pelvic exenteration for a gynecologic malignancy between July 1992 and December 2003. Patient charts were reviewed for information regarding demographics, site of cancer, histology, pathology report, and time to recurrence. RESULTS: Fifty-eight women had undergone total pelvic exenteration for recurrent gynecologic malignancies during the study period and 57 were available for analysis. Primary cancer site was as follows: cervix, 37 (65%); vagina, 8 (14%); vulva, 5 (9%); and uterine corpus, 7 (12%). In 30 patients (53%), the mesorectal lymph node status was pathologically evaluated. Of these 30 patients, 3 (10%) had positive mesorectal lymph nodes at the time of total pelvic exenteration. All 3 patients had rectal wall involvement (rectal submucosa, 2; rectal mucosa, 1), and all 3 patients recurred within 4 months of pelvic exenteration. The median time to recurrence after surgery was 2.4 months in those patients with positive mesorectal lymph nodes compared with 7.3 months in those with negative mesorectal lymph nodes (P = 0.005). When individually adjusted for other prognostic variables, such as margin status, tumor grade, lymphovascular space involvement, primary cancer site, and histologic type, a finding of positive mesorectal lymph nodes was associated with a shorter time to recurrence of disease (all P < 0.05). CONCLUSIONS: Mesorectal lymph node involvement is a common finding at total pelvic exenteration, particularly in patients with rectal wall involvement. Patients with positive mesorectal lymph nodes appear to have a worse outcome with a shorter time to recurrence of disease.     

Value of indocyanine green pelvic lymph node mapping in the surgical approach of cervical cancer

Lymph node metastasis is a significant predictive factor for disease recurrence and survival in cervical cancer patients and relevant for therapeutic strategies. We evaluated the clinical value of indocyanine green (ICG) by measuring the sensitivity and negative predictive value of sentinel lymph node mapping compared with the gold standard of complete lymphadenectomy in detecting lymph node metastases for cervical cancer. We utilized the near-infrared imaging agent ICG to detect tumor-infested lymph nodes in the pelvis analogue to a classical sentinel lymph node procedure by analyzing data from 20 patients who had undergone surgery for cervical cancer at our institution. A laparoscopic lymph node mapping procedure by means of ICG, followed by a complete pelvic lymphadenectomy with or without paraaortic lymphadenectomy was done in all patients. Histological examination identified seven patients with tumor-positive pelvic nodes, whereas mapping with ICG identified only five of these patients. Detection rate of positive nodes by ICG mapping and false negative rate was 71.4% and 28.6%, respectively; bilateral detection rate was 83.3%. One of the two false negative patients additionally suffered from deep infiltrating endometriosis. Our results indicate that ICG can identify the relevant pelvic nodes independent of tumor size, provided bilateral detection is achieved and additional, related diseases are excluded. This trial is registered within the German Clinical Trial Register (DRKS-ID: DRKS00014692).     

Detection of pelvic lymph node micrometastasis in stage IA2-IB2 cervical cancer by immunohistochemical analysis

OBJECTIVES: The objectives of this study were to (1) determine the incidence of lymph node micrometastasis in cervical cancer by immunohistochemical analysis and (2) determine if the presence of micrometastasis is a poor prognostic feature in early cervical cancer. METHODS: We retrospectively reviewed the medical records of 62 patients who underwent radical hysterectomy and lymphadenectomy for FIGO stage IA2-IB2 cervical cancer at Stanford University Hospital from 1990 to 2000. Forty-nine patients with negative lymph nodes were identified. A total of 976 formalin-fixed paraffin-embedded pelvic lymphadenectomy specimens were serially sectioned and stained with anti-cytokeratin antibodies AE1 and AE1/CAM5.2. RESULTS: Six patients had stage IA2 disease, 37 had stage IB1, and 6 had IB2. The mean age of the patients was 44 years (range, 24-76). Seventy-one percent had squamous cell carcinomas, 22% had adenocarcinomas, and 6% had other types. Lymph node micrometastases were immunohistochemically detected in 4 of the 49 (8.1%) patients, comprising 4 of 976 (0.41%) pelvic lymph nodes examined. Twelve of 45 (15.6%) patients with negative nodes had lymph-vascular space invasion (LVSI) whereas 3 of 4 (75%) patients with micrometastases had LVSI. At a mean follow-up time of 39.4 months, 2 of 4 (50%) patients with micrometastasis had recurrent disease, while 3 of 45 (6.7%) patients without micrometastasis developed recurrent disease. CONCLUSIONS: These preliminary data suggest that immunohistochemical detection of pelvic lymph nodes is more frequent in patients with LVSI and may identify patients needing adjuvant chemoradiation.     

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.     

Do the pelvic lymph nodes predict the parametrial status in cervical cancer stages IB–IIA?

The aim of this study was to determine whether the pelvic lymph nodes would predict the parametrial status in patients with cervical cancer stages IB1-IIA submitted to radical surgery and pelvic lymphadenectomy. To this end, we evaluated the relationship between positive and negative pelvic lymph nodes and their parametria. Our final purpose was to use this information to recommend the tailoring of the parametrial resection according to the status of pelvic lymph nodes to decrease the morbidity related with radical paratrectomy. From January 1996 to December 2001, 107 consecutive patients with cervical cancer stages IB1 and IIA were primarily treated by radical hysterectomy type III with systematic pelvic lymphadenectomy in a prospective study. Parametria were studied in two sections: the first included the tissue adjacent to the cervix, and the second the distal 2/3. Lymph nodes were routinary processed. Twenty-two patients (20.6%) had positive pelvic nodes and 16 patients (14.9%) had parametrial involvement, mostly by direct extension. Eight patients with positive pelvic nodes (36.4%) had parametrial involvement, whereas among 85 patients with negative pelvic nodes only eight patients (9.4%) had parametrial involvement (P < 0.001), most in internal parametria (62.5%). The sensitivity of pelvic lymph nodes for parametrial involvement was 50% and the positive predictive value was 36.4%, whereas the specificity was 84.6%; and the negative predictive value 90.6%. In the group of negative pelvic lymph nodes, only two patients (2.3%) had parametrial involvement beyond internal parametria. The univariated and multivariated analysis of prognostic factors was always significant but without a significant independent factor for positive parametria. Pelvic lymph nodes appear as good predictors of parametrial status, especially in node-negative patients, and could be used to decrease the paratrectomy in radical surgery.     

Endosalpingiosis-an underestimated cause of chronic pelvic pain or an accidental finding? A retrospective study of 16 cases

OBJECTIVE: The relevance of endosalpingiosis as a cause of chronic pelvic pain is controversial. To examine the clinical presentation of endosalpingiosis, the files of the Institute of Pathology at the University of Münster for the years 1994-1999 were screened by keyword search for the diagnosis of endosalpingiosis and the patient files were reviewed. PATIENTS: Thirteen patients with the diagnosis endosalpingiosis treated at our institution were identified within the past 6 years. Five patients (38%) presented with pelvic pain, five (38%) with hyper- or dysmenorrhea, five (38%) patients had no complaints at all, one of these had primary and one had secondary infertility, three had persistent ovarian cysts. The diagnosis of endosalpingiosis was confirmed by a second pathologist for all patients included in this study. RESULTS: Mean age at diagnosis was 43 (range 24-82), of the five patients presenting with pelvic pain, the localization of endosalpingiosis was consistent with the localization of pain in only four (30%) patients. Localization and macroscopic appearance of endosalpingiosis and endometriosis seems to be the same in our cases. Five (38%) patients suffered from myomatous uterus, five (38%) had additional endometriosis, five (15%) patients had hydrosalpinx (postinflammatory tubal disease), and seven (53%) had pelvic adhesions. Nine patients had previously been admitted for surgery, only two (15%) patients had tubal surgery, two (15%) had cesarian section and five (38%) had a history of more than two abdominal operations. Eleven (85%) cases of endosalpingiosis were diagnosed by the same pathologist. CONCLUSIONS: Endosalpingiosis seems to be an accidental finding, associated with additional pelvic pathology, rather than being a frequent cause of pelvic pain.     

Pelvic adhesion formation at second-look surgery after laparoscopic partial and total peritoneal excision for women with endometriosis

The purpose of this study was to determine the incidence of pelvic adhesion formation at second-look surgery after laparoscopic excision of the pelvic peritoneum for pelvic endometriosis. The setting was a district hospital in the UK with a specialised unit for laparoscopic surgical treatment of endometriosis; this was a retrospective study. We used data from the hospital computer database to identify patients who had undergone laparoscopic excision of pelvic endometriosis from April 1998 to March 2004. All subsequent admissions for surgery (laparoscopic or open) were reviewed for the presence of pelvic adhesions as documented in the records and collaborated with photographs from surgery. Forty-eight cases were identified from a cohort of 236 patients who initially had laparoscopic excision of pelvic peritoneum affected with endometriosis. Forty-six had laparoscopic surgery and two had open surgery. At second look surgery, 44 patients (91.7%) had no de-novo pelvic adhesions in the areas where the initial excision was performed. Four patients (8.3%) had filmy adhesions in the pelvis; these patients had other surgical procedures (two had LAVH) or on-going disease (one with recto-vaginal endometriosis nodule and the other with ovarian endometrioma at initial surgery). There were no dense or significant pelvic adhesions. Laparoscopic excision of the pelvic peritoneum as a treatment for pelvic peritoneal endometriosis is not associated with significant pelvic adhesion formation.     

Clinical implication of laparoscopic pelvic lymphadenectomy in patients with vulvar cancer and positive groin nodes

OBJECTIVE: At present, no clear guidelines for the treatment of patients with vulvar cancer and positive groin nodes exist. In general, the decision for additional pelvic radiation is based on findings by imaging techniques and/or the number of groin nodes involved. The aim of this case series was to demonstrate that histologic result of laparoscopic removed pelvic lymph nodes can be used to select patients who should not undergo pelvic irradiation. METHODS: From July 1997 to October 2004, 12 consecutive patients with primary or recurrent vulvar cancer underwent laparoscopic pelvic lymphadenectomy following primary or secondary surgical treatment. RESULTS: There were 8 patients with primary cancer of the vulva and 4 patients with recurrent disease in the inguinal and/or pelvic lymph nodes. The mean age was 61 (26-83) years and the mean body-mass-index was 27.1 (20.8-36.6). Positive groin nodes were found in five patients on the right side and in five patients on the left side; in one patient, positive groin nodes were present in both sides. In another patient with a history of vulvar cancer and positive groin nodes the CT-scan indicated the presence of positive iliac and paraaortic lymph nodes. Only in two patients tumor involved lymph nodes were diagnosed by laparoscopic pelvic lymphadenectomy (one left-sided, one right-sided). The number of harvested pelvic lymph nodes was 13.7 (5-20) in unilateral and 27.8 (16-37) in bilateral lymphadenectomy. The histologic examination of removed pelvic lymph nodes confirmed pelvic radiation in only 2 out of 12 patients, whereas 10 patients were spared from whole pelvis irradiation. CONCLUSION: With respect to small sample size, laparoscopic lymphadenectomy seems to be a good tool to avoid unnecessary pelvic radiation in patients with vulvar cancer and confirmed positive groin nodes.     

Preoperative pelvic lymphoscintigraphy is of limited usefulness for sentinel lymph node detection in cervical cancer

Objectives

To analyze concordance between preoperative lymphoscintigraphy and intraoperative lymphatic mapping (ILM) for sentinel lymph node identification using technetium 99m-labeled-dextran 500 (99m-Tc) and patent blue dye in patients with early cervical cancer undergoing radical hysterectomy and pelvic lymphadenectomy, as well as to evaluate sentinel lymph node (SLN) detection.

Study design

Forty-seven patients underwent surgical treatment for cervical cancer. For SLN identification, 99m-Tc and blue patent were injected into the cervix on the eve and day of surgery, respectively. Preoperative pelvic lymphoscintigraphy was performed in all patients after 99m-Tc injection. Concordance between preoperative lymphoscintigraphy and ILM was evaluated.

Results

Of the 56 patients who underwent preoperative lymphoscintigraphy, 43 (81.13%) had at least one lymph node identified. Bilateral lymph nodes were identified in 21 (37.5%) patients. Sentinel lymph nodes detected on ILM had been previously found on preoperative lymphoscintigraphy in 66.7%, 67.2% and 0% in the right, left and central locations, respectively. In 14 patients (25%), only one lymph node was identified on preoperative lymphoscintigraphy, but more than one sentinel lymph node was detected on intraoperative mapping. In nine (16.1%) patients, lymphoscintigraphy showed only unilateral lymph nodes, but ILM identified bilateral sentinel lymph nodes.

Conclusion

The combination of patent blue and radionuclide techniques produced excellent results for SLN detection in cervical cancer. Preoperative lymphoscintigraphy does not offer any advantage over ILM for SLN identification.     

机器人辅助广泛性子宫切除术和盆腔淋巴结切除术的初步研究

目的 探讨将机器人手术系统应用于宫颈癌的广泛性子宫切除+盆腔淋巴结切除术的可行性.方法 2008年12月-2009年8月,采用da Vinci机器人手术系统,对5例Ⅰb1～Ⅱ a期宫颈癌患者行机器人辅助广泛性子宫切除+盆腔淋巴结切除术.记录手术时间、术中出血量、术中及术后并发症的发生情况、手术前后血红蛋白含量变化、术后体温及排气时间、术后恢复自主排尿时间、术后住院时间、病理检查结果、盆腔淋巴结切除数等.结果 5例患者全部顺利完成手术,无中转开腹,无术中或术后并发症出现.5例患者的手术时间分别为305、365、275、240和245 min,平均为286 min;术中出血量分别约为200、400、650、300和400 ml,平均为390 ml.5例患者术后最高体温均未超过37.5℃,术后36 h均排气.5例患者术后住院时间分别为11、13、9、12和12 d,平均为11.4 d.5例患者的病理检查结果均为鳞状细胞癌,阴道残端和宫旁切缘均无残留病灶.盆腔淋巴结切除数分别为14、22、16、21和18个,平均为18.2个,淋巴结无转移.结论 机器人手术系统可以应用于宫颈癌的广泛性子宫切除+盆腔淋巴结切除术,这一新方法为宫颈癌的手术治疗提供了一个新的选择.     

Retroperitoneal lymph node metastasis in patients with ovarian cancer

From 1979 to 1987 retroperitoneal lymph node dissection was performed at the Tokyo University Hospital in 41 cases (pelvic lymph node biopsy was done in 4 cases, pelvic lymphadenectomy in 23 cases, pelvic and paraaortic lymphadenectomy up to the renal vessels in 14 cases) of Stage Ia to IV ovarian cancer following cytoreductive surgery. The incidence of retroperitoneal positive nodes was 11.1% (2/18) in Stage I, 50.0% (5/10) in Stage II, 50.0% (5/10) in Stage III and 0% (0/3) in Stage IV (FIGO criteria without considering the pathologic findings of retroperitoneal lymph nodes). The positive rate of lymph node involvement in Stage II and Stage III was significantly higher than that in Stage I. The tumors involving both ovaries were more likely to metastasize to retroperitoneal lymph nodes. Enlargement of tumors and increased ascites were not the risk factors of retroperitoneal lymph node metastasis. These data suggest that the occurrence of retroperitoneal lymphatic spread in ovarian cancer is comparable to that in uterine cancer and increased by involvement of both ovaries and extension to other pelvic tissues.     

Is intraoperative frozen section analysis of pelvic lymph nodes accurate after neoadjuvant chemotherapy in patients with cervical cancer?

OBJECTIVE: Intraoperative frozen section examination of pelvic lymph nodes is frequently used in patients with cervical cancer, some of whom have received neoadjuvant chemotherapy (NACT). However, NACT can cause necrosis, fibrosis, or keratinization of tumor deposits in extirpated lymph nodes, and it is unclear whether intraoperative frozen section analysis of extirpated nodes is accurate after NACT. We analyzed the accuracy of frozen section examination of pelvic lymph nodes in patients after NACT for cervical cancer. METHODS: We reviewed 134 patients with invasive cervical cancer who underwent surgery including systematic pelvic lymphadenectomy with intraoperative frozen section examination of pelvic lymph nodes. Results of frozen section examination were related to definitive histology and compared between patient groups of NACT and primary surgery. RESULTS: A total of 1670 pelvic lymph nodes were evaluated intraoperatively by frozen section examination, and 6689 pelvic lymph nodes were analyzed by final histopathology. Overall frozen section analysis had nine false negative results among 53 patients with positive lymph nodes (false negative rate, 16.9%). After NACT, there were two false negative diagnoses in twelve patients with node metastases (false negative rate, 16.7%). No false positive cases were noted. The sensitivity and negative predictive value of frozen section examination were 83% and 82%, respectively, in patients after NACT, and 83% and 91% at primary surgery. CONCLUSION: NACT does not appear to compromise the diagnostic accuracy of intraoperative frozen section examination of pelvic lymph nodes in patients with cervical cancer.     

Asymmetries in pelvic lymph nodes and their metastatic involvement by gynecologic cancer cells

AIM: The aims of this study were to re-examine left-right asymmetry in pelvic lymph node distribution in patients with gynecologic malignancies, and to investigate if there is a left-right asymmetry in pelvic lymph node metastatic involvement by gynecologic cancer cells. METHODS: The oncologic database of our gynecologic department was reviewed to identify patients who had pelvic lymphadenectomy as part of treatment for a variety of gynecologic malignancies. Right and left lymph node counts with and without involvement of cancer cells were retrieved from the pathological reports. RESULTS: Three hundred and thirteen patients were included in the study. The numbers of external iliac, and hypogastric + obturator lymph nodes were higher on the right side than on the left in all gynecologic malignancies. The numbers of involved external iliac, and hypogastric + obturator lymph nodes by metastatic cancer cells were significantly higher on the right side than on the left in all gynecologic malignancies. CONCLUSION: The results suggest the existence of a left-right asymmetry in pelvic lymph node distribution and pelvic lymph node distribution involved by gynecologic cancer cells. This situation may be due to the asymmetry in the number of pelvic lymph nodes. In addition, stronger cell-mediated immune activity in the left side of humans may be associated with the blocking of metastatic invasion of cancer cells from gynecologic malignancies in the left side of the body.     

Postoperative pelvic radiotherapy for cervical cancer patients with positive parametrial invasion

OBJECTIVE: To evaluate patterns of failure in cervical cancer patients with histopathologic parametrial invasion treated with postoperative pelvic radiation therapy. METHODS: Records of 117 stages IB-IIB cervical cancer patients with parametrial invasion treated with postoperative radiation therapy from 1985 to 2002 were retrospectively reviewed. Patients were divided into two groups based on status of pelvic lymph nodes. Patterns of recurrence and prognosis by status of pelvic lymph nodes were statistically analyzed. RESULTS: Status of pelvic lymph nodes had significant impact on both recurrence and survival. Extrapelvic recurrence was observed in 23 of 66 node-positive patients compared with 6 of 51 node-negative patients (P = 0.005). Of 66 patients with a positive pelvic lymph node, 18 developed visceral metastases, whereas only three visceral metastases were noted in the 51 node-negative patients (P = 0.003). Five-year overall survival in node-positive and -negative patients was 52% and 89%, respectively (P = 0.0005). Corresponding rates for recurrence-free survival were 44% and 83%, respectively (P = 0.0002). The correlation between nodal metastasis and prognosis was enhanced when node-positive patients were stratified into two groups based on number of positive nodes (n = 1 and n > or = 2). Five-year recurrence-free survival rates for patients with negative, one positive, and two or more positive nodes were 83%, 61%, and 31%, respectively (P = 0.0001). CONCLUSIONS: Extrapelvic recurrence was uncommon in node-negative patients with parametrial invasion. These findings do not support use of systemic therapy for cervical cancer patients with parametrial invasion if pelvic lymph node metastasis is negative.     

Accuracy of frozen section examination of pelvic lymph nodes in patients with FIGO stage IB1 to IIB cervical cancer

OBJECTIVE: We evaluated the accuracy of intraoperative frozen section histology of pelvic lymph nodes in patients with FIGO stage IB1 to IIB cervical cancer. METHODS: A total of 96 patients with cervical cancer FIGO stage IB1 to IIB had surgery including systematic pelvic or pelvic and paraaortic lymphadenectomy and intraoperative frozen section examination of pelvic lymph nodes at our department between January 1997 and October 2001. The results of frozen section were compared with those of final histology. RESULTS: A total of 1044 pelvic lymph nodes underwent intraoperative frozen section examination and node metastases were found in 29 patients (30%). Final histopathology yielded a total of 5042 lymph nodes and identified an additional seven patients with node metastases for a false negative rate of 19%. The specificity and the positive predictive value of frozen section examination were 100%; the negative predictive value was 90% (60/67). CONCLUSION: The diagnostic accuracy of frozen section analysis of pelvic lymph nodes should be considered when intraoperative decisions are based on its results.     

Low colorectal anastomosis after radical pelvic surgery: a risk factor analysis

OBJECTIVE: This study was conducted to analyze our experience with low (8-12 cm above the anal verge) and very low (<6 cm above the anal verge) colorectal resection and primary anastomosis at the time of radical en bloc resection of pelvic malignancies. STUDY DESIGN: A retrospective review of 77 patients undergoing supralevator pelvic exenteration with low colorectal resection and primary anastomosis in our gynecologic oncology service was carried out. Data were obtained from patient medical records and from the tumor registry. Univariate statistical analysis of the data was used. RESULTS: The distribution of primary malignancies in this cohort was as follows: 33 (43%) recurrent or primary cervical carcinomas, 27 (35%) primary or recurrent ovarian carcinomas, 7 (9%) recurrent vaginal carcinomas, 4 (5%) endometrial carcinomas, 3 (4%) colon carcinomas, and 3 (4%) cases of stage IV endometriosis. Forty patients underwent total pelvic exenteration, and 37 patients underwent posterior exenteration. Thirty-six patients in the total pelvic exenteration group had a history of pelvic irradiation. Twelve (30%) of these patients had development of breakdown or fistulas of the anastomosis. Six of the 12 patients (50%) had undergone protective colostomy. Thirty-seven patients underwent posterior exenteration with primary anastomosis for ovarian cancer, endometrial cancer, colon cancer, or endometriosis, and only 1 of these had received pelvic irradiation. This patient did not have a protective colostomy, and a rectovaginal fistula developed. In addition, there were 3 other breakdowns in the posterior exenteration group. Finally, the presence of preoperative ascites did not appear to alter the breakdown rate of the anastomosis among the patients with ovarian cancer who underwent cytoreductive surgery. CONCLUSION: Radical resection of pelvic tissue remains a crucial part of the armamentarium of the gynecologic oncologist. Previous pelvic irradiation appears to be a major risk factor (35% vs 7.5%) for anastomotic breakdown and fistulas, independent of the presence of a protective colostomy. The overall results appear to be better for patients undergoing this procedure as part of a posterior exenteration.     

Human papillomavirus (HPV) DNA in primary cervical cancer and in cancer free pelvic lymph nodes--correlation with clinico-pathological parameters and prognostic significance

OBJECTIVE: To assess whether the presence of human papilloma virus (HPV) DNA and/or several genotypes of HPV DNA in primary cervical cancer and cancer free pelvic lymph nodes are correlated with several clinicopathological parameters of well-defined prognostic significance and whether virological parameters are predictors of long-term survival in cancer patients. PATIENTS AND METHODS: 223 cases of cervical cancer patients included in this retrospective study underwent follow-up evaluation. Survival and cause of death were examined for 204 (91.4%) patients, with a mean follow-up time of 4.4 years. HPV DNA was detected using the high sensitive polymerase chain reaction (PCR) method followed by HPV DNA sequencing for HPV genotyping. These results were correlated with well-defined clinicopathological parameters and survival data. RESULTS: HPV DNA was detected by PCR in 150 of 203 (73.4%) tissue specimens of cervical cancer patients. DNA sequence analysis revealed the presence of HPV 16 (n = 68, 45.3%), HPV 18 (n = 49, 32.6%) and rare HPV types (n = 33, 22.1%). HPV genotypes correlated significantly with histological tumor types, node status, blood vessel invasion and lymph space involvement. The presence of HPV DNA in cervical cancer as well as the genotype of HPV 16 could also be confirmed as significant prognostic factors in the univariate Cox Regression Analysis (RR 2.856, p < 0.003 resp. RR 3.444, p < 0.0001). The presence of HPV DNA in cancer free pelvic lymph nodes was significantly correlated to the concomitant manifestation of pelvic lymph node metastases (RR 3.1, p < 0.0001). In the multivariate analysis, however, HPV DNA in primary tumor and in negative pelvic lymph nodes failed to be of prognostic relevance. Exclusively, HPV 16 appears to impact independently on the overall survival in cervical cancer patients (RR 3.653, p < 0.002). CONCLUSION: The detection of HPV 16 genotype may play an important adjunct role in assessing prognosis of cervical cancer patients. The clinical impact of the presence of HPV DNA in primary tumors and cancer free pelvic lymph nodes remains to be investigated in further studies. The exact mechanisms by which HPV influence the prognosis of cervical cancer patients have to be defined.