Endometrial cancer metastatic to infrarenal aortic lymph nodes unrecognized during laparoscopic inframesenteric aortic lymph node dissection

BACKGROUND: The incidence of isolated aortic nodal metastasis in clinical stages I and II endometrial cancer is generally low. Nevertheless, para-aortic nodes are still assessed during staging procedures, which include hysterectomy, bilateral salpingo-oophorectomy (BSO), and pelvic and para-aortic lymph node sampling up to the level of the inferior mesenteric artery (IMA). The procedure can be performed either abdominally or laparoscopically. It is unclear, however, as to whether infrarenal aortic nodal sampling above the IMA should be routinely performed. CASE: We describe a case of endometrial cancer metastatic to the infrarenal para-aortic lymph nodes above the IMA, missed during laparoscopic inframesenteric lymph node dissection, and found on subsequent laparotomy performed to resect matted pelvic nodes. CONCLUSIONS: The infrarenal para-aortic region above the IMA may be at risk for nodal metastasis in women with endometrial cancer. Consideration should be given to evaluate this area during staging laparotomy or laparoscopy. The role of routine bilateral infrarenal aortic nodal dissection needs further evaluation.     

Endosalpingosis in the pelvic peritoneum and pelvic lymph nodes

The pelvic peritoneum with macroscopic findings characteristic of endometriosis was biopsied in 18 cases at conservative surgery for endometriosis and examined. Pelvic lymph nodes removed in 76 cases at radical surgery for uterine cervical, corpus cancer or ovarian cancer patients were examined. In 3 of the 18 cases, endosalpingiosis was encountered in the pelvic peritoneum. In 2 of these 3 cases combined lesions of endometriosis and endosalpingiosis were observed. On the other hand, in 4 of the 76 patients with gynecological malignancies, benign glandular inclusions were found in pelvic lymph nodes. In 3 of these 4 patients, there was endosalpingiosis, and another there was endometriosis. Endosalpingiosis is an interesting lesion offering some clues to the histogenesis of endometriosis, and important in the differential diagnosis of malignant tumors.     

The importance of the histologic processing of pelvic lymph nodes in the treatment of cervical cancer

Four hundred and twenty surgical specimens from patients undergoing radical abdominal hysterectomy and complete pelvic lymphadenectomy for stage Ib, IIa or IIb cervical cancer underwent meticulous histologic and morphometric study. Complete processing of the extirpated lymphatic fatty tissue led to reproducible findings including the number of removed nodes, the number and size of tumor deposits in the nodes, and the location of the latter in the pelvis. An average of 32 nodes was removed per patient regardless of clinical size, tumor size, or stage. Thirty one per cent of patients with stage Ib disease had positive nodes as did 45% of those with stage IIb disease. The number of node metastases increased proportionally with the size of the primary tumor. In stage Ib 30% of the node metastases were smaller than 2 mm in diameter as were 21% of those in stage IIb. The size of the metastases was directly proportional to the size of the primary tumor. In patients with small tumors 43% of the nodes were smaller than 2 mm, as compared with 15% of those in patients with large tumors. The 5-year survival rate of patients with negative nodes was 89.3%. Survival dropped to 69.8% and 37.9% in patients with 1 or ≥ 4 positive nodes, respectively. The 5-year survival rate of patients with node metastases smaller than 2 mm and larger than 20 mm was 70% and 39%, respectively. In patients with identical numbers of positive nodes, survival decreased with increasing tumor size. In patients with tumors of a given size, the number of node metastases was an additional prognostic factor. The number of lymph nodes removed in a given patient is an objective measure of the thoroughness of a lymphadenectomy.     

Involvement of pelvic lymph nodes in ovarian cancer

In contrast to earlier operating standards some authors have in the past few years, also removed pelvic lymphnodes when ovarian cancer was diagnosed. From 26 of our patients suffering from ovarian cancer, one third proved to have positive lymphnodes, when pelvic lymphonodectomy was carried out. Our data, along with-data from other authors, were reviewed and included in a statistical evaluation.     

Ectopic (pelvic) kidney mimicking bulky lymph nodes at pelvic lymphadenectomy

BACKGROUND: Ectopic (pelvic) kidney is the most common congenital renal anomaly with an incidence of 1 in 500 to 1 in 2000. A pelvic kidney can be encountered at pelvic or paraaortic lymphadenectomy. CASE REPORTS: In two patients undergoing pelvic lymphadenectomy, lobulated tumors near the pelvic brim were initially interpreted as bulky lymph node conglomerates. Further dissection showed the ureter to originate from the masses, leading to a diagnosis of pelvic kidney. CONCLUSION: Pelvic kidneys mistaken for bulky lymph nodes are a potential intraoperative pitfall in patients with gynecologic malignancies. Keys to recognition include an index of suspicion, identifying the course of the ureter and origin of the renal vessels, and confirming absence of a kidney at the normal location.     

Fine needle aspiration of para-aortic and pelvic lymph nodes showing lymphangiographic abnormalities

Fifty-six fine needle aspirations of lymphangiographically abnormal pelvic and para-aortic lymph nodes were performed in 50 patients at The University of Michigan between January 1, 1977, and May 31, 1980. Fine needle aspiration was used both in the initial evaluation of patients with gynecologic malignancies and in the investigation of persistent and recurrent malignant disease. The overall diagnostic accuracy of fine needle aspiration was 74.0%. Fine needle aspiration yielded diagnostic cytologic specimens; it was safe and well tolerated, and in some instances it permitted the diagnosis of lymph node metastasis without laparotomy.     

Anatomical study of para-aortic and pelvic lymph nodes in gynecologic malignancies.

Between January 1986 and June 1990, systematic para-aortic and pelvic lymphadenectomy was performed in 208 women with untreated ovarian, endometrial, and cervical cancers. This study aimed to evaluate the median number of nodes collected from each pelvic and para-aortic group and to verify a new detailed nomenclature for the various lymph node groups. The para-aortic nodes were distinguished as paracaval, precaval, and retrocaval, depending on their relationship with the vena cava. Para-aortic, pre-aortic, and retro-aortic nodes were located close to the aorta. The nodes situated between the vena cava and aorta were designated intercavo-aortic. A median of 26 (range 15-48) para-aortic nodes were collected during ovarian or endometrial cancer operations. The lymphatic system of the pelvis was divided into six groups, depending on the relationship with the pelvic blood vessels. The pelvic nodes were distinguished as common, internal and external iliac, presacral, obturator, and parametrial. In cases of cervical cancer, the median number of pelvic nodes collected was 38 (range 20-88). Such anatomical study of the lymphatic system shows that a higher number of nodes than expected can be found in the retroperitoneum.     

The importance of parametrial lymph nodes in the treatment of cervical cancer

This study aimed to determine the presence, distribution, and metastatic involvement of lymph nodes in the parametria of patients undergoing radical hysterectomy for cervical cancer. Parametrial nodes were present in the giant sections of 280 (78%) of 359 surgical specimens, and metastatically involved nodes were found in 63 (22.5%) of these 280. Both positive and negative nodes were distributed through the entire parametrium. The frequency of positive nodes was linearly associated with both the clinical stage and with the tumor volume. The recurrence rate was higher when the parametrial nodes were positive than when they were negative. Survival dropped when the parametrial nodes were positive, regardless of the clinical stage.     

Spread of endometriosis to pelvic sentinel lymph nodes: gene expression analysis

Objective

Endometriotic spread to the lymphatic system has been described, but little is known about the molecular events and changes in gene expression associated with this process. We sought to determine the expression levels of a panel of 28 genes in samples of primary endometriosis lesions (EL), isolated endometriotic-like cells (IELC)-positive pelvic sentinel lymph nodes (PSLN), and IELC-negative PSLN, in order to identify candidate genes that may play a role in this process.

Study design

Quantitative real-time PCR and immunohistochemistry (IHC) of primary EL and PSLN samples with and without IELC from patients with ovarian and/or peritoneal endometriosis.

Results

Gene expression was analyzed in EL (n = 13), IELC-positive PSLN (PSLN+, n = 11), and IELC-negative PSLN (PSLN−, n = 8). Gene expression differences between PSLN+ and PSLN− were analyzed and evaluated in relation to their expression levels in EL. Genes expressed at high levels in EL but not in PSLN− and known to be expressed in IELC (such as ESR1, PGR) served as controls and the expected gene dilution effect was clearly observed. Expression of a set of genes (CXCR4, CD68, MKI67, and CD44) was found to be higher in PSLN+ vs. PSLN−, while lowest in EL, indicating upregulation in IELC. In contrast, EPCAM and E-cadherin, which were strongly expressed in EL, were not found to be expressed in PSLN+, and thus likely absent from IELC. IHC confirmed the expression of CXCR4, CD44s, and CD44v6 in IELC, as well as the absence of E-cadherin from IELC.

Conclusion

Our data indicate that spread of endometriosis to PSLN is accompanied by differential expression of several genes, including EPCAM, CDH1 (E-cadherin), CXCR4, and CD44, suggesting an involvement of CD44 splice variants as well as CXCR4 signalling in this process.     

Negative sentinel lymph node accurately predicts negative status of pelvic lymph nodes in uterine cervix carcinoma

OBJECTIVE: The significance of negative sentinel lymph nodes (SLN) is important in the staging and treatment of melanoma and a few other cancers, but is controversial in uterine cervix carcinoma. Our study was aimed at correlating the SLN status in cervical carcinoma with non-sentinel lymph nodes (non-SLN), in a uniform and well controlled population. METHODS: This study includes 36 patients with stage I and IIA cervical carcinoma and bilaterally negative SLN on final pathology. SLN were identified using blue dye and radioisotopic techniques. Frozen section examination was performed for all SLN; the rest of the tissue was formalin fixed and paraffin embedded. The protocol used for SLN was also applied for non-SLN. For each block, six 4-micro m thick sections were cut at 40 micro m intervals and stained with H and E; an additional section taken between the 3rd and 4th levels was imunostained using AE1/AE3 cytokeratin. RESULTS: The mean age for the study population was 39 years (range 25-76); the number of SLN ranged from 2 to 6 (mean 2.7) and the non-SLN from 8 to 49 (mean 23) per case. No metastasis was found in any SLN and non-SLN by step sections and IHC. CONCLUSION: Our study demonstrates that bilaterally negative SLN on final pathology accurately predict the absence of metastases in non-SLN in cervical carcinoma. If confirmed by larger trials, these results may influence the clinical management of early cervical cancer.     

Number and distribution of pelvic lymph nodes and effect of surgical pathologic factors on pelvic lymph node status in patients with early-stage cervical carcinoma treated with radical hysterectomy and pelvic lymph node dissection

PURPOSE OF INVESTIGATION: To report the number and distribution of pelvic lymph nodes and to identify surgical pathologic factors that best predict positive pelvic lymph nodes in patients with early-stage cervical carcinoma treated with radical hysterectomy and pelvic lymph node dissection (RHND). METHODS: Data from the files of 126 patients with cervical carcinoma treated by RHND at the Soroka Medical Center from 1962 through 2005 were analyzed. RESULTS: The status of pelvic lymph nodes was known in 114 patients. The exact number of lymph nodes removed from the pelvis of each patient was known in 111 patients. The mean number of lymph nodes removed from the pelvis per patient was 26.6 (median 23; range 1-62). Positive pelvic lymph nodes were found in 35 (30.7%) of the patients with a mean of 3.4 (median 2; range, 1-15) positive pelvic lymph nodes per patient. In a univariate analysis, positive lymph vascular space invasion and positive parametrial and/or paracervical involvement were significant predictors of positive pelvic lymph nodes, whereas penetration > or = 50% of the thickness of the cervical wall and grade 2+3 were of borderline significance. In a multivariate analysis, positive lymph vascular space invasion was the strongest and the only significant predictor of positive pelvic lymph nodes, whereas positive parametrial and/or paracervical involvement was of borderline significance. CONCLUSIONS: In patients with early-stage cervical carcinoma treated with RHND, positive lymph vascular space invasion emerged to be the strongest and most significant predictor of positive pelvic lymph nodes.     

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.