Laparoscopic para-aortic lymphadenectomy in advanced cervical cancer: morbidity and impact on therapy

BackgroundLaparoscopic para-aortic lymphadenectomy (PAL) is being used increasingly to stage patients with locally advanced cervical cancer (LACC) and to define radiation field limits before chemoradiation therapy (CRT). This study aimed to define clinical implications, review complications, and determine whether surgical complications delayed the start of CRT.Patients and methodsWe retrospectively reviewed a continuous series of patients with LACC, with no positive para-aortic (PA) nodes on positron emission tomography-computed tomography (PET-CT) and who had undergone a primary laparoscopic PAL.ResultsFrom November 2007 to June 2010, 98 patients with LACC underwent pretherapeutic PAL. Two patients did not undergo PAL: extensive carcinomatosis was discovered in one case and a technical problem arose in the other. No perioperative complications occurred. Seven patients had a lymphocyst requiring an imaging-guided (or laparoscopic) puncture. Eight patients (8.4%, which corresponds to the false-negative PET-CT rate) had metastatic disease within PA lymph nodes. In cases of suspicious pelvic nodes on PET-CT, the risk for PA nodal disease was greater (24.0% versus 2.9%). When patients with and without surgical morbidity were compared, the median delay to the start of treatment was not significantly different (15 days; range, 3–49 days versus 18 days; range, 3–42 days).Discussion and conclusionsThe morbidity of laparoscopic PAL was limited and the completion of treatment was not delayed when complications occurred. Nevertheless, if PET-CT of the pelvic area is negative, the interest in staging PAL could be discussed because the risk for PA nodal disease is very low.     

宫颈癌手术盆腹腔淋巴结切除相关问题

盆腹腔淋巴结切除是宫颈癌手术治疗的重要组成部分。如何评判盆腔淋巴结切除是否彻底？哪些患者需要腹主动脉旁淋巴结切除？前哨淋巴结在宫颈癌治疗中的作用？这些是当今宫颈癌淋巴结切除面临的问题,文章就以上问题进行讨论。     

子宫颈癌患者腹腔镜下广泛子宫切除术联合淋巴结切除术的临床效果评估

目的 评估腹腔镜下广泛子宫切除术联合盆腹腔淋巴结切除术用于治疗子宫颈癌的临床效果。方法 对57例Ⅰa～Ⅱb期的子宫颈癌患者,施行腹腔镜下广泛子宫切除术联合盆腔及腹主动脉周围淋巴结切除术。其中子宫颈鳞状细胞癌48例,腺癌7例,腺鳞癌2例。结果 除2例外,所有患者均在腹腔镜下完成手术,平均手术时间为186min(150～320min),术中平均出血168ml(120～700ml),切除盆腔和腹主动脉周围淋巴结数量平均为18．6个和8．2个;8例患者淋巴结为阳性。所有切除组织边缘大体检查均为阴性。术中2例膀胱损伤、1例静脉损伤,均于镜下修补成功;2例中转开腹。术后肛门排气时间平均为2．3d,恢复自主排尿时间平均为10．2d。手术后每3个月随访1次,发现轻度输尿管狭窄1例,尿潴留2例,阴道残端复发3例,病情未控1例。结论 腹腔镜下广泛子宫切除术联合盆腹腔淋巴结切除术j治疗子宫颈癌手术创伤小、并发症少、术后恢复快,是一种治疗子宫颈癌的理想方法。     

Potential therapeutic role of para-aortic lymphadenectomy in node-positive endometrial cancer

OBJECTIVE: The aim of this study was to assess the potential therapeutic role of para-aortic lymphadenectomy (PAL) in high-risk patients with endometrial cancer. METHODS: We studied two groups of patients with endometrial cancer who underwent operation at Mayo Clinic (Rochester, MN) during the interval 1984 to 1993: (1) 137 patients at high risk for para-aortic lymph node involvement (myometrial invasion >50%, palpable positive pelvic nodes, or positive adnexae), excluding stage IV disease, and (2) 51 patients with positive nodes (pelvic or para-aortic), excluding stage IV disease. By our definition, PAL required removal of five or more para-aortic nodes. RESULTS: In both groups, no significant difference existed between patients who had PAL (PAL+) and those who did not (PAL-) in regard to clinical or pathologic variables, percentage irradiated, or surgical or radiation complications. Among the 137 high-risk patients, the 5-year progression-free survival was 62% and the 5-year overall survival was 71% for the PAL- group compared with 77 and 85%, respectively, for the PAL+ group (P = 0.12 and 0.06, respectively). For the 51 patients with positive nodes, the 5-year progression-free survival and 5-year overall survival for the PAL- group were 36 and 42% compared with 76 and 77% for the PAL+ group (P = 0.02 and 0.05, respectively). Lymph node recurrences were detected in 37% of the PAL- patients but in none of the PAL+ patients (P = 0.01). Multivariate analysis suggested that submission to PAL was a cogent predictor of progression-free survival (odds ratio = 0.25; P = 0.01) and overall survival (odds ratio = 0.23; P = 0.006). CONCLUSIONS: These results suggest a potential therapeutic role for formal PAL in endometrial cancer.     

Robot assisted laparoscopic transperitoneal para-aortic lymphadenectomy in the management of advanced cervical carcinoma

ObjectivesAdequate staging of advanced cervical cancer is essential in order to optimally treat the patient. FIGO clinical staging, imaging techniques such as CT scan, MRI and PET sometimes underestimate the extension of tumors. The presence of para-aortic lymph node metastases in advanced cervical cancer identifies patients with poor prognosis who need to be treated aggressively. Laparoscopic para-aortic lymph node dissection is now proposed as a diagnostic tool in many guidelines. We evaluated the feasibility and safety of a robot assisted laparoscopic transperitoneal approach to para-aortic lymph node dissection.Study designEight patients with advanced cervical carcinoma who were eligible for primary pelvic radiotherapy combined with concurrent cisplatin chemotherapy or pelvic exenteration underwent a pre-treatment robot assisted transperitoneal laparoscopic para-aortic lymphadenectomy.ResultsWe isolated from 1 to 38 para-aortic nodes per patient and had one para-aortic node positive patient who was treated with extended doses of pelvic radiotherapy. We did not encounter any major complications and post-operative morbidity was low.ConclusionsRobot assisted transperitoneal laparoscopic para-aortic lymphadenectomy is feasible and provides the surgeon with greater precision than classical laparoscopy. Larger prospective multicentric trials are needed to validate the generalised usefulness of this technique.     

腹腔镜与开腹手术在宫颈癌腹主动脉旁淋巴结清扫术的安全性和生存结局比较

目的:探讨腹腔镜与开腹手术在宫颈癌腹主动脉旁淋巴结清扫术的安全性和生存结局比较。方法:回顾分析2015年1月至2016年12月于武汉大学人民医院行腹主动脉旁淋巴结清扫的86例宫颈癌患者的临床资料。其中50例行腹腔镜术(腹腔镜组),36例行开腹术(开腹组)。比较两组患者的手术时间、术中出血量、腹主动脉旁淋巴结清扫数、术中及术后并发症、术后肛门排气时间、总住院时间、预后情况。结果:两组患者的手术时间比较,差异无统计学意义(P0.05)。与开腹组比较,腹腔镜组的术中出血量明显减少,术后肛门排气时间早,术后总住院时间短,淋巴结清扫数多,差异均有统计学意义(P0.05)。两组的术中输尿管损伤、血管损伤、术后淋巴囊肿、尿潴留、肠梗阻、深静脉血栓、呼吸系统感染发生率比较,差异均无统计学意义(P0.05)。开腹组切口液化4例,腹腔镜组无切口液化,差异有统计学意义(P0.05)。腔镜组与开腹组患者的远期临床预后并无明显差异。结论:腹腔镜下腹主动脉旁淋巴结清扫手术用于宫颈癌治疗有较好的安全性,值得临床推广。     

De novo adhesions with extraperitoneal endosurgical para-aortic lymphadenectomy versus transperitoneal laparoscopic para-aortic lymphadenectomy: a randomized experimental study

OBJECTIVE: The objective of this study was to compare the risk of adhesion formation and the site of postoperative adhesions after transperitoneal versus extraperitoneal laparoscopic para-aortic lymphadenectomy. STUDY DESIGN: A prospective study was conducted on 66 pigs, randomly allocated to 2 groups of 33 animals that underwent transperitoneal versus extraperitoneal laparoscopic para-aortic lymphadenectomy. RESULTS: No statistically significant difference was observed between the 2 techniques in terms of operating time, number of lymph nodes removed, and intraoperative and postoperative morbidity. More lymphoceles were observed in the extraperitoneal laparoscopy group (P =.0002). The overall adhesion rates were 76% in the transperitoneal group and 43.33% in the extraperitoneal group (P =.04). The adhesion score specific to the operative site was lower in the extraperitoneal group (P =.0005). A stereolocalization study showed that almost all adhesions after transperitoneal laparoscopy were situated in the para-aortic external irradiation field, whereas adhesions after extraperitoneal laparoscopy were predominantly situated outside this field. CONCLUSION: Extraperitoneal laparoscopy generates significantly fewer adhesions in the para-aortic irradiation field.     

宫颈癌淋巴结切除适应证和争议

NCCN和FIGO指南对淋巴结切除适应证做出推荐,但就宫颈癌淋巴结切除仍存在争议点。对于局部晚期宫颈癌行手术分期是安全可行的。前哨淋巴结切除术目前尚不能替代系统性淋巴结切除术。对于ⅠA2~ⅡA2期宫颈癌,建议行腹主动脉旁淋巴结取样术,上界达肠系膜下动脉水平足够。有转移肿大的淋巴结建议手术切除。     

Significance of para-aortic node irradiation in the treatment of cervical cancer

In 1980, we introduced para-aortic node irradiation as a part of our treatment of cervical cancer. Eighty-six patients with cervical cancer were selected for such treatment, based on histologic or radiologic criteria for lymph node involvement. We delivered 45 Gy to the para-aortic nodes in 5 weeks. Comparison studies on the prognosis and on the incidence of side effects with and without para-aortic node irradiation were carried out on a total of 783 patients who had invasive cervical cancer and were treated from 1975 to 1984. For patients in stages Ib and II who met, or before 1980 would have met, our criteria there was no significant difference in survival for those in stage Ib, but in stage II the para-aortic node irradiation group did significantly better (P less than 0.01). For the entire series of patients, for all stages from Ib to IV, the prognosis for the group treated after the introduction of para-aortic node irradiation was superior, with a statistically significant difference from the prognosis for patients treated before the introduction of this mode (Ib, P less than 0.05; II, P less than 0.01; III, P less than 0.01; IV, P less than 0.05). None of the patients had severe complications after para-aortic node irradiation. We conclude that, by irradiating the para-aortic nodes, we can improve the prognosis of cervical cancer patients who may have para-aortic node involvement, a situation which formerly was considered hopeless.     

Standardized technique of laparoscopic pelvic and para-aortic lymphadenectomy in gynecologic cancer optimizes the perioperative outcomes

Introduction  

The main objective of this study is to illustrate the effectiveness and the safety of standardized technique of laparoscopic lymphadenectomy (LNE), newly introduced in a University Hospital, in patients with gynecologic malignancy.     

Systematic pelvic and para-aortic lymphadenectomy in advanced ovarian cancer patients with no residual intraperitoneal disease

A comparative non-randomized study was carried out to evaluate the role of systematic pelvic and para-aortic lymphadenectomy (SL) on patients with no residual intraperitoneal disease (NRID) of advanced ovarian cancer (stage IIIC–IV). A total of 142 optimally cytoreduced patients (macroscopic disease absent on peritoneal surface) were divided into two groups: Group A, consisting of 98 patients (53 previously untreated and 45 pretreated at other Institutions), who underwent SL; Group B, consisting of 44 patients (21 previously untreated and 23 pretreated at other Institutions), who did not undergo SL. Each group had statistically equivalent histology, grading, performance status and variety of cytoreductive operations performed. Group A pretreated patients had a greater number of stage III than Group B ( P  = 0.03). Systematic pelvic and para-aortic lymphadenectomy could be carried out with an acceptable morbidity and no mortality. All 142 patients received post-operative chemotherapy including carboplatin. The number of chemotherapy sessions did not differ between the two groups. Comparison of survival revealed that SL significantly improved the survival of previously untreated patients ( P  = 0.02). The survival was significantly different with nodal status ( P  = 0.006). Cox's proportional hazard analysis showed that only systematic lymphadenectomy was a significant covariate. The survival was not significantly different in Group A vs Group B pretreated patients; however, it was significantly different with respect to nodal status ( P <0.001). Cox's proportional hazard analysis showed that only the initial stage of disease was a significant covariate. The results of the present study shows that aggressive surgical cytoreduction with SL could be therapeutic in previously untreated patients with NRID. Currently, an international prospective randomized study is ongoing to clarify definitively the clinical role of SL.