Incidence of metastasis in circumflex iliac nodes distal to the external iliac nodes in intermediate- and high-risk endometrial cancer

Objective

The aim of this study was to elucidate the incidence of metastasis in circumflex iliac nodes distal to the external iliac nodes (CINDEIN), which are also called suprainguinal nodes, in intermediate- and high-risk endometrial cancer. Removal of these nodes needs to be discussed from the viewpoint of patient's quality of life because removal of CINDEIN is strongly related to lower extremity lymphedema.

Methods

A retrospective chart review was carried out for 508 patients with intermediate- and high-risk endometrial cancer who were included in this study. We identified patients with lymph node metastasis. Lymph node sites were classified into four groups: (1) CINDEIN, (2) external iliac nodes, (3) Group A consisting of circumflex iliac nodes to the distal obturator nodes, internal iliac nodes, obturator nodes, cardinal ligament nodes (including deep obturator nodes), and sacral nodes, and (4) Group B consisting of common iliac nodes and para-aortic nodes. Logistic regression analysis was used to select risk factors for CINDEIN metastasis.

Results

In an analysis of 508 patients with intermediate- and high-risk disease, CINDEIN metastasis was found in fourteen (2.8%) of the patients. Multivariate analysis confirmed that high-risk histology (OR = 5.7, 95% CI = 1.2-16.1) and Group A node metastasis (OR = 9.7, 95% CI = 2.9-31.4) were independent risk factors for CINDEIN metastasis. None of the patients with G1 endometrioid adenocarcinoma had CINDEIN metastasis. Three (2.5%) of the patients with G2 endometrioid adenocarcinoma had CINDEIN metastasis and all of these three patients had other pelvic node metastasis.

Conclusion

Removal of CINDEIN can be eliminated in patients with G1 endometrial cancer and patients with G2 endometrial cancer who have no pelvic node metastasis.     

Sentinel lymph node mapping for endometrial cancer improves the detection of metastatic disease to regional lymph nodes

Objective

To compare the incidence of metastatic cancer cells in sentinel lymph nodes (SLN) vs. non-sentinel nodes in patients who had lymphatic mapping for endometrial cancer and to determine the contribution of metastases detected on ultrastaging to the overall nodal metastasis rate.

Methods

All patients who underwent lymphatic mapping for endometrial cancer were reviewed. Cervical injection of blue dye was used in all cases. Sentinel nodes were examined by routine hematoxylin and eosin (H&E), and if negative, by standardized institutional pathology protocol that included additional sections and immunohistochemistry (IHC).

Results

Between 09/2005 and 03/2010, 266 patients with endometrial cancer underwent lymphatic mapping. Sentinel node identification was successful in 223 (84%) cases. Positive nodes were diagnosed in 32/266 (12%) patients. Of those, 8/266 patients (3%) had the metastasis detected only by additional section or IHC as part of SLN ultrastaging. Excluding the 8 cases with positive SLN on ultrastaging only, 24/801 (2.99%) SLN and 30/2698 (1.11%) non-SLN were positive for metastatic disease (p = 0.0003).

Conclusion

Using a cervical injection for mapping, metastatic cells from endometrial cancer are three times as likely to be detected in SLN than in the non-sentinel nodes. This finding strongly supports the concept of lymphatic mapping in endometrial cancer to fine tune the nodal dissection topography. By adding SLN mapping to our current surgical staging procedures we may increase the likelihood of detecting metastatic cancer cells in regional lymph nodes. An additional benefit of incorporating pathologic ultrastaging of SLN is the detection of micrometastasis, which may be the only evidence of extrauterine spread.     

Prevalence of lymph nodes in the parametrium of radical vaginal trachelectomy (RVT) specimen

Objective

In order to evaluate radicality in fertility preserving surgery in women with early invasive cervical cancer we analyzed the parametrium of specimens of patients treated by radical vaginal trachelectomy for the presence of lymph nodes. We tried to identify morphologic factors associated with the presence of parametrial lymph nodes.

Methods

We analyzed surgical specimens of 112 patients who underwent radical trachelectomy between June 2004 and April 2009 at the Department of Gynecologic Oncology at Charité Campus Benjamin Franklin and Campus Mitte. All parametrial tissue was step sectioned and a total of 1878H&;E stained histological sections were analyzed.

Results

In 8 patients (7.1%) a total of 13 lymph nodes were detected. Five lymph nodes in four patients had been primarily detected by routine histological examination. In one of these patients (0.9%) a 2 mm lymph node metastasis was found. Serial sectioning revealed additional seven lymph nodes in four patients. The thickness of parametrium correlated significantly with the presence of lymph nodes in the parametrium.

Conclusion

The presence of small lymph nodes in the parametrium of specimens of radical trachelectomy is low. In patients with early-stage cervical cancer, the incidence of metastasis is less than 1%. Preoperative assessment of the volume of the parametrium may indicate which patients need parametrial resection.     

Clinical use of laparoscopic ultrasonography in detecting nodal metastasis in advanced-stage cervical carcinoma

Objective

To assess the clinical use of a laparoscopic ultrasound scan (LUS) to identify pelvic and para-aortic node metastasis in patients with advanced-stage cervical cancer.

Methods

After examination under general anesthesia and cystoscopy, LUS was used to examine the pelvic nodes of patients with advanced-stage cervical cancer. Abnormal nodes were excised before definitive treatment to confirm the nodal status. Patients without abnormal para-aortic nodes on preoperative computer tomography/magnetic resonance imaging in the past 3 years were surgically staged via laparoscopic extraperitoneal aortic node sampling, and the findings were correlated with LUS findings. The predictive values of abnormal pelvic nodes on LUS for pelvic and aortic node metastasis were determined.

Results

A total of 119 advanced-stage cervical cancer patients underwent LUS of pelvic nodes. Abnormal pelvic nodes were found in 62 (52.1%) patients, and metastasis was confirmed by histology in 38 (31.9%) patients. Three patients had micro-metastasis in para-aortic nodes, and all of these patients had abnormal pelvic lymph nodes on LUS.

Conclusion

Abnormal pelvic nodes are commonly found on LUS in patients with advanced-stage cervical cancer, and selective excision biopsy is needed to confirm pelvic node metastasis. Surgical staging of aortic nodes might be considered for patients with abnormal pelvic nodes on LUS.     

Sentinel lymph node biopsy in the management of early-stage cervical carcinoma

Objectives

We aimed to determine the sentinel lymph node detection rates, accuracy in predicting the status of lymph node metastasis, and if pathologic ultrastaging improves the detection of micrometastases and isolated tumor cells at the time of primary surgery for cervical cancer.

Methods

A prospective, non-randomized study of women with early-stage (FIGO stage IA1 with lymphovascular space involvement — IIA) cervical carcinoma was conducted from June 2003 to August 2009. All patients underwent an intraoperative intracervical blue dye injection. Patients who underwent a preoperative lymphoscintigraphy received a 99 m Tc sulfur colloid injection in addition. All patients underwent sentinel lymph node (SLN) identification followed by a complete pelvic node and parametrial dissection. SLN were evaluated using our institutional protocol that included pathologic ultrastaging.

Results

SLN mapping was successful in 77 (95%) of 81 patients. A total of 316 SLN were identified, with a median of 3 SLN per patient (range, 0-10 SLN). The majority (85%) of SLN were located at three main sites: the external iliac (35%); internal iliac (30%); and obturator (20%). Positive lymph nodes (LN) were identified in 26 (32%) patients, including 21 patients with positive SLN. Fifteen of 21 patients (71%) had SLN metastasis detected on routine processing. SLN ultrastaging detected metastasis in an additional 6/21 patients (29%). Two patients had grossly positive LN at exploration, and mapping was abandoned. Three of 26 (12%) patients had successful SLN mapping; however, the SLN failed to identify the metastatic LN. Of these 3 false negative cases, 2 patients had a metastatic parametrial node as the only positive LN with multiple negative pelvic nodes including negative SLN. One patient with stage IA1 disease and lymphovascular invasion had unilateral SLN mapping and a metastatic common iliac LN identified on completion lymphadenectomy of the contralateral side that did not map. The 4 (5%) patients with unsuccessful mapping included 1 who had grossly positive nodes identified at the time of laparotomy; the remaining 3 occurred during each surgeon's initial SLN mapping learning phase.

Conclusion

SLN mapping in early-stage cervical carcinoma yields high detection rates. Ultrastaging improves micrometastasis detection. Parametrectomy and side-specific lymphadenectomy (in cases of failed mapping) remain important components of the surgical management of selected cases.     

Significance of numbers of metastatic and removed lymph nodes in FIGO stage IB1 to IIA cervical cancer: Primary surgical treatment versus neoadjuvant chemotherapy before surgery

Objective.

The objective of this study was to compare the significance of numbers of metastatic (MLN) and removed lymph nodes (RLN) between primary surgical treatment (PST) and neoadjuvant chemotherapy followed by surgery (NCS) in patients with FIGO stage IB1 to IIA cervical cancer.

Methods.

Among 1124 patients with cervical cancer, PST (n = 451) and NCS (n = 73) groups were enrolled for evaluating the association between numbers of MLN and RLN, and clinical outcomes including the pattern of recurrence and survival according to the 2 treatments.

Results.

Mean values of progression-free survival (PFS) were 100.8 vs. 87.6 vs. 57.7 months in 0 vs. 1-2 vs. ≥ 3 MLN, suggesting that ≥ 3 MLN was associated with poor PFS (adjusted HR, 2.71; 95% CI, 1.02 to 7.21). However, there was no association between the number of MLN and survival in NCS group. The increased number of MLN was also associated with the increase of distant metastasis in PST group (44.0% vs. 72.7% vs. 78.6%; p = 0.02), whereas there was no association between the number of MLN and the pattern of recurrence in NCS group. Moreover, mean values of PFS were 57.2 (< 20 RLN) vs. 77.9 months (≥ 20 RLN) in PST group with lymph node metastasis (p = 0.04), demonstrating that ≥ 20 RLN improved PFS in PST group (adjusted HR, 0.48; 95% CI, 0.25 to 0.95).

Conclusions.

The increased number of MLN may be more significant for predicting poor survival and distant metastasis, and the increased number of RLN may be associated with better survival in the patients treated with PST than those treated with NCS.     

Differentiation of metastatic from non-metastatic lymph nodes in patients with uterine cervical cancer using diffusion-weighted imaging

Objective

This study aims to determine the diagnostic value of diffusion-weighted imaging (DWI) in the differentiation of metastatic lymph nodes from non-metastatic lymph nodes in uterine cervical cancer.

Methods

In 42 patients who underwent lymph node dissection for uterine cervical cancer, conventional MRI and DWI examinations were performed before surgery. Of the 1109 total dissected pelvic lymph nodes, 188 enlarged nodes with a short-axis diameter of 5 mm or greater were included for further analysis. Each of the size-based criteria (i.e., short-axis diameter and long-axis diameter) and ADC-based criteria (i.e., mean ADC, minimum ADC, mean rADC (relative ADC) and minimum rADC) were compared between metastatic lymph nodes and non-metastatic lymph nodes.

Results

There were statistically significant differences between metastatic and non-metastatic lymph nodes in the short-axis diameter, long-axis diameter, mean ADC, minimum ADC, mean rADC and minimum rADC (P < 0.001). The Az of the minimum ADC (0.990) was greater than that of the other ADC-based criteria (0.974, 0.939, 0.976 for mean ADC, mean rADC and minimum rADC, respectively) and all size-based criteria (0.878 for short-axis diameter and 0.858 for long-axis diameter) (P < 0.05). Using the minimum ADC criteria (≤ 0.881 × 10^− 3mm²/s), the sensitivity and specificity for differentiating metastatic from non-metastatic lymph nodes were 95.7% and 96.5%, respectively.

Conclusions

DWI is feasible for differentiating metastatic from non-metastatic pelvic lymph nodes in patients with uterine cervical cancer and minimum ADC could be served as a representative marker.     

Pattern analysis of regional spread and therapeutic lymph node dissection in cervical cancer based on ontogenetic anatomy

Objective

In cervical cancer lymph node dissection is applied for regional tumor staging. Up to now, the use of (chemo)radiation in the nodal positive patient has prevented the exact pattern analysis of regional tumor spread and the evaluation of the therapeutic role of lymph node dissection. New surgical techniques founded on ontogenetic instead of functional anatomy for the treatment of cervical cancer dispensing with adjuvant radiotherapy offer the possibility to accurately determine the topography of regional lymph node metastases which is the prerequisite for optimized diagnostic and therapeutic lymph node dissection.

Methods

Patients with cervical cancer FIGO stages IB-IIB were treated with total mesometrial resection (TMMR) and lymph node dissection after exposing the ontogenetic visceroparietal compartments of the female pelvis. Resected lymph nodes were allocated to regions topographically defined by the embryonic development of the iliac, lumbar and mesenteric lymph systems prior to histopathological assessment.

Results

71 of 305 treated patients had lymph node metastases. Topographic distribution of these metastases at primary surgery and analysis of pelvic failures showed a spatial pattern related to the ontogenesis of the abdominopelvic lymphatic system. Five-year locoregional tumor control probability was 96% (95% CI: 94-98) for the whole group and 87% (95% CI: 77-97) for nodal positive patients.

Conclusions

The pattern of regional spread in cervical cancer can be comprehended and predicted from ontogenetic lymphatic compartments. In patients with early cervical cancer lymph node dissection based on ontogenetic anatomy achieves high regional tumor control without adjuvant radiation.     

Location of aortic node metastases in locally advanced cervical cancer

Background

To assess the location of aortic node metastasis in patients with locally advanced cervical cancer undergoing extraperitoneal aortic lymphadenectomy to define the extent of the aortic lymphadenectomy.

Material and methods

Between August 2001 and December 2010, 100 consecutive patients with primary locally advanced cervical cancer underwent extraperitoneal laparoscopic aortic and common iliac lymphadenectomy. The location of aortic node metastases, inframesenteric or infrarenal was noted.

Results

The mean number ± standard deviation (SD) of aortic nodes removed was 15.9 ± 7.8 (range 4-62). The mean number ± SD of inframesenteric (including common iliac) nodes removed was 8.8 ± 4.5 (range 2-41) and the mean number ± SD of infrarenal nodes removed was 7.8 ± 4.1 (range 2-21). Positive aortic nodes were observed in 16 patients, and in 5 (31.2%) of them the infrarenal nodes were the only nodes involved, with negative inframesenteric nodes.

Conclusion

Inframesenteric aortic nodes are negative in the presence of positive infrarenal nodes in about one third of patients with locally advanced cervical cancer and aortic metastases.     

Pelvic lymph node dissection in early ovarian cancer: success of retrieval of lymph nodes by individual lymph node groups in respect to pelvic laterality

Objective

To evaluate the differences in number of harvested retroperitoneal pelvic lymph nodes by specific lymph node regions in respect to pelvic laterality.

Study design

We extracted cases of early ovarian cancer (EOC) with lymphadenectomy from the medical database which were treated at our institution in the period between 1994 and 2008. Recommendations of FIGO and EGSOC (European Guidelines for Staging in Ovarian Cancer) for staging of ovarian malignancies were followed. Stage of the disease was established on the basis of intra-abdominal condition which we found during surgery and histopathologic status of retroperitoneal lymph nodes (LN). For each case and every LN group, we subtracted the number of dissected lymph nodes on the left side from the number of dissected lymph nodes on the right side of the pelvis. The result would represent the difference between number of removed LN on each side of the pelvis for specific LN group. A negative difference means that a greater number of LN was extracted from the left side and a positive difference that the greater number of LN was extracted from the right side of the pelvis. We used Wilcoxon signed-rank test for statistical analysis of differences.

Results

48 cases with EOC underwent lymphadenectomy. In three cases, metastatic retroperitoneal pelvic lymph nodes were found. There were 79.1%, 50.0%, 45.8%, 93.8%, 52.1%, 60.4% and 70.8% of cases with left-right difference in number of removed lymph nodes in external iliac region, common iliac region, presacralic, above obturator nerve, under obturator nerve, lateral from the external ilac vessels and lateral from the common iliac vessels nodal group, respectively. The mean differences between left and right groups were in the range from 2 to 4 lymph nodes. There was no identifiable bias toward either side of the pelvis for any of the analyzed lymph node groups.

Conclusion

There is a right and left prevalence of retrieved LN by individual LN regions in the pelvis that could be influenced by asymmetry in right-left pelvic LN distribution. However, we did not find any evidence that the observed imbalance is, on average, directed toward either side of the pelvis.     

The importance of applying a sentinel lymph node mapping algorithm in endometrial cancer staging: beyond removal of blue nodes

Objective

To determine the false-negative rate of a surgical sentinel lymph node (SLN) mapping algorithm that incorporates more than just removing SLNs in detecting metastatic endometrial cancer.

Methods

A prospective database of all patients who underwent lymphatic mapping for endometrial cancer was reviewed. Cervical injection of blue dye was used in all cases. The surgical algorithm is as follows: 1) peritoneal and serosal evaluation and washings; 2) retroperitoneal evaluation including excision of all mapped SLNs and suspicious nodes regardless of mapping; and 3) if there is no mapping on a hemi-pelvis, a side-specific pelvic, common iliac, and interiliac lymph node dissection (LND) is performed. Paraaortic LND is performed at the attendings' discretion. The algorithm was retrospectively applied.

Results

From 9/2005 to 4/2011, 498 patients received a blue dye cervical injection for SLN mapping. At least one LN was removed in 95% of cases (474/498); at least one SLN was identified in 81% (401/498). SLN correctly diagnosed 40/47 patients with nodal metastases who had at least one SLN mapped, resulting in a 15% false-negative rate. After applying the algorithm, the false-negative rate dropped to 2%. Only one patient, whose LN spread would not have been caught by the algorithm, had an isolated positive right paraaortic LN with a negative ipsilateral SLN and pelvic LND.

Conclusions

Satisfactory SLN mapping in endometrial cancer requires adherence to a surgical SLN algorithm and goes beyond just the removal of blue SLNs. Removal of any suspicious node along with side-specific lymphadenectomy for failed mapping are an integral part of this algorithm. Further validation of the false-negative rate of this algorithm is necessary.     

A validation study of the new revised FIGO staging system to estimate prognosis for patients with stage IIIC endometrial cancer

Objective

The aim of this study was to validate the role of the new FIGO staging system for estimating prognosis for patients with stage IIIC endometrial cancer.

Methods

A total of 93 cases with stage IIIC were entered in this study and classified into three groups: one group of patients who underwent pelvic lymphadenectomy (PLX) and para-aortic lymphadenectomy (PALX) and who were for positive for pelvic node metastasis (PLNM) and negative for para-aortic node metastasis (PANM) (Group 1), one group of patients who underwent PLX alone and were positive for PLNM (Group 2) and one group of patients who underwent PLX and PALX and were positive for PANM (Group 3). Information on clinicopathologic findings and treatments was obtained from medical charts. Cox regression analysis was used to select prognostic factors.

Results

The 5-years survival rates were 89.3% in Group 1, 46.5% in Group 2 and 59.9% in Group 3. The overall survival rate in Group 1 was significantly better than that in Group 2 (p = 0.0001) and Group 3 (p = 0.0016). No significant difference in overall survival was found between Group 2 and Group 3. Age, number of metastatic lymph nodes, type of lymphadenectomy and type of adjuvant therapy were significantly and independently related to overall survival. Only when patients received PALX, PANM was a prognostic risk factor.

Conclusion

Sub-classification of stage IIIC would be functional for estimating prognosis in the revised FIGO staging system. Systematic lymphadenectomy including PALX has therapeutic significance for patients with stage IIIC endometrial cancer. Prognosis of patients with stage IIIC endometrial cancer would depend much more on application of lymphadenectomy including PALX than nodal status.     

Color Doppler analysis of pelvic arteries following bilateral internal iliac artery ligation for severe postpartum hemorrhage

Objective

To compare Doppler blood flow characteristics of the uterine, arcuate, and ovarian arteries of women who underwent bilateral internal iliac artery ligation with those of controls.

Methods

Thirteen women who underwent bilateral internal iliac artery ligation for severe postpartum hemorrhage (PPH) were matched with 15 healthy women of reproductive age. Transvaginal color and pulsed (duplex) Doppler modes were used to visualize the pelvic arteries. The pulsatility index, the resistance index, the systolic/diastolic blood flow ratio, the peak systolic velocity, and the end-diastolic velocity were measured.

Results

The mean age was 26.1 ± 5.2 years in the study group and 27.0 ± 5.4 years in the control group. All participants had regular menstrual periods. There were no significant differences between the groups regarding each of the vascular indices for the uterine, arcuate, and ovarian arteries.

Conclusion

These findings are consistent with published data demonstrating that pelvic circulation is not compromised after bilateral internal iliac artery ligation.     

Patterns of first recurrence following adjuvant intraperitoneal chemotherapy for stage IIIC ovarian cancer

Objective

Adjuvant intraperitoneal (IP) platinum-based chemotherapy has been shown to improve outcome for patients with advanced ovarian cancer. We hypothesize that patients who have received adjuvant IP chemotherapy more commonly recur first at extraperitoneal sites than patients who have received adjuvant intravenous (IV) chemotherapy.

Methods

Patients with newly diagnosed stage IIIC optimally debulked serous ovarian cancer were identified from institutional databases. Patterns of recurrence were compared between patients who received IV and IP chemotherapy using standard two-sided statistical tests.

Results

Of the 104 patients who met inclusion criteria, 60 received IV chemotherapy and 44 received IP chemotherapy. Patients in the IV group had a first recurrence more commonly in the lower abdomen or pelvis than the IP group. Patients in the IP group more commonly recurred in the upper abdomen and extra-abdominal lymph nodes. More patients in the IP group than the IV group recurred at extra-abdominal sites (45.5% versus 23.3%, P = 0.018).

Conclusions

Patients receiving adjuvant IP chemotherapy are less likely to first recur in the lower abdomen or pelvis and more likely to recur outside of the abdominal cavity. The data suggest that IP chemotherapy is highly effective in the anatomic areas of peritoneal distribution.     

Video-assisted thoracic surgery (VATS) evaluation of intrathoracic disease in patients with FIGO III and IV stage ovarian cancer

Objectives

The aim of this study was to assess the influence of video-assisted thoracic surgery (VATS) on our treatment decisions in FIGO III and IV ovarian cancer patients.

Methods

Patients with ovarian cancer and suspected supra-diaphragmatic involvement (pleural effusions, pleural carcinomatosis, lung metastasis, or enlarged supra-diaphragmatic lymph nodes) at chest computer tomography (CT) scan underwent VATS with or without laparoscopy (LSC) to decide for primary cytoreduction or neoadjuvant chemotherapy. Operation time, VATS complications (intrapleural hematoma, secondary hemorrhage with intervention, pneumonia and empyema) and shift in the therapeutic strategy due to VATS were evaluated.

Results

17 patients were included into this study (1 patient with FIGO stage IIIb, 1 with IIIc and 15 with stage IV). The median operation time for VATS only was 46.5 min (range: 20-50 min, n = 3). Perioperatively, no complications occurred. After surgical staging, the tumor was confined to the abdomen in four patients in whom primary cytoreduction was attempted. All other 13 patients underwent neoadjuvant chemotherapy. VATS altered the therapeutic management in 6/17 ovarian cancer patients (3 times upstaging, 3 times downstaging). Negative predictive values (NPV) for local and diffuse pleural carcinomatosis ranged between 0.5 and 0.71.

Conclusion

In this case series, VATS in addition to LSC showed negligible morbidity related to surgery and a short operation time. We were able to improve the accuracy of the FIGO staging and assessed operability more reliably in these patients than through imaging techniques alone.     

Regional variation in surgical assessment of lymph nodes for staging among women with early-stage epithelial ovarian cancer

Objective

To investigate geographical and socioeconomic variations in performance of lymph node dissection for the evaluation of patients with early-stage epithelial ovarian cancer.

Methods

A population-based, retrospective cohort study was conducted using data from the National Cancer Institute's SEER Program for 15 geographic registries and county-level measures. Women with early-stage epithelial ovarian cancer registered between 2000 and 2008 with known lymph node assessment status were studied. A multiple logistic regression analysis was used to evaluate the differences in the likelihood of lymph node assessment according to geographic SEER region.

Results

After adjusting for tumor characteristics, demographics, and area-based socioeconomic measures, a significant relationship between SEER region and lymph node dissection remained. Compared to the region with the highest proportion of lymph node dissection, there is a significantly lower probability of surgical assessment of lymph nodes in 8 of the remaining 14 geographical regions.

Conclusions

The variation in ovarian cancer surgical care by region reported in this study has implications for access and outcomes for patients with early-stage disease. Study findings merit further investigation and should be characterized to permit targeted interventions aimed at reducing the observed disparities.     

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.     

Exenteration in the treatment of Stage III/IV vulvar cancer

Objectives and methods

Vulvar carcinomas are rare genital malignancies. While advanced primary cancer chemoradiation is often preferred over pelvic exenteration (PE), PE is often the only therapy available in cases of recurrence. In a retrospective study, we analyzed predictive factors and outcomes of patients who underwent exenteration for vulvar cancer in our department during the past 10 years.

Results

We identified 27 patients; 9 of them suffered from primary disease, and 18 had experienced a recurrence. A total of 18 patients presented with stage FIGO III, and 9 patients presented with stage IV. In 10 patients, the disease had spread to the inguinal lymph nodes, and in 3 patients, it had also spread to the pelvic nodes. At the end of surgery, all patients were macroscopically tumor free, which was confirmed microscopically in 20 patients (74%, R0), with the other 7 patients having microscopic tumor remnants. For all patients, median time of survival was 37 months, the five-year survival rate (5YSR) was 62%, and the overall survival (OS) was 59%. Patients with tumor-free lymph nodes had an OS of 76% and a 5YSR of 83% vs. 40% and 36%, respectively, for patients with tumorous spread to the nodes (p = 0.03). The 5YSR correlated to the degree of resection (R0 vs. R1, 74% vs. 21%, p = 0.01).

Conclusion

PE is a therapeutic option in advanced primary or relapsed vulvar carcinoma, offering median- to long-term survival for many patients. Carcinomatous spread to regional lymph nodes and complete resection are the most important prognostic factors.     

Detection of sentinel lymph nodes in patients with endometrial cancer undergoing robotic-assisted staging: a comparison of colorimetric and fluorescence imaging

Objective

To retrospectively compare results from lymphatic mapping of pelvic sentinel lymph nodes (SLN) using fluorescence near-infrared (NIR) imaging of indocyanine green (ICG) and colorimetric imaging of isosulfan blue (ISB) dyes in women with endometrial cancer (EC) undergoing robotic-assisted lymphadenectomy (RAL). A secondary aim was to investigate the ability of SLN biopsies to increase the detection of metastatic disease.

Methods

Thirty-five patients underwent RAL with hysterectomy. One mL ISB was injected submucosally in four quadrants of the cervix, followed by 0.5 mL ICG [1.25 mg/mL] immediately prior to placement of a uterine manipulator. Retroperitoneal spaces were dissected for colorimetric detection of lymphatic pathways. The da Vinci^® camera was switched to fluorescence imaging and results recorded. SLN were removed for permanent analysis with ultra-sectioning, H&E, and IHC staining. Hysterectomy with RAL was completed.

Results

Twenty-seven (77%) and 34 (97%) of patients had bilateral pelvic or aortic SLN detected by colorimetric and fluorescence, respectively (p = 0.03). Considering each hemi-pelvis separately, 15/70 (21.4%) had “weak” uptake of ISB in SLN confirmed positive with fluorescence imaging. Using both methods, bilateral detection was 100%. Ten (28.6%) patients had lymph node (LN) metastasis, and 9 of these had SLN metastasis (90% sensitivity, one false negative SLN biopsy). Seven of nine (78%) SLN metastases were ISB positive and 100% were ICG positive. Twenty-five had normal LN, all with negative SLN biopsies (100% specificity). Four (40%) with LN metastasis were detected only by IHC and ultra-sectioning of SLN.

Conclusions

Fluorescence imaging with ICG detected bilateral SLN and SLN metastasis more often than ISB, and the combination resulted in 100% bilateral detection of SLN. Ultra-sectioning/IHC of SLN increased the detection of lymph node metastasis.     

Laparoscopic salpingo-oophorectomy for ovarian ablation in women with hormone-sensitive breast cancer

Objective

To evaluate institutional experiences regarding laparoscopic salpingo-oophorectomy in breast cancer patients and to compare the technique with gonadotropin-releasing hormone (GnRH) analogs among premenopausal women with hormone-sensitive breast cancer.

Methods

Between 2004 and 2009, 103 women with breast cancer underwent laparoscopic salpingo-oophorectomy at Addenbrooke's Hospital, Cambridge, UK. All relevant medical records—including reasons for salpingo-oophorectomy, peri-operative events, and subsequent follow-up—were reviewed.

Results

In the study period, 3 (2.9%) women experienced a recurrence of breast cancer but none had primary peritoneal/ovarian cancer within a median follow-up interval of 34 months (range, 0-70 months). No operative complications were noted among these women and all of them went home on the day of their operation.

Conclusion

Laparoscopic salpingo-oophorectomy seems to be a safe, permanent, and cost-effective method of ovarian ablation compared with the use of GnRH analogs. Salpingo-oophorectomy also considerably reduces the risk of subsequent ovarian/fallopian tube malignancy in this high-risk population.