Radiation therapy for pelvic lymph node metastasis from uterine cervical cancer

Objectives

This study aimed to evaluate the efficacy of radiation therapy for pelvic lymph node metastasis from uterine cervical cancer and identify an optimal radiation regimen.

Methods

A total of 111 metastatic pelvic lymph nodes, ranging from 11 to 56 mm (median, 25 mm) on CT/MRI, in 62 patients with uterine cervical cancer were treated initially with curative radiation therapy, with 46 patients receiving concurrent chemotherapy. Total radiation doses ranged from 45 to 61.2 Gy (median, 50.4 Gy) in 1.8–2 Gy (median, 1.8 Gy) fractions.

Results

At a median follow-up of 33 months, 46 of the 62 patients survived. Only 2 irradiated lymph nodes, 24 and 28 mm in diameter, in 1 patient progressed after irradiation alone with 50.4 Gy in 1.8 Gy fractions. All 33 metastatic lymph nodes ≥ 30 mm in diameter were controlled by irradiation at a median dose of 55.8 Gy. The 3-year lymph node-progression free rates were 98.2% in all 62 patients and 98.0% in all 111 metastatic lymph nodes. Except for transient hematologic reactions, 2 patients developed grade ≥ 3 therapy-related toxicities, 1 with an ulcer and the other with perforation of the sigmoid colon. In addition, 2 patients experienced ileus after irradiation.

Conclusions

Radiation therapy effectively controlled pelvic lymph node metastases in patients with uterine cervical cancer, with most nodes < 24 mm in diameter controlled by total doses of 50.4 Gy in 1.8 Gy fractions and larger nodes controlled by 55.8 Gy, particularly with concurrent chemotherapy. Higher doses to metastatic lymph nodes may increase intestinal toxicities.     

Lymph node metastasis in endometrioid adenocarcinomas of the uterine corpus with occult cervical involvement

Objective

Surgical-pathologic studies have defined the risk of lymphatic metastasis in clinical stage I endometrial cancers. However, data on the risk of lymph node metastasis in endometrial cancers involving the uterine cervix are less robust. The aim of this study was to determine the risk of lymphatic metastasis in patients with endometrial cancers with occult tumor extension to the uterine cervix.

Methods

Our institutional tumor registry identified all patients with endometrioid endometrial cancers who underwent comprehensive surgical staging. Patients with gross involvement of the cervix and patients with extra-uterine disease were excluded. The risk of lymphatic metastasis associated with cervical involvement was analyzed in the context of known uterine risk factors for lymphatic metastasis such as age, depth of invasion, grade, and lymphovascular space invasion (LVSI).

Results

We identified 169 patients who met inclusion and exclusion criteria. Univariate analyses revealed that LVSI (p < 0.01), tumor grade (p < 0.01), depth of myometrial invasion (p < 0.01), tumor free distance (p < 0.01), tumor size (p = 0.02), and cervical involvement (p < 0.01) were associated with lymphatic metastasis while age at diagnosis (p = 0.85) was not. Multivariate analyses revealed that only LVSI (p < 0.01), tumor grade (p = 0.02), and depth of myometrial invasion (p = 0.03) were independently associated with lymphatic metastasis.

Conclusion

Cervical involvement is not an independent predictor of lymphatic metastasis in endometrial cancer. In an unstaged patient, decisions regarding adjuvant treatment or additional diagnostic procedures such as lymphadenectomy should be based on uterine factors.     

Pre-operative systemic inflammatory response markers in predicting lymph node metastasis in endometrioid endometrial adenocarcinoma

Objectives

To evaluate the correlation of pre-operative systemic inflammatory response (SIR) markers with lymph node (LN) metastasis compared with serum CA-125 in endometrioid endometrial adenocarcinoma.

Study design

Retrospective review of 319 patients who were pathologically proven to have endometrioid endometrial adenocarcinoma after staging operations. Serum CA-125 and pre-operative SIR markers [neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), C-reactive protein (CRP), albumin, platelets and fibrinogen] were assessed. Receiver operating characteristic (ROC) curves were plotted for each SIR marker and serum CA-125.

Results

NLR, PLR and serum CA-125 were higher in the LN-positive group compared with the LN-negative group (p = 0.003, 0.012 and 0.025, respectively). Serum albumin was significantly lower in the LN-positive group compared with the LN-negative group (p < 0.001). ROC curves demonstrated the best cut-off values for NLR (≥1.97), PLR (≥9.14), albumin (≤4.15 g/dl) and serum CA-125 (≥32.50 U/ml) for pre-operative diagnosis of LN metastasis. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of serum CA-125 were 63.3%, 87.6%, 37.3%, 95.4% and 85.1%, respectively. No pre-operative SIR markers were superior to serum CA-125 in terms of sensitivity, specificity, PPV, NPV or accuracy, with the exception of the slightly higher sensitivity of PLR (64.5%).

Conclusions

Pre-operative SIR markers do not appear to be more effective in predicting LN metastasis than serum CA-125 in endometrioid endometrial adenocarcinoma.     

Predicting pelvic lymph node metastasis in endometrial carcinoma

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

Analysis of clinicopathologic factors predicting para-aortic lymph node metastasis in endometrial cancer

The purposes of this study were to compare the relationships between para-aortic lymph node metastasis and various clinicopathologic factors to evaluate whether para-aortic lymph node dissection is necessary when treating endometrial cancer. A retrospective study was performed on 841 patients with endometrial cancer, who underwent the initial surgery at the Keio University Hospital. Clinicopathologic factors related to para-aortic lymph node metastasis significant on a univariate analysis were analyzed in a multivariate fashion using a logistic model. According to the multivariate analysis, the clinicopathologic factor most strongly related to the existence of para-aortic lymph node metastasis was positive pelvic lymph node metastasis (P < 0.01). Among the 155 patients who underwent pelvic and para-aortic lymph node dissection, the difference of 5-year overall survival by the presence of retroperitoneal lymph node metastasis was examined by Kaplan-Meier method. The prognosis was poor even if para-aortic lymph node dissection was performed in cases of positive para-aortic lymph node metastasis. In conclusion, when deciding whether to perform para-aortic lymph node dissection in patients with endometrial cancer, it is necessary to consider the pelvic lymph nodal status. If there is no pelvic lymph node metastasis, it could not be necessary to perform para-aortic lymph node dissection.     

早期宫颈鳞癌患者盆腔淋巴结转移的相关因素分析

目的:探讨早期宫颈鳞状细胞癌患者盆腔淋巴结转移的危险因素。方法:回顾分析152例行手术治疗的ⅠB~ⅡA期宫颈鳞癌患者的临床资料,分析患者的年龄、临床分期、肿瘤细胞分化程度、宫颈间质浸润深度、肿瘤直径大小、脉管癌栓、术前血清宫颈鳞状上皮抗原(SCC-Ag)水平、治疗前血浆纤维蛋白原(FⅠB)水平及D-二聚体水平9个指标与盆腔淋巴结转移的关系。结果:152例ⅠB~ⅡA期宫颈鳞癌患者中20例存在盆腔淋巴结转移(13.16%)。单因素分析结果显示,宫颈间质浸润深度、肿瘤直径、脉管癌栓、术前血清SCC-Ag水平及血浆FⅠB水平与盆腔淋巴结转移有关,差异有统计学意义(P0.05);淋巴结阳性患者的血浆D-二聚体水平高于阴性患者,但差异无统计学意义(P0.05)。多因素分析结果显示,脉管癌栓、术前血清SCC-Ag及血浆FⅠB水平与盆腔淋巴结转移相关,差异有统计学意义(P0.05)。结论:脉管癌栓、术前血清SCC-Ag水平及治疗前血浆FⅠB水平是ⅠB~ⅡA期宫颈鳞癌患者盆腔淋巴结转移的独立危险因素,而术前D-二聚体水平与盆腔淋巴结转移之间的关系,尚需进一步研究。     

An unusual case of recurrent endometrial cancer presented with isolated cervical lymph node metastasis

Endometrial cancer (EC) is the most common malignancy of the female genital tract. Lymph node involvement is one of the major prognostic factors. Therefore, pelvic and paraaortic lymph nodes dissection is a part of the surgical management of these patients. Isolated peripheral lymph node metastasis has not been previously reported as a finding of recurrence in EC. We report a 67-year-old woman with recurrent EC presented with an isolated cervical lymph node metastasis (ICLM). Following the combination chemotherapy of doxorubicin, cisplatin and cyclophosphamide, her cervical lymph node was completely regressed. To our knowledge, this is the first case of recurrent EC presented with ICLM. We suggest that for women with EC who had isolated peripheral lymphadenopathies, peripheral lymph node metastasis should be considered as the finding of recurrence in patient with EC.     

术前SCC-Ag对早期宫颈鳞癌盆腔淋巴结转移预测价值研究

目的 探索鳞状细胞癌抗原(SCC-Ag)对宫颈鳞癌盆腔淋巴结转移的预测价值.方法 回顾性分析2007年1月至2017年1月于南充市中心医院接受初始治疗为根治性手术的603例早期宫颈鳞癌患者.统计学比较其临床病理特征,并采用Logistic回归分析影响盆腔淋巴结转移的危险因素,绘制ROC曲线确定SCC-Ag 预测盆腔淋巴...     

CXCR4 expression is associated with pelvic lymph node metastasis in cervical adenocarcinoma

The aim of this study is to investigate the expression of CXCR4 receptor in cervical adenocarcinoma and related mechanisms involved in pelvic lymph node metastasis. Immunohistochemistry was used to evaluate the expression of CXCR4 and the association of pelvic lymph node metastasis in archived tissue from clinical stage IB cervical adenocarcinomas (n = 37) and from benign specimens obtained at hysterectomy for other causes (n = 48). The HeLa cell (cervical adenocarcinoma-derived cell) line that expresses CXCR4 was used to study the interaction between the CXCR4 receptor and stromal cell-derived factor 1alpha (SDF-1alpha). Cell migration assays, cell numbers, flow cytometry, cell proliferation assay, and western blot were used to study the function of CXCR4 and its downstream signal transduction. The positive cases were semiquantitatively divided into three score classes according to their staining. Tumors with strong CXCR4 stainings were more likely to have pelvic lymph node metastasis than those with weak or negative stainings (87.5% vs 34.5%; P = 0.014). Only 25% of the benign specimens had weak or negative staining for CXCR4. Functioning CXCR4 receptor was expressed on HeLa cells. SDF-1alpha provoked significant signal transduction events, including chemotaxis and rescue from apoptosis. These actions were apparently mediated by the activation and phosphorylation of the extracellular signal-regulated kinase 1/2 and AKT pathways. We conclude CXCR4 expression is associated with cervical adenocarcinoma cell migration and proliferation, and primary cervical adenocarcinoma cells expressing CXCR4 are significantly more likely to metastasize to pelvic lymph nodes.     

Pelvic and aortic lymph node metastasis in epithelial ovarian cancer

OBJECTIVE: The appropriate management of advanced ovarian cancer has been controversial in recent years. There are no adequate data about the importance of lymphadenectomy and the appropriate sites for lymph node assessment. We sought to evaluate the distribution, size, and number of pelvic and aortic lymph node metastases in patients with epithelial ovarian carcinoma. METHODS: Retrospective chart review of 116 patients with stage IIIC or IV epithelial ovarian carcinoma treated at Mayo Clinic who underwent systematic bilateral pelvic and aortic lymphadenectomy between 1996 and 2000. RESULTS: Eighty-six (78%) of 110 patients who underwent pelvic lymphadenectomy were found to have nodal metastases in 422 (16%) of 2705 pelvic nodes that were removed. Eighty-four (84%) of 100 patients had documented aortic lymph node metastases in 456 (35%) of 1313 aortic nodes that were removed. Fifty-five (59%) of 94 patients had bilateral metastatic pelvic and aortic lymph nodes and bilateral aortic lymphadenectomy was conducted in 53 (72%) of 74 patients. The most representative group for detection of nodal metastases was the aortic group (83%) followed by the external iliac group (59%) and the obturator nodes (53%). There was no significant difference between the mean size of positive (1.8 cm) and negative nodes (1.6 cm). Thirty-seven patients had unilateral tumor, and 1 patient (7%) had contralateral node metastasis. CONCLUSION: The incidence of positive nodes bilaterally and positive high aortic nodes indicates the need for bilateral pelvic and aortic node dissection (extending above the inferior mesenteric artery) in all patients regardless of laterality of the primary tumor.     

Magnetic resonance imaging to identify risk of lymph node metastasis in patients with endometrial cancer

Objective

To assess the value of magnetic resonance imaging (MRI) to identify endometrial cancer patients at risk of lymph node metastasis.

Methods

Retrospective review of data from 108 patients with clinical stage I endometrial cancer who underwent preoperative MRI and were treated surgically. Patients at risk of lymph node metastasis were defined as those who had more than 50% myometrial infiltration or cervical invasion. Preoperative MRI reports were compared with final pathologic results.

Results

The mean age of the patients was 69.5 years and most patients had endometrioid cancer. On final pathologic analysis, 59 patients had deep myometrial infiltration or cervical invasion. For diagnosis of deep myometrial infiltration, cervical invasion, or both, MRI sensitivity and specificity were 56% and 85%; 47% and 83%; and 67% and 77%, respectively.

Conclusion

MRI has limited value in identifying patients with endometrial cancer who are at risk of lymph node metastasis. Minimally invasive laparoscopic lymph node staging should be undertaken when it is feasible.     

子宫颈癌盆腔淋巴结转移相关因素分析

目的探讨子宫颈癌盆腔淋巴结转移的分布规律及相关高危因素,为指导宫颈癌的个体化治疗提供依据。方法对471例行根治性手术的ⅠA～ⅡB期宫颈癌患者的临床病理资料进行回顾性分析,对淋巴结转移的高危因素采用卡方检验或多元Logistic回归分析。结果 471例宫颈癌患者盆腔淋巴结转移率为19.10%,其中以闭孔淋巴结转移率最高。临床分期、SCCAg>4μg/L、深肌层浸润、宫旁浸润(P<0.05)是影响宫颈癌淋巴结转移的独立危险因素。结论在宫颈癌各组淋巴结转移中,闭孔淋巴结是最易受累的部位。结合临床病理因素,研究影响宫颈癌患者淋巴结转移的相关高危因素,可以为其个体化治疗提供依据。     

Effect of radiotherapy on pelvic lymph node metastasis in cervical cancer stages IB2–IVA: a retrospective analysis of two comparative series

Efficiency of radiotherapy in controlling lymph node metastasis is a controversial issue. A continuous series of 87 patients affected by cervical cancer stages IB2-IVA and treated using pelvic radiotherapy is presented. A retrospective comparison is made between two populations. In the two populations, a staging lymphadenectomy was carried out before the onset of the therapeutic program. In the first population (53 patients), the pelvic nodes only were dissected and in the second one (34 patients), the pelvic lymph nodes were left in place and the paraaortic nodes only were dissected. In both series, a completion surgery was performed after finalization of the radiotherapy. It was carried out at open abdomen in both series. It included a systematic pelvic dissection for the patients whose pelvic nodes had been intentionally left in place at the time of the initial staging lymphadenectomy. Both series were identical as far as classic risk factors were concerned (FIGO stage, maximal tumor diameter, lymphovascular space involvement). The radiotherapy administered to the pelvis was the same in both populations. The number of patients with pelvic lymph node metastasis was 21 (39.6%) in the first population versus 6 (17.6%) in the second one (P = 0.03). The percentage of positive lymph nodes among the retrieved lymph nodes was 18.94 in the first population versus 2.8 in the second one (P = 0.0001). Pelvic radiotherapy is likely to control most of the pelvic lymph node metastasis, but not all of them. Practical deductions and further developments are discussed.     

The utility of sentinel lymph node mapping in the management of endometrial atypical hyperplasia

Objectives

To determine the risk of endometrial cancer (EC) and lymph node involvement in patients with a preoperative diagnosis of “AH-only” versus “AH - cannot rule out carcinoma” and to study the value of SLN mapping.

Prospective assessment of the prevalence of pelvic,paraaortic and high paraaortic lymph node metastasis in endometrial cancer

Objective

To prospectively define the prevalence of lymph node metastasis (LNM) in at risk endometrial cancer (EC).

Methods

From 2004 to 2008, frozen section based Mayo Criteria prospectively identified patients “not at-risk” of LNM (30% EC population; grade I/II, < 50% myometrial invasion and tumor diameter ≤ 2 cm) where lymphadenectomy was not recommended. The remaining 70% EC cohort was considered “at-risk” of LNM; where a systematic pelvic and infrarenal paraaortic lymphadenectomy was recommended. Patients were prospectively followed. The area between renal vein and inferior mesenteric artery (IMA) was labeled as high paraaortic area. For calculating the prevalence of LNM in high paraaortic area, the denominator was the population with known anatomic location of nodal tissue in relation to the IMA.

Results

Of the 742 patients, 514 were at risk; of which 89% underwent recommended lymphadenectomy. A mean (± standard deviation) of 36 (± 14) pelvic and 18 (± 9) paraaortic nodes were harvested. The prevalence of pelvic and paraaortic LNM was 17% and 12%, respectively. In presence of pelvic LNM, 51% had paraaortic LNM. In absence of pelvic LNM, 3% had paraaortic LNM; of which 67% was located exclusively in high paraaortic area. Among patients with paraaortic LNM, 88% had high paraaortic LNM; and 35% had only high paraaortic LNM. The cases of paraaortic LNM with negative pelvic nodes seemed to cluster in moderate to high grade endometrioid EC with ≥ 50% myometrial invasion.

Conclusion

We present reference data for the prevalence of LNM in at-risk EC patients to guide lymphadenectomy decisions for clinical and research purposes.     

Ⅰ期子宫内膜样腺癌前哨淋巴结活检术学习曲线分析#br##br#

【Abstract】?Objective?To explore learning curve of sentinel lymph node biopsy (SLNB) for stage I endometrioid adenocarcinoma. Methods?Sixty patients with stageⅠendometrioid adenocarcinoma from October 2015 to June 2018 were selected and divided into three groups according to the order of operation time: Group A (October 2015 to December 2016), Group B (December 2016 to February 2018) and Group C (February 2018 to June 2018). There were 20 patients in each group. The SLNB operation time, detection rate, and sensitivity were compared. Results?The operation time of SLNB in group C was significantly shorter than groups A and B (P<0.05). Among the 60 patients, 51 (85%) were successful SLN mapping, 43(71.67%) bilaterally SLN mapping, 47 (78.33%) were external iliac lymph nodes, 31 (51.67%) were obturator lymph nodes. The rate of group A, B, and C was 70% (14/20), 90% (18/20), and 95% (19/20), respectively. The difference between the total detection rates of three groups was statistically significant (P=0.021). The sensitivity of SLNB in group A was 50%, and the negative predictive value was 92.30%, and both groups B and C were 100%. Conclusion?There is a learning curve for SLNB. After 40 cases of SLNB, more proficient and accurate level can be achieved.     

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.