Extraperitoneal laparoscopic para-aortic lymphadenectomy for lymph node recurrence of fallopian tube carcinoma

The endoscopic retroperitoneal approach is a minimally invasive method for surgical staging of cervical cancer. A 57-year-old woman had an intraoperative diagnosis of carcinoma of the left fallopian tube and undergone a retroperitoneal pelvic and para-aortic lymphadenectomy with no peritonization during surgical staging. Small suspicious nodes in the serous membrane of the sigmoid colon and peritoneal washings were positive for malignancy. A total of 12 nodes were obtained, all of which were negative. She received six cycles of paclitaxel and platinum-based chemotherapy and showed a complete clinical response. Thirty-two months after surgery, the abdominal computed tomography scan showed a left para-aortic lymph node, 19 mm in diameter, which was successfully removed through an extraperitoneal laparoscopic approach. The extraperitoneal laparoscopic approach of the para-aortic region is a feasible procedure after previous transperitoneal lymphadenectomy and chemotherapy.     

Extraperitoneal laparoscopic para-aortic lymphadenectomy as a diagnostic procedure for lymph node recurrence of gynaecological cancers

OBJECTIVE: The aim of this study was to evaluate the feasibility of extraperitoneal laparoscopic para-aortic lymphadenectomy for lymph node recurrence of gynecological cancers. METHODS: Seven patients underwent extraperitoneal laparoscopic para-aortic lymphadenectomies for suspected lymph node recurrence, detected by magnetic resonance image or CT scan. The suspicious nodes were removed through an extraperitoneal laparoscopic approach. RESULTS: The median age of patients was 51 years (range: 39-67). The median operating time was 207 min (range 120-300). There were no intraoperative or postoperative complications. The median nodal yield was 7.3 (range: 1-15). The median hospital stay was 2.5 days (range: 2-3). Histological examination revealed metastasis in 6 of the 7 patients. CONCLUSION: The extraperitoneal laparoscopic para-aortic lymphadenectomy for lymph node recurrence of gynecological cancers is a safe and feasible procedure which should be considered in the case of possible recurrence.     

Port site metastases after laparoscopic lymph node staging of cervical carcinoma.

The literature revealed only six cases of cervical carcinoma metastatic to a port site after laparoscopic lymphadenectomy. A woman with a poorly differentiated squamous cell carcinoma of the cervix had port site metastases after laparoscopic lymph node staging. The frequency of this event might be higher than expected. Therefore, surgeons should reduce mechanical irritation of port sites and spillage of tumor cells.     

Extraperitoneal lymph node dissection in cervical cancer patients

AIM: Extraperitoneal lymph node dissection (EPLD) has been performed in 14 patients with invasive cervical cancer. The technique of EPLD has been described and presented as well as its feasibility, especially as staging procedure in locally advanced stages of cervical cancer.     

In vitro fertilization in unstimulated cycles: the University of Southern California experience.

OBJECTIVE: To describe the clinical experience of our center with in vitro fertilization (IVF) in unstimulated cycles and to provide a comparison to stimulated cycles. DESIGN: Spontaneous ovulatory cycles were triggered with human chorionic gonadotropin in the midcycle, and 78 aspirations for IVF were performed, with the remainder of the IVF cycle proceeding in a standard manner. SETTING: The IVF program of the University of Southern California and the California Medical Center, Los Angeles, California. PATIENTS: Spontaneously ovulatory women (n = 46) with predominantly pelvic factor as their principal cause of infertility, under the age of 40, and no male factor. INTERVENTIONS: Human chorionic gonadotropin administration in midcycle, follicle aspiration, IVF, and embryo transfer. MAIN OUTCOME MEASURES: Embryo implantation and pregnancy. RESULTS: Seventy-eight follicle aspirations resulted in 11 clinical (14%) and 9 ongoing (12%) pregnancies. The per embryo implantation rate was 13% clinical and 11% ongoing. There was no decrease in per cycle pregnancy rates (PRs) for up to three unstimulated cycles. CONCLUSIONS: Unstimulated IVF is a viable alternative to stimulated cycles with PRs approximately one half those of stimulated cycles. It is reasonable to offer patients up to three cycles of unstimulated IVF without expecting a decrease in PRs.     

Establishment of a nonanonymous donor oocyte program: preliminary experience at the University of Southern California

Transvaginal ultrasound-directed oocyte retrieval was performed on eight women functioning exclusively as gamete donors for 10 patients with ovarian failure. Donors included sisters, personal friends, and compensated participants selected by the recipient couple. Oocyte donors underwent controlled ovarian hyperstimulation and transvaginal oocyte aspiration. Thirteen initiated cycles resulted in 11 embryo transfers and six ongoing pregnancies. There were no complications, and all donors stated a willingness to undergo the procedure again. The use of nonanonymous oocyte donation appears both efficacious and efficient and is recommended as an option for achieving pregnancy in women with ovarian failure.     

Sentinel lymph node biopsy improves staging in early cervical cancer

OBJECTIVES: The main study objective was to describe the distribution of sentinel lymph nodes (SLNs) and the prevalence of SLN micrometastases in patients with early cervical cancer. The secondary objective was to confirm the SLN detection rate and negative predictive value found in our preliminary study. PATIENTS AND METHODS: We prospectively included 25 patients with early cervical cancer, each of whom received an injection of 120 MBq of technetium-99m for preoperative lymphoscintigraphy and intraoperative node detection using an endoscopic gamma probe. Patent blue dye was injected intraoperatively. SLNs were sought in the pelvic and para-aortic drainage areas. Radical iliac dissection was performed routinely at the end of the procedure. SLNs were examined after hematoxylin-eosin-saffron staining; negative specimens were assessed using immunohistochemistry. RESULTS: Most (85%) of the SLNs were in the inter-iliac territory. Para-aortic or parametrial SLNs were found respectively in 2 patients and common iliac SLNs in 5 patients. Thus 9/25 patients had additional information due to SLN detection. One metastasis and one micrometastasis were detected in SLNs. No patients had positive non-sentinel nodes with negative SLNs. CONCLUSION: SLN detection ensures the identification of SLNs in unusual locations in 36% of patients. SLN disease was found in 8% of our patients. Thus, SLN biopsy improves staging in patients with early cervical cancer. Studies in larger patient populations are needed to evaluate the clinical impact of SLN biopsy.     

Increasing experience in laparoscopic staging of early ovarian cancer

We assessed the effect of increasing experience of a single surgeon (learning curve) in the laparoscopic staging procedure for women with early ovarian cancer and compared the results with the literature. We retrospectively analysed a total of 25 women with apparent early-stage ovarian cancer who underwent a laparoscopic staging procedure by the same surgeon. Three time periods, based on date of surgery, were compared with respect to operating time, amount of lymph nodes harvested and surgical outcome. There was no significant difference in operation time, estimated blood loss and hospital stay between the three periods. There was, however, a significant increase in the median number of pelvic and para-aortal lymph nodes harvested (group1 = 6.5, group 2 = 8.0 and group 3 = 21.0; P < 0.005). For the total period, median operation time was 235 min and median estimated blood loss was 100 ml. The median length of hospital stay was 4.0 days. Two intraoperative and two postoperative complications occurred. The upstaging rate was 32%. The mean interval between initial surgery and laparoscopic staging was 51.2 days. Mean duration of follow-up was 43 months, range (1–116 months). Five (20%) patients had recurrences, and two (8%) patients died of the disease. In conclusion, there is a significant learning curve for the laparoscopic full staging procedure in ovarian cancer. In our study this is mainly reflected in the amount of lymph nodes harvested and not in the total operating time.     

Sentinel lymph node biopsy in breast cancer patients--results and experience after 500 sentinel lymph node biopsies

INTRODUCTION: Sentinel lymph node biopsy (SLNB) is a widely used technique for axillary staging in breast cancer patients. The principle to evaluate the axillary status of a breast cancer patient with a less invasive surgery than axillary lymph node dissection (ALND) meets the new minimally invasive concept in breast cancer surgery. Some breast cancer centers proceed to SLNB without ALND in SLN-negative patients. PATIENTS AND METHODS: Between March 1998 and March 2002, 500 SLNBs were performed. After a learning period with SLNB and ALND in 75 patients with a sensitivity of 96.2% and a false-negative rate of 3.8%, SLNB alone without further ALND was performed in a group of patients. In addition, the feasibility of SLNBin patients with locally advanced breast cancer, in patients after neoadjuvant chemotherapy and in patients with multicentricity was evaluated. The combined method with blue dye and technetium-99m-labeled human albumin for identification of SLNs was applied. RESULTS: 500 SLNBs were performed. The identification rate was 86.2%. After exclusion of patients with neoadjuvant chemotherapy and patients with multicentricity, the identification rate was 94.5%. SLNs were positive in 41.3% of patients and negative in 58.7% of patients. DISCUSSION: SLNB is an excellent method for axillary stag-ing and an alternative for ALND in a certain group of breast cancer patients.     

Extraperitoneal lymph node dissections with use of a midline incision in patients with female genital cancer

Recent investigations have suggested that extraperitoneal, as compared to transperitoneal, lymph node dissections may result in significantly less morbidity in patients who later have external beam irradiation. Some incisions designed to perform such dissections do not afford easy access to the opposite side. With use of a midline incision carried down to the preperitoneal space, 30 patients underwent bilateral pelvic lymph node dissections. When necessary, access to the para-aortic nodes by an extraperitoneal approach was accomplished by use of a modification of this midline incision. Operating time to complete the pelvic dissection ranged from 35 to 90 minutes. The mean estimated blood loss for the dissection was 135 ml. The advantages of this extraperitoneal approach include easy access to lymph nodes on either side, ability to use the peritoneum as a pack, and an easier access to the obturator space nodes.     

Para-aortic lymph node evaluation in cervical cancer: the impact of staging upon treatment decisions and outcome

Petereit DG, Hartenbach EM, Thomas GM. Para-aortic lymph node evaluation in cervical cancer: the impact of staging upon treatment decisions and outcome. Int J Gynecol Cancer 1998; 8 :353–364.
This article reviews both surgical and nonsurgical staging options for cervical cancer and determines the ultimate impact of these staging pathways. Surgical staging is the most sensitive method for detecting para-aortic lymph node metastases; however, a negative lymphangiogram precludes surgical staging since it is a highly sensitive and specific radiographic study. CT and MRI are not as sensitive for detecting para-aortic disease, therefore a false negative study would ultimately result in the loss of about 4 stage IIB and 5 stage IIIB patients out of 100. Judicious use of existing staging options will enhance the ultimate benefit to individual patients, rather than surgically staging all patients prior to radiotherapy.     

Sentinel lymph node biopsy. Preferred method of axillary staging for breast cancer

Sentinel lymph node (SLN) biopsy has replaced routine axillary lymph node dissection (ALND) for most breast cancer patients with clinically normal lymph nodes. The morbidity (lymphedema, arm numbness) of SLN biopsy is significantly less than ALND. The use of alternative injection sites (skin or subareolar) yields high SLN identification rates and may shorten the learning curve associated with standard peritumoral injection. The dual-agent (radiocolloid plus blue dye) technique is recommended to decrease false-negative rates, especially when surgeons are just learning how to perform SLN biopsy. Regardless of the technique employed, SLN identification rates should be > 95% with a false-negative rate of < 5%. Using serial sectioning and immunohistochemistry, SLN micrometastases can be identified in 10% to 20% of node-negative patients. However, the clinical significance of micrometastases is not known. Axillary recurrence is rare for patients without SLN metastases who do not undergo further axillary surgery. Outside a clinical trial, ALND is recommended for most patients with SLN metastases, except for cases with SLN metastases < 0.2 mm detected by immunohistochemistry alone. The indications for SLN biopsy have expanded and include breast cancer patients with multifocal/multicentric disease and large tumors, and male breast cancer. Although minimally invasive internal mammary SLN biopsy is feasible, the usefulness of this procedure is not established.     

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.     

Total laparoscopic hysterectomy with and without lymph node dissection for uterine neoplasia

STUDY OBJECTIVE: To compare surgical outcomes of patients with uterine neoplasia undergoing total laparoscopic hysterectomy only (TLH) with those having TLH and lymph node dissection (TLHND) from September 5, 1996 through January 13, 2007. DESIGN: Retrospective chart analysis (Canadian Task Force classification II-2). SETTING: Three tertiary surgical centers in California. PATIENTS: 112 patients with uterine neoplasia operated on from 1996 through 2006. INTERVENTIONS: All patients underwent total laparoscopic hysterectomy and bilateral salpingoophorectomy; however, 30 patients with FIGO stage IC or higher, lymph channel involvement, or grade 3 disease also underwent pelvic and aortic node dissection. MEASUREMENTS AND MAIN RESULTS: Of 807 patients having TLH, 112 had a uterine neoplasia: twenty-one hyperplasia, 86 carcinoma, 2 ovarian and endometrial carcinoma, and 3 low-grade endometrial stromal sarcoma; 82 had TLH and adnexectomy; and 30 had TLHND. For both groups, the mean age was 60 (NS), Quatlet index was 31.2 (NS), parity was 1.6 (NS), and the mean blood loss was 148 mL (NS). The node dissection added 56 minutes to TLH (132 vs 188 minutes, p <.001) and yielded a mean of 25 nodes. Patients in both groups spent a median of 1 day in the hospital (NS). There were 7 complications (6.3%) in the series: among the patients in the TLH group, 1 conversion to laparotomy for bleeding from an ovarian artery, 1 vaginal rupture during coitus at 6 weeks, and 1 nonsurgical episode of diverticulitis. There were 4 patients in the TLHLND group with complications: 1 ureteral injury, 1 trocar-site hernia, 1 vaginal laceration, and 1 pelvic abscess. CONCLUSIONS: Node dissection added 56 minutes and entailed no additional blood loss, transfusion, or length of hospital stay, as well as minimal risk of complication. Total laparoscopic hysterectomy with indicated lymph node dissections for endometrial disease is reasonably well tolerated and warrants prospective randomized study to document its role in the therapy of endometrial carcinoma.     

Risk factors for lymph node metastasis in apparent early-stage epithelial ovarian cancer: implications for surgical staging

Objectives

The extent of lymphadenectomy to be performed in apparent early-stage epithelial ovarian cancer (EOC) is not well defined. We evaluated the patterns of lymphatic spread in apparent early-stage EOC and risk factors for lymph node metastasis, as these have potential implications for clinical decision making.

Methods

All cases of apparent early-stage EOC diagnosed at our institution between January 1994 and December 2003 were retrospectively identified. Apparent early-stage EOC was defined as gross disease that appeared confined to the pelvis without abdominal spread at the time of initial exploration. Demographics, pathologic findings, staging procedures performed, and clinical impression at surgery were analyzed. Patterns of lymph node positivity and risk factors associated with upstaging were assessed.

Results

One hundred and ninety patients with apparent early-stage EOC undergoing primary surgical staging met criteria for inclusion. All patients had at least some pathologic assessment of lymph nodes, with 115 having both bilateral pelvic and paraaortic lymphadenectomy performed. After review of pathology and operative reports, the final FIGO staging within the cohort was 54 IA (28.4%), 10 IB (5.3%), 51 IC (26.8%), 1 IIA (0.5%), 4 IIB (2.1%), 37 IIC (19.5%), 8 IIIA (4.2%), 25 IIIC (13.2%). Overall 25/190 (13%) had lymph nodes metastasis as follows: 8 (32%) had positive pelvic nodes, 12 (48%) had positive paraaortic nodes, and 5 (20%) had both positive pelvic and paraaortic lymph nodes. Significant risk factors for lymph node metastasis included bilateral vs. unilateral primary lesion (26.8% vs. 7.5%, p < 0.001), positive cytologic washings vs. negative (22.4% vs. 9.1%, p = 0.012), ascites vs. no ascites (28.2% vs. 9.3%, p = 0.002), serous vs. other histology (28% vs. 9%, p = 0.001), grade 1 vs. grade 2 vs. grade 3 disease (2.7% vs. 1.9% vs. 23.2%, p < 0.001), and preoperative CA 125 levels of > 35 vs. ≤ 35 U/ml (22.4% vs.0% p = 0.006). No patients with mucinous cancers (n = 29) had lymph node metastases. Patterns of LN metastases were largely independent of laterality of primary lesions: among those with unilateral lesions and positive nodes (n = 10), 5 (50%) had ipsilateral lymph node involvement, 4 (40%) had bilateral involvement, and 1 (10%) had isolated contralateral lymph nodes positive.

Conclusions

Complete surgical staging in EOC patients with gross disease confined to the ovaries and pelvis should include bilateral pelvic and paraaortic lymphadenectomy.Even in patients with unilateral lesions, lymph node metastases are commonly bilateral. Bilateral ovarian lesions, positive cytology, presence of ascites, high grade histology, and serous histology are risk factors for lymph node involvement. This information may be helpful in counseling patients presenting for consideration of re-staging after unexpected findings of malignancy.