妇科恶性肿瘤淋巴结转移的腹膜后与腹腔化学治疗的比较

目的 比较妇科恶性肿瘤患者淋巴结转移的腹膜后化学治疗（化疗）和腹腔化疗的疗效,并进一步评价腹膜后化疗。方法 选择６２例妇科恶性肿瘤患者,手术前分别随机进行腹膜后化疗４３例、腹腔化疗重复给药１１例和腹腔化疗单次注药（５氟嘧啶,５－ＦＵ）８例,采用高效液相色谱侧定法（ＨＰＬＣ）检测淋巴结内－５ＦＵ的浓度。其中１６例腹膜后化疗重复给药患者,比较注药侧与未注药侧淋巴结内５－ＦＵ的浓度。选择腹膜后化疗患者６     

盆腔腹膜外化疗法重复给药的临床研究

目的：探讨盆腔腹膜外化疗法重复给药用于临床治疗肿瘤淋巴系转移的可行性。方法：选２５只家犬和２４例妇科恶性肿瘤患者，经空腹膜餐间隙穿刺插管注入５－氟尿嘧啶（５－ＦＵ）、噻替派或氨甲喋呤采用高效液相色谱和病理检查的方法，观察药物分布内淋巴结及其周围组织的药物２和病理改变。结果：动物实验结果表明，重复给药对给药区血管、输尿管及其它正常组织未见毒性作用；淋巴结内５－ＦＵ浓度是周围结缔组织的７－９倍，重复给     

盆腔腹膜外化疗法用于妇科恶性肿瘤淋巴系转移的初步研究

通过动物实验及临床研究，对经盆腔腹膜外间隙穿刺插管进行化疗的可行性及其对妇科恶性肿瘤淋巴系转移的疗效进行探讨。动物实验结果表明，于盆腔腹膜外间隙注入５－氟脲嘧啶（５－ＦＵ）及伊索显（Ｉｓｏｖｉｓｔ－３００）混合剂后，注药部位局部细胞形态无改变，仅有少量淋巴细胞浸润；临床观察结果表明，（１）注药后Ｘ线摄片，可见髂外、髂内、闭孔、腹股沟深及大部分髂总淋巴结所在位置均包括在药物分布范围之内，重复给药，药物分布范围不变；（２）注药后４８小时内，注药侧淋巴结内、ＦＵ浓度高于对照侧，差异有极显著性（Ｐ＜０．０１）。腹主动脉旁淋巴结内５－ＦＵ浓度介于注药侧与对照侧淋巴结内浓度之间；（３）对己有肿瘤细胞转移的淋巴结，注药后显微镜下可见淋巴结内转移的癌细胞有明显变性、坏死；（４）本组患者未发生并发症及明显的全身毒副作用，本研究结果提示，经盆腔腹膜外间隙化疗是一种简便、安全、效果可靠的化疗方法。     

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.     

Anatomical and pathological study of retroperitoneal nodes in endometrial cancer

Benedetti-Panici P, Maneschi F, Cutillo G, D'Andrea G, Manci N, Rabitti C, Scambia G, Mancuso S. Anatomical and pathological study of retroperitoneal nodes in endometrial cancer. Int J Gynecol Cancer 1998; 8 : 322–327.
To assess the patterns of lymphatic spread in endometrial carcinoma, data from 91 endometrial cancer patients (surgical FIGO stage I: 59; II: 12; III–IV: 20) who underwent systematic pelvic and aortic lymphadenectomy were analyzed. The median number of nodes removed was 27 aortic (range 15–57) and 31 pelvic (range 20–68) nodes. Positive nodes were found in 16 patients (18%), seven having pelvic, one aortic, and eight both pelvic and aortic metastasis. The median number of positive nodes was three (range 1–29) aortic and two (range 1–18) pelvic nodes. Isolated pelvic node metastasis was observed in seven patients and aortic metastasis in one patient.
Pre-paracaval, pre-paraortic and intercavoaortic, with superficial obturator, external iliac and common iliac were the node groups most frequently involved. These nodes may be considered primarily invaded by the tumor. The higher prevalence of pelvic with respect to aortic metastasis, and the low risk of isolated aortic spread, suggest that endometrial cancer spreads preferentially to the pelvic area. Multivariate analysis showed that depth of myoinvasion and adnexal metastasis were independent factors predicting the risk of lymphatic spread. The risk of aortic spread was also predicted by the pelvic node status. These data may be useful for tailoring lymphadenectomy.     

Retroperitoneal lymph node metastasis in patients with ovarian cancer

From 1979 to 1987 retroperitoneal lymph node dissection was performed at the Tokyo University Hospital in 41 cases (pelvic lymph node biopsy was done in 4 cases, pelvic lymphadenectomy in 23 cases, pelvic and paraaortic lymphadenectomy up to the renal vessels in 14 cases) of Stage Ia to IV ovarian cancer following cytoreductive surgery. The incidence of retroperitoneal positive nodes was 11.1% (2/18) in Stage I, 50.0% (5/10) in Stage II, 50.0% (5/10) in Stage III and 0% (0/3) in Stage IV (FIGO criteria without considering the pathologic findings of retroperitoneal lymph nodes). The positive rate of lymph node involvement in Stage II and Stage III was significantly higher than that in Stage I. The tumors involving both ovaries were more likely to metastasize to retroperitoneal lymph nodes. Enlargement of tumors and increased ascites were not the risk factors of retroperitoneal lymph node metastasis. These data suggest that the occurrence of retroperitoneal lymphatic spread in ovarian cancer is comparable to that in uterine cancer and increased by involvement of both ovaries and extension to other pelvic tissues.     

Sentinel lymphatic mapping among women with early-stage cervical cancer: A systematic review

The presence of pelvic lymph node metastases is without doubt the most significant prognostic factor that determines recurrences and survival of women with early-stage cervical cancer. To avoid the underdiagnosis of lymph node metastasis, pelvic lymphadenectomy procedure is routinely performed with radical hysterectomy procedure. However, the pelvic lymphadenectomy procedure may not be necessary in most of these women due to the relatively low incidence of pelvic lymph node metastasis. The removal of large numbers of pelvic lymph nodes could also render non-metastatic irreversible damages for these women, including vessel, nerve, or ureteral injuries; formation of lymphocysts; and lymphedema. Over the past decades, the concept of sentinel lymph node biopsy has emerged as a popular and widespread surgical technique for the evaluation of the pelvic lymph node status in gynecologic malignancies. The histological status of sentinel lymph node should be representative for all other lymph nodes in the regional drainage area. If metastasis is non-existent in the sentinel lymph node, the likelihood of metastatic spread in the remaining regional lymph nodes is very low. Further lymphadenectomy is therefore not necessary for a patient with negative sentinel lymph nodes. Since the uterine cervix has several lymphatic drainage pathways, it is a challenging task to assess the distribution pattern of sentinel lymph nodes in women with early-stage cervical cancer. This review article will adapt the methodology proposed in these studies to systematically review sentinel lymphatic mapping among women with early-stage cervical cancer.     

Lymphatic mapping and sentinel node identification as related to the primary sites of lymph node metastasis in early stage ovarian cancer

OBJECTIVE: We evaluated the primary sites of lymph node (LN) metastasis in patients during the early stage of ovarian cancer. METHODS: Study 1: patients with clinical stage I and II common epithelial ovarian carcinoma (n = 150) underwent systematic retroperitoneal LN dissection of the pelvic and paraaortic areas. The relationship between the incidence and location of LN metastasis and clinical and histological characteristics was examined. Study 2: we studied 11 women with endometrial or fallopian tube tumors. At laparotomy, activated charcoal solution was injected into the unilateral cortex of the ovary. Ten minutes later, the retroperitoneal spaces were opened and charcoal uptake within the pelvic lymph node (PLN) and paraaortic node (PAN) as far as the level of renal vein was examined. RESULTS: Study 1: The incidence of LN metastasis by stage was 6.5% (8/123) in stage I and 40.7% (11/27) in stage II. Among 19 patients with LN metastasis, 14 had only PAN, 2 had only pelvic LN, and 3 had both PAN and PLN metastases. Metastasis was limited to the ipsilateral side in 12 (63%) patients, but was bilateral in 5 (26%) and contralateral to the neoplastic ovary in 2 (11%). Positive peritoneal cytology was significantly (P < 0.05) correlated with lymph node metastasis. Study 2: Lymphatic channels along the ovarian vessels were identified in all injected ovaries. Charcoal was deposited in the LN of all patients. The locations of these nodes included PAN in all patients, common iliac node in three, and external iliac node in one. CONCLUSION: PAN is the primary site of LN metastasis in ovarian cancer. Bilateral PAN dissections are necessary to determine the extent of tumors even in stage I ovarian carcinoma.     

Is common iliac lymph node dissection necessary in early stage cervical carcinoma?

OBJECTIVES: Nodal metastasis is one of the most important prognostic factors in early stage cervical carcinoma and has an immense impact on the subsequent management. Thus, searching for nodal metastasis by pelvic lymphadenectomy is an integral part in the surgical management of cervical carcinoma. Complete nodal clearance of lymphatic tissue up to 2 cm above the bifurcation of common iliac vessels is therefore performed as a routine in our unit. The aim of this study is to investigate the incidence and pattern of pelvic lymph node metastases in patients with early stage cervical carcinoma to determine the role of common iliac node dissection in the surgery. METHODS: We retrospectively reviewed 174 operation and histopathology reports of patients who underwent pelvic lymphadenectomy because of stage IA2 to IIA cervical carcinoma. Lymph nodes collected below and above the bifurcation of common iliac vessels were labeled as pelvic nodes and common iliac nodes, respectively. The incidence and distribution of nodal metastases were analyzed. RESULTS: Complete and selective pelvic lymphadenectomy was performed in 163 and 11 patients, respectively. Nodal metastasis was documented in 35 (20.1%) patients. Pelvic and common iliac nodes were involved in 34 and 8 cases, respectively. All except one patient with common iliac node metastases were also found to have pelvic node metastasis. CONCLUSIONS: In early stage cervical carcinoma, isolated common iliac lymph node metastasis is rare, especially in cases without associated high risk factors. Less extensive pelvic lymphadenectomy may be considered in these patients in order to reduce operation morbidity and time.     

Lymph node pathway in the spread of endometrial carcinoma

OBJECTIVE: To elucidate the sentinel nodes of endometrial carcinoma, the spread pathway was clarified. The correlation between lymph node spread and other clinicopathological variables was also analyzed. METHODS: Dissected lymph node samples in 342 patients who underwent pelvic and selective paraaortic lymphadenectomy were reviewed. Pelvic and paraaortic node (PLN and PAN) status was compared with clinicopathological parameters. RESULTS: Lymph node metastasis was demonstrated in 52 patients, including 46 cases with PLN metastasis and six patients with independent PAN metastasis. The metastatic sites were most frequent in the obturator and internal iliac nodes. Eleven of 49 patients who underwent PAN dissection were positive for metastasis. Sixteen of 23 cases with parametrial metastasis also metastasized in the retroperitoneal lymph node. CONCLUSION: The lymph node spread pathway in endometrial carcinoma consists of a major route via the obturator node or internal iliac node with or without parametrial involvement, and rarely a direct PAN pathway.     

Multivariate analysis of histopathologic prognostic factors for invasive cervical cancer treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy

BACKGROUND: The aim of this study was to identify the independent histopathologic prognostic factors for patients with cervical carcinoma treated with radical hysterectomy including paraaortic lymphadenectomy. METHODS: A total of 187 patients with stage IB to IIB cervical carcinomas treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy were retrospectively analyzed. The median follow-up period was 83 months. Cox regression analysis was used to select independent prognostic factors. RESULTS: Using multivariate Cox regression analysis, lymph node (LN) status (negative vs. metastasis to pelvic nodes except for common iliac nodes vs. common iliac/paraaortic node metastasis), histopathologic parametrial invasion, lymph-vascular space invasion (LVSI), and histology of pure adenocarcinoma were found to be independently related to patients' poor survival. For patients who had a tumor histologically confined to the uterus and have neither parametrial invasion nor lymph node metastasis, LVSI was the most important prognostic factor, and histologic type, depth of cervical stromal invasion, and tumor size were not related to survival. The survival of patients with a tumor extending to parametrium or pelvic lymph node(s) was adversely affected by histology of pure adenocarcinoma. When the tumor extended to common iliac or paraaortic nodes, patients' survival became quite poor irrespective of LVSI or histologic type of pure adenocarcinoma. Patients' prognosis could be stratified into low risk (patients with a tumor confined to the uterus not associated with LVSI: n = 80), intermediate risk (patients with a tumor confined to the uterus associated with positive LVSI, and patients with squamous/adenosquamous carcinoma associated with pelvic lymph node metastasis or parametrial invasion: n = 86), and high risk (patients with pure adenocarcinoma associated with pelvic lymph node metastasis or parametrial invasion, and patients with common iliac/paraaortic node metastasis: n = 21) with an estimated 5-year survival rate of 100 +/- 0 (mean +/- SE)%, 85.5 +/- 3.9%, and 25.1 +/- 9.7%, respectively. CONCLUSIONS: LN status, parametrial invasion, LVSI, and histology of pure adenocarcinoma are important histopathologic prognostic factors of cervical carcinoma treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy. Prognosis for patients with cervical carcinoma may be stratified by combined analysis of these histopathologic prognostic factors. Postoperative therapy needs to be individualized according to these prognostic factors and validated for its efficacy using randomized clinical trials.     

Lymph node metastasis of ovarian cancer: a preliminary survey of 74 cases of lymphadenectomy

Retroperitoneal lymph node dissection was performed in 74 cases of various types of ovarian malignancies. Fifty-three (71.6%) were histologically confirmed as cancer of epithelial origin and 19 (25.7%) as germ cell tumors. The results indicate that lymphatic metastasis is an exceedingly important route of spreading of this group of malignant diseases. The overall incidence of retroperitoneal positive nodes was 56.8% (42/74). In 49 cases undergoing systemic lymphadenectomy 32 were found to have glandular involvement, of which both aortic and pelvic nodes were positive in 17 cases (53.1%), aortic nodes positive but pelvic negative in six (18.8%), and pelvic nodes positive but aortic negative in nine (28.1%). In 32 cases with primary cancer that originated from the left ovary, 17 (53.1%) were found to have positive pelvic nodes, whereas in 19 cases with cancer arising from the right ovary, only one (5.3%) had metastasis of ipsilateral pelvic nodes. The routes of lymphatic spreading and the significance of lymphadenectomy in ovarian cancer are discussed.     

Intraoperative sentinel node identification in early stage cervical cancer using a combination of radiolabeled albumin injection and isosulfan blue dye injection

OBJECTIVES: We investigated the feasibility of sentinel lymph node identification using radioisotopic lymphatic mapping with technetium-99m-labeled human serum albumin and isosulfan blue dye injection in patients undergoing radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer. METHODS: Between September 2000 and October 2002, 25 patients with cervical cancer FIGO stage I (n=24) or stage II (n=1) underwent sentinel lymph node detection with preoperative lymphoscintigraphy (technetium-99m colloid albumin injection around the tumor) and intraoperative lymphatic mapping with blue dye and a handheld or laparoscopic gamma probe. Complete pelvic or paraaortic lymphadenectomy was performed in all cases by open surgery or laparoscopic surgery. RESULTS: In 23 evaluable patients, a total of 51 sentinel lymph nodes were detected by lymphoscintigraphy (mean 2.21 nodes per patient). Intraoperatively, 61 sentinel lymph nodes were identified, with a mean of 2.52 nodes per patient by gamma probe and a mean of 1.94 nodes per patient after isosulfan blue injection. Forty percent of sentinel nodes were found in the interiliac region and 25% in the external iliac area. Microscopic nodal metastases (four nodes) were confirmed in 12% of cases. All these lymph nodes were previously detected as sentinel lymph nodes. The remaining 419 nodes after pelvic lymphadenectomy were histologically negative. CONCLUSIONS: Sentinel lymph node identification with technetium-99m-labeled nanocolloid combined with blue dye injection is feasible and showed a 100% negative predictive value, and potentially identified women in whom lymph node dissection can be avoided.     

Pattern of lymph node metastasis and the optimal extent of pelvic lymphadenectomy in FIGO stage IB cervical cancer

AIM: To evaluate the distribution pattern of lymph node metastasis and to determine the optimal extent of pelvic lymphadenectomy (LA) in FIGO stage IB cervical cancer. METHODS: The medical records of 187 patients with FIGO stage IB cervical cancer from March 1996 to December 2002 were reviewed retrospectively. The distribution pattern and risk factors of lymph node metastases were analyzed in 31 patients with lymph node metastases confirmed surgically. One hundred patients, who underwent type III hysterectomy with pelvic LA but did not receive any adjuvant treatment, were analyzed to evaluate whether the extent of LA affected the prognosis of FIGO stage IB cervical cancer. Type I LA included the external iliac nodes, hypogastric nodes, obturator nodes, and parametrial nodes. Type II LA included the pelvic nodes described in type I LA, the common iliac nodes, gluteal nodes, deep inguinal nodes and sometimes the presacral nodes. RESULTS: Solitary lymph node metastasis confined to one node group was seen in the obturator, external iliac or hypogastric lymph nodes. All patients with lymph node metastases at multiple sites had metastasis in at least one of these lymph-node groups. There was no significant difference in disease-free survival and overall survival in patients without pathologic high-risk factors according to the type of pelvic LA. CONCLUSION: The extent of LA should be adjusted to reduce complications and not to affect adversely the prognosis of FIGO stage IB cervical cancer patients without pathologic high-risk factors.     

Left–right asymmetry in pelvic lymph nodes distribution: Is there a right-side prevalence?

OBJECTIVE: To assess whether pelvic lymph nodes have a left-right asymmetric distribution. STUDY DESIGN: The oncologic databases of two gynecologic academic departments were used to identify consecutive patients undergoing pelvic systematic lymphadenectomy as part of the treatment for a variety of gynecologic malignancies. All procedures were carried out in a standardized fashion. Lymph node counts were retrieved from pathological reports. RESULTS: Four hundred and twenty-eight women underwent pelvic lymphadenectomy during the study period. The median lymph node count was higher on the right side than on the left side [10 (0-33) versus 8 (0-29); P<0.0001]. A prevalence of right-sided nodes was found in 265 (61.9%) patients, while in 44 (10.3%) cases pelvic nodes were equally distributed on the two sides. The right-sided prevalence was significantly higher than the expected 50% in each type of malignancy and surgical technique subgroup. The right-sided prevalence was statistically significant even when the analysis was performed for different nodal groups [external iliac nodes: 5 (0-23) versus 4 (0-13), P=0.005; hypogastric and obturator nodes: 6 (0-17) versus 5 (0-19), P=0.04]. Moreover, nodal count was higher on the right than on the left in obese [10 (1-33) versus 8 (1-26), P=0.0002] and nonobese women [10 (0-32) versus 9 (0-29), P<0.0001]. CONCLUSION: Our findings suggest the existence of a left-right asymmetry in pelvic lymph nodes distribution, with right-sided prevalence.     

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.     

Pelvic Lymphadenectomy in Vulvar Cancer – Does it make sense?

Since the publication of the updated German guideline in 2015, the recommendations for performing pelvic lymphadenectomy (LAE) in patients with vulvar cancer (VSCC) have changed considerably. The guideline recommends surgical lymph node staging in all patients with a higher risk of pelvic lymph node involvement. However, the current data do not allow the population at risk to be clearly defined, therefore, the indication for pelvic lymphadenectomy is still not clear. There are currently two published German patient populations who had pelvic LAE which can be used to investigate both the prognostic effect of histologically verified pelvic lymph node metastasis and the relation between inguinal and pelvic lymph node involvement. A total of 1618 patients with primary FIGO stage ≥ IB VSCC were included in the multicenter AGO CaRE-1 study (1998 – 2008), 70 of whom underwent pelvic LAE. During a retrospective single-center evaluation carried out at the University Medical Center Hamburg-Eppendorf (UKE), a total of 514 patients with primary VSCC treated between 1996 – 2018 were evaluated, 21 of whom underwent pelvic LAE. In both cohorts, around 80% of the patients who underwent pelvic LAE were inguinally node-positive, with a median number of three affected groin lymph nodes. There were no cases of pelvic lymph node metastasis without inguinal lymph node metastasis in either of the two cohorts. Between 33 – 35% of the inguinal node-positive patients also had pelvic lymph node metastasis; the median number of affected groin lymph nodes in these patients was high (> 4), and the maximum median diameter of the largest inguinal metastasis was > 40 mm in both cohorts. Pelvic lymph node staging and pelvic radiotherapy is therefore probably not necessary for the majority of node-positive patients with VSCC, as the relevant risk of pelvic lymph node involvement was primarily found in node-positive patients with high-grade disease. More, ideally prospective data collections are necessary to validate the relation between inguinal and pelvic lymph node involvement.Key words: vulvar cancer, lymph node metastasis, pelvic lymphadenectomy, recurrence, prognosis     

Number of Removed Pelvic Lymph Nodes as a Prognostic Marker in FIGO Stage IB1 Cervical Cancer with Negative Lymph Nodes

Study ObjectiveTo investigate whether the number of removed lymph nodes (RLNs) influences the clinical outcome of stage IB1 cervical cancer on the premise of uniform pelvic lymphadenectomy.DesignRetrospective cohort study.SettingObstetrics and Gynecology Hospital of Fudan University.PatientsWomen (n = 782) with stage IB1 cervical cancer.InterventionsLaparoscopic radical hysterectomy and uniform pelvic lymphadenectomy (common iliac, external iliac, internal iliac, obturator) for stage IB1 cervical cancer. The median time of follow-up was 64.7 months (range, 4.3–102.8).Measurements and Main ResultsOf 782 patients with stage IB1 cervical cancer, the median number of pelvic RLNs was 19 (range, 7–49). Twenty-one patients (2.7%) had RLNs ≤ 10, 461 (59.0%) had 11 to 20, 263 (33.6%) had 21 to 30, and 37 (4.7%) had RLNs ≥ 31. The differences were not statistically significant in the clinicopathologic characteristics between the 4 groups (p >.05). In the multivariate analysis, pelvic RLN number became an independent prognostic factor for progression-free survival (PFS) and cancer-specific survival (CSS) in stage IB1 cervical cancer (p = .029; .015 for CSS and PFS). After the stratified analysis by lymph node metastasis, RLN number remained an independent predictive value (p = .026 for CSS, p = .012 for PFS) in patients with negative pelvic lymph nodes. Moreover, patients with RLN number ≤ 10 carried a 5.550-fold higher risk for progression (p <.001) and 5.596-fold greater likelihood of death (p = .001) than those with RLN number > 10 in case of no lymph node metastasis.ConclusionWith uniform pelvic lymphadenectomy, the total pelvic RLN number could be a valuable predictor of outcome in stage IB1 cervical cancer without lymph node metastasis during a follow-up of at least 5 years.     

Clinical implication of laparoscopic pelvic lymphadenectomy in patients with vulvar cancer and positive groin nodes

OBJECTIVE: At present, no clear guidelines for the treatment of patients with vulvar cancer and positive groin nodes exist. In general, the decision for additional pelvic radiation is based on findings by imaging techniques and/or the number of groin nodes involved. The aim of this case series was to demonstrate that histologic result of laparoscopic removed pelvic lymph nodes can be used to select patients who should not undergo pelvic irradiation. METHODS: From July 1997 to October 2004, 12 consecutive patients with primary or recurrent vulvar cancer underwent laparoscopic pelvic lymphadenectomy following primary or secondary surgical treatment. RESULTS: There were 8 patients with primary cancer of the vulva and 4 patients with recurrent disease in the inguinal and/or pelvic lymph nodes. The mean age was 61 (26-83) years and the mean body-mass-index was 27.1 (20.8-36.6). Positive groin nodes were found in five patients on the right side and in five patients on the left side; in one patient, positive groin nodes were present in both sides. In another patient with a history of vulvar cancer and positive groin nodes the CT-scan indicated the presence of positive iliac and paraaortic lymph nodes. Only in two patients tumor involved lymph nodes were diagnosed by laparoscopic pelvic lymphadenectomy (one left-sided, one right-sided). The number of harvested pelvic lymph nodes was 13.7 (5-20) in unilateral and 27.8 (16-37) in bilateral lymphadenectomy. The histologic examination of removed pelvic lymph nodes confirmed pelvic radiation in only 2 out of 12 patients, whereas 10 patients were spared from whole pelvis irradiation. CONCLUSION: With respect to small sample size, laparoscopic lymphadenectomy seems to be a good tool to avoid unnecessary pelvic radiation in patients with vulvar cancer and confirmed positive groin nodes.     

Benign müllerian inclusions in pelvic and paraaortic lymph nodes

OBJECTIVE: This study was undertaken to determine the incidence and distribution of the location of benign müllerian inclusions in pelvic and paraaortic lymph nodes. METHODS: A total of 114 patients operated on for gynecologic malignancy between 1995 and 1998 underwent surgery including systematic pelvic (n = 114) or pelvic and paraaortic (n = 70) lymphadenectomy. The lymph node material was labeled according to anatomic origin, immediately fixed en bloc, embedded in paraffin, and processed as step-serial sections at intervals of 400 microm. The 5-microm-thick sections were stained with hematoxylin and eosin. RESULTS: Overall, 26 of 114 patients (23%) had benign müllerian inclusions. Inclusions were most common in the paraarotic (34%), external iliac (12%), and common iliac (9%) regions (P > 0.05). Multiple anatomic sites were involved in 14 of 26 patients (54%). Two women had paraaortic inclusions and negative pelvic nodes. Benign müllerian inclusions were seen in 13 of 51 patients (24%) with ovarian carcinoma, 11 of 47 (23%) with cervical carcinoma, 1 of 9 (11%) with endometrial carcinoma, and 1 of 2 with ovarian serous borderline tumor, (P > 0.05). CONCLUSIONS: Benign müllerian inclusions occur in approximately one-fifth of patients with gynecologic malignancies in all anatomic regions of pelvic and paraaortic lymph nodes. They must be distinguished from metastatic deposits.