Frequency and prediction of deep uterine involvement in advanced high-grade epithelial ovarian cancer: is uterine preservation an option?

INTRODUCTION: Hysterectomy is traditionally part of the surgical treatment for advanced high-grade epithelial ovarian carcinomas, although the incidence of uterine involvement has not been fully investigated. Some young patients with advanced high-grade epithelial ovarian carcinomas want uterine preservation. We aimed to determine the frequency of non-serosal (deep) uterine involvement in patients with high-grade epithelial ovarian carcinomas and to establish predictive factors for such involvement. METHODS: A retrospective cohort study was performed of 366 consecutive patients with advanced high-grade epithelial ovarian carcinomas who had surgery between January 2012 and December 2019. Data collected included demographic and clinical details, and surgical and pathological reports to determine macroscopic and microscopic deep uterine involvement. The characteristics of the patients with and without deep uterine involvement were compared and univariate and multivariate Cox proportional hazard models were used to assess correlations and determine risk factors. RESULTS: A total of 311 patients were included in the final analysis. The mean age was 62±11.6 years, with 32 (10.3%) being younger than 45. Most (92.3%) had serous carcinoma. Uterine involvement, excluding superficial (serosa-only), was present microscopically in 194 patients (62.4%) but was detected macroscopically at surgery in only 166 patients. Deep involvement was missed at surgery in 28 patients (14.4%), including parametrial involvement (n=18), parametria plus cervix (n=2), cervical involvement (n=3), endometrium (n=3), and myometrium (n=2). Multivariate analysis identified factors associated with deep uterine involvement including residual disease at surgery (HR 2.43, 95% CI 1.13 to 4.48; p=0.004) and CA125 >1000 U (HR 1.8, 95% CI 1.09 to 2.94; p=0.02). CONCLUSIONS: The incidence of deep uterine involvement in high-grade epithelial ovarian carcinomas is high. It can be diagnosed in most but not all cases on gross examination at surgery and is associated with residual disease and CA125 >1000 U. Patients who desire uterine preservation should be advised on an individual basis, given these factors and the operative findings.

Clinical significance of preoperative serum concentrations of interleukin-6 as a prognostic marker in patients with esophageal cancer.

BACKGROUND: Although the clinical outcome of esophageal cancer has recently improved, the relapse rate remains high for all disease stages. At present, there is no diagnostic method to predict the long-term outcome for esophageal cancer. In this study, we evaluated serum preoperative proinflammatory cytokine levels and investigated the correlation between preoperative interleukin-6 (IL-6) and IL-8 levels and survival of patients with esophageal cancer. METHODS: Between 2008 and 2015, we evaluated preoperative serum cytokine levels in 122 patients who underwent esophagectomy for esophageal cancer. Serum IL-6 and IL-8 levels were measured by enzyme-linked immunosorbent assays. We investigated the relationship between serum cytokine levels and the response to chemotherapy and survival. RESULTS: The preoperative IL-6 levels were significantly associated with shorter recurrence-free survival (RFS, p = 0.001) and overall survival (OS, p = 0.001) after esophagectomy. Higher IL-8 levels were significantly associated with RFS (p = 0.018). In the multivariate analysis, age, preoperative chemotherapy, lymph node metastasis, serum C-reactive protein (CRP) levels and serum IL-6 levels (hazard ratio (HR), 2.888; p = 0.049) were significantly independent prognostic factors of RFS. Additionally, age, pathological stage, and serum IL-6 levels (HR, 3.247; p = 0.027) were shown to be significantly independent prognostic factors of OS. Serum IL-6 levels were significantly higher in the non-responder group (pathological response pGrade0 and pGrade1) after neoadjuvant therapy. CONCLUSIONS: High preoperative serum IL-6 levels are associated with a poor response to chemotherapy or chemoradiotherapy and poor prognosis after esophagectomy. Preoperative serum IL-6 levels may be a useful independent prognostic marker for esophageal cancer patients.

Sentinel Lymph Node Biopsy in the Treatment of Endometrial Cancer: Why We Fail? Results of a Prospective Multicenter Study on the Factors Associated with Failure of Node Mapping with Indocyanine Green.

BACKGROUND: The sentinel lymph node (SLN) mapping for endometrial cancer staging is gaining wide diffusion, but there is no definitive evidence on the factors associated with the failure of mapping. OBJECTIVES: To analyze the factors associated with the possible failure of bilateral SLN mapping with indocyanine green (ICG). METHODS: A prospective observational study without control on 110 patients with endometrial cancer apparently confined to the uterus, underwent laparoscopic surgical staging with SLN mapping with ICG. RESULTS: Possible risk factors associated with bilateral mapping failure were analyzed, and a multivariate analysis was performed. The bilateral detection rate for SLNs mapping was 72.7%, whereas at least one SLN was detected in 79.1% of patients. No SLNs were identified in 6.3%. None of the patients or features related to tumor were associated with a risk of failure of the method. The only factor analyzed that was significantly associated with the success of bilateral mapping was the surgeon (p = 0.003). CONCLUSIONS: Neither obesity nor the presence of lymph node metastases was associated with mapping failure. However, there remains a need for further studies to understand all the mechanisms linked to the unsuccessful method results and to reduce the use of systematic lymphadenectomy in the case of mapping failure.

Adverse events during CT colonography for screening, diagnosis and preoperative staging of colorectal cancer: a Japanese national survey.

OBJECTIVES: To retrospectively evaluate the frequencies and magnitudes of adverse events associated with computed tomographic colonography (CTC) for screening, diagnosis and preoperative staging of colorectal cancer. METHODS: A Japanese national survey on CTC was administered by use of an online survey tool in the form of a questionnaire. The questions covered mortality, colorectal perforation, vasovagal reaction, total number of examinations, and examination procedures. The survey data was collated and raw frequencies were determined. Fisher's exact test was used to determine differences in event rates between groups. RESULTS: At 431 institutions, 147,439 CTC examinations were performed. No deaths were reported. Colorectal perforations occurred in 0.014% (21/147,439): 0.003% (1/29,823) in screening, 0.014% (13/91,007) in diagnosis and 0.028% (7/25,330) in preoperative staging. The perforation risk was significantly lower in screening than in preoperative staging CTC procedures (p = 0.028). Eighty-one per cent of perforation cases (17/21) did not require emergency surgery. Vasovagal reaction occurred in 0.081% (120/147,439): 0.111% (33/29,823) in screening, 0.088% (80/91,007) in diagnosis and 0.028% (7/25,330) in preoperative staging. CONCLUSIONS: The risk of colorectal perforation and vasovagal reaction in CTC is low. The frequency of colorectal perforation associated with CTC is least in the screening group and greatest in the preoperative-staging group. KEY POINTS: • The colorectal perforation rate during preoperative-staging CTC was 0.028 %. • The perforation rates for screening and diagnosis were 0.003 % and 0.014 %, respectively. • The perforation risk is significantly lower in screening than in preoperative staging. • Eighty-one per cent of perforation cases did not require emergency surgery. • Use of an automatic colon insufflator can reduce the risk of bowel perforation.

Impact of Surgical Route in Influencing the Risk of Lymphatic Complications After Ovarian Cancer Staging.

Lymphatic complications are a common occurrence after staging surgery for early-stage ovarian cancer (eEOC). We investigated whether the introduction of minimally invasive surgery influences the risk of developing lymphoceles and lymphorrhea in patients undergoing staging for eEOC. For this purpose, data of consecutive patients affected by eEOC undergoing staging surgery between January 1980 and January 2016 were retrospectively reviewed, and a systematic review and meta-analysis was performed. This systematic review was registered in the International Prospective Register of Systematic Review. Among 341 patients included in the present study, 47 severe postoperative complications occurred (13.7%), including 40 lymphatic complications: 31 symptomatic lymphoceles (9%) and 9 cases of lymphorrhea (2.6%), respectively. Laparoscopic staging correlated with a lower risk of developing any severe lymphatic complications in comparison with open surgery (p = .02). In particular, the laparoscopic approach and para-aortic node involvement were associated with a trend toward lower lymphoceles (odds ratio, .13; 95% confidence interval, .07-2.20; p = .05) and a trend toward higher risk of lymphorrhea developing (odds ratio, 4.02; 95% confidence interval, .93-17.3; p = .06), respectively. In conclusion, the implementation of a minimally invasive approach might result in a slight reduction of lymphatic complications after eEOC staging.

The Adoption of Single-port Laparoscopy for Full Staging of Endometrial Cancer: Surgical and Oncology Outcomes and Evaluation of the Learning Curve.

STUDY OBJECTIVE: To study the safety, feasibility, learning curve, and surgical outcome for single-port laparoscopic full staging of endometrial cancer. DESIGN: A retrospective study (Canadian Task Force classification II-3). SETTING: A university academic hospital. PATIENTS: Women with endometrial cancer undergoing single-port laparoscopic full surgical staging. INTERVENTIONS: This was a single-center, retrospective consecutive study of patients undergoing single-port laparoscopic full staging of endometrial cancer from March 2012 to December 2015. MEASUREMENTS AND MAIN RESULTS: One hundred ten consecutive cases were included in the study. The mean age was 63 years (standard deviation = 14), and the mean body mass index was 34 kg/m2 (standard deviation = 7). Medical comorbidity was noted in 62% (68/110) of patients, and 55% (61/110) of patients had previous abdominal surgery. Preoperative histology included grade 1 (63%), grade 2 (23%), grade 3 (4%), papillary serous (6%), clear cell (3%), and mixed (1%). Postoperatively, 73% of patients were stage I, 2% were stage II, 21% were stage III, and 4% were stage IV. The conversion rate to multiple ports or to laparotomy was 6.3%. The average total surgical time was 186 minutes. Comparing the last 30 cases of our cohort with the first 20, there was a significant improvement in the reduction of the total operative time (191 vs 152 minutes, p = .036), estimated blood loss (389 vs 121 mL, p = .002), conversion rate (20 % vs 0%, p = .02), and rate of surgical complication (10% vs. 0%, p = .03). The readmission rate was 11% (12/110) with 75% of those patients being readmitted for surgical indications and 25% for medical indications. The rate of ventral hernia was 1.8% (2/110) with an average follow-up of 298 days (31-1085 days). CONCLUSION: Single-port laparoscopic staging of endometrial cancer is a safe and feasible technique to introduce into a gynecologic oncology practice that is compatible with other minimally invasive modalities with similar complication rates, discharge timing, and operative times. Drastic improvement in surgical time can be seen after approximately the first 20 cases.

[Preoperative prognostic factors and preoperative risk stratification of upper tract urothelial carcinoma].

OBJECTIVE: To identify the preoperative prognostic factors of upper tract urothelial carcinoma (UTUC) and construct preoperative risk stratification system. METHODS: A retrospective study including 686 patients who were diagnosed with UTUC and received radical nephroureterectomy or partial ureterectomy in Peking University First Hospital during 2003 and 2013. RESULTS: Of the 686 UTUC patients, 303 (44.2%) were male and 383 (55.8%) female. The postoperative pathological examination showed that 203 (29.6%) had high tumor stages (T3, T4), 300 (43.7%) had high tumor grades (G3) and 54 (7.9%) had lymph nodes metastasis (N1). After multivariate analysis, renal pelvic tumor, large tumor, estimated glomerular filtration rate (eGFR)≥30 mL/min, and male were associated with high tumor stage. Ureteral tumor, large tumor, and non-smoking history were associated with high tumor grade. Renal pelvis tumor, large tumor, and preoperative anemia were associated with positive N status. During the follow-up, 208 (30.3%) died for cancer and 210 (30.6%) developed intravesical recurrence. Multivariate analysis showed: large tumor (P=0.001), concomitant ipsilateral hydronephrosis (P=0.041), and preoperative anemia (P=0.001) were independently associated cancer-specific mortality after surgery, while ureteral tumor (P=0.04), multiple tumor (P=0.005), and high preoperative creatinine (P=0.036) were independent risk factors for intravesical recurrence. CONCLUSION: Of the preoperative clinical parameters of UTUC patients, the large tumor, concomitant ipsilateral hydronephrosis, and preoperative anemia were independently associated with cancer-specific mortality after surgery. Ureteral tumor, multiple tumor, and high preoperative creatinine were independently associated with intravesical recurrence after surgery.

Analysis of a continuous series of 34 young patients with early-stage cervical cancer selected for a vaginal radical trachelectomy: should "staging" conization be systematically performed before this procedure?

OBJECTIVE: Vaginal radical trachelectomy (VRT) is the most widely evaluated form of conservative management of young patients with early-stage (IB1) cervical cancer. Patients with nodal involvement or a tumor size greater than 2 cm are not eligible for such treatment. The aim of this study is to report the impact of a "staging" conization before VRT. METHODS: This is a retrospective study of 34 patients potentially selected for VRT for a clinical and radiologic cervical tumor less than 2 cm. Among them, 28 underwent finally a VRT (20 of them having a previous conization before this procedure) and 6 patients with macroscopic cervical cancer, confirmed by punch biopsies, "eligible" for VRT (<2 cm) had undergone "staging" conization (without further VRT) to confirm the tumor size and lymphovascular space involvement (LVSI) status. RESULTS: Six patients having "staging" conization before VRT had finally been deemed contraindications to VRT due to the presence of a histologically confirmed tumor greater than 2 cm and/or associated with multiple foci of LVSI. Among 28 patients who underwent VRT, 1 received adjuvant chemoradiation (this patient recurred and died of disease). Two patients treated with RVT (without postoperative treatment) recurred. Ten pregnancies (9 spontaneous and 1 induced) were observed in 9 patients. Among 4 patients with macroscopic "visible" tumor who do not underwent a "staging" conization before VRT, 2 recurred. Among 11 patients who underwent VRT and having LVSI, 3 recurred. CONCLUSIONS: These results suggest that if a conization is not performed initially, it should then be included among the staging procedures to select patients for VRT.

Minimally invasive staging of endometrial cancer is feasible and safe in elderly women.

STUDY OBJECTIVE: To compare the surgical outcome of elderly and younger patients undergoing laparoscopic or robotic surgical staging of endometrial cancer. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: One hundred twenty-nine patients comprised the study group. Sixty patients were aged 65 years or older (elderly group), and 69 patients were younger than 65 years (younger group). INTERVENTION: Abdominal, laparoscopic, or robotic hysterectomy. MEASUREMENTS AND MAIN RESULTS: Among the 109 patients who underwent laparoscopic or robotic staging, there were no differences in estimated blood loss, lymph node count, surgical time, complications, rate of blood transfusion, conversion to laparotomy, and mean postoperative stay between elderly and younger patients. CONCLUSION: Minimally invasive surgical staging for endometrial cancer is both feasible and safe in the elderly population and offers similar outcomes as in younger patients.

Is endorectal coil necessary for the staging of clinically localized prostate cancer? Comparison of non-endorectal versus endorectal MR imaging.

PURPOSE: The goal of this study was to compare the diagnostic use and safety of endorectal coil (ERC) MRI with those of phased-array coil MRI. METHODS: We retrospectively included 91 consecutive patients who had undergone 1.5-T MRI with ERC or with phased-array coil MRI before radical prostatectomy at our institution. We compared 47 patients' phased-array coil MRI and 44 patients' ERC-MRI with histologic findings. We also evaluated adverse events following the MRI procedure. RESULTS: The serum PSA levels ranged from 2.85 to 33.51 ng/mL (10.72 ± 1.9), and the median Gleason score was 7 (range 4-9). The mean interval between diagnostic prostate biopsy and staging MRI was 18.4 days (range 2-37). In assessing organ-confined disease, extracapsular extension and seminal vesicle invasion by MRI, there were no significant differences between ERC-MR group and phased-array coil MR group. The AUC values were 0.671 (95% CI 0.530-0.813) for ERC-MR and 0.657 (95% CI 0.503-0.811) for phased-array coil MR. No significant differences were found between the two groups (p = 0.24). Five patients (11.4%) developed rectal complications after ERC-MRI. However, no complications were found in phased-array coil MRI group. CONCLUSIONS: In terms of diagnostic accuracy and comfort of patients, the use of ERC-MRI did not significantly improve the staging of prostate cancer and presented several complications. Therefore, phased-array coil MRI is a better alternative considering comorbidity.

PET/MRI Versus PET/CT for Whole-Body Staging: Results from a Single-Center Observational Study on 1,003 Sequential Examinations.

Our purpose was to investigate differences between PET/MRI and PET/CT in lesion detection and classification in oncologic whole-body examinations and to investigate radiation exposure differences between the 2 modalities. Methods: In this observational single-center study, 1,003 oncologic examinations (918 patients; mean age, 57.8 ± 14.4 y) were included. Patients underwent PET/CT and subsequent PET/MRI (149.8 ± 49.7 min after tracer administration). Examinations were reviewed by radiologists and nuclear medicine physicians in consensus. Additional findings, characterization of indeterminate findings on PET/CT, and missed findings on PET/MRI, including their clinical relevance and effective dose of both modalities, were investigated. The McNemar test was used to compare lesion detection between the 2 hybrid imaging modalities (P < 0.001, indicating statistical significance). Results: Additional information on PET/MRI was reported for 26.3% (264/1,003) of examinations, compared with PET/CT (P < 0.001). Of these, additional malignant findings were detected in 5.3% (53/1,003), leading to a change in TNM staging in 2.9% (29/1,003) due to PET/MRI. Definite lesion classification of indeterminate PET/CT findings was possible in 11.1% (111/1,003) with PET/MRI. In 2.9% (29/1,003), lesions detected on PET/CT were not visible on PET/MRI. Malignant lesions were missed in 1.2% (12/1,003) on PET/MRI, leading to a change in TNM staging in 0.5% (5/1,003). The estimated mean effective dose for whole-body PET/CT amounted to 17.6 ± 8.7 mSv, in comparison to 3.6 ± 1.4 mSv for PET/MRI, resulting in a potential dose reduction of 79.6% (P < 0.001). Conclusion: PET/MRI facilitates staging comparable to that of PET/CT and improves lesion detectability in selected cancers, potentially helping to promote fast, efficient local and whole-body staging in 1 step, when additional MRI is recommended. Furthermore, younger patients may benefit from the reduced radiation exposure of PET/MRI.

Multiple adverse histological features increase the odds of under staging T1 bladder cancer.

PURPOSE: The clinical under staging of T1 bladder cancer potentially delays therapy and undermines survival. In this study we evaluated clinicopathological features to aid in the identification of patients with clinical T1 bladder cancer at risk for under staging. MATERIALS AND METHODS: We identified patients diagnosed with clinical T1 bladder cancer who underwent cystectomy within 4 months. Muscularis propria was present and uninvolved in initial biopsies or patients had a re-staging biopsy with muscle [corrected] present. Under staging was defined as pT2 or greater, N+ or M+ disease at radical cystectomy. A logistic regression multivariable model was used for the risk of under staging. Overall survival was assessed using the Kaplan-Meier method. RESULTS: Of 95 patients 26 (27%) had under staged disease. Median followup was 24 months. Compared to accurately staged cases under staged cases were more likely to have muscularis mucosae invasion (54% vs 19%, p = 0.001), mixed histology (42% vs 17%, p = 0.02) and urethral involvement (31% vs 10%, p = 0.03). In a multivariable model muscularis mucosae invasion increased the odds of under staging 9-fold (95% CI 1.5-54.5, p = 0.01). The cumulative association of these risk factors increased the odds of under staging 20-fold (95% CI 1.8-217, p = 0.0029). Median overall survival (years) was lower in patients with under staged disease (1.4 vs 10.6, p <0.001), those with muscularis mucosae invasion (2.2 vs 6.5, p = 0.04) and those with urethral involvement (25th percentile 0.8 vs 2.0, p = 0.01). CONCLUSIONS: Under staging adversely impacts survival. Muscularis mucosae invasion, urethral involvement and mixed histology cumulatively increase the risk of under staging, and may be valuable in counseling patients regarding early, aggressive intervention.

The effect of radiologic imaging studies on the risk of secondary malignancy development in patients with Hodgkin lymphoma.

PURPOSE: Recently, reports have been published, which suggest that diagnostic radiologic imaging studies could play a role in the risk of secondary malignancy development in patients with cancer. The aims of our study are to calculate the average amount of accumulated radiation dose gained by means of radiologic imaging studies performed intensively in diagnosis and follow-up of patients with Hodgkin lymphoma and to evaluate whether this amount of accumulation accounts for a real risk for secondary malignancies. PATIENTS AND METHODS: This study consists of 15 male patients, whose mean age was 23.67 years +/- 4.24 years. All radiologic imaging studies performed in patients with Hodgkin lymphoma were noted in detail, and average radiation dose accumulation was calculated. RESULTS: Median radiation doses to which patients were subjected during a median of 14.5 months of disease duration were 85.19 mSv and 161.08 mSv according to data of the National Radiological Protection Board and Biological Effects of Ionizing Radiation VII report, respectively. The cumulative radiation dose, because of radiologic imaging studies, is 8.5-16-times greater than that of the described dose having 1 in 1,000 chance of cancer development according to Biological Effects of Ionizing Radiation VII report. Approximately, this amount is equivalent to the dose of natural background radiation received during 35-70 years. CONCLUSION: Our study demonstrated that radiation dose accumulation because of radiologic imaging studies used in diagnosis, staging, and follow-up of patients with Hodgkin lymphoma was high enough to cause development of secondary malignancies. Finally, it is obvious that the radiologic imaging study policies used in follow-up of these patients should be overviewed.

Prognostic factors and expression of p53 and mdm-2 in uterine sarcomas.

OBJECTIVES: To evaluate the clinicopathologic prognostic factors of uterine sarcoma, and determine whether overexpression of p53 and mdm-2 proteins correlate with overall survival and prognostic factors. METHODS: Thirty specimens from 43 patients with uterine sarcoma were available for slide review and evaluated by immunohistochemistry at Yonsei and Ajou University Medical Centers for the expression of p53 and mdm-2. RESULTS: Overall survival was found to correlate to histologic type of uterine sarcoma, surgical stage, tumor grade, and mitotic index. Whereas 63% of the sarcomas expressed p53, with a significant correlation to overall survival, 60% expressed mdm-2, with a significant correlation to the mitotic index but not to overall survival. CONCLUSION: Histologic type, surgical stage, tumor grade, mitotic index, and p53 expression were prognostic factors of the overall survival of patients with uterine sarcoma.

[Preliminary investigation of intramural lateral spread distance in pull-through conformal resection of low rectal cancer].

OBJECTIVE: To investigate the intramural lateral spread distance in low rectal cancer in order to provide basis for safety lateral resection margin of pull-through conformal resection (PTCR). METHODS: The patients with low rectal cancer who received low anterior resection or abdominal-perineal resection in Changhai Hospital from December 2015 to March 2016 were enrolled and Surgical specimens were collected. After the specimens were fixed in 10% formaldehyde for 24 hours, a piece of tissue that was 1.5 cm in length and 0.5 cm in width from the edge of tumor was cut. The tissue was obtained in the direction of 3, 5, 7 and 9 o'clock clockwise. The distance of intramural lateral spread was measured in the specimens and the risk factors were analyzed. RESULTS: A total of 83 specimens were collected and the overall proportion of intramural lateral spread was 71.1%(59/83). The rate of lateral spread from 3 to 9 o'clock was 34.9%(29/83), 26.5%(22/83), 32.5%(27/83) and 37.3%(31/83) respectively, and the difference was not statistically significant(χ2=2.444 9, P=0.485 3). The median distance of lateral spread in each direction was all 0 mm and the quartile range was 1 mm, 0.5 mm, 0.55 mm and 1 mm respectively. The 5th percentile (P5) of each direction was all 0 mm and the 95th percentile(P95) of each direction was 2.5 mm, 1.6 mm, 2.6 mm, 2.5 mm, respectively and the difference was not statistically significant either(χ2=5.331 0, P=0.148 9). The rate of lateral spread of T1, T2, T3 and T4 was 0/4, 58.3%(14/24), 83.0%(44/53) and 1/2 respectively, and there was significant difference(P=0.005 0). The multivariate analysis indicated that T stage (P=0.002 2, OR=3.741, 95% CI: 1.606-8.716) was the risk factor of intramural lateral spread. CONCLUSIONS: The intramural lateral spread does exist in low rectal cancer and T stage is the risk factor of lateral spread. The lateral resection margin should be 5 mm from the tumor edge at least when PTCR is performed.

Single-port laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy as part of staging operation for early ovarian cancer and high grade endometrial cancer.

OBJECTIVE: The aim of this paper was to demonstrate the techiniqes of single-port laparoscopic transperitoneal infrarenal paraaortic lymphadenectomy as part of surgical staging procedure in case of early ovarian cancer and high grade endometrial cancer. METHODS: After left upper traction of rectosigmoid, a peritoneal incision was made caudad to inferior mesenteric artery. Rectosigmoid was mobilized, and then the avascular space of the lateral rectal portion was found by using upward traction of rectosigmoid mesentery. Inframesenteric nodes were removed without injury to the ureter and the left common iliac nodes were easily removed due to the upward traction of the rectosigmoid. The superior hypogastric plexus was found overlying the aorta and sacral promontory, and presacral nodes were removed at subaortic area. Peritoneal traction suture to right abdomen was needed for right para-aortic lymphadenectomy. After right lower para-aortic node dissection, operator was situated between the patient's legs. After upper traction of the small bowel, left upper para-aortic nodes were removed. To prevent chylous ascites, we used hemolock or Ligasure application (ValleyLab Inc.) to upper part of infrarenal and aortocaval nodes. RESULTS: Single-port laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy was performed without serious perioperative complications. CONCLUSION: Even though the technique of single-port surgery is still a difficult operation, the quality of single-port laparoscopic transperitoneal infrarenal para-aortic node dissection is excellent, especially mean number of para-aortic nodes. In cases of staging procedures for ovary and endometrial cancer, single-port transperitoneal para-aortic lymphadenectomy is acceptable as an oncologic procedure.

Cost-minimization analysis of alternative diagnostic approaches in a modeled patient with non-small cell lung cancer and subcarinal lymphadenopathy.

OBJECTIVE: To evaluate the costs of alternative diagnostic evaluations of enlarged subcarinal lymph nodes (SLNs) in modeled patients with non-small cell lung cancer (NSCLC). METHODS: A cost-minimization model was used to compare 5 diagnostic approaches in the evaluation of enlarged SLNs in modeled patients with NSCLC. Values for the test performance characteristics and prevalence of malignancy in patients with SLN were obtained from the medical literature. The target population was adult patients known or suspected to have NSCLC with SLNs with a short axis length of at least 10 mm on thoracic computed tomography (CT). RESULTS: The lowest-cost diagnostic work-up was by initial evaluation with endoscopic ultrasonography-guided fine-needle aspiration (EUS FNA) biopsy ($11,490 per patient) compared with mediastinoscopy (with biopsy) ($13,658), transbronchial FNA biopsy ($11,963), CT-guided FNA biopsy ($13,027), and positron emission tomography ($12,887). The results were sensitive to rate of SLN metastases and EUS FNA sensitivity. The EUS FNA biopsy remained least costly if the probability of SLN metastases exceeded 24% or EUS FNA sensitivity was higher than 76%. Primary mediastinoscopy was the most economical if not. CONCLUSIONS: Which testing strategy is least costly for SLN evaluation in a modeled patient with NSCLC may be determined by the pretest probability of nodal metastases. Use of EUS FNA biopsy minimizes the cost of diagnostic evaluation in most cases.

The effects of staging laparoscopy on trocar site and peritoneal recurrence of pancreatic cancer.

BACKGROUND: Staging laparoscopy (SL) has been used to assess resectability of patients with pancreatic cancer. It has lead to increased resectability rates and decreased morbidity. However, experimental data suggests that laparoscopy and peritoneal insufflation can promote tumor growth and potential recurrence. Few clinical data exist to allow assessment of whether these theoretical concerns translate into clinical problems. The purpose of this study was to determine if SL increases the incidence of trocar-site and peritoneal recurrence of pancreatic cancer. METHODS: A retrospective review of all patients evaluated for pancreatic cancer from 1996 to 2001, inclusive, was included in this study. Patients were divided into five groups: nonoperative management (NM), SL followed by resection (SL-R), SL without resection (SL-NR), exploratory laparotomy with resection (EL-R), and exploratory laparotomy without resection (EL-NR). Patient records were assessed for postoperative occurrence of carcinomatosis and/or malignant ascites, trocar- or incisional-site recurrence, use of postoperative chemotherapy or radiation therapy, and survival. RESULTS: A total of 235 patients were included. Peritoneal progression of disease: NM 15.9%, SL 24.2%, EL 31.6% ( p = 0.03). Trocar/incisional recurrence: SL 3.0%, EL 3.9% ( p = NS). Use of chemotherapy/radiotherapy: NM 29.4%, SL-R 76.5%, SL-NR 62.5%, EL-R 69.6%, EL-NR 41.5%. Median survival (months): NM 3; SL-R 15, EL-R 10 ( p = NS); SL-NR 6, EL-NR 5 ( p = NS). CONCLUSION: SL does not increase the occurrence of trocar-site disease or peritoneal disease progression of pancreatic cancer. Patients who are found not to be resectable by SL are more likely to receive postoperative treatment. However, this does not appear to affect survival greatly. Nevertheless, avoidance of nontherapeutic laparotomy is worthwhile in these patients.

Acute cholecystitis resulting from hemobilia after tru-cut biopsy: a case report and brief review of the literature.

Acute cholecystitis following hemobilia is very rare, with only five cases reported in the literature. A case report of a 22-year-old woman who underwent a liver biopsy for staging of Hodgkin's lymphoma and developed cholecystitis due to hemobilia is presented. The incidence of hemobilia has increased with the advent of more invasive hepatobiliary procedures, but the mortality has been decreasing due to better recognition and therapy. Acute cholecystitis associated with hemobilia is very rare, but will be seen with increasing frequency; and a high index of suspicion needs to be maintained to ensure timely diagnosis and treatment.