Where to look for the sentinel lymph node in cervical cancer.

OBJECTIVE: The aim of this study was to analyze lymphatic spread to pelvic, parametrial, and paraaortic lymph nodes in patients with cervical cancer. STUDY DESIGN: We reviewed 619 patients with invasive cervical cancer treated by radical abdominal hysterectomy and systematic pelvic or pelvic and paraaortic lymphadenectomy between 1971 and 2005. The present study included 61 patients with one positive lymph node (10%) and 59 patients with two positive lymph nodes (10%) at any location. RESULTS: The external iliac (43%) and obturator (26%) regions and the parametrium (21%) were the most commonly involved pelvic lymph node sites with solitary metastases. Isolated metastases to common iliac, presacral (internal iliac), and paraaortic nodes were found in 7%, 1%, and 1% of patients, respectively. Patients with 2 positive nodes had 1 parametrial and 1 pelvic node involved (32%), 2 ipsilateral positive nodes (31%), 1 positive lymph node on both sides of the pelvis (27%), and 2 positive nodes within the parametrium (10%). CONCLUSIONS: In cervical cancer patients with only 1 positive lymph node, this node is most frequently located within the external iliac and obturator regions and the parametrium. Sentinel node identification should primarily address these lymph node sites. If 1 positive lymph node is found, further metastases are unpredictable within pelvic and parametrial lymph node sites. Paraaortic spread without pelvic node involvement is rare.

Is intraoperative frozen section analysis of pelvic lymph nodes accurate after neoadjuvant chemotherapy in patients with cervical cancer?

OBJECTIVE: Intraoperative frozen section examination of pelvic lymph nodes is frequently used in patients with cervical cancer, some of whom have received neoadjuvant chemotherapy (NACT). However, NACT can cause necrosis, fibrosis, or keratinization of tumor deposits in extirpated lymph nodes, and it is unclear whether intraoperative frozen section analysis of extirpated nodes is accurate after NACT. We analyzed the accuracy of frozen section examination of pelvic lymph nodes in patients after NACT for cervical cancer. METHODS: We reviewed 134 patients with invasive cervical cancer who underwent surgery including systematic pelvic lymphadenectomy with intraoperative frozen section examination of pelvic lymph nodes. Results of frozen section examination were related to definitive histology and compared between patient groups of NACT and primary surgery. RESULTS: A total of 1670 pelvic lymph nodes were evaluated intraoperatively by frozen section examination, and 6689 pelvic lymph nodes were analyzed by final histopathology. Overall frozen section analysis had nine false negative results among 53 patients with positive lymph nodes (false negative rate, 16.9%). After NACT, there were two false negative diagnoses in twelve patients with node metastases (false negative rate, 16.7%). No false positive cases were noted. The sensitivity and negative predictive value of frozen section examination were 83% and 82%, respectively, in patients after NACT, and 83% and 91% at primary surgery. CONCLUSION: NACT does not appear to compromise the diagnostic accuracy of intraoperative frozen section examination of pelvic lymph nodes in patients with cervical cancer.

Isolated recurrence at the residual uterine cervix after abdominal radical trachelectomy for early cervical cancer.

BACKGROUND: We report an isolated recurrence at the residual cervix shortly after abdominal radical trachelectomy for cervical cancer. CASE: A 34-year-old woman underwent radical abdominal trachelectomy and pelvic lymphadenectomy for FIGO stage IB1 squamous cell cervical cancer. The tumor measured 10 mm in maximum diameter with 4 mm of invasion. Histology showed lymph vascular space involvement with no infiltration of adjacent structures and no pelvic lymph node metastases. Tumor-free resection margins exceeded 15 mm. At the 6-month follow-up examination, cervical cytology showed cells suspicious for recurrent cervical cancer. Abdominal hysterectomy was performed and histology showed an isolated 3-mm recurrence in the residual cervix. The patient is free of disease 8 months after hysterectomy. CONCLUSION: Recurrence at the residual cervix is a potential risk of abdominal trachelectomy for early cervical cancer. Patients should be counseled accordingly and followed closely.

Ectopic (pelvic) kidney mimicking bulky lymph nodes at pelvic lymphadenectomy.

BACKGROUND: Ectopic (pelvic) kidney is the most common congenital renal anomaly with an incidence of 1 in 500 to 1 in 2000. A pelvic kidney can be encountered at pelvic or paraaortic lymphadenectomy. CASE REPORTS: In two patients undergoing pelvic lymphadenectomy, lobulated tumors near the pelvic brim were initially interpreted as bulky lymph node conglomerates. Further dissection showed the ureter to originate from the masses, leading to a diagnosis of pelvic kidney. CONCLUSION: Pelvic kidneys mistaken for bulky lymph nodes are a potential intraoperative pitfall in patients with gynecologic malignancies. Keys to recognition include an index of suspicion, identifying the course of the ureter and origin of the renal vessels, and confirming absence of a kidney at the normal location.

Placement of a retropubic drain with the tension-free vaginal tape operation.

Intraoperative bleeding and postoperative hematomas are recognized complications of the tension-free vaginal tape (TVT) operation. We devised a connector to attach a drain to the end of the TVT needle. The drain is pulled upward with the tape itself and is left in the space of Retzius in the tract created by the needle. The drain connector provides a simple method to place a drain in the space of Retzius during the TVT operation.

Mode of delivery and outcome of 699 term singleton breech deliveries at a single center.

OBJECTIVE: Elective cesarean delivery has been postulated to improve the outcome of term fetuses in breech presentation. We retrospectively compared the short- and long-term outcomes of term infants who were delivered from a breech presentation at a single center. STUDY DESIGN: We reviewed 699 consecutive term breech presentations according to the intended mode of delivery at a single center between January 1993 and December 1999. The short-term outcome measures were perinatal death, neonatal death, or serious neonatal morbidity; the long-term outcome measures were developmental delay and spasticity. RESULTS: The rate of serious perinatal morbidity in the trial-of-labor and cesarean delivery groups was 2.3% and 0.5%, respectively (P =.12). There was no perinatal or neonatal death in either group. With a median follow-up period of 57 months (range, 13-100 months), the rate of developmental delay was 1.9% and 0.5%, respectively (P =.29). Spasticity was not noted in any of the children. CONCLUSION: Our data suggest that planned vaginal delivery remains an option for selected term breech presentations.

Groin recurrence after micrometastasis in a sentinel lymph node in a patient with vulvar cancer.

BACKGROUND: The sentinel lymph node concept is attractive in vulvar cancer because of the potential to avoid the morbidity associated with formal groin dissection. CASE: An 84-year-old patient with a T2 carcinoma of the anterior vulva underwent surgery including bilateral sentinel node excision after identification with technetium-labeled nanocolloid. Frozen section histology showed a tumor deposit <1 mm in diameter in a left groin node whereas four nodes in the right groin were apparently negative. Completion lymphadenectomy was performed only for the left groin. Final histology including serial sectioning showed a micrometastasis in one of seven nodes from the right groin; no further treatment was given. Sixteen months postoperatively the patient developed a recurrence in the right groin; the left groin was free of tumor. CONCLUSION: This case indicates that groins with a micrometastasis detected by sentinel lymph node excision require further treatment.