Survival benefits of para-aortic lymphadenectomy in colorectal cancer with clinically suspected para-aortic lymph node metastasis: a meta-analysis and systematic review.

BACKGROUND AND OBJECTIVES: In patients with colorectal cancer and clinically suspected para-aortic lymph node metastasis, the survival benefit of para-aortic lymphadenectomy is unknown. We conducted a meta-analysis and systematic review to investigate it. METHODS: PubMed, Web of Science, and EMBASE were searched until January 2000 to April 2022 to identify studies reporting overall survivals, complication rates, and hazard ratios of prognostic factors in patients with colorectal cancer undergoing para-aortic lymphadenectomy, and those data were pooled. RESULTS: Twenty retrospective studies (1021 patients undergoing para-aortic lymphadenectomy) met the inclusion criteria. Meta-analysis indicates that participants undergoing para-aortic lymphadenectomy were associated with 5-year survival benefit, compared to those not receiving para-aortic lymphadenectomy (odds ratio = 3.73, 95% confidence interval: 2.05-6.78), but there was no significant difference in complication rate (odds ratio = 0.97, 95% confidence interval: 0.46-2.08). Further analysis of para-aortic lymphadenectomy group showed that 5-year survival of the positive group with pathologically para-aortic lymph node metastasis was lower than that of the negative group (odds ratio = 0.19, 95% confidence interval: 0.11-0.31). Moreover, complete resection (odds ratio = 5.26, 95% confidence interval: 2.02-13.69), para-aortic lymph node metastasis (≤4) (hazard ratio = 1.88, 95% confidence interval: 0.97-3.62), and medium-high differentiation (hazard ratio = 2.98, 95% confidence interval: 1.48-5.99) were protective factors for survival. Preoperative extra-retroperitoneal metastasis was associated with poorer relapse-free survival (hazard ratio = 1.85, 95% confidence interval: 1.10-3.10). CONCLUSION: Para-aortic lymphadenectomy had promising clinical efficacy in prolonging survival rather than complication rate in patients with colorectal cancer and clinically diagnostic para-aortic lymph node metastasis. Further prospective studies should be performed. TRIAL REGISTRATION: PROSPERO: CRD42022379276.

Does para-aortic lymphadenectomy improve survival in pathologically diagnosed early-stage grade 3 endometrioid and non-endometrioid endometrial cancers? A retrospective cohort study in Korea and Taiwan.

PURPOSE: The therapeutic effect of para-aortic lymphadenectomy in early-stage high-grade endometrial cancer remains controversial. In this study, we investigated whether combined pelvic and para-aortic lymphadenectomy has a survival benefit compared to pelvic lymphadenectomy alone in patients with pathologically diagnosed FIGO stage I-II grade 3 endometrioid and non-endometrioid endometrial cancers. METHODS: We retrospectively reviewed the medical records of 281 patients with histologically confirmed FIGO stage I-II grade 3 endometrioid and non-endometrioid endometrial cancers who underwent pelvic lymphadenectomy alone or combined pelvic and para-aortic lymphadenectomy in staging surgery at two tertiary centers in Korea and Taiwan. Prognostic factors to predict outcomes in these cases were also analyzed. RESULTS: Among 281 patients, 144 underwent pelvic lymphadenectomy alone and 137 underwent combined pelvic and para-aortic lymphadenectomy. Within a median follow-up of 45 months, there was no significant difference in recurrence-free survival (RFS) and overall survival (OS) between the two groups. In multivariable analysis, age at diagnosis ≥60 years (HR = 2.20, 95% CI 1.25-3.87, p = 0.006) and positive lymph-vascular space invasion (LVSI) (HR = 2.79, 95% CI 1.60-4.85, p < 0.001) were associated with worse RFS, and only non-endometrioid histology was associated with worse OS (HR = 3.18, 95% CI 1.42-7.12, p = 0.005). In further subgroup analysis, beneficial effects of combined pelvic and para-aortic lymphadenectomy on RFS and OS were not observed. CONCLUSIONS: In this study, combined pelvic and para-aortic lymphadenectomy could not improve survival compared to pelvic lymphadenectomy alone in patients with FIGO stage I-II grade 3 endometrioid and non-endometrioid endometrial cancers. Therefore, para-aortic lymphadenectomy may be omitted for these cases.

Comparison of survival outcomes with or without Para-aortic lymphadenectomy in surgical patients with stage IB1-IIA2 cervical cancer in China from 2004 to 2016.

BACKGROUND: Current opinions on whether surgical patients with cervical cancer should undergo para-aortic lymphadenectomy at the same time are inconsistent. The present study examined differences in survival outcomes with or without para-aortic lymphadenectomy in surgical patients with stage IB1-IIA2 cervical cancer. METHODS: We retrospectively compared the survival outcomes of 8802 stage IB1-IIA2 cervical cancer patients (FIGO 2009) who underwent abdominal radical hysterectomy + pelvic lymphadenectomy (n = 8445) or abdominal radical hysterectomy + pelvic lymphadenectomy + para-aortic lymphadenectomy (n = 357) from 37 hospitals in mainland China. RESULTS: Among the 8802 patients with stage IB1-IIA2 cervical cancer, 1618 (18.38%) patients had postoperative pelvic lymph node metastases, and 37 (10.36%) patients had para-aortic lymph node metastasis. When pelvic lymph nodes had metastases, the para-aortic lymph node simultaneous metastasis rate was 30.00% (36/120). The risk of isolated para-aortic lymph node metastasis was 0.42% (1/237). There were no significant differences in the survival outcomes between the para-aortic lymph node unresected and resected groups. No differences in the survival outcomes were found before or after matching between the two groups regardless of pelvic lymph node negativity/positivity. CONCLUSION: Para-aortic lymphadenectomy did not improve 5-year survival outcomes in surgical patients with stage IB1-IIA2 cervical cancer. Therefore, when pelvic lymph node metastasis is negative, the risk of isolated para-aortic lymph node metastasis is very low, and para-aortic lymphadenectomy is not recommended. When pelvic lymph node metastasis is positive, para-aortic lymphadenectomy should be carefully selected because of the high risk of this procedure.

Radical lymphadenectomy of a para-aorta lymph node metastasis in colorectal cancer prolongs relapse-free survival.

BACKGROUND: It is highly controversial whether a lymphadenectomy for treating distant lymph nodes, such as the para-aortic lymph node, provides clinical benefit in colorectal cancer (CRC). This study aimed to investigate the benefit of a lymphadenectomy for para-aortic lymph node metastasis (PALM) in CRC, by evaluating the extent of dissection. METHODS: This retrospective cohort study included 28 consecutive patients with pathologically positive PALMs in CRC that underwent lymphadenectomies from October 2001 to March 2018 at our institute. We analyzed the rates of 3-year recurrence-free survival (RFS), postoperative complications, and peri-operative death. We examined RFS in two groups with different operation types. One group received radical resections (radical group), defined as a systematic dissection of para-aortic lymph nodes, which removed the area under the renal vein and above the aortic bifurcation. The other group (targeted group) received targeted dissections, which removed specific swollen para-aortic lymph nodes. RESULTS: The radical group had a significantly better RFS than the targeted group. In addition, females had significantly better RFS prognoses than males. Univariate and multivariate Cox regression analyses identified two clinical factors significantly associated with RFS: sex (P = 0.0100) and surgical procedure (P = 0.0033). Postoperative complications after PALM resections occurred in 35.7% of patients. There was no postoperative mortality. CONCLUSION: Our study suggested that a radical lymphadenectomy for treating PALMs in CRC could be performed safely and could prolong the RFS. More studies are necessary to strengthen the evidence in support of this conclusion.

Role of systematic pelvic and para-aortic lymphadenectomy in delayed debulking surgery after six neoadjuvant chemotherapy cycles for high-grade serous ovarian carcinoma.

INTRODUCTION: We analyzed the role of systematic pelvic and para-aortic lymphadenectomy in delayed debulking surgery after six neoadjuvant chemotherapy (NACT) cycles for advanced high-grade serous ovarian carcinoma. MATERIALS AND METHODS: We retrospectively reviewed patients with advanced ovarian carcinoma who underwent NACT with carboplatin-paclitaxel between 2008 and 2016. Patients were included only if they had FIGO IIIC-IVB high-grade serous carcinoma with clinically negative lymph nodes after six NACT cycles (carboplatin-paclitaxel) and underwent complete or near complete cytoreduction. Patients with partial lymphadenectomy or bulky nodes were excluded. Patients who underwent systematic pelvic and aortic lymphadenectomy and those who did not undergo lymph node dissection were compared. Progression-free and overall survivals were analyzed using the Kaplan-Meier method. RESULTS: Totally, 132 patients with FIGO IIIC-IVB epithelial ovarian carcinoma were surgically treated after NACT. Sixty patients were included (39 and 21 in the lymphadenectomy and nonlymphadenectomy group, respectively); 40% had suspicious lymph nodes before NACT. Patient characteristics, blood transfusion numbers, and complication incidence were similar between the groups. In the lymphadenectomy group, 12 patients (30.8%) had histologically positive lymph nodes and the surgical time was longer (229 vs. 164 min). The median overall survival in the lymphadenectomy and nonlymphadenectomy groups, respectively, was 56.7 (95% CI 43.4-70.1) and 61.2 (21.4-101.0) months (p = 0.934); the corresponding disease-free survival was 8.1 (6.2-10.1) and 8.3 (5.1-11.6) months (p = 0.878). Six patients exclusively presented with lymph node recurrence. CONCLUSIONS: Systematic lymphadenectomy after six NACT cycles may have no influence on survival.

Sentinel node mapping using indocyanine green and near-infrared fluorescence imaging technology for endometrial cancer: A prospective study using a surgical algorithm in Indian patients.

BACKGROUND: Indocyanine green (ICG) fluorescence with high-definition, three-dimensional imaging systems is emerging as the latest strategy to reduce trauma and improve surgical outcomes during oncosurgery. MATERIALS AND METHODS: This is a prospective study involving 100 patients with carcinoma endometrium who underwent robotic-assisted Type 1 pan-hysterectomy, with ICG-directed sentinel lymph node (SLN) biopsy from November 2017 to December 2019. The aim was to assess the feasibility and diagnostic accuracy of SLN algorithm and to evaluate the location and distribution of SLN in pelvic, para-aortic and unusual areas and the role of frozen section. RESULTS: The overall SLN detection rate was 98%. Bilateral detection was possible in 92% of the cases. Right side was detected in 98% of the cases and left side was visualised in 92% of the cases. Complete node dissection was done where SLN mapping failed. The most common location for SLN in our series was obturator on the right hemipelvis and internal iliac on the left hemipelvis. SLN in the para-aortic area was detected in 14% of cases. In six cases, SLN was found in atypical locations, that is pre-sacral area. Eight patients had SLN positivity for metastasis and underwent complete retroperitoneal lymphadenectomy. Comparison of final histopathological report with frozen section reports showed no false negatives. CONCLUSIONS: SLN mapping holds a great promise as a modern staging strategy for endometrial cancer. In our experience, cervical injection was an optimal method of mapping the pelvis. ICG showed a high overall detection rate, and bilateral mapping appears to be a feasible alternative to the more traditional methods of SLN mapping in patients with endometrial cancer. The ICG fluorescence imaging system is simple and safe and may become a standard in oncosurgery in view of its staging and anatomical imaging capabilities. This approach can reduce the morbidity, operative times and costs associated with complete lymphadenectomy while maintaining prognostic and predictive information.

Tumour and pelvic lymph node metabolic activity on FDG-PET/CT to stratify patients for para-aortic surgical staging in locally advanced cervical cancer.

PURPOSE: The aim of our study was to comprehensively evaluate the most valuable metabolic parameters of cervical tumours and pelvic lymph nodes (PLN) by FDG-PET/CT to predict para-aortic lymph node (PALN) metastasis and stratify patients for surgical staging. METHODS: The study included patients with locally advanced cervical cancer, negative PALN uptake on preoperative FDG-PET/CT, and para-aortic lymphadenectomy. Two senior nuclear medicine physicians expert in gynaecologic oncology reviewed all PET/CT exams, and extracted tumour SUVmax, MTV, and TLG, as well as PLN. Prognostic parameters of PALN involvement were identified using ROC curves and logistic regression analysis. RESULTS: One hundred and twenty-five consecutive locally advanced cervical cancer patients were included. The FDG-PET/CT false-negative rate was, respectively, 27.7% (13/47) and 5.1% (4/78) in patients with and without FDG-PET/CT PLN uptake. The AUC of cervical tumour size, SUVmax, MTV, and TLG was, respectively, 0.75 (0.62-0.87), 0.59 (0.44-0.76), 0.75 (0.60-0.90), and 0.71 (0.56-0.86). The AUC of PLN size, SUVmax, SUVmean, PLN SUVmax/Tumour SUVmax ratio, MTV, and TLG was, respectively, 0.57 (0.37-0.78), 0.82 (0.68-0.95), 0.77 (0.61-0.94), 0.85 (0.72-0.98), 0.69 (0.51-0.87), and 0.74 (0.57-0.91). The metabolic parameter showing the best trade-off between sensitivity and specificity to predict PALN involvement was the ratio between PLN and tumour SUVmax. CONCLUSION: The risk of PALN metastasis in FDG-PET/CT negative PLN patients is very low, so para-aortic lymphadenectomy does not seem justified. In patients with preoperative PLN uptake on FDG-PET/CT, surgical staging led to treatment modification in more than 25% of cases and should therefore be performed. Patients with more than one positive PLN and high PLN metabolic activity are at high risk of para-aortic extension and recurrence. Further prospective evaluation is required to consider intensified treatment modalities without prior PALN dissection.

Para-aortic lymph node surgical staging in locally-advanced cervical cancer: comparison between robotic versus conventional laparoscopy.

OBJECTIVE: With the expansion of the use of minimally invasive surgical techniques within the field of gynecological oncology, a robot assisted procedure seems to be an attractive technique for para-aortic lymph node sampling. The aim of this study was to compare robotic versus conventional laparoscopic para-aortic lymphadenectomy in patients with locally advanced cervical cancer. METHODS: In this monocentric retrospective study, we included patients with locally-advanced cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB2-IVA or IB1 with suspicious pelvic lymph nodes), who underwent a para-aortic lymphadenectomy up to the inferior mesenteric artery between December 1994 and December 2016 (robotic technique starting from December 2012). RESULTS: A total of 217 patients were included in the study (robotic, n=55 vs laparoscopic, n=162). When comparing conventional laparoscopic versus robotic para-aortic lymphadenectomy, the median age was 48 versus 49 years and the median body mass index was 24.4 vs 24.7 kg/m2, respectively. In the robotic or laparoscopic group, 85% and 83% were squamous carcinomas, respectively. Patients who underwent a robotic procedure had a higher American Society of Anesthesiologists (ASA) score (ASA2: 62% vs 56%, ASA3: 20% vs 2%, p<0.001), more prior major abdominal surgery (18% vs 6%, p=0.016), less estimated blood loss (median, 25 mL vs 62.5 mL, p<0.001), more para-aortic lymph nodes removed (11 vs 6, p<0.001), shorter postoperative stay (1.8 vs 2.3 days, p=0.002), and a higher, but non-significant, rate of metastatic para-aortic lymph nodes (13% vs 5%, p=0.065) compared with the laparoscopic procedure, respectively. There was no difference in complication rates between the two approaches. The most frequent complications were grade I and grade II according to the Clavien Dindo classification. No difference was observed in progression-free survival between robotic and laparoscopic para-aortic lymphadenectomy after 2 years (both groups 66%) (p=0.472). Also, 2 year overall survival was similar between the groups (77% vs 81% for robotic vs conventional laparoscopy group, respectively) (p=0.749). CONCLUSION: Robotic para-aortic lymphadenectomy in patients with locally-advanced cervical cancer resulted in better perioperative outcomes and similar survival outcomes when compared with a conventional laparoscopic approach.

A direct endoscopic approach for left-sided infrarenal para-aortic lymphadenectomy immediately after hysterectomy for endometrial cancer treatment: left dome formation (LDF).

BACKGROUND: Endoscopic surgery for infrarenal para-aortic lymphadenectomy has been widely accepted. Two major approaches, "transperitoneal" and "extraperitoneal", are generally used; however, they have several disadvantages. A "transperitoneal" approach to the left para-aortic region is usually indirect, often performed after wide extension of the right para-aortic region. An "extraperitoneal" approach is unsuitable when a peritoneal tear exists after a prior surgical procedure such as hysterectomy. Here, we propose a modified transperitoneal technique, "Left dome formation (LDF)," which directly provides a surgical field for left infrarenal para-aortic lymphadenectomy even after hysterectomy. METHODS: The LDF procedure comprised three processes: (1) setting, (2) dissection of inframesenteric lymph nodes (step 1), and (3) dissection of infrarenal lymph nodes (step 2). SETTING: two trocars were added 4 cm bilateral to the low-mid abdominal trocar that was used in prior hysterectomy. Step 1: The posterior layer of the renal fascia along with the left ureter and left ovarian vessel were separated from the left common iliac artery and iliopsoas. Left inframesentric nodes were removed from the surgical field. Step 2: The left ureter was isolated from the posterior renal fascia, and the dome was expanded cranially to the left renal vein, with the ovarian vein always visualizable at the dome ceiling. Left infrarenal nodes were removed. RESULTS: We applied LDF to ten endometrial cancer patients, recommended for additional dissection of para-aortic nodes based on intraoperative evaluation using the laparoscopically removed uterus. The operative time and number of removed lymph nodes in Step 1 and Step 2 were 28.8 (20-49) min and 5.3 (2-10) and 54.6 (52-70) min and 6.5 (1-11), respectively. Blood loss was below 50 ml. No serious organ injury occurred during procedures. CONCLUSION: Since the left ureter is always observable, LDF procedure facilitates effective surgery to overcome the anatomical complexity of the left para-aortic region and is potentially useful for sentinel node sampling.

Laparoendoscopic Single-site Surgery for Comprehensive Staging of Early Ovarian Cancer.

STUDY OBJECTIVE: To demonstrate the procedure and suspension skills of laparoendoscopic single-site (LESS) staging surgery with infrarenal para-aortic lymphadenectomy for early-stage ovarian cancer. DESIGN: A presentation of the surgery through this technical video. SETTING: A hospital. PATIENT AND INTERVENTIONS: A 45-year-old woman presented with a pelvic mass on gynecologic examination and a serum cancer antigen 125 level of 5910 U/mL (normal = <35 U/mL). A computed tomographic scan revealed a mixture of solid and cystic components (70 × 77 × 71 mm) arising from the right ovary and characterized by the "ovarian vascular pelvic" sign. Clinically early-stage ovarian cancer was suspected. Subsequently, LESS staging surgery was performed by an experienced surgeon in our department. RESULTS: The surgery lasted 280 minutes, and the volume of blood loss was 50 mL; there were no intra- or postoperative complications. We "hid" the incision perfectly for cosmetic purposes. The histopathologic findings supported high-grade serous ovarian cancer of the right ovary with the left fallopian tube involved as well. In addition, a total of 34 negative pelvic and 18 negative para-aortic lymph nodes were identified, and a stage of IIA was diagnosed as a result. CONCLUSION: We performed an LESS staging surgery for early-stage ovarian cancer successfully. Our video shows that the LESS approach provided feasible, cosmetic, and safe access among the selected malignant gynecologic surgery. Therefore, we have experienced that the effective suspension was an auxiliary measure for LESS lymphadenectomy. In addition, compared with multiport laparoscopy, the LESS approach could provide easier access to infrarenal para-aortic regions; furthermore, it was safe and quick to extract an unknown sample.

Lack of Survival Benefit of Para-Aortic Lymphadenectomy in Advanced Cervical Cancer.

INTRODUCTION: The presence of positive para-aortic lymph nodes in advanced cervical cancer remains the most important prognostic factor for survival and also defines the treatment. Our aim was to define the influence of staging para-aortic lymphadenectomy in patients' survival. MATERIAL AND METHODS: The medical records of 74 patients with advanced cervical cancer (FIGO IIB-IVA) were reviewed. In 31 patients (41.9%), the assessment of lymph nodes was performed with imaging test (group 1) and in 43 (58.1%) within a surgical staging para-aortic lymphadenectomy (group 2). We compared both groups according to stage of disease, treatment, progression-free survival (PFS), and overall survival (OS). RESULTS: The extended-field radiotherapy was performed in 44.2 and 19.4% of patients in surgical and imaging staging group, respectively (p = 0.045). The disease-free survival rate was 17.4 ± 17.4 months in group 1 and 14.4 ± 12.6 months in group 2 (p = 0.456). No differences in OS were found between these 2 groups (p = 0.676). CONCLUSIONS: Despite the higher diagnostic accuracy of surgical staging and the higher number of patient who received extended field radiotherapy, we did not find differences between the overall and PFS rates in both the studied groups. Further prospective study on a higher number of patients would be necessary.

The role of oral oil administration in displaying the chylous tubes and preventing chylous leakage in laparoscopic para-aortic lymphadenectomy.

BACKGROUND AND OBJECTIVES: This study is aimed to investigate the possibility of preoperative oral oil administration in displaying the chylous tubes and preventing chylous leakage in laparoscopic para-aortic lymphadenectomy. MATERIALS AND METHODS: In this retrospective nonrandomized study, of the 30 patients with gynecological malignancies who had indications for laparoscopic para-aortic lymphadenectomy up to renal vessels, 15 were administered preoperative oral oil (oil a administration) (control group) at our hospital between September 2017 and June 2018. The chylous tube displaying rates, incidences of chylous leakage, and other perioperative data of the two groups were compared. RESULTS: Successful display of chylous tubes was observed in 93.3% (14/15) patients in the oil administration group. The chylous leakage was zero in the oil administration group, and 33.3% (5/15) in the control group. The postoperative drainage duration (4.1 ± 1.0 days vs 7.6 ± 1.4 days, P = 0.000), somatostatin application time (0 day vs 5.9 ± 0.8 days), and postoperative hospital stay (6.0 ± 2.3 days vs 9.1 ± 2.1 days, P = 0.001) were significantly shorter in the oil administration group. The total cost is lower in the oil administration group (4972.52 ± 80.54 dollars vs 6260.80 ± 484.47 dollars, P = 0.000). CONCLUSIONS: Preoperative oil administration is a feasible and effective method to display the chylous tubes and to prevent the chylous leakage in para-aortic lymphadenectomy.

Single-Site Robot-Assisted Laparoscopic Staging Surgery for Presumed Clinically Early-Stage Ovarian Cancer.

STUDY OBJECTIVE: To present the demonstration of robotic-assisted laparoendoscopic single-site (R-LESS) staging surgery in presumed clinically early-stage ovarian cancer. DESIGN: A step-by-step presentation of the procedure using video (Canadian Task Force classification III). SETTING: A university hospital. PATIENT: A 29-year-old woman was referred from a local clinic for an 8 × 6 cm left ovarian tumor suggesting malignancy. Her serum cancer antigen 125 level was 1636 U/mL. There was no evidence of a metastatic tumor or lymph node enlargement on magnetic resonance imaging or positron emission tomographic/computed tomographic imaging. INTERVENTION: Under general anesthesia, a 2-cm vertical intraumbilical incision was made, and a Lap Single trocar (Sejong Medical, Ltd, Gyeonggi-do, South Korea) was applied. The entire abdominal cavity was clear without any seeding tumor or adhesion. We performed laparoendoscopic single-site left salpingo-oophorectomy. On frozen section, high-grade epithelial malignancy was diagnosed. We started R-LESS staging surgery with the Da Vinci Xi system (Intuitive Surgical, Inc, Sunnyvale, CA). Fenestrated bipolar forceps and a permanent cautery hook were introduced. Both pelvic and inferior mesenteric para-aortic lymphadenectomy was performed. The patient was tilted in a reverse Trendelenburg position while performing infracolic omentectomy. MAIN RESULTS: The total operation took 280 minutes, and the console time was 135 minutes. The estimated blood loss was 100 mL. The patient was discharged on the next day after surgery. Histopathologic evaluation revealed a poorly differentiated endometrioid carcinoma. A total of 15 pelvic lymph nodes and 7 para-aortic lymph nodes were retrived. Among them, 2 para-aortic lymph nodes showed malignancy. CONCLUSION: We could successfully perform R-LESS staging surgery for presumed clinically early-stage ovarian cancer without any complications.

Comparison of robotic-assisted versus laparoscopy for transperitoneal infrarenal para-aortic lymphadenectomy in patients with endometrial cancer.

AIM: This study was conducted to evaluate the clinical feasibility of robotic-assisted transperitoneal infrarenal para-aortic lymphadenectomy (TIPAL) in patients with endometrial cancer. METHODS: From June 2006 to October 2016, we retrospectively analyzed 42 patients who underwent laparoscopic (n = 16) or robotic-assisted (n = 26) staging operations, including TIPAL for endometrial cancer. Perioperative data including age; body mass index; operation duration; the number of lymph nodes retrieved and the ratio of time to lymph node retrieval during pelvic, infrarenal para-aortic and total lymphadenectomy; estimated blood loss and postoperative complications were compared. RESULTS: The operative duration of pelvic (21.7 ± 5.31 vs 30.7 ± 10.8 min; P = 0.002), and total (62.6 ± 14.0 vs 87.0 ± 30.4 min; P = 0.010) lymphadenectomy was significantly shorter in the robotic-assisted than the laparoscopic group, whereas there was no statistical difference in the duration of infrarenal para-aortic lymphadenectomy. By contrast, the number of infrarenal para-aortic lymph nodes retreived was significantly higher (29.4 ± 10.7 vs 23.3 ± 9.16; P = 0.016) in the robotic-assisted group. Consequently, the ratio of time to number of lymph nodes retrieved during infrarenal (1.51 ± 0.49 vs 2.62 ± 1.34; P = 0.002) and total (1.43 ± 0.48 vs 2.15 ± 0.93; P = 0.014) lymphadenectomy was lower in the robotic-assisted compared to the laparoscopic group. CONCLUSIONS: The robotic-assisted approach took less time per infrarenal para-aortic and total lymph nodes retrieved compared to the conventional laparoscopic approach. Robotic-assisted TIPAL could be feasible and effective for the staging and treatment of patients with endometrial cancer.

Pretherapeutic staging of locally advanced cervical cancer: Inframesenteric paraaortic lymphadenectomy accuracy to detect paraaortic metastases in comparison with infrarenal paraaortic lymphadenectomy.

BACKGROUND: Extended-field chemoradiation therapy is usually performed in patients with locally advanced cervical cancer (LACC) and paraaortic (PA) node metastases. Considering the very low rate of skip metastases above inferior mesenteric artery, ilio-inframesenteric paraaortic lymph node dissection (IM-PALND) seems to be an adequate pattern of PALND. Our objective was to assess the accuracy of this management to determine PA nodal status in comparison with infrarenal paraaortic lymphadenectomy (IR-PALND) in case of squamous or glandular cervical cancer. METHODS: All patients with LACC and negative MRI and PET/CT imaging at paraaortic level had laparoscopic staging (followed, if negative, by extraperitoneal paraaortic lymphadenectomy). From January 2011 to September 2015, patients who had IM-PALND were included and were compared to a previous historical series of IR-PALND patients. The two groups differed only at the upper level of dissection. Characteristics of nodal involvement at paraaortic level depending on level of dissection, PET/CT imaging and histology were studied. RESULTS: 119 women were included in our study, with 56 patients in the IM-PALND group and 63 in the IR-PALND group. In the IM-PALND group, fewer nodes were resected (p<0.001). There was no difference between the two groups regarding nodal status at paraaortic level (p=0.77). Patterns of nodal involvement were similar whichever the histological subtype of cervical cancer (squamous or glandular). CONCLUSION: IM-PALND appears to be equally effective to assess paraaortic nodal involvement in LACC for both histological subtypes - glandular and squamous carcinomas - and to select patients for extended-field chemoradiation therapy.

Para-aortic lymphadenectomy can be omitted in most endometrial cancer patients at risk of lymph node metastasis.

OBJECTIVES: To determine the predictive factors of para-aortic lymph node (PALN) metastasis in endometrial cancer (EC) and recommend a subgroup of patients who can safely forgo PALN dissection. METHODS: We analyzed a series of 255 patients who were at risk of lymph node metastasis and treated from June 2007 to June 2015. All patients underwent systematic pelvic and para-aortic lymphadenectomy. RESULTS: The median number of pelvic lymph nodes (PLN) and PALNs that were resected was 33 and 15, respectively. Fifty (19.6%) patients had LN metastasis-43 (16.9%) pelvic, 28 (11%) para-aortic, 21 (8.2%) pelvic and para-aortic, and 7 (2.7%) isolated PALN metastasis. PALN metastasis was significantly associated with PLN metastasis, the presence of lymphovascular space invasion, deep myometrial invasion (MI), and histological grade 3. In the multivariate analysis, only pelvic LN metastasis and deep MI remained independent risk factors of PALN metastasis. For patients without LN enlargement ± adnexal metastasis, when deep MI and PLN metastasis were absent, the risk of PALM was 0.8%. CONCLUSIONS: Our series supports that PALN metastasis is a rare event in the absence of PLN metastasis and that most patients can safely forego PALN dissection. This subgroup can be identified by the combined absence of PLN metastasis and deep MI.

Comprehensive Staging of Uterine Carcinosarcoma Using a Multiquadrant Robotic Platform.

STUDY OBJECTIVE: To demonstrate the feasibility of multiquadrant staging of a uterine carcinosarcoma using the latest-generation robotic platform. DESIGN: Step-by-step explanation of the technique using videos and pictures (educative video). SETTING: Although laparoscopic and robotic-assisted laparoscopic staging of high-risk uterine cancer is well incorporated into many gynecologic oncology practices, extensive para-aortic lymphadenectomies above the inferior mesenteric artery are less commonly performed. Additionally, infracolic omentectomies are frequently performed in lieu of infragastric omentectomies. PATIENT: A 67-year-old woman with a newly diagnosed uterine carcinosarcoma. INTERVENTION: Multiquadrant comprehensive staging of uterine carcinosarcoma using the latest-generation robotic platform. MEASUREMENTS AND MAIN RESULTS: We demonstrate in this video a facile approach for robotic surgeons to perform an extensive para-aortic lymphadenectomy up to the renal vessels, as well an infragastric omentectomy, using the latest-generation multiquadrant robotic platform. This platform allows for facile rotation from an upper abdominal view to perform the para-aortic lymphadenectomy and omentectomy, to a pelvic view to complete the pelvic lymphadenectomies, hysterectomy and bilateral salpingo-oophorectomy. We demonstrate this technique in a 67-year-old woman with a newly diagnosed uterine carcinosarcoma who underwent a robotic-assisted laparoscopic total hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymphadenectomy, and infragastric omentectomy via the Xi Da Vinci Robot (Intuitive Surgical, Sunnyvale, CA). Total operative time was 280 minutes (50 minutes for the omentectomy, 86 minutes for the para-aortic lymphadenectomy). Estimated blood loss was 50 mL. Final pathology revealed a stage IA uterine carcinosarcoma; a total of 27 para-aortic lymph nodes and 20 pelvic lymph nodes were removed, and the size of the excised omentum was 68 × 10 × 1.2 cm. CONCLUSION: The technique of using alternating dual perspectives (upper abdominal or pelvic views) through a multiquadrant robotic platform enables the robotic surgeon to perform extensive para-aortic lymphadenectomies and omentectomies without resorting to laparoscopic surgery to complete these procedures.

Should the Presence of Metastatic Para-Aortic Lymph Nodes in Locally Advanced Cervical Cancer Lead to More Aggressive Treatment Strategies?

STUDY OBJECTIVE: To evaluate risk factors in patients with locally advanced cervical cancer (LACC) undergoing pretherapeutic laparoscopic para-aortic lymphadenectomy (LPL) as well as the progression-free and overall survival rates specifically in the subgroup of patients with metastatic para-aortic lymph nodes (PLNs). DESIGN: Retrospective study conducted on demographic data, pathologic and surgical findings, complications, and disease status recorded for LACC patients undergoing LPL during the period 2009 to 2015. SETTING: Department of Gynecologic Oncology of the Complejo Hospitalario Universitario Insular-Materno Infantil, Canary Islands, Spain (Canadian Task Force Classification II-3). PATIENTS: Women with LACC undergoing pretherapeutic LPL. All patients were treated with definitive chemoradiotherapy after surgery, and those with metastatic PLN received extended lumboaortic radiation therapy. INTERVENTIONS: Survival analysis was performed with the Kaplan-Meier method. Statistical significance was considered for p <.05. MEASUREMENTS AND MAIN RESULTS: The study included 139 patients. The median age was 48 years (range, 28-73). The most frequent histologic type was squamous cell carcinoma (77%), and the most frequent 2009 FIGO stage was IIB (48.2%). LPL identified metastatic PLN in 18.7% of patients (n = 26). The mean overall survival for the whole population, after 23 months of follow-up, was 68.2 months (95% CI, 63-73.4). For patients without para-aortic metastases, the mean survival time was 76.9 months (95% CI, 70.3-80.4), whereas for patients with positive PLNs the median survival time was 21 months (95% CI, 6.1-35.9; p <.0001). A logistic regression analysis revealed that the presence of metastatic PLNs and tumor size (>5 cm) were both independent risk factors for poor survival (OR, 117.5; 95% CI, 11.6-990.2; p <.0001, and OR, 21.5; 95% CI, 2-230.3; p = .01, respectively). CONCLUSION: LACC patients with metastatic PLNs had a poor prognosis and low survival rate. We postulate that this finding could be accounted for by the presence of hidden systemic disease and high recurrence rate after therapy. Efforts should be made to improve available therapeutic strategies for this particular subgroup of patients.

The role of para-aortic lymphadenectomy in stage IIIC endometrial cancer: A single-institute study.

The therapeutic value of para-aortic lymphadenectomy (PAL) in women with endometrial cancer (EC) remains uncertain. We retrospectively analysed 25 patients with stage IIIc EC (17 stage IIIC1; 8 IIIC2) who were treated in our institution. All subjects had undergone pelvic lymphadenectomies in which para-aortic nodes were sampled, or removed only when these nodes were enlarged. Sampling of para-aortic nodes or PAL was performed in all patients with stage IIIC2 disease and one of 17 with stage IIIC1 disease. Para-aortic lymph nodes were the most frequent site of recurrence in stage IIIC1 patients, but no such recurrences occurred in stage IIIC2 patients. Overall survival tended to be shorter in stage IIIC1 patients than stage IIIC2 patients. Our findings indicate that PAL improves the outcomes of patients with EC and high risk of para-aortic lymph node metastasis, such as those with positive pelvic lymph nodes or enlargement of para-aortic lymph nodes. Impact statement Para-aortic lymph node (PALN) metastases are important prognostic factors in endometrial cancer. Overall survival of patients with stage IIIC1 disease is generally longer than for those with stage IIIC2 disease. Retrospective studies - but no prospective studies - have suggested that para-aortic lymphadenectomy (PAL) provides a survival benefit. In our institution, we had performed PAL or para-aortic sampling for patients with enlarged PALNs; therefore, as most IIIC1 patients had no enlarged PALNs, they underwent pelvic lymphadenectomy only, whereas all IIIC2 patients had enlarged PALNs and underwent pelvic lymphadenectomy and PAL or PALN sampling in addition to pelvic lymphadenectomy. However, under this policy, survival of stage IIIC1 patients was not better than for stage IIIC2 patients. Our retrospective study indicates a survival benefit for PAL in patients with pelvic node-positive or enlarged PALN. PAL warrants a prospective randomised trial to see whether it should be a standard treatment in these patients.

Comparison Between Laparoscopy and Laparotomy in Systematic Para-Aortic Lymphadenectomy for Patients with Endometrial Cancer: A Retrospective Multicenter Study.

Objective: Laparoscopic surgery has been developed worldwide due to its minimal invasion as well as noninferiority, compared with laparotomy. However, whether or not laparoscopic systematic para-aortic lymphadenectomy for endometrial cancer is feasible and has advantages of various clinical factors, such as a short hospital stay, less blood loss, and faster recovery, compared with open surgery has not yet been clarified. The aim of this study was to compare a laparoscopic procedure with laparotomy for para-aortic lymphadenectomy for patients with endometrial cancer. Study Design: This was a retrospective multicenter study of laparoscopic systematic para-aortic lymphadenectomy for endometrial cancer in five institutions. Materials and Methods: The current authors conducted a retrospective multicenter study of laparoscopic systematic para-aortic lymphadenectomy for endometrial cancer. The study involved patients from five institutions in Japan between January 2008 and March 2016. Clinical data were compared with those of a laparotomic procedure performed around the same period. Results: A total of 54 patients in the laparoscopic group and 99 patients in the laparotomic group were analyzed. In the laparoscopic group, 21 patients had stage IA disease, 19 had stage IB disease, 5 had stage II disease, and 9 had stage III disease. In the laparotomic group, 35 patients had stage IA disease, 19 had stage IB disease, 9 had stage II disease, and 36 had stage III disease. There were no significant differences in characteristics between the groups, including age, body mass index, and histologic type. The mean operative time in the laparoscopic group was 483 ± 102 minutes, while that in the laparotomic group was 481 ± 106 minutes (p = 0.9). The laparoscopic group had less intraoperative blood loss (143 ± 253 versus 988 ± 694 mL; p < 0.01) and shorter hospital stays (8.4 ± 5.7 versus 16.1 ± 8.0 days; p < 0.01). The rates of intraoperative complications were not significantly different between the groups. No cases of ileus occurred in the laparoscopic group. Procedures for 2 of the 54 patients in the laparoscopic group were converted to laparotomy. The number of dissected pelvic lymph nodes (31.8 ± 10.1 versus 39.9 ± 15.9, p < 0.01) and para-aortic lymph nodes (26.2 ± 10.9 versus 31.1 ± 13.2; p = 0.02) were lower in the laparoscopic group than in the laparotomic group. The postoperative minimum level of hemoglobin was higher in the laparoscopic group than in the laparotomic group (10.4 ± 1.1 g/dL versus 9.9 ± 1.4 g/dL; p = 0.02). In contrast, the postoperative maximum level of C-reactive protein was lower in the laparoscopic group than in the laparotomic group (6.3 ± 3.8 mg/dL versus 10.2 ± 4.9 mg/dL; p < 0.01). The recurrence rate was not significantly different between the groups in the above time period (7.4% versus 14.3%; p = 0.2). Conclusions: Laparoscopic systematic para-aortic lymphadenectomy is feasible and can be substituted for laparotomic procedures for patients with early stage endometrial cancer. ( J GYNECOL SURG 33:105).