Pretreatment transperitoneal laparoscopic staging pelvic and paraaortic lymphadenectomy in large (> or = 5 cm) stage IB2 cervical carcinoma: report of a pilot study

Feasibility of Laparoscopic Para-Aortic Lymphadenectomy for Locally Advanced Cervical Cancer

Background

Radiological evaluation of para-aortic lymph node metastasis in patients with locally advanced cervical cancer (LACC) possess the risk of missing microscopic metastasis. We commenced laparoscopic para-aortic lymphadenectomy (Lap-PAN) on patients with LACC for surgical staging in 2016. We assessed the feasibility of Lap-PAN in patients with LACC.

Methods

We retrospectively reviewed the records of 31 patients with LACC who were staged at International Federation of Gynecology and Obstetrics (FIGO) 2009 IIB to IVA without enlargement of the para-aortic lymph nodes who underwent radiation therapy in our hospital between January 1, 2011 and December 31, 2018. The postoperative outcomes of Lap-PAN were analyzed, and distinct parameters for each patient, including sites of recurrence and disease-free survival, were compared between the Lap-PAN (n = 12) and no surgery (n = 19) groups.

Results

The average operation time for Lap-PAN was 167 min, and the estimated blood loss was less than 50 ml in all patients. There were no perioperative complications. The average number of excised lymph nodes was 25, and no pathological metastases were observed. There was no difference in disease-free survival rates between the Lap-PAN and no surgery groups (p = 0.42). During the follow-up period, there were two cases of recurrence in the cervix in the Lap-PAN group, and three and four cases of lung and para-aortic lymph node recurrence, respectively in the no-surgery group.

Conclusions

Lap-PAN was safely performed as a pretherapeutic staging method for LACC without worsening patient prognosis. Although Lap-PAN requires a high level of skill, it may be a method to avoid excessive radiation for LACC.

Transperitoneal versus extraperitoneal laparoscopic aortic lymph nodal staging for locally advanced cervical cancer: A systematic review and meta-analysis

Cervical cancer is the fourth most common neoplasm in women. In locally advanced cervical cancers, the international guidelines recommend nodal aortic assessment. Two techniques have been described to perform laparoscopic aortic lymphadenectomy: transperitoneal laparoscopic lymphadenectomy (TLL) and extraperitoneal laparoscopic lymphadenectomy (ELL). This meta-analysis aims to compare the surgical outcomes of TLL and ELL for staging purposes. The systematic review was carried out in agreement with the preferred reporting items for systematic reviews and meta-analyses statement (PRISMA). Two hundred and twenty studies were analyzed, and 19 studies were included in the review (7 for TLL and 12 for ELL group). 1112 patients were included in the analysis: 390 patients were included in group 1 and 722 patients in group 2.38 patients (9.7%) in the TLL group and 69 (9.5%) patients in the ELL group developed major complications. The analysis of all complications (intraoperative and postoperative) rate through pooled analysis did not show a significant difference between the two groups (p = 0.979), although a significantly higher intraoperative complication rate (p = 0.018) occurred in the TLL group compared to ELL. No significant differences were found between groups for BMI (p = 0.659), estimated blood loss (p = 0.889), length of stay (p = 0.932), intraoperative time (p = 0.932), conversion to laparotomy rate (p = 0.404), number of lymph node excised (p = 0.461) and postoperative complication (p = 0.291). TLL approach shows a higher rate of intraoperative complications, while no significant difference was found between the two techniques when postoperative complications were analyzed.

A new technique of laparoscopic para-aortic lymphadenectomy optimizes perioperative outcome

Objective

The aim of the present study was to introduce a new technique for laparoscopic para-aortic lymphadenectomy (PAL): an invented retroperitoneum suspension needle combined with modified trocar placement.

Methods

This prospective pilot study randomly categorized women with cervical cancer of stage I–II into 2 groups. The patients in the study group would have laparoscopic PAL with our new technique, while those in the control group with control method. Patients' characteristics and perioperative outcomes were compared between the 2 groups.

Results

A total of 37 patients were included in our study, of which 20 cases in the study group and 17 cases in the control group. As a result, the mean number of para-aortic lymph nodes (PALNs) resected in the study group was significantly more than that in the control group (p<0.001). The time for resecting PALNs (p<0.001) and total operative time (p<0.001) in the study group decreased significantly than those in the control group.

Conclusions

For laparoscopic PAL, this new technique was effective and practical.

Advances in diagnosis and treatment of metastatic cervical cancer

Cervical cancer is one of the most common cancers in women worldwide. The outcome of patients with metastatic cervical cancer is poor. We reviewed the relevant literature concerning the treatment and diagnosis of metastatic cervical cancer. There are two types of metastasis related to different treatments and survival rates: hematogenous metastasis and lymphatic metastasis. Patients with hematogenous metastasis have a higher risk of death than those with lymphatic metastasis. In terms of diagnosis, fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) and PET-computed tomography are effective tools for the evaluation of distant metastasis. Concurrent chemoradiotherapy and subsequent chemotherapy are well-tolerated and efficient for lymphatic metastasis. As for lung metastasis, chemotherapy and/or surgery are valuable treatments for resistant, recurrent metastatic cervical cancer and chemoradiotherapy may be the optimal choice for stage IVB cervical cancer. Chemotherapy and bone irradiation are promising for bone metastasis. A better survival is achieved with multimodal therapy. Craniotomy or stereotactic radiosurgery is an optimal choice combined with radiotherapy for solitary brain metastases. Chemotherapy and palliative brain radiation may be considered for multiple brain metastases and other organ metastases.

Laparoscopic technique of para-aortic lymph node dissection: A comparison of the different approaches to trans- versus extraperitoneal para-aortic lymphadenectomy

Since Dr Dargent first reported endoscopic surgery using retroperitoneal pelvicoscopy to perform pelvic lymph node sampling in 1987, many literature reviews on the safety and feasibility of laparoscopic staging surgery of gynecologic malignancies have been published. However, the procedure of laparoscopic lymphadenectomy is more difficult to perform due to the limited surgical space and associated technical problems. Especially in the para-aortic lymphadenectomy procedure, there are many barriers to overcome in the surgical field, learning curve, and technique. We present a review of lymphadenectomy, especially para-aortic lymphadenectomy.

Should Systematic Infrarenal Para-aortic Dissection Be the Rule in the Pretherapeutic Staging of Primary or Recurrent Locally Advanced Cervix Cancer Patients With a Negative Preoperative Para-aortic PET Imaging?

Background

Extended-field chemoradiation is the usual management of patients with locally advanced cervical cancer (LACC) and para-aortic node metastases (PA pN1). It is efficient but not without morbidity. Assessment of PA lymph node positivity by PA lymphadenectomy is the most accurate method to select the candidates for this treatment. Hence, to clarify the dissection pattern, we wanted to test the true incidence of isolated/skip node metastasis, above the level of the inferior mesenteric artery (IMA).

Materials and Methods

All patients with LACC and negative magnetic resonance imaging and positron emission tomography–computed tomography imaging at the PA level were offered a laparoscopic staging encompassing a diagnostic laparoscopy followed, if negative, by an extraperitoneal PA lymphadenectomy. All nodes were removed from both common iliac bifurcations up to the left renal vein. Node groups, below and above the IMA, were separately sent to the pathologist for definitive examination.

Results

From January 2010 to December 2013, 196 stage IB1 with pelvic pN1, IB2, to IVA LACC patients from 2 cancer centers who fulfilled the criteria were included in this institutional review board–approved study after informed consent. Thirty patients (15%) had PA pN1. Only 1 patient had positive nodes exclusively located above the IMA (3.3% of the pN1 group; 95% confidence interval, 0%–9.7%). Complications were observed in 15 (7.6%) of 196 patients.

Conclusions

Given the very low rate of skip metastases above the IMA and the potential additional morbidity of a systematic extended dissection, a bilateral ilioinframesenteric dissection seems to be an acceptable pattern of PA lymphadenectomy in LACC patients.

Nodal-staging surgery for locally advanced cervical cancer in the era of PET

Chemoradiation therapy is deemed the standard treatment by many North American and European teams for treatment of locally advanced cervical cancer. The prevalence of para-aortic nodal metastasis in these tumours is 10-25%. PET (with or without CT) is the most accurate imaging modality to assess extrapelvic disease in such tumours. The true-positive rate of PET is high, suggesting that surgical staging is not necessary if uptake takes place in the para-aortic region. Nevertheless, false-negative results (in the para-aortic region) have been recorded in 12% of patients, rising to 22% in those with uptake during PET of the pelvic nodes. In such situations, laparoscopic surgical para-aortic staging still has an important role for detection of patients with occult para-aortic spread misdiagnosed on PET or PET-CT, allowing optimisation of treatment (extension of radiation therapy fields to include the para-aortic area). Complications of the laparoscopic procedure were noted in 0-7% of patients. Survival of individuals (missed by PET) with para-aortic nodal metastasis of 5 mm or less (and managed by extended field chemoradiation therapy) seems to be similar to survival of those without para-aortic spread, suggesting a positive therapeutic effect of the addition of staging surgery. Nevertheless, the effect on survival of potential delay of chemoradiation owing to use of PET and staging surgery, and acute and late complications of surgery followed by chemoradiation therapy (particularly in case of extended field chemoradiation to para-aortic area), need to be studied.

Accuracy of 18-fluoro-2-deoxy-D-glucose positron emission tomography in the pretherapeutic detection of occult para-aortic node involvement in patients with a locally advanced cervical carcinoma

PURPOSE

Patients with locally advanced cervical cancer (LACC) are usually treated with concurrent chemoradiotherapy. Extended-field chemoradiotherapy is indicated in case of para-aortic node involvement at initial assessment. 18-Fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18-FDG PET/CT) is currently considered to be the most accurate method of detection of node or distant metastases. The goal of this study was to evaluate the accuracy of PET at detecting para-aortic lymph node metastases in LACC patients with a negative morphological imaging.

METHODS

Patients from five French institutions with LACC and both negative morphologic (magnetic resonance imaging, CT scan) and functional (PET or PET/CT) findings at the para-aortic level and distantly were submitted to a systematic infrarenal para-aortic node dissection either by laparoscopy or laparotomy. On the basis of pathological results, sensitivity, specificity, and positive and negative predictive values of PET/CT were assessed for para-aortic lymph node involvement.

RESULTS

A total of 125 LACC patients (stage IB2-IVA disease with two local recurrences) fulfilled the inclusion criteria. All had an ilio-infrarenal para-aortic lymphadenectomy, either by laparoscopy (n = 117) or laparotomy (n = 8). Twenty-one patients (16.8%) had pathologically proven para-aortic metastases. Among them, 14 (66.7%) had negative PET/CT. Overall morbidity of surgery was 7.2%. All but one of the complications were mild and did not delay chemoradiotherapy. Sensitivity, specificity, and positive and negative predictive value of the PET/CT were 33.3, 94.2, 53.8, and 87.5%, respectively, for the detection of microscopic lymph node metastases.

CONCLUSIONS

Laparoscopic staging surgery seems warranted in LACC patients with negative PET scan who are candidates for definitive concurrent chemoradiotherapy or exenteration.

Laparoscopic para-aortic lymphadenectomy and positron emission tomography scan as staging procedures in patients with cervical carcinoma stage IB2IIIB

The objective of this study was to determine the role of laparoscopic lower para-aortic lymphadenectomy and positron emission tomography (PET) scan in the staging of cervical carcinoma. Ninety consecutive patients with FIGO stage IB2-IIIB were scheduled for laparoscopic para-aortic lymphadenectomy.

EXCLUSION CRITERIA

obvious metastatic para-aortic nodes on computed tomography (CT)/PET or PET-CT. The procedure was stopped when a node was positive on frozen section. In ten patients, no para-aortic lymphadenectomy was performed as scheduled. Forty-seven patients were operated retroperitoneally, 22 transperitoneally, and 21 cases were converted from retroperitoneally to transperitoneally. Median number of removed nodes was 6 (1-24). In 10 of 80 patients, para-aortic metastases were diagnosed. Despite a nonsuspect PET result, 5 of 44 patients had positive para-aortic nodes. Two-year survival was 76% and 16% without and with para-aortic metastases, respectively (P = 0.0001). Laparoscopic para-aortic lymphadenectomy showed metastases in 13% of the patients. In the subgroup with negative PET scan, 11% had metastases. The procedure had a low morbidity and identified a group with an extremely poor prognosis.

Which role for pre-treatment laparoscopic staging?

OBJECTIVE

To investigate in cervical cancer patients the impact of pre-treatment laparoscopic staging on treatment plan and disease free survival.

METHODS

A review of the present literature has been performed and data have been compared to results obtained in a large series of patients not surgically staged.

RESULTS

Among 134 abstracts resulting from Medline research, 13 were deemed potentially relevant to the study questions. The presence of intraperitoneal diffusion of disease can be recognized in locally advanced cervical cancer patients (LACC) in a percentage ranging between 1.9% and 29%. The rate of aortic positive nodes in clinically negative LACC patients cases has been reported between 11% and 25%, by laparoscopy. In our Division, 152 LACC patients have been treated between October 1997 and February 2007. None of the patients has been submitted to pre-treatment laparoscopic staging, whereas in all cases a pre-operative MRI has been performed. With a median follow-up 28.0 months (range 3-126 months), 31 recurrences have been observed. The 5-year DFS has been 83% and OS 90%. Although only a retrospective analysis can be carried out, such result well compares to cases surgically staged.

CONCLUSIONS

Pre-treatment surgical staging can identify positive nodes in LACC patients considered clinically negative, and recognize intraperitoneal disease, thus making the physician tailor the treatment on the bases of histopathological result. Moreover, it offers the potential advantage of debulking of macroscopically positive nodes, and to transpose the ovary outside the radiation. However, the positive impact on DFS has still to be demonstrated.

Therapeutic value of pretherapeutic extraperitoneal laparoscopic staging of locally advanced cervical carcinoma

BACKGROUND

Although cervical cancer is clinically staged, surgery has long been considered the best means to assess extrapelvic disease and remains the gold standard for the detection of both intraperitoneal spread and small volume nodal metastases. The objective of this study was to determine short- and long-term outcomes for patients with locally advanced cervical cancer who underwent pretherapeutic laparoscopic staging.

METHODS

From 1997 to 2004, 184 patients with stages IB2-IVA cervical cancer underwent pretherapeutic laparoscopic staging procedure including transperitoneal abdomino-pelvic exploration and extraperitoneal bilateral infrarenal paraaortic lymph node dissection. Patients were then treated with definitive radiotherapy tailored according to the staging results.

RESULTS

The median age and BMI were respectively 45.8 years old and 27.1 kg/m2. Most lesions were squamous (n=172) and clinical stage was evenly distributed. Median operative time was 155 min with an average of 20.8 lymph nodes removed. Postoperative hospital stay averaged 1.4 days. Major complications included 1 intraoperative ureteral injury and 1 postoperative bowel obstruction from an umbilical trocar site hernia. The final pathology revealed that 44 patients (24.3%) had metastatic disease within paraaortic lymph nodes. With a median follow-up of 26.8 months (average 32.9), 67 patients (36.4%) had recurrent disease. Overall 5-year survival rate was 58.3%. Successful resection of positive lymph node correlated with a survival advantage.

CONCLUSIONS

Pretherapeutic laparoscopic assessment of patients with locally advanced cervical cancer offers valuable information for individualized treatment planning with minimal morbidity. This appears to be a therapeutic effect with resection of positive nodes followed by a tailored chemoradiation therapy.

Laparoscopic lower para-aortic staging lymphadenectomy in stage IB2, II, and III cervical cancer

The presence of metastases in the para-aortic lymph nodes has important implications in the management of cervical carcinoma in many centers. In this study we investigated the role of laparoscopic lower para-aortic lymphadenectomy in patients with cervical carcinoma. In 42 consecutive patients with stage IB2-IIIB cervical carcinoma without suspicious para-aortic lymph nodes on CT scanning, a laparoscopic lower para-aortic lymphadenectomy was performed between January 1998 and April 2001. The transperitoneal route was used in the first 21 patients, and in the remaining 21 patients the procedure was started with the left retroperitoneal approach. The number of patients with stage IB2, II, and III was 7, 30, and 5, respectively. The median age was 51 years (range 30-81). The median weight and length were 62 kg (range 45-83) and 162 cm (range 150-175), respectively. In four patients-two operated via the transperitoneal route and the other two operated via the retroperitoneal route-the procedure was abandoned, in three patients because of adhesions following prior surgery and in one because of a camera failure. Conversion from the retropertitoneal to the transperitoneal approach was necessary because of a peritoneal tear in five of the 21 cases (all of them in the first 10 cases). Median estimated blood loss during the operation was 78 ml (range 10-300). The median hemoglobin (Hb) decrease was 1.3 g/dL (range 0-3.7). The median duration of the procedure was 64 min (range 20-115). Lymphadenectomy was stopped when one of the nodes was positive on frozen section. The number of para-aortic lymph nodes removed ranged from one to 15 (median 6). In seven (18%) of the 38 patients with successful lymphadenectomy, para-aortic metastases were observed (stage IB2, 1/6; stage II, 5/28 and stage III, 1/4). The only major complication was the development of a retroperitoneal hematoma on the first postoperative day in one patient (Hb fall of 3.7 g/dL). Patients with para-aortic lymph node metastases were treated with extended field para-aortic radiotherapy. None of these developed bowel obstruction. The median follow-up was 15 months (range 1-40 months). Actuarial 1-year crude survival was 88% and 33%, respectively, for patients with negative and positive para-aortic nodes. Laparoscopic para-aortic staging in cervical carcinoma is feasible with low morbidity. Eighteen percent of the patients, without suspicion of para-aortic metastases on CT, proved to have metastases in the lower para-aortic region.

Combined laparoscopic and vaginal radical surgery in cervical cancer

OBJECTIVE

The purpose of our study was to review our experience with laparoscopic staging and vaginal radical surgery in the treatment of early stage cervical cancer.

STUDY DESIGN

We reviewed the charts of 102 patients who had a laparoscopic pelvic lymphadenectomy followed by vaginal radical hysterectomy (VRH) or vaginal radical trachelectomy (VRT).

RESULTS

Patients' age ranged from 25 to 68 years (median: 36). Squamous and adenocarcinoma histology occurred in 68 and 32%, respectively. Stage Ib1 occurred in 77% of cases and the rest were stage Ia1 (1%), 1a2 (16%), and IIa (6%). Patients were divided into three groups: VRH (57), VRT (34), and node only (NO) (11), when positive nodes were identified on frozen section. Median operative time for VRH and VRT were 270 and 260 min compared to 200 min in the NO group (half also had bilateral paraaortic node dissection, which lengthened the OR time). Hospital stay was shorter in the NO group (2 days). For each group (VRH, VRT, and NO) the median pelvic node count was 27, 26, and 23 and the median paraaortic node count was 3, 4, and 9. Two VRH were converted to an abdominal procedure because of technical difficulties and one VRT was converted to a VRH because of positive endocervical margins. Intraoperative complications related to laparoscopy included two iliac and one epigastric vessel injuries. Complications related to the radical surgeries included three cystostomies, managed vaginally, and a laparotomy for parametrial bleeding after VRT. Postoperative complications occurred in 6% of patients and only one was considered major (an abscess which required surgical drainage). Overall, there were only four recurrences in the vaginal surgery groups and one in the NO group. There were no ureteral or intestinal injuries and there have been no trocar site recurrences.

CONCLUSION

Our data show that approaching cervical cancer with a combined laparoscopic and vaginal surgery is feasible. The overall morbidity and complication rate are low and the lymph node count is satisfactory. Staging the nodes laparoscopically first to identify positive nodes is advantageous, particularly since we favor the use of chemoradiation therapy in those cases. The laparoscopic node staging thus avoids an unnecessary laparotomy in patients with positive nodes, reduces morbidity, and allows for early radiation therapy.

Laparoscopic surgery for gynecologic cancers

In conclusion, laparoscopic techniques are useful for the evaluation and treatment of selected gynecologic malignancies and provide major benefits to patients. The benefits, however, can be expected only from gynecologic oncologists well-versed in advanced laparoscopic techniques. Results must be interpreted cautiously, depending on the laparoscopic expertise of the reporting authors. Numerous questions remain unanswered, particularly those associated with long-term recurrences and survival. The use of laparoscopic procedures for gynecologic malignancies must be considered investigational until adequate long-term survival data are available.

Technical development and results of left extraperitoneal laparoscopic paraaortic lymphadenectomy for cervical cancer

OBJECTIVE

The aim of this study was to describe the development of our technique for laparoscopic paraaortic lymphadenectomy for cervical cancer and to evaluate the accuracy of the left extraperitoneal route to perform complete paraaortic lymphadenectomy.

METHODS

A retrospective study of a consecutive series of 44 patients with cervical cancer undergoing laparoscopic paraaortic lymphadenectomy between July 1992 and November 1998 was performed, as well as a comparison of the three routes successively used to perform paraaortic lymphadenectomy: transperitoneal, bilateral extraperitoneal, and left extraperitoneal.

RESULTS

The initial choice of surgical access was transperitoneal (n = 9) in 20%, bilateral extraperitoneal (n = 14) in 32%, and left extraperitoneal (n = 21) in 48% of cases. Success rates of laparoscopic paraaortic lymphadenectomy were 78% for the transperitoneal approach, 93% for the bilateral extraperitoneal approach, and 95% for the left extraperitoneal approach. Conversion from extraperitoneal to transperitoneal laparoscopic paraaortic lymphadenectomy, because of a peritoneal tear, was necessary in 3 cases (21.4%) for the bilateral extraperitoneal route and in 3 cases (14.3%) for the left extraperitoneal route (P = 0.43). The extent of dissection varied with experience. Systematic paraaortic lymphadenectomy (up to the left renal vein) was performed via the transperitoneal route in 1 case with 19 aortic nodes removed (common iliac nodes excluded) in 160 min, via the bilateral extraperitoneal route in 6 cases with a mean of 16 +/- 2 (range: 14-19) aortic nodes removed in 153 +/- 22 min (range: 130-180), and via the left extraperitoneal route in 12 cases with a mean of 15 +/- 3 (range: 10-19) aortic nodes removed in 119 +/- 14 min (range: 100-150). There were no statistically significant differences in the total number of nodes removed between the two extraperitoneal routes, although the bilateral extraperitoneal route yielded more right-sided aortic nodes (P < 0. 01). The operating time was significantly shortened using the left extraperitoneal route (P < 0.05).

CONCLUSION

Systematic paraaortic lymphadenectomy by a left extraperitoneal route is feasible. Information on right-sided aortic nodes can be obtained although the sampling is reduced compared to that of bilateral extraperitoneal route. It provides the advantages related to the use of the extraperitoneal route while reducing manipulations and thus the risk of peritoneal tearing compared to those of the bilateral extraperitoneal route.

New development of laparoscopic ultrasound and laparoscopic pelvic lymphadenectomy in the management of patients with cervical carcinoma

OBJECTIVES

The objectives of this study were to evaluate the use of laparoscopic ultrasonography (USG) in combination with laparoscopic pelvic lymphadenectomy in the management of patients with cervical carcinoma.

METHODS

A technique for detecting pelvic and para-aortic lymph node metastases through laparoscopic USG was developed. Laparoscopic USG was done prior to pelvic lymphadenectomy performed either laparoscopically or by laparotomy. Laparoscopic USG findings were compared with pathologic findings.

RESULTS

The sensitivity and specificity of laparoscopic USG in detecting pelvic lymph node metastases were 91 and 100%, respectively. Metastatic pelvic lymph nodes could be completely removed through laparoscopes in 7 of 11 patients, with no complications.

CONCLUSION

Laparoscopic USG is highly sensitive in detecting metastatic pelvic lymph nodes. Detection and removal of metastatic pelvic lymph nodes laparoscopically allow quick recovery from the operation and early commencement of radiotherapy.