Retrocrural Lymph Node Metastasis Disclosed by (18)F-FDG PET/CT: A Predictor of Supra-diaphragmatic Spread in Ovarian Cancer

Management of chylothorax after retrocrural lymphadectomy in a patient with ovarian cancer: a case report

Introduction and importance

With the widespread use of positron emission tomography and computed tomography (PET/CT), a significantly greater proportion of patients with advanced ovarian cancer (OC) are now diagnosed with superior renal-vein lymph node metastases involving retrocrural and mediastinal nodes. To the authors' knowledge, retrocrural lymphadenectomy has not yet been reported in patients with OC. The authors performed retrocrural lymph node resection in a patient with ovarian cancer.

Case presentation

A 64-year-old woman with ovarian cancer who had not undergone surgery upon initial diagnosis was admitted to the authors' hospital because tumour markers increased during bevacizumab maintenance therapy. PET/CT imaging revealed adnexal masses and multiple metastases in pelvic, para-aortic, retrocrural, and mediastinal lymph nodes. Reduction surgery was performed, and retrocrural lymph nodes were excised. However, the patient's postoperative course was complicated by a chylothorax. Because of the failure of conservative treatment, interventional embolization was performed, but failed to obstruct lymphatic vessels. The patient underwent reoperation. A fistula was located where Hem-o-lock clips penetrated the pleura, clearly indicating the injury site, which was then sutured and embedded in the surrounding diaphragmatic tissue and filled with gel sponge. The patient recovered from chylous leakage postoperatively. She later underwent chemotherapy and targeted maintenance therapy.

Clinical discussion

The authors may have injured the communicating branch of the thoracic duct posterior to the diaphragm during the first operation and did not ligate it. The accumulated chylous fluid finally penetrated through the weak point on the pleura and led to chylothorax 3 days later. If conservative treatment or interventional embolization are unsuccessful, surgical treatment should be selected in time.

Conclusion

The location of the retrocrural lymph node at the anastomosis of the chylous cistern and the thoracic duct may pose a significant risk of chylous leakage as a complication of lymphadenectomy. Full exposure of the surgical field and thorough ligation of the lymphatic vessels may lead to successful superior renal-vein lymphadenectomy.

Neglected Anatomical Areas in Ovarian Cancer: Significance for Optimal Debulking Surgery

Ovarian cancer (OC), the most lethal gynecological malignancy, usually presents in advanced stages. Characterized by peritoneal and lymphatic dissemination, OC necessitates a complex surgical approach usually involving the upper abdomen with the aim of achieving optimal cytoreduction without visible macroscopic disease (R0). Failures in optimal cytoreduction, essential for prognosis, often stem from overlooking anatomical neglected sites that harbor residual tumor. Concealed OC metastases may be found in anatomical locations such as the omental bursa; Morison's pouch; the base of the round ligament and hepatic bridge; the splenic hilum; and suprarenal, retrocrural, cardiophrenic and inguinal lymph nodes. Hence, mastery of anatomy is crucial, given the necessity for maneuvers like liver mobilization, diaphragmatic peritonectomy and splenectomy, as well as dissection of suprarenal, celiac, and cardiophrenic lymph nodes in most cases. This article provides a meticulous anatomical description of neglected anatomical areas during OC surgery and describes surgical steps essential for the dissection of these "neglected" areas. This knowledge should equip clinicians with the tools needed for safe and complete cytoreduction in OC patients.

Chylothorax after Retrocrural Lymphadectomy and Consideration of Ultraradical Surgery in Ovarian Cancer: A case report.. [DOI: 10.21203/rs.3.rs-2960465/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Purpose: Retrocrural lymph node resection has not yet been reported in patients with ovarian cancer. We tried to do so. Patients and Methods: This report presents one ovarian cancer patient, complicated by multiple distant lymph node metastases in PET/CT imaging. Ovarian cancer reduction surgery was performed, and retrocrural lymph nodes were removed. However, the patient developed a chylothorax after surgery. Thoracotomy was performed after failed interventional therapy and a clear leakage point was identified. Subsequently, the peripheral diaphragm was sutured and filled with gel sponge. Results: The chylothorax was cured, and the patient continues to receive chemotherapy. Conclusions: There is a critical need to identify an effective approach to perform systemic R0 surgery with fewer complications.

Ovarian cancer reporting lexicon for computed tomography (CT) and magnetic resonance (MR) imaging developed by the SAR Uterine and Ovarian Cancer Disease-Focused Panel and the ESUR Female Pelvic Imaging Working Group

OBJECTIVES

Imaging evaluation is an essential part of treatment planning for patients with ovarian cancer. Variation in the terminology used for describing ovarian cancer on computed tomography (CT) and magnetic resonance (MR) imaging can lead to ambiguity and inconsistency in clinical radiology reports. The aim of this collaborative project between Society of Abdominal Radiology (SAR) Uterine and Ovarian Cancer (UOC) Disease-focused Panel (DFP) and the European Society of Uroradiology (ESUR) Female Pelvic Imaging (FPI) Working Group was to develop an ovarian cancer reporting lexicon for CT and MR imaging.

METHODS

Twenty-one members of the SAR UOC DFP and ESUR FPI working group, one radiology clinical fellow, and two gynecologic oncology surgeons formed the Ovarian Cancer Reporting Lexicon Committee. Two attending radiologist members of the committee prepared a preliminary list of imaging terms that was sent as an online survey to 173 radiologists and gynecologic oncologic physicians, of whom 67 responded to the survey. The committee reviewed these responses to create a final consensus list of lexicon terms.

RESULTS

An ovarian cancer reporting lexicon was created for CT and MR Imaging. This consensus-based lexicon has 6 major categories of terms: general, adnexal lesion-specific, peritoneal carcinomatosis-specific, lymph node-specific, metastatic disease -specific, and fluid-specific.

CONCLUSIONS

This lexicon for CT and MR imaging evaluation of ovarian cancer patients has the capacity to improve the clarity and consistency of reporting disease sites seen on imaging.

KEY POINTS

• This reporting lexicon for CT and MR imaging provides a list of consensus-based, standardized terms and definitions for reporting sites of ovarian cancer on imaging at initial diagnosis or follow-up. • Use of standardized terms and morphologic imaging descriptors can help improve interdisciplinary communication of disease extent and facilitate optimal patient management. • The radiologists should identify and communicate areas of disease, including difficult to resect or potentially unresectable disease that may limit the ability to achieve optimal resection.

Metastatic retro-crural lymph nodes from transitional cell carcinoma of bladder successfully treated with single session cryoablation

Bladder cancer (BC) is a relatively common tumor, with a male preponderance. High-grade muscle invasive bladder cancer (MIBC) has a very high incidence of pelvic lymph node metastasis at presentation. Involvement of the retro-crural lymph nodes, although has been described in other pelvic tumors, is very uncommon for BC. Cryoablation in the retro-crural region is extremely challenging due to the proximity to the critical structures like inferior venacava and aorta and has not been extensively reported. We describe a 56-year old male patient with MIBC who underwent extensive treatments including radical cystoprostatectomy, chemoradiation and immunotherapy, ultimately with localized disease in the retro-crural region. Single session cryoablation of these lymph nodes was performed with a curative intent yielding a positive response that has persisted for more than 2 years.

Behavior of FDG-avid supradiaphragmatic lymph nodes in PET/CT throughout primary therapy in advanced serous epithelial ovarian cancer: a prospective study

BACKGROUND

Epithelial ovarian cancer (EOC) typically spreads intra-abdominally, but preoperative evaluation with FDG PET/CT often reveals metabolically active supradiaphragmatic lymph nodes (sdLNs). Their clinical significance and behavior during treatment has not been established.

METHODS

EOC patients with PET positive sdLNs at diagnosis were prospectively followed with PET/CT after primary chemotherapy and at the first recurrence. In each patient, 2 most active LNs in 5 different supradiaphramatic regions were evaluated and the size and changes in FDG uptake (SUVmax) were recorded. The patients´ overall response to primary treatment was defined with RECIST criteria. The behavior of sdLNs during chemotherapy were compared in treatment responders and non-responders. Recurrence patterns were monitored.

RESULTS

Forty-one patients with 127 PET/CT scans were systematically evaluated. In pretreatment scan, 76% (31/41) of patients had FDG-avid sdLNs in multiple anatomical sites. Only a minority (22/136) of the sdLNs were enlarged in size, but their histopathologic confirmation by biopsy was not possible. Only 6/41 patients had FDG-avid sdLNs in a single surgically approachable site. The sdLNs became inactive during primary chemotherapy more often in the RECIST responders compared to the non-responders (HR 1.46 (95%CI: 1.09-1.96), p = 0.002). The size and SUVmax values did not predict treatment outcome. In 50% of the responders the same sdLNs reactivated when recurrence occurred. Persistent post-treatment metabolic activity did not predict earlier disease relapse (p = 0.59).

CONCLUSION

The behavior of metabolically active sdLNs during chemotherapy supports their metastatic nature. Due to their distribution to multiple regions, the benefit of removal of reachable sdLNS seems unlikely.

TRIAL REGISTRATION

NCT, NCT01276574 . Registered 1 September 2010.

Diagnostic value of positron emission tomography (PET) and PET/computed tomography in recurrent/metastatic ovarian cancer: A meta-analysis

AIM

The study was conducted to assess and compare the overall diagnostic value of positron emission tomography (PET) alone and PET/computed tomography (CT) for the detection of recurrent/metastatic ovarian cancer.

METHODS

A systematic literature search in PubMed, EMBASE and Chinese literature databases (CNKI, VIP and Wanfang) up to August 2014 was performed to identify relevant articles. The diagnostic performance of PET alone or PET/CT was assessed in terms of the following evaluation indexes: summary sensitivity, specificity, positive and negative likelihood ratio, diagnostic odds ratio and area under the curve summary receiver operating characteristics.

RESULTS

Sixty-four studies with 3722 patients were included in this meta-analysis. Favorable results were obtained for both PET/CT and PET alone with similar sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio and area under the curve in diagnosing recurrent/metastatic ovarian cancer (P > 0.05). However, the sensitivity of PET/CT was significantly higher than PET alone in European patients.

CONCLUSIONS

Both PET and PET/CT have promising diagnostic value in recurrent/metastatic ovarian cancer. The diagnostic performance of PET/CT may be superior to PET alone in European patients.

Prognostic implication of retrocrural lymph node involvement revealed by (18)F-FDG PET/CT in patients with uterine cervical cancer

OBJECTIVES

Lymph node involvement in cervical cancer is an indication of poor prognosis and the risk tends to increase according to the level of lymph node involvement. However, the specific prognostic significance of retrocrural lymph node involvement has not been well characterized because of its small size and deep location. The aim of this study was to assess its prognostic value.

PATIENTS AND METHODS

A total of 217 patients with newly diagnosed International Federation of Gynecology and Obstetrics (FIGO) stage IA2-IVA cervical cancer were retrospectively enrolled. All the patients had undergone pretreatment (18)F-fluorodeoxy-D-glucose ((18)F-FDG) PET/CT. Of these patients 145 were treated with concurrent chemoradiotherapy, and in this group we assessed the relationship of retrocrural lymph node involvement with the risk of disease progression.

RESULTS

Retrocrural lymph node involvement was seen in 7.4% of patients (16/217). All of them had para-aortic lymph node involvement and 56% of the 16 patients (9/16) had concomitant supraclavicular lymph node involvement. In the patients treated with concurrent chemoradiotherapy it was found that the higher the level of (18)F-FDG-positive lymph nodes detected in them, the worse the progression-free survival experienced by them (none vs. pelvic, pelvic vs. para-aortic, para-aortic vs. retrocrural; P<0.05); however, there was no difference in progression outcome between retrocrural and supraclavicular areas (P=NS). On multivariate Cox proportional hazard analysis, the highest level of (18)F-FDG PET/CT-positive lymph nodes in the para-aortic [hazard ratio (HR) 6.05, 95% confidence interval (CI) 2.18-16.81], retrocrural (HR 17.05, 95% CI 5.34-54.44), and supraclavicular areas (HR 19.56, 95% CI 7.15-53.54) was a significant prognostic factor.

CONCLUSION

The highest level of lymph node involvement in para-aortic, retrocrural, supraclavicular areas was a significant prognostic factor for progression in uterine cervical cancer patients who were treated with concurrent chemoradiotherapy. Retrocrural lymph node involvement shows a similar outcome with supraclavicular involvement, but leads to a worse outcome in terms of progression compared with para-aortic lymph node involvement.