Reduction/prevention of lower extremity lymphedema after pelvic and para-aortic lymphadenectomy for patients with gynecologic malignancies

BACKGROUND

Lower extremity lymphedema (LEL) is a serious complication caused by lymphadenectomy in patients with gynecologic malignancies. In this study, we evaluated the effect of preserving the circumflex iliac lymph nodes (CILNs), i.e., the most caudal external iliac lymph nodes, for the prevention and reduction of LEL by comparing two groups of patients, one in which CILN were removed and the other in which CILNs were preserved.

METHODS

We retrospectively reviewed 329 patients with gynecologic malignancies who had undergone abdominal complete systematic pelvic and para-aortic lymphadenectomy. The patients were divided into nonpreserved (n = 189) and preserved (n = 140) groups, depending on whether CILNs were removed. Primary outcome measures included the incidence and severity of LEL.

RESULTS

The incidence of LEL was significantly lower in the preserved group than in the nonpreserved group (P < 0.0001). The frequency of LEL was also significantly lower in the preserved group than in the nonpreserved group regardless of the range of pelvic and para-aortic lymphadenectomy (P < 0.0001). LEL in the overwhelming majority of cases in the preserved group was mild, and no patients experienced severe LEL. Further, the incidence of cellulitis was 0% in the preserved group, while it was 12.7% in the nonpreserved group (P < 0.0001). Lymphoscintigraphy revealed collateral pathways from the preserved CILN along the iliac and large abdominal vessels.

CONCLUSIONS

This method of lymph node preservation is a simple and extremely effective approach for preventing/reducing LEL after pelvic and para-aortic lymphadenectomy for patients with gynecologic malignancies.

Retrospective analysis of two modes of lymphadenectomy (para-aortic + pelvic vs. pelvic alone) with regard to survival in endometrial cancer: A comparative study of two gynecologic units

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Background: Patients with endometrial cancer are at high risk of severe post-operative complications because of obesity, diabetes mellitus, and hypertension. The purpose of this study is, for minimizing surgical injury, to determine whether para-aortic lymph nodes dissection is dispensable. Methods: 295 patients received hysterectomy and lymphadenectomy during 1995 - 2005 in two gynecologic units of hospitals, one of where para-aortic lymph nodes (to the level of renal vein) and pelvic lymph node (PAN+PLN) dissection were routinely performed and the other only pelvic lymph node (PLN) were dissected, were enrolled. Their overall survival was retrospectively compared between these units. Results: Mean lymph node count was 58.9±19.7 in 99 patients with PAN+PLN lymphadenectomy, and 36.8±14.6 in 196 patients with PLN alone. 5-year survival was 93.3% in PAN+PLN cases and 92.9% in PLN, with no significant difference. Cases who died of the disease (DD) were 6.1% in PAN+PLN and 9.2% in PLN (relative risk = 0.660). Distribution in each stage was ignorable between two units; however, specific histology types, such as serous, clear cell, and carcinosarcoma, were highly counted in DD of the PLN unit. 5-year survival of only endometrioid type, excluding specific histology types, was 92.9% in PAN+PLN and 95.1% in PLN, and DD were 6.6% in PAN+PLN and 6.0% in PLN (RR = 1.095). Lymph node metastases were found 13.1% in PAN+PLN and 4.1% in PLN. One case was observed PAN-alone metastsis, where histology was serous type. Conclusions: Overall survival in patients received PAN+PLN and PLN dissection is not significantly different in endometrial cancer. It is supposed that only PLN dissection is sufficient and PAN dissection is omittable especially in endometrioid type, however, PAN+PLN lymphadenectomy might be suggestive to reduce death in specific histology types.

No significant financial relationships to disclose.

[Anesthetic management of a patient with amyotrophic lateral sclerosis]

A 49-year-old male with amyotrophic lateral sclerosis (ALS) was scheduled for gastrectomy. Anesthetic management was performed under general anesthesia with sevoflurane and epidural anesthesia with lidocaine. He showed increased response to vecuronium under monitoring of neuromuscular block. But he responded favorably to anticholineesterase. He had little pain and showed no progress in neurological symptoms in the postoperative period. Neuromuscular monitoring is essential in administrating non-depolarizing neuromuscular blocking agents to patients with ALS, and epidural anesthesia may be useful for perioperative management of patients with ALS.

Auditory stimuli as a major cause of syncope in a patient with idiopathic long QT syndrome

A 35-year-old woman was hospitalized due to frequent attacks of syncope immediately after the ringing of a bell or alarm clock. Her standard electrocardiograms showed a long QT interval (QTc = 0.56 s) with a bizarre T-wave inversion in precordial leads. After admission, a total of 9 events of syncope were observed. Malignant ventricular tachyarrhythmia (torsade de pointes, ventricular flutter or fibrillation) was recorded during each episode, and DC shock was required to abolish such tachyarrhythmias on 3 occasions. On monitored electrocardiograms, an additional 8 events of ventricular tachycardia without syncope were also detected. Auditory stimuli appeared to be involved in the initiation of malignant ventricular arrhythmia. Immediately after auditory stimuli, changes in the QT interval and T-wave morphology resulted in ventricular premature beats, leading to ventricular tachycardia. The episodes of syncope or malignant ventricular arrhythmia were frequently observed early in the morning and near midnight. She had been treated with various types of antiarrhythmic agents, and propranolol was the most effective in preventing ventricular arrhythmia. These findings indicate that auditory stimuli may cause ventricular arrhythmia and subsequent cardiac syncope, or even sudden cardiac death, in some patients with long QT syndrome.

Effects of acetyl salicylic acid and cilostazol administration on serum thrombomodulin concentration in diabetic patients

Serum thrombomodulin (sTM) is an endothelial cell marker which would reflect the endothelial damage. In order to examine whether some antiplatelet agents decrease the endothelial damage in diabetic patients, sTM concentrations were measured by enzyme-linked immunosorbent assay before and after oral administration of a daily 100 mg of cilostazol for 4 weeks in 9 diabetics or a daily 81 mg of acetyl salicylic acids (ASA) for 4 weeks in 8 diabetics. Basal concentrations of sTM were elevated in most of these patients as compared with healthy subjects. The sTM concentrations were decreased after administration of cilostazol from 28.1 +/- 7.1 ng/ml to 23.6 +/- 5.4 ng/ml (p < 0.01), and after ASA from 30.7 +/- 10.9 ng/ml to 27.9 +/- 11.6 ng/ml (p < 0.05). These results suggest that such drugs can decrease the endothelial damage, resulting in the reduced risk of diabetic vascular complications.