José M. Martínez-Palones

Sentinel Lymph Node Identification and Radical Hysterectomy with Lymphadenectomy in Early Stage Cervical Cancer: Laparoscopy Versus Laparotomy

STUDY OBJECTIVE To estimate the feasibility and results of sentinel lymph node identification and radical hysterectomy with pelvic lymphadenectomy entirely completed by laparoscopy versus laparotomy in early stage cervical cancer. DESIGN Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2). SETTING Acute care, teaching hospital. PATIENTS From September 2000 through January 2005, 50 consecutive patients with International Federation of Gynecology and Obstetrics stage IA2, IB1, and IIA disease less than 4 cm underwent radical hysterectomy and lymphadenectomy with intraoperative sentinel lymph node biopsy. INTERVENTIONS The operation was performed entirely by laparoscopy in 20 patients and using the conventional abdominal approach in 30. Feasibility of sentinel lymph node identification, surgical morbidity, overall survival, and recurrence rate-free survival in both groups were compared. MEASUREMENTS AND MAIN RESULTS The overall detection rate of the sentinel lymph node was 100% (false negative 0%). A mean of 2.50 sentinel nodes/patient was detected in the laparotomy group compared with a mean of 2.55 nodes in the laparoscopic group (p=.874). Bifurcation of the right common iliac artery was the most frequent nodal location. Blood loss and length of stay were significantly lower in the laparoscopic group, but surgical time was significantly longer. The median follow-up was 35 months (range 5-57) in the laparotomy group and 22.5 (range 2-52) in the laparoscopic group. Differences in overall survival and disease-free survival were not observed. CONCLUSION Sentinel lymph node identification and radical hysterectomy in the initial treatment of early stage cervical cancer can be performed safely by laparoscopy with lower morbidity and overall survival and recurrence-free survival similar to standard laparotomy.

Change in clinical management of sentinel lymph node location in early stage cervical cancer: The role of SPECT/CT

OBJECTIVE The aim of this study was to investigate the feasibility of the sentinel lymph node (SLN) identification with SPECT/CT lymphoscintigraphy imaging in the early stage invasive cervical cancer in patients undergoing radical hysterectomy and pelvic lymphadenectomy. METHODS Between March 2007 and June 2009, a prospective consecutive study was designed for SLN mapping. Twenty-two patients with cervical cancer FIGO stage IB1 (n=20) or stage IIA1 (n=2) underwent SLN identification with preoperative SPECT/CT and planar images (technetium-99m colloid albumin injection around the tumor) and posterior intraoperative detection with both blue dye and a handheld or laparoscopic gamma probe. Complete pelvic lymphadenectomy was performed in all cases by open (n=2) or laparoscopic (n=20) surgery. RESULTS In the present series, a total of 35 SLN were detected with planar images and 40 SLN were identified and well located by SPECT/CT lymphoscintigraphy (median 2.0 nodes per patient). In 5/22 patients (22.7%) SPECT/CT procedure improves the number of localized SLN. Intraoperatively, 57 SLNs were identified, with a median of 3 SLNs per patient by gamma probe (a total of 53 hot nodes) and a median of 2 nodes per patient after blue dye injection (a total of 42 blue nodes). Microscopic nodal metastases (eight nodes, corresponding to four patients) were confirmed in 18.18% of cases; all these lymph nodes were previously detected as SLN. The remaining 450 nodes, including SLNs, following complete pelvic lymphadenectomy, were histologically negative. CONCLUSIONS Sentinel lymph node detection is improved by SPECT/CT imaging because of the increased number of SLN detected and the better tridimensional anatomic location, allowing easier intra-operative detection with gamma probe and showing, in this series, a 100% negative predictive value.

Risk of recurrence during follow-up for optimally treated advanced epithelial ovarian cancer (EOC) with a low-level increase of serum CA-125 levels

BACKGROUND Our group evaluated the risk of recurrence for optimally treated advanced epithelial ovarian cancer (adEOC) in patients with a low-level rising serum CA-125 concentration within the normal range (0-35 kU/l). In addition, we tested the new proposed early CA-125 signal of progressive disease (EPD) criterion in the same study population. PATIENTS AND METHODS Patients treated from 1998 to 2006 for adEOC were identified at our institution. Inclusion criteria were as follows: CA-125 at time of diagnosis (>35 kU/l); International Federation of Gynecology and Obstetrics stages III-IV treated with optimal primary treatment; and complete response (CR) to primary treatment with normalization of CA-125. RESULTS Median progression-free survival and overall survival for the recurrence group (n = 60) were 17.7 and 38.2 months, respectively. The median follow-up time from CR to last contact was 40.2 months for patients in the nonrecurrence group (n = 36). An absolute increase in serum CA-125 levels of >or=5 kU/l compared with baseline CA-125 nadir values was significantly predictive of recurrence (odds ratio for recurrence = 402.98, P < 0.0001). The progression date was predated by the EPD criterion in 77% of patients with known progressive disease (median, 58 days early) with a sensitivity of 90%, a positive predictive value of 96.4%, and a false-positive rate of 5.6%. CONCLUSIONS Among patients with optimally treated adEOC in complete remission, a low-level increase in serum CA-125 concentration within the normal range is a strong independent predictive factor for disease recurrence. In this patient population, future prospective randomized trials should consider the evaluation of the EPD criterion.

Impact of extraperitoneal lymphadenectomy on treatment and survival in patients with locally advanced cervical cancer

During the last years, and coinciding with the beginning of the concomitant treatment with radio-chemotherapy, a better control of local cervical cancer has been reached, although failures in the systemic control of the illness have been more frequent. One of the main causes is not treating the illness at the level of the para-aortic lymph nodes, basically because their affectation is unknown and because imaging tests have a high percentage of false negative results. At this time, it is when laparoscopic para-aortic lymphadenectomy arises, in order to be able to know the extension of the illness better before treatment. A extraperitoneal laparoscopic approach is described in order to reduce complications derived from a possible extended irradiation. Between August 2001 and October 2007, a total of 69 patients with bulky and locally advanced cervical cancer (FIGO stages IB2, IIA > 4 cm and IIB-IVA) underwent extraperitoneal laparoscopic lymphadenectomy for surgical staging. Extraperitoneal aortic lymphadenectomy by laparoscopic approach is a technique with low morbidity. Special laparoscopic material is not required and if it is performed by a team trained in technical endoscopics it is not difficult. Radio-chemotherapy treatment began immediately after laparoscopy because of its minimal aggression.

Usefulness of extraperitoneal laparoscopic paraaortic lymphadenectomy for lymph node recurrence in gynecologic malignancy

Objective. The aim of this study was to evaluate the safety and feasibility of extraperitoneal laparoscopic paraaortic lymphadenectomy for suspected lymph node recurrence of gynecological cancers. Design. Descriptive study. Setting. Unit of Gynecologic Oncology of an acute‐care teaching hospital in Barcelona, Spain. Population. Between December 2002 and October 2007, eight women underwent extraperitoneal laparoscopic paraaortic lymphadenectomy for suspected lymph node recurrence, detected by magnetic resonance image (MRI), computed tomography (CT) scan or 18F‐fluorodeoxyglucose positron emission tomography (PET) scanning. The suspicious nodes were removed through an extraperitoneal laparoscopic approach. Resuts. The median age of patients was 66.5 years (range: 54–74). The median operating time was 157.5 minutes (range: 120–240). The median blood loss was 112.5 mL (range: 50–150). The mean nodal yield was 9.4±4.72 (range: 1–16). There were no intraoperative or postoperative complications. The median hospital stay was two days. Histological examination revealed metastasis in seven of eight patients. Conclusions. The extraperitoneal laparoscopic paraaortic lymphadenectomy for lymph node recurrence of gynecological cancers is a safe and feasible procedure which should be considered where there is isolated involvement of retroperitoneal lymph nodes. This procedure is a minimally invasive technique that allows an excellent approach to the paraaortic lymph nodes.