2. Gynecologic cancers represent a major global
healthcare problem since they are associated with a
significant mortality and morbidity.
Endometrial, ovarian and cervical cancers:
*Represent 95% of all gynecologic cancers.
* Collectively rank fourth among women’s cancers in
both incidence and mortality.
* Account for 14% of cases and 11% of deaths from
solid tumors in women.
3. In 2008 (the most recent year numbers are available):
* 83,662 women in the United States were diagnosed
with a gynecologic cancer.
* 27,813 women in the United States died from a
gynecologic cancer.
4. Cancer of the endometrium is the most common
cancer of the female reproductive organs.
It is estimated that 47,130 new cases of endometrial
cancer will be diagnosed in the U.S. in 2012, and about
8,010 women will die from endometrial cancer.
5. Ovarian cancer is the eighth most common cancer
among women.
It is estimated that about 22,280 new cases of ovarian
cancer will be diagnosed in the U.S. in 2012.
Ovarian cancer accounts for 3 percent of all new
cancers in women and causes more deaths than any
other cancer of the female reproductive system.
It is estimated that there will be about 15,500 deaths
from ovarian cancer during 2012.
6. The mortality rates for cervical cancer have declined
sharply as Pap screenings have become more
prevalent.
About 12,170 cases of invasive cervical cancer will be
diagnosed in the U.S. during 2012.
It is estimated that 4,220 women will die from cervical
cancer during 2012.
7. Gynecologic cancers tend to metastasize to
the distant organs through lymph channels.
Therefore, dissection of the regional lymph
nodes is considered as a part of the
standard surgery for gynecologic cancer.
There is no question that evaluation of
lymph node status provides important
prognostic information.
8. Unfortunately, MRI, CT , PET and
lymphangiography have low accuracy in
the evaluation of lymph nodes and do not
detect lymph node metastases measuring
< 10 mm.
Therefore, systematic lymphadenectomy
is the only procedure that facilitates an
accurate and thorough evaluation of
lymph node status.
9. Pelvic lymphadenectomy is defined as complete vessels
skeletonization from all lymph node bearing fat tissue
caudal to the circumflex iliac vein to the aortic bifurcation
including: the common iliac, external iliac, internal iliac,
obturator, parametrial, and the sacral lymph nodes.
10. Para-aortic lymphadenectomy was defined as skeletonization of
the nodes lateral to the vena cava, aorto-caval nodes, and nodes
lateral to the aorta from the bifurcation of the aorta to the level of
the left renal vein.
12. Common iliac lymph nodes. (a) Axial contrast material–enhanced computed tomographic (CT)
image and (b) volume-rendered reformation of contrast-enhanced CT image show locations of named
subgroups of common iliac lymph nodes: 1 = lateral, 2 = medial, 3 = middle. The relationship of these node
locations to common iliac artery (a) and vein (v) can be seen.
13. External iliac lymph nodes. (a) Axial contrast-enhanced CT image and (b) volume-rendered
reformation of contrast-enhanced CT image show location of named subgroups of external iliac lymph nodes:
1 = lateral, 2 = middle, 3 = medial (including obturator). The relationship of these node locations to external
iliac artery (a) and vein (v) can be seen.
14. Internal iliac lymph nodes. (a) Axial contrast-enhanced CT image and (b) volume-rendered
reformation of contrast-enhanced CT image show location of named subgroups of internal iliac lymph nodes:
1 = lateral sacral, which are adjacent to lateral sacral artery (arrow); 2 = presacral; 3 = anterior, which are
anterior to anterior division of internal iliac artery (arrowhead); 4 = hypogastric.
15. Lymphadenectomy for early ovarian
cancer:
According to the FIGO classification,
FIGO stage IIIc is defined by the presence
of pelvic or para-aortic lymph node
metastasis.
An accurate staging is mandatory for the
indication of adequate adjuvant
chemotherapy.
16. Many lymph node metastases are present
in non-bulky nodes and have a diameter
measuring uncommonly no more than 2
mm, so that palpation of lymph node
metastasis is not a safe evaluation
method.
17. Recently, in regard to the SEER
database, Chan and coworkers
reported a significant association of
lymphadenectomy and overall survival
in stage I ovarian cancer patients.
18. So in early stage ovarian cancer,
systematic lymph node dissection is
required in order to perform accurate
clinical staging and to select an adequate
adjuvant systemic chemotherapy.
Nevertheless, the effect of lymph node
dissection on progression-free survival
and on overall survival is still unclear.
19. Recently, Ditto et al;2012 demonstrated the
prognostic value of lymphadenectomy in
eEOC. Menopause, age, bilaterality,
histology, and tumor grade are identifiable
factors that can help the surgeon decide
whether to perform comprehensive surgical
staging with lymph node dissection.
These parameters may be used in planning
subsequent treatment.
20. Lymphadenectomy for advanced
ovarian cancer:
According to the FIGO classification,
tumour masses larger than 2 cm, or the
presence of lymph node metastasis lead to
stage IIIc.
But FIGO IIIc based only on lymph node
involvement is associated with a better
outcome than is true intraperitoneal FIGO
IIIc.
21. For advanced ovarian cancer with
minimal tumor residuals of up to 10 mm,
it can be concluded that systematic lymph
node dissection will produce a significant
benefit in progression-free survival, but
not in overall survival when compared to
lymph node sampling only.
22. Today, for patients without any visible
postoperative tumor residuals many
guidelines recommend, that systematic
lymph node dissection should be
performed despite the lack of evidence
from randomized trials. Therefore, the
conduction of prospective studies is really
warranted.
23. Recently, Chang et al; 2012
concluded that systematic
lymphadenectomy in stage IIIc
EOC may have a therapeutic value
and be significantly associated with
improved survival in patients with
grossly no visible residual disease.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40. Lymphadenectomy for endometrial
cancer:
In approximately 10% of women with endometrial cancer,
lymph node metastases can be found.
There is a lack of consensus on the extent of surgical
staging in endometrial carcinoma. The ability of surgical
staging to accurately identify lymphatic spread and how
this information affects prognosis and alters the use of
adjuvant therapies are a source of controversy.
41. Pelvic and Para-aortic LN dissection recommendation
is based on nonrandomized retrospective studies
reporting of prolonged survival after
lymphadenectomy.
Systematic para-aortic lymphadenectomy is advocated
on all high-risk patients, or in patients with two or
more positive pelvic lymph nodes.
42. The most frequent form of endometrial
carcinoma
(stage I, G1, G2, endometroid type,
MI<50%) can be cured in more than 90%
by hysterectomy and bilateral
adnexectomy alone.
It is very unlikely that lymphadenectomy
can further improve survival time.
43. A radical procedure with pelvic and para-
aortic lymphadenectomy would be
overtreatment for this group of women,
leading to an unnecessary impairment of
quality of life for a carcinoma with
otherwise good prognosis.
44. The strongest argument for routine
lymphadenectomy is the avoidance of pelvic
radiation therapy following thorough nodal
assessment and confirmation of node-
negative disease and low risk status.
45. In an attempt to avoid complete lymphadenectomy,
the concept of sentinel node identification has been
investigated in endometrial carcinoma.
Data are scant, and studies are still addressing
feasibility and standardization of technique.
Certain issues regarding the primary tumor and the
patterns of lymphatic drainage make sentinel lymph
node biopsy for endometrial carcinoma less practical.
46. First, the lymphatic drainage of the uterus is
considerably more complicated than that of the vulva
and cervix.
Second, there is no easily accessible or visible lesion in
endometrial cancer as there is in vulvar or cervical
cancers, making injection difficult.
Third, the variation of reported locations of sentinel
nodes ranges from the parametrium to the para-aortic
region on either side of the body.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60. Lymphadenectomy for cervical cancer:
The status of the regional lymph nodes is
one of the most important prognostic
factors for cervical cancer.
We have to consider that the mainstay of
detecting lymph node metastasis is still
the histologic evaluation, therefore
resection of lymph nodes remains a crucial
surgical step when treating cervical cancer.
61. In the Gynecologic Oncology Group’s
(GOG) surgical-pathology study of
patients with IB cervical cancer, the 3-
year disease free interval was 74% for
those with positive nodes versus 86% for
node negative patients.
Other studies have suggested that
survival decreases with the number of
positive nodes.
62. Recently, some studies suggested that the
extent of lymphadenectomy performed for
women with early-stage cervical cancer
influences survival.
Among node-negative women, survival is
improved when a greater number of lymph
nodes are removed.
63. There is no consensus about the extent of para-aortic
lymph node dissection in these patients.
Relevant literature to determine the extension of para-
aortic lymphadenectomy in patients with cervical
cancer in order to establish whether lymph node
dissection up to the inferior mesenteric artery or
higher to the level of renal vessels should be
performed,indicated that no need to perform
dissection above the level of IMA.
64. Eiriksson and Covens; 2011 believe that sentinel
lymph node mapping should become the standard
over conventional pelvic lymphadenectomy.
The status of regional lymph nodes is accurately
represented by the status of the sentinel lymph node.
Consequently, adverse events associated with complete
lymphadenectomy can be significantly decreased with
sentinel lymph node biopsy alone, where the risk of
lymphoedema, sensory loss, and operative time have
been reduced, whereas quality of life is significantly
enhanced
65. A chief concern in the adoption of the sentinel lymph
node concept is the rate of false negatives. This
apprehension is well founded, as unidentified
lymphatic metastases, left untreated, present an
increased risk of recurrence and consequently an
increased morbidity of attempted salvage, when
salvage is possible.
However, with strict definitions and criteria for the
implementation of sentinel lymph node mapping,
false-negative rates have proven to be minimal.
66. Studies have demonstrated that sentinel lymph nodes
are less likely to be identified if the tumour size is
greater than 2 cm.
1-Obstruction of cervical stromal lymphatic channels.
2-Complete involvement of the sentinel lymph nodes by
tumor.
3-Large tumors replacing the exocervix (the tracer must
be injected into normal cervical stroma).
4-The use of neo-adjuvant chemotherapy may also
decrease sentinel lymph node detection.
5-Prior cervical conisation may distort the cervix,
thereby complicating tracer injection;
67. The combined use of tracers and ultrastaging, the
sensitivity of sentinel lymph node mapping is superior to
complete lymph node dissections. In due course, as has
been seen in the staging of breast cancer,
malignant melanoma, and vulvar cancer,
Eiriksson and Covens; 2011 anticipate that sentinel
lymph node mapping will become the standard of care,
replacing pelvic lymphadenectomy in the surgical
management of early-stage cervical cancer.
68. Complications
An extensive para-aortic lymphadenectomy
significantly increases operating time and blood loss
and also increases postoperative morbidity,
particularly lower limb lymphoedema (in about 20% of
patients).
Lymphoedema is often complicated by recurrent
episodes of cellulitis.
It could thus be argued that primary prevention of
lymphoedema by selective use of pelvic
lymphadenectomy and avoidance of systematic para-
aortic lymphadenectomy is highly desirable.
69. Lymphatic ascites is an under recognized and
infrequently reported postoperative complication.
Although it usually resolves spontaneously or with
conservative management without sequelae, this
condition can significantly prolong postoperative
recovery and cause patient discomfort.
70. Frey et al, 2012 reviewed the charts of 300 patients who
underwent lymphadenectomy as part of the surgical
management for a gynecologic cancer.
12 patients with lymphatic ascites were identified (4%).
The most common reported symptom was leakage of clear
fluid per vagina (7, 58%), followed by abdominal
distension (4, 33%).
The median interval from surgery to development of
symptoms was 12.5 days (range 0-22 days).
5 patients had complete resolution of symptoms with
dietary modifications alone while 7 patients required
paracentesis.
The median time from surgery to resolution of symptoms
was 44 days (range 9-99).
71. Para-aortic lymph node dissection may be associated
with postoperative chylous ascites.
Patients may have their chylous ascites successfully
treated with conservative management.
An abdominal drainage tube can be a simple and
effective approach and should be considered in the
treatment.
72. Han et al; 2012 retrospectively reviewed the cases of 4119
patients who underwent pelvic and/or para-aortic lymph
node dissection for gynecologic malignancies in Fudan
University-China.
7 (0.17%) patients had chylous ascites postoperatively.
The incidence of chylous ascites after para-aortic
lymphadenectomy was approximately 0.32% (5/1540),
whereas the rate after pelvic lymphadenectomy alone was
0.077% (2/2579).
All cases with chylous ascites were resolved by conservative
treatment. This included placement of a peritoneal
drainage tube.
The mean time to resolution was 13 days (range, 2-28 days).
None of the cases had recurrent chylous ascites during
follow-up
73. Our own experience
A study included 86 patients with cervical,
endometrial and ovarian malignancies
Eighteen patients were included with cervical
carcinoma
Inclusion criteria: Patients with stage (Ib-IV)
squamous and adenocarcinoma of the cervix.
Surgical procedure: Radical hysterectomy and bilateral
pelvic and paraaortic Lymphadenectomy.
74. Thirty nine patients were included with endometrial carcinoma.
Inclusion criteria: Patients with stage (I-IV).
Surgical procedure: Total abdominal or radical hysterectomy,
bilateral salpingo-oophorectomy, peritoneal cytology, and
bilateral pelvic and para-aortic lymphadenectomy.
Twenty nine patients were included with ovarian carcinoma.
Inclusion criteria: Patients with stage (I-IV) primary epithelial
ovarian carcinoma
Surgical procedure: Total abdominal hysterectomy,bilateral
salpingo-ophorectomy, omentectomy, peritoneal cytology and
bilateral pelvic and para-aortic lymphadenectomy
75. SUMMARY
I- Cervical Cancer:
No isolated PALN metastasis was diagnosed. Therefore, our
results suggest that PALN metastasis occurs secondarily to
extensive lymphatic metastasis in the pelvic area.
The most common sites of PLN metastasis were external
iliac and parametrial then obturator PLNs, this confirming
that paracervical tissue is a major route of spread of cervical
cancer.
pelvic or paraaortic lymph nodes metastasis was absent in
early stage cervical carcinoma.
76. PLN and PALN metastases were significantly
correlated with lymph nodes enlargment.
Vaginal, parametrial and cervical stromal invasion
were significantly correlated to pelvic and paraaortic
lymph nodes metastases.
Postoperative treatment plan tailored according to
PLN and PALN dissection.
Intra and post-operative complications were minimal.
77. II- Endometrial Cancer:
The most commonly involved PLN groups were
internal iliac and obturator groups so that the
principal connections are between the uterine
corpus and the internal iliac and obturator basins.
Isolated paraaortic lymph nodes metastasis was
noticed in 7.7% of patients. so, a direct route may
exist from the corpus to the para-aortic node-
bearing basins.
pelvic or paraaortic lymph nodes metastasis in
advanced stage (III and IV) was significantly
higher than early stage carcinoma (I and II)
78. PLN and PALN metastases were significantly
correlated with lymph nodes swelling . But, we
can't exclude formal LNs dissection depending on
palpation only because of that non palpable LNs
showed 8.7% and 4.3% positive PLN and PALN
metastasis rates respectively so microscopic
metastases can be missed.
33.3% of patients with PALN metastasis were with
tumor grade 1 and 2, so even patients with low
grade carcinoma have a chance of presence of PLN
or PALN metastasis.
Surgical morbidity was minimal.
79. III- Ovarian Cancer:
No isolated PLN metastasis was found. Therefore,
aortic nodal metastases are the initial route for the
spread of EOC, with the pelvic nodes constituting a
second metastatic site.
The most commonly involved aortic group was the
preaortic (supra and inframesentric). Therefore,
PALN dissection must be up to the level of left renal
vein.
80. Lymph nodes metastasis was only detected in
advanced stage disease (stage III or IV). Therefore,
debulking surgery should include pelvic and
paraaortic lymphadenectomy to remove
retroperitoneal tumor sites.
Peritoneal metastasis, omental involvement and
presence of ascites were significantly correlated with
PALN metastasis. So, nodal metastasis increases with
intraperitoneal dissemination.
81. CONCLUSIONS
Cervical Cancer:
In early stage carcinoma, formal paraaortic
lymphadenectomy can be avoided in patients with
small early stage tumors, or can be accompanied by
PALN sampling inferior to IMA.
In advanced carcinoma, surgical staging including
formal pelvic and paraaortic lymph nodes dissection
should be done to provide important information
about postoperative treatment planning and
prognosis.
82. Endometrial Cancer:
Complete pelvic and para-aortic lymphadenectomy
should be done in all patients with endometrial
carcinoma. This will facilitate the accurate
determination of the type and extent of adjuvant
therapy.
83. Ovarian Cancer:
•In early-stage ovarian cancer, formal pelvic and
paraaortic lymph node dissection is necessary for
accurate staging which can help to avoid
unnecessary postoperative adjuvant therapy.
•In advanced ovarian cancer, lymphadenectomy is
an important step for optimal surgical debulking.
•In general, Lymphadenectomy is safe operation
with minimal surgical morbidity.
