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Purpose: The survival effect of presence or absence of lymphadenectomy in early stage epithelial ovarian cancer (EOC) was priorly shown but the effect of number of removed lymph nodes kept in background. We aimed to evaluate the survival impact of number of removed lymph nodes and their localizations in stage I EOC.Methods: Study included 182 patients. Best cut-off levels for number of pelvic and para-aortic lymph nodes(PaLN) were 24 and 10, respectively. Univariate and multivariate survival analyses were performed for these cut-offs and other prognostic factors. Results: Median age of the patients was 49. Median number of removed pelvic and paraartic lymph nodes were 29 and 9, respectively. Median overall(OS) and Progression-free survival(PFS) were 67 and 50 months, respectively. The OS rate was 89.6%. Recurrence occured in 24 (19.5%) patients. In univariate analyses tumor grade(p:0.005), pelvic LN number(p:0.041) and PaLN number(p:0.004) were the factors that were significantly associated with PFS. Tumor grade and PaLN number were independently and significantly associated with PFS in multivariate analyses (p:0.015 and p:0.017, respectively). In OS analyses, age, tumor grade, presence of LVI, number of pelvic and PaLNs were the significantly associated factors (pConclusions: The number and localizations of removed lymph nodes may have a survival affect in stage I EOC. We also think that this study may constitute a kernel point for larger prospective series on lymph node number and lymphatic regions.

Previous studies have proposed 2 different contouring guidelines for the prophylactic radiation of para-aortic lymph nodes (PANs) for locally advanced cervical cancer. Because PAN-mapping atlases in current literature are limited to small patient samples and nodal populations, we updated the PAN atlas with a large data set of positron emission tomography (PET)-positive PANs on PET/computed tomography (CT) from patients with cervical cancer.We identified 176 PET-positive PANs on pretreatment PET/CT of 47 patients with diagnosed International Federation of Gynecology and Obstetrics stage IB to IVA cervical cancer. PANs were classified as left-lateral para-aortic (LPA), aortocaval (AC), or right paracaval (RPC). PAN clinical target volume (CTV) contours were drawn for all patients based on previously published guidelines by Takiar (CTV-T) and Keenan (CTV-K) and nodal volumetric coverage was assessed.We identified 94 LPA nodes (54%), 71 AC nodes (40%), and 11 (6%) RPC nodes. CTV-T had improved nodal center coverage of 97.6% compared with 85.0% for CTV-K (P.001). Nodal center coverage for CTV-K and CTV-T (with corresponding PAN) were 79 (84.0%) and 93 (99.0%) LPA nodes (P = .001), 64 (90.1%) and 68 (95.8%) AC nodes (P = .221), and 5 (45.5%) and 9 (81.8%) RPC nodes (P = .134), respectively. Additionally, our updated PAN atlas identified nodal centers anterior to the aorta and inferior vena cava that are not covered by CTV-T but covered by CTV-K due to the 10 mm anterior aortic expansion of CTV-K.We have updated the PAN anatomic map of 176 PET-positive nodes from 47 patients and demonstrated that CTV-T has significantly better PAN coverage over CTV-K for posterior LPA and retrocaval regions for our data set. Additionally, we suggest a modification that includes a blend of CTV-T and CTV-K to provide optimal coverage for the mapped nodes anterior to the great vessels in our data set.

Highlights • Postoperative chylous ascites is an important clinical issue in surgery for gynecological malignancy. • Our patient with refractory chylous ascites after surgery for tubal cancer. • She received great benefit from the microsurgical lymphaticovenular anastomosis. • The microsurgical lymphaticovenular anastomosis is the treatment of choice. • The entire procedure was performed under local anesthesia.

Purpose: To compare the utility of RapidArc® technique with mono or dual isocentre using high-definition 120 multileaf collimator (HD120™MLC) for irradiation of whole pelvis and lower para-aortic lymph node (PALN) in cervical carcinoma.Methods: Ten patients having more than 22-cm treatment target length were delivered 45 Gy in 25 fractions by RapidArc® technique using mono or dual isocenter. Dose distribution characteristics were monitored using various indices. Doses to critical organs were also compared for the sparing effects.Results: Conformity and dose-gradient indices for mono or dual isocenter plans were comparable. However, mono-isocentric plan decreased the heterogeneity index (0.07±0.01) as compared to dual-isocentric plan (0.08±0.01; p

Purpose This study evaluated the efficacy of extended field irradiation (EFI) in patients with locally advanced cervical cancer without para-aortic nodal involvement. Materials and Methods A total of 203 patients with locally advanced cervical cancer (International Federation of Gynecology and Obstetrics [FIGO] stage, IB2-IIIB) treated with radiotherapy at Keimyung University Dongsan Medical Center from 1996 to 2010 were retrospectively analyzed. The median patient age was 59 years (range, 29 to 83 years). None of the patients had para-aortic node metastases. Of the 203 patients, 88 underwent EFI and 115 underwent irradiation of the pelvis only. Concurrent chemoradiotherapy (CCRT) was administered to 133 patients. EFI field was used for treatment of 26 patients who received radiotherapy alone and 62 who received CCRT. Results The median follow-up period was 60 months. The 2- and 5-year overall survival (OS) rates were 87.8% and 73.5%, respectively, and the 2- and 5-year disease-free survival rates were 81.7% and 75.0%, respectively, however, no survival differences were observed between the two treatment field groups. EFI tended to increase OS in the radiotherapy alone group, but not in the CCRT group. Conclusion These findings suggest that EFI does not have a significant effect in patients with locally advanced cervical cancer, especially in patients receiving CCRT. Conduct of additional studies will be required in order to confirm these findings.

ObjectivePatients with cervical cancer with positive para-aortic lymph nodes have a poor prognosis. Our primary aim was to describe outcomes among this subgroup in the era of modern chemoradiation.MethodsPatients with histologically confirmed cervical cancer metastatic to their para-aortic lymph nodes diagnosed between 1998 and 2011 and treated with curative intent were included in this analysis. Surgicopathologic, demographic, and outcome data were collected. Descriptive and survival statistics were generated to evaluate overall survival (OS) and progression-free survival (PFS) and to compare outcomes by treatment.Pvalues were generated using both Wilcoxon and log-rank methods and listed respectively.ResultsThe median PFS was 19 months. The median OS was 23.4 months. The median PFS for radiation only was 14 months and for chemoradiation was 20 months (P= 0.27 and 0.60, respectively). There was no difference in median OS for the radiation-only group versus chemoradiation. The median OS stratified by stage was 32 months (stage I), 21 months (stage II), 19.4 months (stage III), and 19.8 months (stage IV;P= 0.17 and 0.22).ConclusionsOur study shows a median OS of 23 months, which is less than what was documented in the literature. Despite the use of modern chemoradiation therapy, most of the cohort died within 3 years. The low OS presented in our study highlights the limitations of the current treatment regimens and the need for identification of for more effective therapy.

This photographic review of actual dissections was compiled to demonstrate the various lymphatic pathways and their relationships to the surrounding structures to facilitate the development of QOL surgical procedures.For the purpose of demonstration, three male adult specimens, prepared with 10% formaldehyde solution injected through the femoral artery and preserved in 60% alcohol solution, were used. Dissection was carried out in typical fashion without the use of dyes or a microscope. The dissection results were recorded in sketches, photographs and video recording.Two major lymphatic pathways from the gallbladder are demonstrated: (a) the left oblique pathway to the celiac nodes, and (b) the right descending pathway to the superior retropancreaticoduodenal node (Rouvière). A third and minor pathway to the superior mesenteric nodes is suggested.These three pathways finally reach the para-aortic (lumbar) lymph nodes. The importance of the interaorticocaval nodes at the level of the left renal vein should be emphasized, in particular the significance of the nodes of the right descending pathway, from the viewpoint of surgical treatment of cancer of the gallbladder and the pancreas head.

Objective: To evaluate the usefulness of intraoperative ultrasonography (IU) for para-aortic nodes to identify women who do not require pelvic and paraaortic lymphadenectomy in ovarian carcinoma. Methods: Computed tomography (CT) was used for assessing both pelvic and para-aortic lymph nodes, and IU only for para-aortic nodes in 87 women with ovarian carcinoma. All women underwent surgery with routine systematic pelvic and para-aortic lymphadenectomy. We assumed that no lymphadenectomy had been performed when no enlarged node was detected by either CT or IU or when the woman was in T1 stage. Under these assumptions, the numbers of women who would have had missed metastases and who could have avoided lymphadenectomy were counted. These figures were recounted on the combination of T stage and IU. Results: A total of 22 women had pathological node metastases. The numbers of women with missed metastases on the basis of CT, IU, and T stage were 12, 2, 5, and these who could have avoided lymphadenectomy were 72, 39, and 49, respectively. There were more women avoiding lymphadenectomy by CT than IU and T stage; however, more women with missed node metastases. Both numbers were not significantly different between IU and T stage. On the combination of T stage and IU, 29 of 49 women in T1 stage could have avoided lymphadenectomy without missed metastases. Conclusions: IU for the para-aortic node is a useful method for identifying women who do not require lymphadenectomy for T1 stage ovarian carcinoma.

In 1998, FIGO (International Federation of Gynecologists and Obstetricians) required a change from clinical to surgical staging in early endometrial cancer. This staging requirement raised numerous controversies around the importance of determining nodal status and its impact on outcomes. A diversity of opinions exists as to the actual benefits and toxicities associated with surgical staging which includes lymph node sampling, ranging from those whose opinion is that staging is required for all patients even when the a priori risk of nodal involvement is extremely low through to those who consider that staging is unnecessary in any patient. While knowledge of the presence or absence of extra uterine sites of disease may change treatment approaches and direct different treatment interventions in some patients, the impact of those changes on survival is much less clear. This paper examines recommendations for surgical staging in various subgroups of patients with clinically early endometrial cancer and the impact on survival and toxicity of the various approaches and the subsequent use of adjuvant irradiation and/or chemotherapy.

大動脈周囲リンパ節への著明な跳躍転移を認めたガストリノーマの1例を経験したので報告する. 症例は56歳の女性で, 多発性十二指腸潰瘍の診断で経過観察されていたが, 水様性下痢が出現し, 改善傾向なく近医を受診した. 腹部CTで膵頭部に25mm大の腫瘤を指摘され当院に紹介となった. ホルモン検査で血中ガストリンが異常高値で, 膵頭部のガストリノーマと診断した. 亜全胃温存膵頭十二指腸切除術中に大動脈周囲リンパ節への転移を確認したため, 後腹膜リンパ節郭清を併施した. 病理組織学的検査では, ガストリン染色陽性の膵内分泌腫瘍であり, ガストリノーマと診断した. 腫瘍周囲の所属リンパ節への転移を認めなかったが, 大動脈周囲リンパ節への著明な跳躍転移を認めたまれな症例と考え, 若干の考察を加え報告する.

Introduction Visible para-aortic lymph nodes of ≥2 mm in size are common metastatic patterns of colorectal cancer (CRC) seen on imaging. Their prognostic value, however, remains inconclusive. We aimed to assess the prognostic role of visible para-aortic lymph nodes (PALNs). Methods Patients with confirmed pathologic diagnosis of CRC were enrolled. Correlations among clinicopathologic variables were analyzed using the χ2 test. The Cox proportional hazards model was applied for univariate and multivariate analyses. Survival was estimated using the Kaplan-Meier method and log-rank test. A prognostic model for visible PALNs in CRC patients was established. Results In total, 4527 newly diagnosed CRC patients were enrolled. Patients with visible PALNs had inferior overall survival compared to those without visible PALNs (5-year overall survival, 67% vs. 76%, P = 0.015). Lymphovascular invasion (LVI) (hazard ratio = 1.865, P = 0.015); nodal disease (pN+) status (hazard ratio = 2.099, P = 0.006); elevated preoperative serum carcinoembryonic antigen (CEA) levels (hazard ratio = 2.263, P < 0.001); and visible PALNs ≥10 mm (hazard ratio = 1.638, P = 0.031) were independent prognostic factors for patients with visible PALNs. If each prognostic factor scored one point, 5-year overall survival of lower- (prognostic score 0–1), intermediate- (prognostic score 2), and high- (prognostic score 3–4) risk groups were, 78%. 54%, and 25% respectively (P < 0.001). Conclusions The prognostic model, which included LVI, pN+ status, preoperative serum CEA level, and the size of visible PALNs, could effectively distinguish the outcome of patients with visible PALNs.

肝細胞癌に対して2回の切除術と異時性に出現した鼠径部と傍大動脈リンパ節転移を切除しえた, まれな進展形式を呈した肝細胞癌切除例を経験したので報告する. 症例は69歳の男性で, 1980年胃癌手術時の輸血によりC型肝炎を発症した. 1995年肝細胞癌に対して肝S6切除術を施行し, 以後再発肝細胞癌に対して2度TAEを施行した. 2000年1月右鼠径部腫瘤に対して摘出術を施行した. 組織学的に肝細胞癌のリンパ節転移と診断された. 他に肝外転移巣なく同年3月右葉切除術を施行した. 腫瘍マーカーは正常化し経過観察していた. 3年後の2003年6月超音波検査で傍大動脈にリンパ節腫脹を指摘され, 腫瘍マーカーも上昇しており, 同年8月摘出術を施行した. 組織学的に肝細胞癌のリンパ節転移と診断された. 術後, 腫瘍マーカーは正常化し, 現在, 初回手術より9年, 無再発生存中である.

Objective To investigate the usefulness of intraoperative sonography for the assessment of para-aortic lymph nodes in gynecological malignancies. Methods The assessment of para-aortic lymph node swelling by computed tomography (CT), palpation during surgery and intraoperative sonography was performed in 43 women with a gynecological malignancy. The sensitivity, specificity and predictive values of each technique for assessment of node metastasis were examined in the 33 women who underwent para-aortic lymphadenectomy. For each of the three assessment techniques, the number of para-aortic lymphadenectomies that would have been performed and the number of women who would have had missed metastasis were evaluated assuming a para-aortic lymphadenectomy would be performed only when swollen nodes were detected. Results Para-aortic nodes were assessed to be swollen by CT, palpation, and intraoperative sonography, respectively, in one, six and 10 of 43 women in total, and in one, six and nine of the 33 women who underwent para-aortic lymphadenectomy. The sensitivity and negative predictive value of intraoperative sonography were 100%, while the specificity and positive predictive value of CT were 100%. If para-aortic lymphadenectomy had been performed only when swollen nodes were detected by intraoperative sonography, the number performed would have decreased from 33 to nine without missing lymph-node metastasis. Conclusion Intraoperative sonography has potential for the assessment of para-aortic lymph nodes in gynecological malignancies. Copyright © 2003 ISUOG. Published by John Wiley & Sons, Ltd.

患者は72歳の男性. 大動脈周囲リンパ節転移と肝転移H2を伴う2型進行胃癌に対し, 胃全摘・膵脾合併切除, 肝転移巣切除, D4リンパ節郭清を行ったが, 大動脈周囲リンパ節が完全摘除できず, 非治癒切除となった. 術後化学療法として, 5-FU, adriamycin, mitomycin C (MMC)の肝動注, doxifluridineの内服, および, cisplatin, MMC, etoposide, pirarubicinの静注を行い, 外来でtegafur内服とlentinan静注を継続した. 遺残した大動脈周囲リンパ節転移は術後1年6か月の腹部CTスキャンで消失し, complete responseが5か月間得られた. 患者の状態は良好に保たれ, 血清CEAとimmunosuppressive acidic proteinは術後4年6か月まで正常値を維持した. 術後5年2か月に縦隔リンパ節再発により死亡したが, 肝再発は認めなかった. 本症例の長期生存には, 減量手術と術後早期の導入化学療法が奏効したことに加え, 長期の維持免疫化学療法が寄与したことが示唆された.

This is a reply letter to Dr. M Daniele et al. entitled as "gastric cancer with para-aortic lymph nodes metastasis: do not miss a chance of cure!". Para-aortic lymph node metastasis has been regarded as a pattern of distant metastasis in gastric cancer. Even patients with PAN metastasis undergo extensive lymph nodes, the prognosis is unsatisfactory and the overall survival is not better than the patients receiving palliative chemotherapy. However, for the patients who were responded to the preoperative chemotherapy, subsequent radical gastrectomy performed prolonged survival. Meanwhile, patients who were resistant to the previous chemotherapy were not optimal candidates for curative resection in advanced gastric cancer patients with PAN metastasis. How large with lymph nodes dissection for the patients with initially PAN metastasis after effective neo-chemotherapy is still a controversial issue and needs further large-scale randomized trials.

The management of para-aortic lymph nodes (PALN) in carcinoma of the cervix by surgery and adequate conventional radiotherapy (55 Gy +) is associated with an unacceptably high incidence of major morbidity (greater than 30%) discouraging this therapy. The addition of a proton boost to photon treatment will permit the delivery of 60 to 70 Gy to PALN with a morbidity expected to be equal to that observed with 45 Gy photons (13%). The potential for improved control rates at the increased dose may be of the order of 10 to 20% depending on the initial stage of disease. Suitable selection criteria may increase this further in some subgroups.

The prognosis of patients with gastric cancer and para-aortic lymph node (PALN) metastasis is poor. Recent Japanese randomized trials concluded that prophylactic PALN dissection is not effective for curable advanced gastric cancer. However, the value of curative resection in patients with pathologically positive PALN is not determined yet.We retrospectively identified 178 patients with pathologically positive PALN who underwent curative resection at the Cancer Institute Hospital from 1980 to 2004. Patient characteristics were analyzed and independent prognostic factors for death were identified by Cox proportional hazard model.Partial gastrectomy was the most frequently performed procedure (142 of 178). Postoperative morbidity and mortality rates were 30 and 2%, respectively, with a 5-year survival rate of 13.0%. Multivariate analysis revealed the total number of positive nodes (hazard ratio, 1.804; 95% confidence interval, 1.221-2.665) and macroscopic type (hazard ratio, 1.697; 95% confidence interval, 1.138-2.530) as independent prognostic factors, while age, sex, histology, pathological tumor depth, and degree of PALN dissection were not statistically significant. The 5-year survival rate increased to 28.6% in patients withor =15 positive nodes and macroscopic type other than type 4.Prophylactic PALN dissection can not be justified in curable advanced gastric cancer. However, R0 resection including PALN retrieval might be beneficial in patients with pathologically positive PALN, providing patients are carefully selected and operations are performed safely.

腹部大動脈周囲リンパ節 (No.16) への主要なリンパ経路を把握するため, 微粒子活性炭 (CH44) 注入137例 (術中リンパ節内注入35例, 術前胃壁内注入102例) を用いて検討した. また, No.16郭清を施行した胃癌症例312例を対象に, 原発巣の局在とNo.16および他の胃所属リンパ節転移との関連性を検索した.結果: 1) No.16リンパ節へのリンパ経路は左側経路 ((1) 腹腔動脈系ルート,(2) 脾動脈系ルート,(3) 左横隔膜動脈系ルート) と右側経路 ((1) 腸間膜動脈系ルート,(2) 腹腔動脈系ルート,(3) 膵後面系ルート) が主要経路であった. 2) No.16リンパ節の黒染率は, C癌ではa2-lateralリンパ節 (56.5%), A癌ではb1-interリンパ節 (60.0%) が高率であった. 3) No.16転移陽性78例 (25%) の転移部位は, C癌ではa2, b1-lateral, b1-inter, M癌ではa2, b1-lateral, A癌ではb1-inter, b1-lateralが高率であった. 4) No.16転移陽性例は, P0, H0例で, 相対的非治癒切除ができれば5生率23.1%, また, 転移陽性リンパ節個数が2個以内ならば5生率23.3%と郭清効果が認められた.

Background. PET/CT may be particularly useful to detect the primary cancer in paraneoplastic cerebellar degeneration (PCD) with anti-Yo which is most commonly associated with breast, ovarian and other gynecological cancers. Case. A 60-year-old woman developed a PCD associated with anti-Yo antibodies in serum and cerebrospinal fluid. Conventional imaging was negative. FDG-PET showed an abnormal hot spot in the right ovarian area associated with lombo aortic lymph nodes. The diagnosis was confirmed by surgery as an ovarian adenocarcinoma. Conclusion. In this case report, FDG-PET played a crucial role in detecting the unknown primary tumor in a patient with PCD.

Partial coirradiation of both kidneys is an unavoidable consequence of adequate dose delivery in radiation therapy of para-aortic lymph nodes (PLN). Depending on total dose anteroposterior/posteroanterior (AP/PA), opposed-fields or multifield techniques are used. To optimize the treatment of potentially tumor-affected PLN with minimal kidney involvement, we calculated normal tissue complication probabilities (NTCPs) of coirradiated kidneys for four common irradiation techniques used in the PLN area.Planning target volume (PTV) delineation was performed in computed tomography scans of 21 patients with a lateral safety margin of 3 cm from the aorta and 2 cm aside the vena cava. Ventral and dorsal margins of the PTV were delineated 2 cm from the vessels. As previously shown (Nevinny-Stickel M, et al. Int J Radiat Oncol Biol Phys 2000;48:147-151), PTVs optimized by these altered delineations permit inclusion of at least 97% of potentially involved PLN in contrast to standard delineations based on bony structures that are more likely to miss affected lymph nodes. The present study compared NTCPs for individual PTV-based treatment planning with NTCPs for standard planning based on bony structures. For each patient, four hypothetical treatment plans were created: (A) standard AP/PA opposed fields technique with lateral field margins along the tips of the transverse processes of the vertebral bodies; (B) individually planned AP/PA opposed fields with lateral field margins according to the optimized PTV; (C) standard four-field box technique with lateral width as described for (A), with dorsal borders at the center of the vertebral bodies and ventral margins 3 cm in front of the vertebrae; and (D) individually planned four-field box with lateral field margins according to the optimized PTV. Calculation of irradiation-induced complication probability values for nonuniform kidney irradiation was performed for model doses 19.8 Gy, 30.6 Gy, and 50.4 Gy according to the Lyman-Wolbarst model.No dose showed a statistically significant difference (p0.00833, corrected for six multiple interrelated comparisons) in the median of total organ kidney NTCPs between techniques A, C, and D, with technique D intermediately ranging between technique A and C (e.g., for 50.4 Gy: A: median, 0.39; range, 0.01-0.83; C: median, 0.27 range; 0.05-0.68; D: 0.36; range, 0.03-0.72). In comparison to techniques A, C, and D, the individually planned AP/PA opposed-fields technique (B) was accompanied by significantly higher and intolerable overall kidney NTCP rates (e.g., for 50.4 Gy: median, 0.68; range, 0.01-0.99).Conformal four-field planning with individually optimized PTVs (D) resulted in only moderate tissue complication probabilities in both kidneys with the advantage of providing significantly greater inclusion of potentially involved PLNs in comparison to accepted standard procedures (A and C).

Lymphoscintigraphy to identify the sentinel lymph node is a valuable adjunct for staging cutaneous melanoma. This technique may be particularly useful for truncal melanoma, because marked variability in drainage patterns has been reported. The authors report a case of melanoma of the back draining to three different nodal basins, including what were most likely para-aortic lymph nodes based on SPECT imaging.

From 1965 to 1986, 173 patients with gynaecological cancer received para-aortic radiation treatment using a biaxial-four-segmental-rotating field technique. Seventy-five patients with cervical cancer and proven lymph node involvement were eligible for analysis. Crude survival and disease-free survival in 37 patients with FIGO III and 15 patients with FIGO IVA, receiving initial para-aortic treatment were compared with the corresponding data from patients in whom para-aortic treatment was secondary applied when para-aortic metastases became clinically symptomatic. Five-year survival rates of 37.5% (FIGO III) and 27.3% (FIGO IVA) were encouraging as none of the patients in the secondary group survived for more than 16 months. The number of complications induced by the described method of survived for more than 16 months. The number of complications induced by the described method of para-aortic irradiation appears to be substantially lower than with other methods using equal doses. Five cases of severe but not life-threatening side-effects were observed among 173 treated patients.

Benign metastasizing leiomyoma (BML) is a rare entity, defined as a muscle tumor in association with one or more smooth muscle tumor of the uterus and without evidence of any extra uterine primary site. The lung is the most common site of involvement,2 and the etiology of BML remains unknown. We experienced a case of BML arising in pelvic and para-aortic lymph nodes and report with a brief review of literature.

Summary 60 patients with carcinoma of the prostate of all clinical stages were investigated by lymphography. Positive lymphographic findings were present in about 50% of the cases. The more advanced tumours were found to metastasise more frequently. Lymphography is indispensable to select patients with clinically limited disease to the prostate for radical prostatectomy. The anatomical display of the iliac and aortic lymph nodes on the lymphogram facilitates the selection of the portal fields in external beam megavoltage radiotherapy.