The role of pelvic and para-aortic lymphadenectomy in gynecological malignancies

Mohammed H El Meligy; Ahmed F El Kased; Alaa A El Sisy; Ahmed S El Gammal

doi:10.4103/1110-2098.173600

ORIGINAL ARTICLE

Year : 2015 | Volume : 28 | Issue : 4 | Page : 833-837

The role of pelvic and para-aortic lymphadenectomy in gynecological malignancies

Mohammed H El Meligy MSc , Ahmed F El Kased, Alaa A El Sisy, Ahmed S El Gammal
Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission	10-Jan-2015
Date of Acceptance	26-Feb-2015
Date of Web Publication	12-Jan-2016

Correspondence Address:
Mohammed H El Meligy
Department of General Surgery, Faculty of Medicine, Menoufia University, Yassin Abdel Ghaffar Street of Gamal Abdel Nasser Street, Shebin El-Kom, Menoufia
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1110-2098.173600

Abstract

Objectives
To study the role of pelvic and para-aortic lymphadenectomy in ovarian carcinoma, especially in the early stages in which conventional imaging such as computed tomography and MRI reveal that pelvic and para-aortic lymph nodes were negative.
Background
Pelvic and aortic nodes are common sites of metastasis from gynecologic malignancies, and there is no question that the evaluation of the lymph node status provides important prognostic information.
Materials and methods
Between October 2012 and October 2014, 18 patients who were previously untreated and had biopsy-proven ovarian carcinoma were operated upon in the Department of General Surgery, Menoufia University Hospital. The surgical procedure consisted of total abdominal hysterectomy, bilateral salpingo-oophorectomy, and or omentectomy, in addition to systematic pelvic and para-aortic lymphadenectomy.
Results
Positive nodes were found in eight patients (44.4%): four pelvic, one aortic, and three both pelvic and aortic metastases. The median number of positive nodes was five pelvic (range 1-12) and four aortic (range 1-6) nodes. The most frequently involved node group with ovarian carcinoma was the obturator group.
Conclusion
These data may be useful for tailoring lymphadenectomy in relation to the preferred sites of retroperitoneal lymph node metastasis and the median number of nodes resected from each group, and it confirms that systematic pelvic and aortic lymphadenectomy is a feasible procedure and can be performed with acceptable morbidity and no mortality. However, to provide solid evidence that this procedure has a therapeutic benefit, randomized controlled studies are needed.

Keywords: gynecological malignancies, lymphadenectomy, ovarian cancer

How to cite this article:
El Meligy MH, El Kased AF, El Sisy AA, El Gammal AS. The role of pelvic and para-aortic lymphadenectomy in gynecological malignancies. Menoufia Med J 2015;28:833-7

How to cite this URL:
El Meligy MH, El Kased AF, El Sisy AA, El Gammal AS. The role of pelvic and para-aortic lymphadenectomy in gynecological malignancies. Menoufia Med J [serial online] 2015 [cited 2023 Mar 25];28:833-7. Available from: http://www.mmj.eg.net/text.asp?2015/28/4/833/173600

Introduction

Pelvic and aortic lymph nodes are common sites of metastasis from gynecologic malignancies, and there is no question that the evaluation of the lymph node status provides important prognostic information ^[1] . In addition, information obtained with radiological diagnostic procedures and radioguided punctures are not as sensitive as a complete histological examination of lymph nodes. In the series by Subak et al. ^[2] the sensitivity of computed tomography (CT) and MRI was 62%.

Our knowledge regarding the lymphatic spread of gynecologic malignancies is mostly biased ^[3] . This is due to the different degrees of nodal dissection ranging from sampling to thorough dissection ^[4] , the poor quality of pathology results in which the number of nodes excised and the site of excision are rarely stated ^[5] , and finally the lack of a uniform, surgically based classification ^[6] .

Recently, reports documenting the systematic resection of pelvic and para-aortic nodes have been published, and the significance of the node status for the diagnosis, the prognosis, and the treatment of gynecologic tumors have begun to be investigated ^{[7],[8],[9],[10]} .

The aim of this work was to study the role of pelvic and para-aortic lymphadenectomy in gynecological malignancies, especially in the early stages in which conventional imagining such as CT and MRI reveal that pelvic and para-aortic lymph nodes were negative.

Materials and methods

Between October 2012 and October 2014, 18 patients who were previously untreated, had biopsy-proven ovarian carcinoma, and were referred to the Surgical Oncology Unit, the Department of General Surgery, Menoufia University Hospital, were enrolled in this study. The surgical procedure consisted of total abdominal hysterectomy, bilateral salpingo-oophorectomy, and/or omentectomy, in addition to systematic pelvic and para-aortic lymphadenectomy.

Ethical issue

The procedure followed was in accordance with the ethical standards of the responsible institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 1983.

The pretreatment evaluation consisted of complete history taking, physical and gynecologic examinations, laboratory work-up, cancer antigen 125 levels, chest radiography, and CT scan with oral and intravenous contrast in all cases. Abdominal and pelvic ultrasonography was performed in five cases and intravenous pyelogram in two patients.

Lymphadenectomy eligibility requirements included a maximum age of 70 years, International Federation of Obstetricians and Gynecologists (FIGO) stages I-III ^[11],[12] , adequate renal, cardiac, and hepatic function, and informed consent. Exclusion criteria included severe obesity, high-risk chronic pulmonary and cardiovascular disease, locally advanced tumors, distant metastasis, and the presence of other malignancies.

Patients were staged according to the surgical-pathological FIGO criteria ^[11],[12] . Histological grading was based on the degree of differentiation in accordance with the FIGO guidelines ^[12] .

The surgical technique for lymphadenectomy has been described elsewhere previously ^{[3],[13],[14],[15]} . The upper margin of aortic lymphadenectomy was the origin of renal vessels and the lower margins of pelvic lymphadenectomy were the femoral ring and the pelvic floor. All the lymphatic tissue located within these margins was excised ^[13],[14] . For classification purposes, pelvic lymph nodes were divided into four different node sites: the internal iliac, the external iliac, and the common iliac were the lymph nodes lying next to the respectively named blood vessels and obturator lymph nodes were defined as those lying within the obturator fossa, medial and inferior to the external iliac vessels and surrounding the obturator vessels and nerve. Para-aortic lymph nodes were defined as all lymph nodes lying adjacent to the aorta or the inferior vena cava up to the level of the renal vessels ^[5] .

The excised lymphatic tissue was grouped and labeled according to the different sites and was subjected to histological examination individually. In addition, lymph nodes were counted in each group and the number of lymph node metastases was also examined.

Postoperative thromboembolic prophylaxis based on low-molecular-weight heparin was used over 10 to 15 days. Morbidity and mortality rates of systematic pelvic and para-aortic lymphadenectomy were investigated.

The operating time was defined as the time from abdominal incision to the completion of abdominal closure. Mortality was defined as postoperative death due to any cause within 30 days of the procedure. The anesthesiologist estimated blood loss to the nearest 25 ml on the basis of the observation of the suction catheter and sponges at the completion of the operation.

Statistical analysis

Results were analyzed statistically by statistical package SPSS, version 20 ( SPSS Inc., Chicago, IL, USA). Two types of statistics were performed.

Descriptive: for example, percentage, mean, and SD.
Analytical:
1. Fisher's exact test: it was used to compare two groups regarding one qualitative variable in a 2 × 2 contingency table when the count of any of the expected cells was less than 5.
2. Z-test: it was used to compare two proportions.
3. P value: significant difference if P value less than 0.05; nonsignificant difference if P value more than 0.05; and highly significant difference if P value less than 0.001.

Results

The median age was 45 years (range 24-70 years). The majority of the patients had stage II disease (38.9%) and moderately differentiated cancer (44.4%). Eight patients (44.4%) had positive lymph nodes and 10 patients (55.6%) had negative lymph nodes ([Table 1], [Table 2], [Table 3], [Table 4]).

Table 1 Characteristics of the studied groups

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Table 2 The median number and the range of lymph nodes removed

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Table 3 Distribution of patients with positive nodes in relation to the type of primary tumor

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Table 4 The median number and the range of positive lymph nodes removed according to the type of primary tumor

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The median number of nodes removed was 29, and the range 18-44 (pelvic 19, range 11-33; aortic 13, range 5-18). The median number and the range of lymph nodes removed were based on the type of tumor.

There were four patients (22.2%) with positive pelvic nodes, one patient (5.6%) with positive aortic nodes, and three patients (16.7%) with both positive pelvic and aortic nodes.

The median number of positive nodes was 6, and the range 2-16 (pelvic 5, range 1-12; aortic 4, range 1-6). The most frequently observed sites of positive nodes with ovarian tumors were the obturator group (3, range 1-5). The relationship between pelvic lymph node involvement and para-aortic lymph nodes is shown in [Table 5]. This relationship shows that para-aortic lymph nodes were significantly higher among patients with positive pelvic lymph node involvement (75%) than among patients with negative pelvic lymph node involvement (25%) (P = 0.004).

Table 5 The relation between pelvic lymph node involvement and para-aortic lymph nodes

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FIGO stage I was significantly higher among patients with negative lymph node involvement (70%) than among patients with positive lymph node involvement (0.0%) (P = 0.011). However, it shows that the FIGO grade (poor) was significantly higher among patients with positive lymph node involvement (50%) than among patients with negative lymph node involvement (0.0%) (P = 0.049) ([Table 6] and [Table 7]).

Table 6 The relationship between lymph node involvement and patient and tumor characteristics

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Table 7 The relationship between lymph node involvement in CT and histopatholgy

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Discussion

Systematic pelvic and para-aortic lymphadenectomy represents the only reliable method for the assessment of lymphatic spread in gynecologic oncology, given the low accuracy of imaging techniques ^[2] . In fact, according to the literature, the rate of node involvement in gynecologic malignancies ranges approximately from 22 to 55% ^{[16],[17],[18],[19]} . In this study, an overall positivity rate of 44.4% was found. According to the results of several studies, pelvic nodes were involved in 18 to 55% and para-aortic nodes in 10 to 40% of all patients when complete nodal dissections were performed ^{[7],[8],[20],[21]} . In this study, there were four patients (22.2%) with positive pelvic nodes, one patient (5.6%) with positive aortic nodes, and three patients (16.7%) with both positive pelvic and aortic nodes. The incidence of nodal metastases in relation to the stage (P = 0.020) and the grade (P = 0.027) was statistically significant, and was comparable to that found by other authors ^[22],[23] .

It is stated that a radical pelvic lymphadenectomy should yield at least nine to 37 nodes and a para-aortic lymphadenectomy between five and 12 nodes, respectively ^{[6],[10],[24]} . Our investigation showed that a median of 19 nodes can be collected from the pelvic area and 13 nodes from the para-aortic region. Most published studies have reported a smaller number of nodes because only suspicious nodes were removed ^[7],[8] . Despite individual differences, the surgical oncologist should be aware that, as in axillary lymph node dissection for breast cancer, systematic pelvic and aortic lymphadenectomy requires a minimum number of collected nodes and parameters to be set to standardize the lymphadenectomy ^[21],[25] . The number of node groups and nodes removed indicates the thoroughness of the procedure.

Therefore, data obtained should indicate the number and the pattern of lymphatic spread for gynecologic malignancies with greater precision ^[3] . This study showed that the obturator group is a major route for lymphatic spread in ovarian ^[26] carcinomas. Moreover, aortic nodes were most commonly involved with ovarian carcinoma in accordance with most published series ^[3],[4],[8] .

Para-aortic node metastasis was found in 32-78% of the patients with pelvic node involvement ^{[21],[27],[28]} . In this study, para-aortic lymph node was significantly higher among patients with positive pelvic lymph node involvement (42.9%) than among patients with negative pelvic lymph node involvement (4.3%) (P = 0.030).

Thus, lymph node assessment should include both the aortic and pelvic lymph nodes, which is in agreement with recently published series ^{[3],[4],[22],[29],[30]} .

The present report shows that systematic pelvic and para-aortic lymphadenectomy could be carried out with an acceptable morbidity and no mortality ^[31],[32] . Among the postoperative complications, the development of lymphorrhea was the most frequent and troublesome complication ^[3] Moreover, as the surgical team acquired experience, the operating time and the blood loss gradually diminished in accordance with other reports ^[3],[31] .

Conclusion

In summary, we demonstrated the preferred sites of retroperitoneal lymph node metastases and the median number of nodes excised in patients with ovarian carcinoma. The results of the present study showed that systematic pelvic and aortic lymphadenectomy is a feasible procedure and can be performed with acceptable morbidity and no mortality. The prognosis can be formulated on the basis of the exact knowledge of node involvement, and individualized therapies could be investigated.

However, to provide solid evidence that this procedure has a therapeutic benefit, randomized controlled studies are needed.

Acknowledgements

The authors are grateful to all participants in the study (patients and their families).

Conflicts of interest

There are no conflicts of interest.

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