Risk stratification of endometrial cancer and lymph node metastases prediction using 18F-FDG PET/CT: role of metabolic tumor volume and total lesion glycolysis

Background

Endometrial cancer is the commonest gynecologic malignancy. Pelvic lymph node metastasis is considered one of its most important prognostic factors. Surgery is considered the most important and effective treatment, still there is controversy about indication and necessity of pelvic lymph node dissection. 18F-fluorodeoxyglucose positron emission tomography/computed tomography is investigated in his study to evaluate its value in preoperative detection of lymph node metastases and risk stratification of endometrial cancer.

Results

Reviewing the records of 33 women with endometrial cancer, all 18F-FDG PET/CT studied indices, SUVmax, SUVmean, MTV and TLG, mean difference was statistically significant in all the studied risk categories (tumor grade, Myometrial invasion, lymphovascular space invasion, tumor stage, and risk stratification). SUVmax and TLG showed highest area under the curve for detection of Myometrial invasion > 50% (AUC = 0.911) with cut-off value of SUVmax > 14.55 showing 88.89% sensitivity and 86.67% specificity, and TLG > 192.653 having 88.89% sensitivity and 80% specificity. TLG showed highest AUC (0.889 and 0.921) for detection of LVSI and LNMs with 100% sensitivity and 66.67% specificity for cut-off value > 179.374 and 88.89% sensitivity and 83.33% specificity for cut-off value > 249.366, respectively. Concerning risk stratification of EC, SUVmax and TLG showed highest AUC (0.839) with cut-off value > 14.55 showing 77.27% sensitivity and 90.91% specificity, and > 192.653 having 77.27% sensitivity and 81.82% specificity, respectively.

Conclusion

The results of this study suggest that 18F-FDG PET/CT is a very valuable tool for prediction of lymph node metastases and risk stratification in endometrial cancer patients. Applying TLG cutoff values increases the accuracy and preoperative diagnosis of lymph node metastases which aids in sparing women with low-risk early stage EC unnecessary surgical risk and morbidity of lymphadenectomy.

Randomized comparison between sentinel lymph node mapping using indocyanine green plus a fluorescent camera versus lymph node dissection in clinical stage I-II endometrial cancer: a Korean Gynecologic Oncology Group trial (KGOG2029/SELYE)

BACKGROUND

Sentinel lymph node (SLN) mapping has been suggested as an alternative surgical technique to full lymphadenectomy for early-stage endometrial cancer. However, the survival outcomes of SLN mapping compared with lymphadenectomy have not been established via a prospective study.

METHODS

A multi-center, single-blind, randomized controlled trial has been designed to determine the prognostic value of SLN mapping alone compared with conventional lymphadenectomy for patients with clinical stage I-II endometrial cancer. Eligible participants will be randomly assigned in a 1:1 ratio between the group to undergo SLN mapping using indocyanine green and the conventional lymph node dissection group. A high-risk group will undergo a 2-step SLN mapping procedure. The primary endpoint is the 3-year disease-free survival (DFS). The secondary endpoints are 3-year overall survival (OS), 5-year DFS, 5-year OS after surgery, pattern of recurrence, immediate surgical outcomes, success rate of SLN mapping, postoperative lymph-related complications, postoperative quality of life, and postoperative cost effectiveness. The role of pathologic ultrastaging of SLNs will also be assessed.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier (NCT number): NCT04845828.

Sentinel lymph node biopsy in high-risk endometrial cancer: performance, outcomes, and future avenues

Endometrial cancer is the second most common gynecological malignancy worldwide, with an overall favorable prognosis. However, a subgroup of patients has a high risk of recurrence and poor prognosis. This review summarizes recently published articles that examined sentinel lymph node (SLN) biopsy in patients with high-risk endometrial cancer. We focused on the performance and outcomes of SLN biopsy, and examined potential methods for improving the management of this high-risk subset. Few studies have examined the long-term outcomes of SLN in patients with high-risk endometrial cancer. Thus, we reviewed recently published retrospective studies that have adopted statistical techniques, such as inverse probability weighting or propensity score matching, to examine the outcome of SLN biopsy compared to conventional lymphadenectomy. Potential avenues for future research to fine-tune decision making for this patient subgroup were also discussed.

The Association Between the Number of Retrieved Pelvic Lymph Nodes and Ipsilateral Lower Limb Lymphedema in Patients With Gynecologic Cancer

PURPOSE

While the risk of lower limb lymphedema (LLE) after radical surgery for gynecologic malignancies is multifactorial, the limited assessment of lymph nodes (LNs), such as sentinel LN biopsy, has been incorporated into a standard procedure. We assessed the relationship between the number of LNs retrieved from the hemipelvis and the incidence of ipsilateral LLE (iLLE).

METHODS

This retrospective study included 103 women with gynecologic cancer who had LNs removed with minimally invasive surgery between January 2014 and December 2018. For early detection of LLE, the patients were followed up by a lymphedema specialist who complied with the International Society of Lymphedema criteria. Potential risk factors for LLE were collected, and the risk factors were further investigated according to the number of LNs removed in a side-specific manner.

RESULTS

LLE was diagnosed in 32 (31.1%) patients, and most of them were diagnosed with unilateral (n = 22) LLE rather than bilateral (n = 10). The number of pelvic LNs removed (p = 0.018), no lymphatic mapping (p = 0.034), and radiation (p = 0.020) were associated with the development of one or both LLEs. A side-specific analysis revealed that the incidence of iLLE increased significantly when four or more LNs were removed from the hemipelvis compared with three or fewer LNs (22.9% vs. 8.3%, p = 0.048).

CONCLUSIONS

The number of pelvic LNs retrieved was associated with the incidence of LLE in patients with early gynecologic cancer. We identified the cutoff number per hemipelvis through side-specific analysis that could minimize the risk of iLLE. Further studies are needed to validate our results.

Risk factors for lymphatic complications following lymphadenectomy in patients with endometrial cancer

OBJECTIVE

Lymph node (LN) metastasis is among the important prognostic factors for survival in endometrial cancer (EC). This study aimed to evaluate the occurrence of lymphatic complications following lymphadenectomy in patients with EC.

MATERIALS AND METHODS

EC patients were retrospectively evaluated. Lower extremity lymphedema (LEL) and pelvic lymphocele (PL) were evaluated according to the International Society of Lymphology guidelines and the National Cancer Institute Common Terminology Criteria for Adverse Events, respectively.

RESULTS

A total of 289 patients were enrolled. Surgery was performed via laparotomy and laparoscopy in 200 (69.2%) and 89 (30.8%) patients, respectively. LEL and PL occurred in 43 (14.9%) and 33 (11.4%) patients, respectively. In multivariate logistic regression analysis, circumflex iliac node (CIN) removal (odds ratio [OR]: 3.22; 95% CI: 1.43-7.98; P = 0.004) was an independent risk factor for LEL, while the surgical approach (OR: 4.46; 95% CI: 1.13-29.9; P = 0.004) was an independent risk factor for PL.

CONCLUSION

CIN dissection was a significant risk factor for LEL, while laparotomy was an independent risk factor for PL compared to laparoscopy in EC patients. This suggests that laparoscopic surgery combined with sentinel lymph node navigation surgery will prevent lymphatic complications in low-risk EC patients.

Evaluating the importance of routine drainage following laparoscopic pelvic lymph node dissection for gynecological malignancies

OBJECTIVE

To determine the efficacy of drainage following pelvic lymph node (PLN) dissection, especially for cases involving laparoscopic surgery.

METHODS

In this retrospective study, 368 patients with malignant gynecological tumors who underwent systemic PLN dissection at Keio University Hospital between January 2012 and October 2018 were enrolled. Drainage tubes were placed in the retroperitoneal fossa in all patients. Medical records were used for data collection.

RESULTS

Laparoscopy was performed on 81 patients, and laparotomy was performed on 287 patients. In the laparoscopy group, tubes were removed 1 day post surgery. In the laparotomy group, tubes were removed 1 day post surgery in 167 patients and 4 days post surgery in 120 patients. Compared with the laparotomy group, we determined the laparoscopy group to have a significantly lower prevalence of lymphocyst (6.2% vs 20.2%, p = 0.002) but a similar prevalence of lymphedema (4.9% vs 5.2%), and symptomatic lymphocyst (2.5% vs 4.5%). The two laparotomy groups did not differ significantly with respect to the prevalence of lymphedema (4.8% vs 5.8%), lymphocyst (20.4% vs 20.0%), or symptomatic lymphocyst (4.2% vs 5.0%).

CONCLUSION

Our results suggest that routine drainage should be omitted, especially in cases involving laparoscopic surgery.

Reduced lymphedema after sentinel lymph node biopsy versus lymphadenectomy for endometrial cancer

Objective

Endometrial cancer surgical staging includes lymph node assessment which can lead to lower extremity lymphedema. The aim of this study was to estimate prevalence after sentinel lymph node biopsy versus lymphadenectomy.

Methods

Consecutive patients who underwent minimally invasive surgery at the Mayo Clinic, Rochester, Minnesota, USA, between January 2009 and June 2016 for newly diagnosed endometrial cancer were mailed our validated 13 item lower extremity lymphedema screening questionnaire. We also ascertained via questionnaire whether the patient was ever diagnosed with lower extremity lymphedema.

Results

Among 378 patients included in the analysis, 127 (33.5%) had sentinel lymph node biopsy with or without side specific lymphadenectomy (sentinel lymph node cohort) and 251 (66.4%) underwent bilateral lymphadenectomy prior to sentinel lymph node biopsy implementation at our institution or as 'backup' after sentinel lymph node mapping (lymphadenectomy cohort). The prevalence of lower extremity lymphedema was 41.5% (157/378), with 69 patients (18.3%) self-reporting a lower extremity lymphedema diagnosis after their endometrial cancer surgery at a median of 54.3 months (interquartile range 31.2–70.1 months), and an additional 88 patients (23.3%) identified by the screening questionnaire. The prevalence of lower extremity lymphedema was significantly higher in the lymphadenectomy cohort compared with the sentinel lymph node group (49.4% (124/251) vs 26.0% (33/127); p<0.001). When the cohorts were restricted to patients surgically managed after the introduction of sentinel lymph node, the prevalence of lower extremity lymphedema was still significantly higher in the lymphadenectomy cohort compared with the sentinel lymph node cohort (39.0% (41/105) vs 26.0% (33/127); p=0.03). In a multivariable analysis adjusted for body mass index, receipt of adjuvant external beam radiation, diabetes, congestive heart failure, and International Federation of Gynecology and Obstetrics grade, the adjusted odds ratio for the association between type of nodal sampling (lymphadenectomy cohort vs sentinel lymph node cohort) and lower extremity lymphedema was 2.75 (95% confidence interval 1.69 to 4.47, p<0.001).

Conclusions

Sentinel lymph node biopsy was associated with a decreased risk of post-treatment lymphedema compared with lymphadenectomy in patients who underwent surgical staging for endometrial carcinoma.

Incidence of lymphedema in the lower limbs and lymphocyst formation within one year of surgery for endometrial cancer: A prospective longitudinal multicenter study

OBJECTIVE

The study aimed to determine the incidence of lower limb lymphedema (LLL) after surgery for endometrial cancer (EC) by means of three methods, and to determine the incidence of lymphocysts after one year.

METHODS

A prospective longitudinal multicenter study was conducted in 14 hospitals in Sweden. Two-hundred-and-thirty-five women with EC were included; 116 underwent surgery that included lymphadenectomy (+LA) and 119 were without lymphadenectomy (-LA). Lymphedema was assessed objectively on four occasions; preoperatively, at 4-6 weeks, six months and one year postoperatively using systematic measurement of leg circumferences, enabling calculation of leg volumes, and a clinical grading of LLL, and subjectively by the patient's perception of lymphedema measured by a lymphedema-specific quality-of-life instrument. Lymphocyst was evaluated by vaginal ultrasonography.

RESULTS

After one year the incidence of LLL after increase in leg volume adjusted for body mass index was 15.8% in +LA women and 3.4% in -LA women. The corresponding figures for clinical grading were 24.1% and 11.8%, and for patient-reported perceived LLL 10.7% and 5.1%. The agreement between the modalities revealed fair to moderate correlation between patient-reported LLL and clinical grading, but poor agreement between volume increase and patient-reported LLL or clinical grading. Lymphocysts were found in 4.3% after one year.

CONCLUSIONS

Although the incidence of LLL and lymphocysts after surgery for EC including LA seemed to be relatively high the study demonstrated significant variations in incidence depending on the measurement modality. This emphasizes the need for a 'gold standard' of measurement of LLL in clinical practice and research.

Prognostic value of metabolic tumor volume and total lesion glycolysis from ¹⁸F-FDG PET/CT in lymph node metastases and risk stratification of endometrial carcinoma

Objective

To investigate the prognostic value of metabolic tumor volume (MTV) and total lesion glycolysis (TLG), measured by preoperative ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT), in risk stratification of patients with endometrial carcinoma (EC).

Methods

The patients with pathological diagnosis of EC who underwent preoperative ¹⁸F-FDG PET/CT imaging were retrospectively selected for analysis of the prognostic values of PET parameters in risk classification and lymph node metastases (LNMs). Receiver-operating-characteristic analysis was used to analyze the correlation of PET parameters cutoff values with deep myometrial invasion (MI), lymphovascular space involvement and LNM for prognostic values in risk stratification.

Results

The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for detection of LNM are 83.3%, 99.7%, 90.9%, 99.5% and 99.2%, respectively. The MTV and TLG of primary lesion of EC in the patients with LNM are notably higher than those in patients without LNM, p<0.010. The MTV and TLG of the EC primary lesions in high-risk patients are significantly higher than those in low-risk patients (p<0.010), but the maximum standardized uptake value (SUVmax) is not. The MTV and TLG of primary lesions were superior to SUVmax for predicting of deep MI, LNM and high-risk of EC (p<0.005).

Conclusion

MTV and TLG of primary lesions are more valuable in predicting risk stratification of EC patients. Preoperative ¹⁸F-FDG PET/CT imaging is useful in predicting the LNM of EC and may help guide pelvic lymphadenectomy to avoid unnecessary pelvic lymphadenectomy in EC patients with low-risk stratification.

Incidence and risk factors for lower limb lymphedema associated with endometrial cancer: Results from a prospective, longitudinal cohort study

BACKGROUND

Evidence on the incidence and risk factors for lower limb lymphedema (LLL) associated with endometrial cancer is limited. Our objective was to use data from a prospective, longitudinal gynecological cancer cohort study to determine LLL incidence up to 24 months post-diagnosis of endometrial cancer and to explore the relationship between personal and treatment-related factors and risk of developing LLL.

METHODS

Women recently diagnosed with endometrial cancer (n = 235) were evaluated at regular intervals post-diagnosis (up to 3-monthly) using bioimpedance spectroscopy (BIS) and self-reported leg swelling (SRLS).

RESULTS

Incidence of LLL at 24 months post-diagnosis was 33% and 45% according to BIS and SRLS, respectively. When analyses were restricted to obese women, incidence at 24 months post-diagnosis increased to 67% (BIS) and 54% (SRLS). Following adjusted analyses, higher body mass index was associated with higher odds of baseline lymphedema (BIS: OR 1.91, 95% CI 1.47-2.49, p < .01; SRLS: OR 1.06, 95% CI 1.00-1.12, p < .01) and LLL incidence by 24 months post-diagnosis (BIS: OR 1.29, 95% CI: 0.99-1.68, p = .055; SRLS: OR 1.06, 95% CI 1.02-1.11, p = .008). According to SRLS, presence of comorbidities was also associated with baseline lymphedema (OR: 1.43, 95% CI: 1.15-1.78, p = .001), and more extensive lymph node dissection (OR 1.06, 95% CI: 1.01-1.12, p = .026) and receipt of chemotherapy (OR: 2.65, 95% CI: 1.12-6.29, p = .027) were identified as risk factors for lymphedema incidence.

CONCLUSIONS

These findings suggest that LLL following endometrial cancer is common, particularly in women with high body mass index, or comorbidities, and those requiring more extensive lymph node dissection or chemotherapy. Future studies should examine the potential of weight loss intervention as a strategy to reduce LLL incidence.

GOG 244-The lymphedema and gynecologic cancer (LEG) study: Incidence and risk factors in newly diagnosed patients

OBJECTIVES

To evaluate the incidence and risk factors for lymphedema associated with surgery for gynecologic malignancies on GOG study 244.

METHODS

Women undergoing a lymph node dissection for endometrial, cervical, or vulvar cancer were eligible for enrollment. Leg volume was calculated from measurements at 10-cm intervals starting 10 cm above the bottom of the heel to the inguinal crease. Measurements were obtained preoperatively and postoperatively at 4-6 weeks, and at 3-, 6-, 9-, 12-, 18-, and 24- months. Lymphedema was defined as a limb volume change (LVC) ≥10% from baseline and categorized as mild: 10-19% LVC; moderate: 20-40% LVC; or severe: >40% LVC. Risk factors associated with lymphedema were also analyzed.

RESULTS

Of 1054 women enrolled on study, 140 were inevaluable due to inadequate measurements or eligibility criteria. This left 734 endometrial, 138 cervical, and 42 vulvar patients evaluable for LVC assessment. Median age was 61 years (range, 28-91) in the endometrial, 44 years (range, 25-83) in the cervical, and 58 years (range, 35-88) in the vulvar group. The incidence of LVC ≥10% was 34% (n = 247), 35% (n = 48), and 43% (n = 18), respectively. The peak incidence of lymphedema was at the 4-6 week assessment. Logistic regression analysis showed a decreased risk with advanced age (p = 0.0467). An exploratory analysis in the endometrial cohort showed an increased risk with a node count >8 (p = 0.033).

CONCLUSIONS

For a gynecologic cancer, LVC decreased with age greater than 65, but increased with a lymph node count greater than 8 in the endometrial cohort. There was no association with radiation or other risk factors.

Lower Extremity Lymphedema in Gynecologic Cancer Patients: Propensity Score Matching Analysis of External Beam Radiation versus Brachytherapy

The goal of this study is to compare the risk of lower extremity lymphedema (LEL) between pelvic external beam radiation therapy (EBRT) and vaginal brachytherapy, and to identify risk factors for LEL in gynecologic cancer patients treated with adjuvant radiation therapy (RT) after radical surgery. A total of 263 stage I–III gynecologic cancer patients who underwent adjuvant RT were retrospectively reviewed. One-to-one case-matched analysis was conducted with propensity scores generated from patient, tumor, and treatment characteristics. Using the risk factors found in this study, high- and low-risk groups were identified. With a median follow-up of 36.0 months, 35 of 263 (13.3%) patients developed LEL. In multivariate analysis, laparoscopic surgery (HR 2.548; p = 0.024), harvesting more than 30 pelvic lymph nodes (HR 2.246; p = 0.028), and para-aortic lymph node dissection (PALND, HR 2.305; p = 0.014) were identified as independent risk factors for LEL. After propensity score matching, the LEL incidence of the brachytherapy group was significantly lower than the EBRT group (p = 0.025). In conclusion, high-risk patients with risk factors such as laparoscopic surgery, harvesting more than 30 pelvic lymph nodes, PALND, and adjuvant pelvic EBRT require closer observation for LEL.

Three-Year Recurrence-Free Survival in Patients With a Very Low Risk of Endometrial Cancer Who Did Not Undergo Lymph Node Dissection (Tree Retro): A Korean Multicenter Study

OBJECTIVE

Randomized studies have not demonstrated a survival benefit of routine lymph node dissection in early-stage endometrial cancer. Many surgeons nevertheless perform lymph node dissection in all patients with early-stage endometrial cancer. This study aimed to ascertain the survival outcomes of very low-risk endometrial cancer patients (by the Korean Gynecologic Oncology Group [KGOG] criteria) who did not undergo lymph node dissection.

MATERIALS AND METHODS

Medical records of 156 consecutive patients who underwent surgical staging without lymph node dissection were collected from 10 institutions. All patients fulfilled the KGOG criteria: (1) endometrioid corpus cancer diagnosed by preoperative endometrial biopsy, (2) serum cancer antigen-125 level ≤35 IU/mL, (3) <50% myometrial invasion with no extension beyond the uterine corpus by magnetic resonance imaging (MRI), and (4) no lymph nodes with a short diameter ≥1.0 cm by MRI or computed tomography. Sampling of <5 nodes was allowed at a surgeon's discretion. We evaluated the 3-year recurrence-free survival (RFS) and 5-year overall survival (OS) using the Kaplan-Meier method.

RESULTS

The median patient age was 52 years (range, 24-86 years). The median follow-up was 59 months (range, 0-189 months). The 3-year RFS and 5-year OS were 98.6% (95% confidence interval [CI], 96.8%-100.0%) and 98.6% (95% CI, 96.7%-100.0%), respectively. No disease-related mortality occurred. The final pathology report revealed ≥50% myometrial invasion in 29 patients (18.6%) and extension beyond the uterine corpus in 2 patients (1.3%). One patient (0.6%) was diagnosed with lymph node metastasis after lymph node sampling. Eighteen patients (11.5%) received adjuvant therapy after the final pathologic results indicated high risk.

CONCLUSIONS

Very low-risk patients who did not undergo lymph node dissection had acceptable survival outcomes. Omitting lymph node dissection may be reasonable in patients satisfying the KGOG criteria.

Lymphedema, serious adverse events, and imaging 1 year after comprehensive staging for endometrial cancer: results from the RASHEC trial

Background and Objectives

In the Robot Assisted Surgery for High Risk Endometrial Cancer (RASHEC) trial, patients with high-risk endometrial cancer were randomly assigned to robot-assisted laparoscopic surgery (RALS) or laparotomy for pelvic and infrarenal para-aortic lymph node dissection. We here report on self-reported lower limb lymphedema (LLL), lymphocyst formation, ascites, and long-term serious adverse events 12 months after surgery.

Patients and methods

Patients were enrolled between 2013 and 2016, and 96 patients were included in the per protocol analysis, evenly distributed between RALS and laparotomy. Self-reported LLL was recorded using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire for endometrial cancer—EN24, assessed before and 12 months after surgery. Computed tomography was assessed at baseline, 3, and 12 months. Medical charts were reviewed for serious adverse events and hospital admissions 31 to 365 days after surgery.

Results

At 12 months after laparotomy and RALS, 61% and 50% patients, respectively, reported LLL (p = 0.31). In univariate analysis, the mean score of LLL at 12 months was significantly higher for laparotomy than for RALS (p < 0.05) and for those without abdominal drainage (p = 0.02), but was not independently associated with LLL in the multivariate analysis. Imaging showed no significant difference in lymphocyst formation or ascites between surgical modalities. No difference was found in serious adverse events and admissions to hospital for any reason. There was no agreement between lymphocyst formation or ascites and self-reported LLL.

Conclusion

Follow-up 1 year after comprehensive surgical staging for high-risk endometrial cancer showed no differences in self-reported LLL, findings on imaging, or SAE between laparotomy and robot-assisted surgery.

The role of pelvic lymphocele in the development of early postoperative complications

With the increasing incidence of gynecologic malignancy, radical hysterectomy represents an important part of the adequate treatment of these patients. The pelvic lymphocele is a known side effect of pelvic and para-aortic lymphadenectomy. The aim of our study was to assess the role of the lymphocele in the development of early postoperative complications.A single-center, retrospective analysis between January 2000 and May 2017 revealed 1867 patients with cervical and endometrial cancer, treated through radical or modified radical hysterectomy and pelvic lymphadenectomy. Postoperative complications and the occurrence of pelvic lymphocele were evaluated.Approximately 47.6% of patients were diagnosed with pelvic lymphocele, with only 5.2% being symptomatic. Early postoperative complications rate recorded an incidence of 8.1%, occurring more frequent if lymphocele were present (P < .001). The pelvic lymphocele represented, in univariate analysis, a risk factor for the development of pelvic abscesses, but not for deep vein thrombosis, lymphedema, or bowel obstruction. Hydronephrosis was found to be significantly correlated with the pelvic lymphocele, but we believe this urological complication to have a different underlining mechanism. Neoadjuvant radiotherapy represented in both uni- and multivariate analysis a risk factor for the occurrence of postoperative complications.In the postoperative context of oncogynecological surgery, pelvic lymphocele occur at high rates, representing a statistical risk factor for hydronephrosis and pelvic abscesses, with neoadjuvant radiotherapy being an independent risk factor for early postoperative complications.

Second primary cancer after primary peritoneal, epithelial ovarian, and fallopian tubal cancer: a retrospective study

Background

In this retrospective study, data from patients listed in the Korea Central Cancer Registry during 1993–2014 were analysed, to investigate the incidence and survival of second primary cancers (SPCs) after a diagnosis of primary peritoneal, epithelial ovarian, and fallopian tubal (POFT) cancer.

Methods

The standardised incidence ratio (SIR) and survival outcomes of patients with SPCs among POFT cancer survivors were analysed.

Results

Among 20,738 POFT cancer survivors, 798 (3.84%) developed SPCs, at an average interval of 5.50 years. SPC risk in POFT survivors (SIR, 1.29) was higher compared to the general population. The most high-risk type of SPC was leukaemia (3.07) followed by the lung and bronchus (1.80), colon (1.58), rectum and rectosigmoid junction (1.42), thyroid (1.34), and breast (1.26). In women aged < 60 years, cancer of the breast (1.30), ascending colon (2.26), and transverse colon (4.07) as SPCs increased. Up to 10 years after POFT cancer treatment, leukaemia risk increased, especially in those < 60 years, with serous histology, and with distant stage, which required aggressive chemotherapy. The median overall survival time was 12.8 years and 14.3 years in women with POFT cancer and SPCs, respectively. Thyroid and breast cancers were favourable prognostic markers among SPCs.

Conclusions

The overall SPC risk increases in POFT cancer survivors, especially in those < 60 years. The cancer risk of breast and the proximal colon increase based on hereditary predisposition, while leukaemia likely develops from aggressive treatment. The median overall survival is favourable in POFT cancer survivors with SPCs.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4700-3) contains supplementary material, which is available to authorized users.

Two-step sentinel lymph node mapping strategy in endometrial cancer staging using fluorescent imaging: A novel sentinel lymph node tracer injection procedure

OBJECTIVE

The current sentinel lymph node (SLN) tracer injection procedure for endometrial cancer commonly uses cervical injection, which can detect SLNs of the uterine cervix but not the uterine body. This study describes an SLN tracer injection procedure, titled two-step SLN mapping, which can identify SLNs of the uterine body and cervix using fluorescent imaging with indocyanine green (ICG) and results of SLN biopsy.

METHODS

In 50 consecutive patients with endometrial cancer, two-step SLN mapping was performed during laparoscopic surgical staging with the PINPOINT^® real-time fluorescence imaging system. The first step was to identify SLNs of the uterine body. In total, 4-6 mL of ICG was injected into the bilateral uterine cornual areas, and lymphatic channels were traced, followed by identification and removal of paraaortic SLNs. The second step was to identify SLNs of the uterine cervix by injecting 4 mL of ICG into the cervix. After harvesting the mapped pelvic SLNs, complete pelvic and paraaortic lymphadenectomy was performed to validate the two-step SLN mapping strategy.

RESULTS

Our two-step SLN mapping strategy produced excellent SLN detection rates: 100% (50/50) overall for SLNs; 98.0% (49/50) for pelvic SLNs; 94.0% (47/50) for bilateral SLNs; and 86.0% (43/50) for paraaortic SLNs. We detected microscopic metastasis in harvested SLNs of 4 patients (8.0%). The sensitivity, specificity, and negative predictive value of SLN detection were all 100%. There was no false negative case.

CONCLUSION

The two-step SLN mapping strategy to identify lymph nodes from the uterine fundus and cervix was feasible. This strategy could be more accurate in identifying paraaortic lymph node metastasis than the cervical injection method.

Mobilization of Fluids in the Intensive Treatment of Primary and Secondary Lymphedemas

Background

Lymphedema is a clinical condition resulting from the accumulation of macromolecules in the interstitial space with a consequent buildup of fluids.

Aim

The objective of this study was to compare the therapeutic response to treatment that mobilizes fluids between primary and secondary lymphedemas.

Method

Thirty-three patients with severe leg lymphedema who underwent intensive treatment for five consecutive days in 2013 and 2014 at the Clínica Godoy were evaluated in a prospective clinical trial. Diagnosis was based on the patient's history and physical examination. Treatment consisted of eight hours/day of Mechanical Lymphatic Therapy using an electromechanical device (RAGodoy®) that performs plantar flexion and extension associated with 15 minutes of Cervical Lymphatic Therapy, a technique developed by Godoy and Godoy that involves stimulation in the cervical region and a grosgrain compression stocking alternated with elastic bandages. The unpaired t-test and Fisher's exact test were used for statistical analysis with an alpha error of 5% (p value < 0.05) being considering acceptable. Secondary lymphedema was more prevalent in women (Fisher exact test p value < 0.01).

Results

The age of patients with secondary lymphedema was greater than those with primary lymphedema (unpaired t-test: p value < 0.03). The mean volume losses were 64.62% and 48.35% for the patients with secondary and primary lymphedema, respectively (p value < 0.03).

Conclusion

Women are more prevalent and older in the secondary lymphedema group. Volumetric reductions below the knee are faster with intensive treatment for secondary rather than for primary lymphedema.

The Combination of Preoperative Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography and Sentinel Lymph Node Mapping in the Surgical Management of Endometrioid Endometrial Cancer

OBJECTIVE

The goal of this study was to evaluate the combination of sentinel lymph node (SLN) mapping and F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) scan in detection of lymph node involvement in patients with endometrioid endometrial cancer (EEC).

METHODS/MATERIALS

Ninety-five patients with EEC who had preoperative PET/CT imaging and underwent SLN mapping were retrospectively analyzed. Methylene blue dye was used and injected to the cervix at 3- and 9-o'clock positions (a total of 4 mL). Pelvic lymphadenectomy was performed on all of the patients after SLN mapping. If the SLN was negative in the initial hematoxylin and eosin staining, an ultrastaging study was performed for the SLNs.

RESULTS

Sentinel lymph nodes were detected in 77 (81.1%) of 95 patients, with a mean of 2.95 SLNs. There was only 1 case (1.4%) with a positive SLN in the intraoperative frozen section examination in those patients with negative PET/CT findings and in whom SLNs were detected (n = 70). Among the remaining 69 patients with negative preoperative PET/CT findings and negative frozen section results for the SLNs, there were 2 patients with SLN involvement in the final ultrastaging pathology. In the patient-based analyses, the sensitivity, specificity, and positive and negative predictive values of the PET/CT and SLN frozen section were 33%, 100%, 100%, and 97.1%, respectively.

CONCLUSIONS

As no metastases in the nonsentinel pelvic lymph nodes were found in patients with EEC who had both negative PET/CT findings and frozen section results of the SLNs in both hemipelvises, we suggest using both methods to reduce the incidence of unnecessary systematic lymphadenectomy.

Sentinel lymph node biopsy in endometrial cancer-Feasibility, safety and lymphatic complications

OBJECTIVE

To compare the rate of lymphatic complications in women with endometrial cancer undergoing sentinel lymph node biopsy versus a full pelvic and infrarenal paraaortic lymphadenectomy, and to examine the overall feasibility and safety of the former.

METHODS

A prospective study of 188 patients with endometrial cancer planned for robotic surgery. Indocyanine green was used to identify the sentinel lymph nodes. In low-risk patients the lymphadenectomy was restricted to removal of sentinel lymph nodes whereas in high-risk patients also a full lymphadenectomy was performed. The impact of the extent of the lymphadenectomy on the rate of complications was evaluated.

RESULTS

The bilateral detection rate of sentinel lymph nodes was 96% after cervical tracer injection. No intraoperative complication was associated with the sentinel lymph node biopsy per se. Compared with hysterectomy alone, the additional average operative time for removal of sentinel lymph nodes was 33min whereas 91min were saved compared with a full pelvic and paraaortic lymphadenectomy. Sentinel lymph node biopsy alone resulted in a lower incidence of leg lymphedema than infrarenal paraaortic and pelvic lymphadenectomy (1.3% vs 18.1%, p=0.0003).

CONCLUSION

The high feasibility, the absence of intraoperative complications and the low risk of lymphatic complications supports implementing detection of sentinel lymph nodes in low-risk endometrial cancer patients. Given that available preliminary data on sensitivity and false negative rates in high-risk patients are confirmed in further studies, we also believe that the reduction in lymphatic complications and operative time strongly motivates the sentinel lymph node concept in high-risk endometrial cancer.

Laparoscopic near-infrared fluorescent imaging as an alternative option for sentinel lymph node mapping in endometrial cancer: A prospective study

BACKGROUND

To evaluate feasibility of sentinel lymph node (SLN) mapping by using near-infrared fluorescent imaging and indocyanine green (NIR/ICG) integrated laparoscopic system in clinically uterine-confined endometrial cancer.

MATERIALS AND METHODS

Patients with clinically early-stage endometrial cancer were included in this prospective study. ICG was injected to the uterine cervix and NIR/ICG integrated laparoscopic system (Spies Full HD D-Light P ICG technology, Karl Storz, Tuttlingen, Germany) was used during the operations. SLN and/or suspicious lymph nodes were resected. Side specific lymphadenectomy was performed when mapping was unsuccessful. Systematic lymphadenectomy was completed following SLN algorithm steps.

RESULTS

Seventy-one eligible patients were analyzed. The overall, unilateral and bilateral SLN detection rates were 95.7%, 18.3%, 77.4%, respectively. There were 8 (11.2%) patients with lymph node metastasis. One of them was isolated para-aortic node metastasis. Negative predictive value, sensitivity and false negative rate for detecting lymphatic spread were 98.4%, 87.5% and 1.5%, respectively.

CONCLUSION

Sentinel lymph node mapping can easily be performed with high accuracy by using NIR/ICG integrated conventional laparoscopic system in endometrial cancer and almost all lymphatic spread can be detected.

Computed tomography-based quantitative assessment of lower extremity lymphedema following treatment for gynecologic cancer

Objective

To develop an algorithmic quantitative skin and subcutaneous tissue volume measurement protocol for lower extremity lymphedema (LEL) patients using computed tomography (CT), to verify the usefulness of the measurement techniques in LEL patients, and to observe the structural characteristics of subcutaneous tissue according to the progression of LEL in gynecologic cancer.

Methods

A program for algorithmic quantitative analysis of lower extremity CT scans has been developed to measure the skin and subcutaneous volume, muscle compartment volume, and the extent of the peculiar trabecular area with a honeycombed pattern. The CT venographies of 50 lower extremities from 25 subjects were reviewed in two groups (acute and chronic lymphedema).

Results

A significant increase in the total volume, subcutaneous volume, and extent of peculiar trabecular area with a honeycombed pattern except quantitative muscle volume was identified in the more-affected limb. The correlation of CT-based total volume and subcutaneous volume measurements with volumetry measurement was strong (correlation coefficient: 0.747 and 0.749, respectively). The larger extent of peculiar trabecular area with a honeycombed pattern in the subcutaneous tissue was identified in the more-affected limb of chronic lymphedema group.

Conclusion

CT-based quantitative assessments could provide objective volume measurements and information about the structural characteristics of subcutaneous tissue in women with LEL following treatment for gynecologic cancer.

Identifying risk factors for occult lower extremity lymphedema using computed tomography in patients undergoing lymphadenectomy for gynecologic cancers

OBJECTIVE

To identify risk factors for lower extremity lymphedema (LEL) using computed tomographic (CT) scan in patients undergoing lymphadenectomy for gynecologic cancers.

METHODS

We retrospectively reviewed 511 consecutive gynecologic cancer patients undergoing lymphadenectomy. Mean difference (3.77±3.14mm) of subcutaneous layer thicknesses between preoperative and postoperative 1-year CT scans of 106 patients with clinical LEL was used as an objective criterion for regrouping all the patients into those with mean difference >3.77mm and ≤3.77mm. Risk factors for clinical LEL and significant increase of subcutaneous layer thickness on CT were evaluated using a logistic regression model.

RESULTS

A total of 106 (20.7%) patients were clinically diagnosed with LEL by a physician. Total number of lymph nodes (LNs) retrieved >30 (Odds ratio [OR] 3.2; 95% Confidence interval [CI] 1.94-5.32; p<0.001) and adjuvant pelvic radiotherapy (OR 3.1; 95% CI 1.75-5.52; p<0.001) were risk factors for clinical LEL. One hundred-nineteen (23.3%) had subcutaneous layer thickness increase of >3.77mm. In addition to number of LNs retrieved >30 (OR 2.3; 95% CI 1.40-3.74; p=0.001) and adjuvant pelvic radiotherapy (OR 1.7; 95% CI 1.01-2.74; p=0.046), open surgery (OR 1.8; 95% CI 1.01-3.11; p=0.045), long operation time (OR 1.7; 95% CI 1.05-2.83; p=0.032), and no use of intermittent pneumatic compression (IPC) (OR 2.1; 95% CI 1.06-4.16; p=0.034) were risk factors for thick subcutaneous layer on postoperative CT.

CONCLUSIONS

In addition to high LN retrieval and adjuvant pelvic radiotherapy, open surgery, long operation time, and no IPC use could be risk factors for occult LEL after lymphadenectomy in gynecologic cancers.

Development of the short version of the Gynecologic Cancer Lymphedema Questionnaire: GCLQ-7

Objective

The Gynecologic Cancer Lymphedema Questionnaire (GCLQ) was designed to identify gynecologic cancer patients with lower limb lymphedema (LLL). The questionnaire consists of 20 items distributed over 7 symptom clusters. The present study aimed to develop an abridged form of the GCLQ for simpler screening and more effective follow-up of LLL.

Methods

Data that had been collected for the development and validation of the Korean version of the GCLQ (GCLQ-K) were used in this study. Receiver-operating characteristic (ROC) curves were drawn according to the individual items of the GCLQ-K. Based on discrimination ability, the candidate items were selected in each symptom cluster. After combining the items, the best model was identified and named GCLQ-7. The area under the ROC curve (AUC) was compared between the GCLQ-7 and the original GCLQ-K.

Results

In total, 11 candidate items were selected from the original GCLQ-K. Among the models made with the candidate items, GCLQ-7, the best model, was constructed with 7 items as follows: 1) limited knee movement, 2) general swelling, 3) redness, 4) firmness/tightness, 5) groin swelling, 6) heaviness, and 7) aching. This model exhibited an AUC of 0.945 (95% confidence interval [CI], 0.900–0.991), which is comparable with that of the original GCLQ-K (AUC, 0.867; 95% CI, 0.779–0.956). The best cutoff value was 2 points, at which the sensitivity and specificity were 97.0% and 76.5%, respectively.

Conclusion

The newly developed short version model, GCLQ-7, showed acceptable discrimination ability as compared with the original GCLQ-K.