Systematic (complete) para-aortic lymphadenectomy: description of a novel surgical classification with technical and anatomical considerations

Transcription

1 DOI: /j x Surgical technique Systematic (complete) para-aortic lymphadenectomy: description of a novel surgical classification with technical and anatomical considerations C Pomel, a,b R Naik, c A Martinez, d G Ferron, d J Nassif, e J Dauplat, a A Jeyarajah f a Jean Perrin Cancer Centre, Clermont-Ferrand, France b INSERM research unit 990, Clermont-Ferrand, France c Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, UK d Claudius Regaud Cancer Institute, Toulouse, France e IRCAD Strasbourg, France American Hospital, Beirut, Lebanon f Department of Gynaecological Oncology, St Bartholomew s Hospital, London, UK Correspondence: Prof. C Pomel, 58 rue Montalembert, BP 358, Clermont-Ferrand, France. christophe.pomel@cjp.fr Accepted 28 August Published Online 21 October The clinical indications for a complete para-aortic lymphadenectomy in the surgical management of gynaecological malignancies remain controversial. The debate on complete para-aortic node dissection is hindered by the absence of an identifiable and accepted definition for the procedure of systematic (complete) para-aortic node dissection. In this paper we propose a classification of para-aortic lymphadenectomy. We have identified and imaged the most common and rare para-aortic vascular anomalies that we have encountered. An understanding of the anatomical anomalies in this area also provides a useful reference for the surgical technique that is adopted in order to ensure the completeness of excision. Keywords Classification, lymphadenectomy, para aortic, surgical technique, vascular anomalies. Please cite this paper as: Pomel C, Naik R, Martinez A, Ferron G, Nassif J, Dauplat J, Jeyarajah A. Systematic (complete) para-aortic lymphadenectomy: description of a novel surgical classification with technical and anatomical considerations. BJOG 2012;119: Introduction The clinical indications for a systematic para-aortic lymphadenectomy in the surgical management of gynaecological malignancies are highly debatable. Despite being routinely performed in many international centres for early-stage ovarian endometrial cancers and advanced-stage ovarian cervical cancers, there is very little published evidence of therapeutic benefit. The UK s National Institute for Health and Clinical Excellence (NICE) recently published the outcomes of it s review on the management of ovarian cancer, and identified only one previous randomised controlled trial on systematic (complete) para-aortic lymphadenectomy in early-stage ovarian cancer, which showed no benefit to survival. 1 As a result, they stated that it should not be performed as a routine procedure in the management of these cases, although it did recommend retroperitoneal nodal assessment to guide determine the need for adjuvant chemotherapy treatment. [Correction added after online publication 28 October 2011: All author initials and surnames were transposed] Similarly, for advanced-stage ovarian cancer, only one randomised controlled trial has previously been performed, again showing no evidence of benefit in overall survival, but suggesting a small but statistically significant improvement in progression-free survival. 2 This investigation is currently being repeated by two studies: the German AGO Group as part of the LION study and the CARACO study in France. For endometrial and cervical cancers, there are no previous randomised controlled trials investigating survival outcomes for systematic (complete) para-aortic node dissection, although non-randomised studies suggest that it may be of value in guiding adjuvant definitive chemotherapy radiotherapy treatment. 3 Although accepting the lack of clear evidence of benefit and the urgent need for well-designed prospective studies, the current debate on systematic (complete) para-aortic node dissection is hindered by the absence of an identifiable and accepted definition for the procedure of systematic (complete) para-aortic node dissection. In addition, although there is common usage of the term para-aortic node sampling, it is unclear as to the precise meaning of this terminology in the absence of an identifiable classification ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG 249

2 Pomel et al. system. Recent publications have proposed a classification system for the procedure of pelvic node dissection, but these publications do not address the para-aortic area. This article presents a definition of a systematic (complete) para-aortic node dissection, supported by photographs illustrating the degree to which the nodal tissues surrounding the abdominal vessels should be resected to qualify as systematic and complete. In addition, we propose a classification system with which to categorise lesser degrees of para-aortic node dissection in addition to other non-excisional forms of para-aortic node assessment. Finally, we describe the technique of performing systematic (complete) para-aortic node dissection with special emphasis on the variations in local anatomy one may expect to encounter in an attempt to avoid reduce the risk of significant injury to the major vessels when performing the procedure, and to ensure the completeness of excision. The value of addressing these objectives is to facilitate continued debate and communication, to encourage further research on the clinical value of systematic (complete) para-aortic node dissection, to advance surgical training of these procedures and to encourage their appropriate performance in select cases. Definition of systematic (complete) para-aortic node dissection Systematic (complete) para-aortic lymphadenectomy is defined as the complete removal of all fat and nodal tissues surrounding the aorta, inferior vena cava (IVC) and renal vessels from the left renal vein cranially to the midpoint of the common iliac vessels caudally. Evidence of complete removal should facilitate the full and complete visualisation of the adventitia of each of the aforementioned vessels, in addition to the full exposure of the anterior common vertebral ligament, anterior and lateral aspects of the vertebral bodies, psoas muscles and anterior sacrum. It includes the separation and removal of all tissues lying between the arterial and venous vessels, and the clear identification of the origin root of the ovarian vessels, inferior mesenteric artery, lumbar vessels and accessory vessels. Classification system for para-aortic node assessment (A) Systematic para-aortic node dissection A1 Complete (includes infrarenal and suprarenal up to the coeliac trunk to midpoint of common iliac vessels). A2 Infrarenal (as above, but does not include suprarenal dissection). A3 Infra-inferior mesenteric artery (IMA) (as above, but does not include dissection above IMA). (B) Para-aortic node sampling B1 Extensive (includes para-aortic areas, but does not allow full visualisation of structures listed above, that is adventicia of vessels, renal vessels, anterior common vertebral ligament, psoas muscles and sacrum). B2 Minimal (includes limited para-aortic areas, and does not allow full visualisation of structures listed above). (C) Non-excisional assessment C1 Palpation (direct), following full exposure of paraaortic areas. C2 Palpation (indirect), transperitoneal without any exposure. C3 Radiological assessment by positron emission tomography (PET) computed tomography (CT), CT or magnetic resonance imaging (MRI). Nodal count is considered to be inaccurate in classification as it depends on other factors, including pathological assessment. Technique of systematic (complete) para-aortic node dissection All patients undergo bowel preparation consisting of 5 days of low-fibre diet and one sachet of Picolax Ò (Ferring Pharmaceuticals Ltd, West Drayton, UK) 2 days prior to surgery. The patient is laid supine or in the modified Lloyd Davis position (if the procedure is part of ovarian cancer debulking), with a Foley catheter, following usual antibiotic prophylaxis. A vertical medial incision is extended to the xyphisternum. Self-retaining Bookwalter retractors allow excellent exposure and access, and free both the surgeon and the assistant during the procedure. The caecum and the right side of the colon in addition to the small bowel mesentery and the duodenum are mobilised by incising the peritoneal layer at the level of the right common iliac artery, medially crossing the midline up to the level of the fourth part of the duodenum. The loose avascular underlying tissues are gently dissected. This Kocher s manoeuvre allows the bowel to be laid onto the lower thorax, protected with a large damp swab, or placed into a bowel bag (Figure S1). 1 The left renal vein is identified. 2 The right ureter is freed medially. 3 The left ureter is identified medially behind the inferior mesenteric vein, above the level of the inferior mesenteric artery. These steps allow the lateral aspects of the vertebral bodies and the psoas muscle to be clearly identified bilaterally. 4 The fatty tissues anterior to the aorta are separated divided, exposing the adventitia of the vessel along its full length and including the right common 250 ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG

3 Complete para-aortic lymphadenectomy iliac artery, mobilising the nodal tissues laterally towards the left and right of the artery. 5 The nodal tissues that have been mobilised towards the left of the aorta are dissected, starting cranially, without undue traction or mobilisation of the aorta, in order to avoid injury to the posterior lumbar vessels. The left para-vertebral sympathetic plexus is identified posteriorely. 6 The nodal tissues along the right of the aorta are then dissected, allowing visualisation of the anterior common vertebral ligament. This dissection is continued to expose the left aspect of the IVC down to the level of the right common iliac artery. As the right common iliac artery has been properly isolated and dissected, this will ease the approach of the anterior aspect of the lower part of the vena cava including the small anterior branches that are commonly encountered in this area. 7 The dissection is continued to include the right side of the IVC with respect to the right paravertebral sympathetic plexus. The ovarian vessels can be dissected and either preserved or ligated at the level of the great vessels. We recommend the use of clips or proper ligation when a large lymphatic duct has been identified. The technique described above is identical when managing bulky confluent nodal masses, except that vascular slings are placed prior to the dissection of the bulky disease. These slings are applied around the IVC at three locations: (1) suprarenal; (2) infrarenal; and (3) around the renal veins (as illustrated in Figure 1). These slings can be used to cut off the blood supply to the relevant areas of the vena cava during the dissection, to allow repair of any vessel injuries that may occur whilst minimising blood loss and major haemorrhage. The use of a steep Trendelenburg position and ensuring that the patient is kept under-hydrated during the procedure are both highly effective methods for reducing venous pressure within the vena cava, and also help to reduce blood loss during the dissection. Vascular injuries are managed in the usual manner, consisting firstly of pressure on the bleeding area. This is usually effective after 2 5 minutes, and will if required allow the insertion of sutures using 5.0 double-bladed monofilament. In the absence of vascular slings, one can consider the use of aortic clamps even for venous bleeding as this will contribute significantly by reducing the haemorrhage until the sutures have been inserted. Further bleeding oozing from the sutured vessel can be effectively managed by using the many haemostatic agents currently available (Evicel Ò, OMRIX Biopharmaceuticals Ltd, Kiryat, Israel; FloSeal Ò, Baxter, Newbury, UK; Fibrillar Ò, Johnson & Johnson Medical Limited, Livingston, UK; Nu-knit Ò, Johnson & Johnson Medical Limited, Livingston, UK; or Surgicel Ò, Johnson & Johnson Medical Limited, Livingston, UK). The technique can be applied in virtually all cases, including patients that are obese and also following chemotherapy, radiotherapy or concomitant chemo-radiation therapy. Associated morbidity ranges from 2 to 13% of cases. 4 Most of these can be considered to be minor, such as lymphocysts and lymphoedema. Neurological morbidities are rare. In their study, Benedetti et al. 2 showed that the number of intraoperative complications was similar in the two arms. Systematic lymphadenectomy had greater perioperative and late morbidity. Most of the difference in morbidity resulted from the formation of lymphocysts and lymphoedema. Massive intraoperative haemorrhage is clearly a major risk with this type of surgery, with the resultant morbidity and potential mortality. From our experience, complete dissection and isolation of the major vessels and their divisions is key to avoiding significant bleeding. In addition it facilitates better control of the operating field should vessel injury occur. Figure 1. Perioperative management of para-aortic lymphadenectomy. Anatomical vascular anomalies variations During 15 years of performing para-aortic node dissection for ovarian, cervical and endometrial cancers, we have identified and imaged the most common and rare paraaortic vascular anomalies that we have encountered. Whereas some of these anomalies were identified on preoperative imaging, many were identified intraoperatively. The mechanisms that lead to vascular abnormalities come from their embryological development. Vascular abnormalities can occur in the vena cava, renal, azygos, pre-vertebral and ascending lumbar venous systems, as well as the renal arteries. Being informed of rare anatomical abnormalities may avoid the risk of damaging branches of the greater ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG 251

4 Pomel et al. vessels. 5 During embryologic development, the kidney arterial supply originates from the aorta at successively higher levels as the kidney ascends from the pelvis. Renal arterial variants, including accessory renal arteries, are quite common, with prevalence as high as 30 40%. Right renal arteries are classically described as passing posterior to the IVC. CT scans report as many as 5% of pre-caval renal arteries. 6 The naming of renal artery variations remains controversial. Supplementary or accessory renal arteries enter the kidney through the hilum, whereas aberrant arteries enter the kidney at the polar level (so-called superior or inferior polar arteries; Figure S2a,b). Venous anomalies occur in about 3% of cases. They include: left-sided IVC (situs inversus); double vena cava; retroaortic renal vein; circum aortic renal vein; and interrupted IVC (Figures S3 and S4a). 7 There are also some rare cases of unique ascending renal arteries (Figure S4b). Care must be taken with the right renal artery, which can be injured below the level of the left renal vein, between the aorta and the vena cava (Figure S4c). Brener and colleagues 8 reviewed venous anomalies found during abdominal aortic reconstructions between 1959 and They observed 31 anomalies of the IVC or renal veins, resulting in 11 complications. The posterior left renal vein and the duplication of the IVC are the most common venous anomalies (Figures 2 and S5). Of the above anomalies, the circumaortic renal collar and the posterior left renal vein pose the greatest threat, as the posterior veins may be easily injured during dissection prior to the placement of an aortic cross clamp or vascular slings. Meticulous attention to detail during the dissection of the infrarenal aorta and common iliac arteries is essential to avoid haemorrhage from anomalous veins. Less than 0.3% of the general population have horseshoe kidneys, which are seen in approximately 1 in 300 pyelographies. The vessels may have varied origin from the aorta at the level of T12 to the internal iliac artery at the lower levels. The total number of vessels may vary from four to seven, and the vessel size ranges from 2 to 8 mm (Figure S6). 9 The anterior aspect of the aorta is the only area that is not affected by any anatomical abnormality or variation. Therefore, after careful imaging review, we strongly advise that the para-aortic node dissection is begun on the anterior aspect of the aorta, as recommended by Zivanovic et al. 10 The para-aortic node dissection is thus divided into two parts: the left para-aortic dissection and the right para-aortic dissection. The latter dissection includes the dissection of the tissues between the aorta and the vena cava, and pre- and retrocaval and right paracaval areas. Conclusion This article provides a rational definition of systematic (complete) para-aortic node dissection and a workable classification system, in an attempt to facilitate discussions and generate future research studies on the clinical value of para-aortic node assessment. An understanding of the anatomical anomalies in this area also provides a useful reference to the surgical technique that is adopted to help minimise the risk of injury to the major vessels, and to ensure the completeness of excision. Disclosure of interests None to declare. Contribution to authorship CP and RN conceived and designed the experiments. CP, GF and JD performed the experiments. CP and RN collected and assembled the data. CP, JD and RN analyzed the data. CP, RN, JN, AM, GF, JD and AJ contributed reagents, materials or analysis tools for the study. CP, RN, JN and AJ wrote the paper. Details of ethics approval None required. Funding None. Acknowledgement None. Figure 2. Duplication of vena cava. Note the right common iliac vein connected to the left inferior vena cava. Supporting information The following supplementary material is available for this article: 252 ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG

5 Complete para-aortic lymphadenectomy Figure S1. Installation. Figure S2. (a) Inferior polar renal arteries. (b) Double right polar arteries with inferior polar vein. Figure S3. Left retroaortic renal vein. Figure S4. (a) Circum left renal vein and ascending left renal artery. (b) Ascending left renal artery at the level of the inferior mesentery artery (IMA). (c) Right renal artery below the level of the left renal vein. Figure S5. Duplication of vena cava associated with precaval renal arteries. Figure S6. Horseshoe kidney with slings around kidney, ureters and vessels. Additional Supporting Information may be found in the online version of this article. Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author. j References 1 Nice guidelines UK. Ovarian cancer guidelines [ uk/guidance/index.jsp?action=download&o=50895]. Last accessed 21 October Benedetti Panici P, Maggioni A, Hacker N, Landoni F, Ackermann S, Campagnutta E, et al. Systematic aortic and pelvic lymphadenectomy versus resection of bulky nodes only in optimally debulked advanced ovarian cancer: a randomized clinical trial. J Natl Cancer Inst 2005;97: Brockbank E, Kokka F, Bryant A, Pomel C, Reynolds K. Pre-treatment surgical para-aortic lymph node assessment in locally advanced cervical cancer. Cochrane Database Syst Rev 2011;4:CD DiRe F, Baiocchi G. Value of lymph node assessment in ovarian cancer: status of the art at the end of the second millennium. Int J Gynecol Cancer 2000;10: Eitan R, Abu-Rustum NR, Walker JL, Barakat RR. Ligation of an anatomic variant of renal vasculature during laparoscopic periaortic lymph node dissection: a cause of postoperative renal infarction. Gynecol Oncol 2003;91: Yeh BM, Coakley FV, Meng MV, Breiman RS, Stoller ML. Precaval right renal arteries: prevalence and morphologic associations at spiral CT. Radiology 2004;230: Downey RS, Sicard GA, Anderson CB. Major retroperitoneal venous anomalies: surgical considerations. Surgery 1990;107: Brener BJ, Darling RC, Frederick PL, Linton RR. Major venous anomalies complicating abdominal aortic surgery. Arch Surg 1974;108: Graves FT. Arterial anatomy of congenitally abnormal kidney. Br J Surg 1969;56: Zivanovic O, Sheinfeld J, Abu-Rustum NR. Retroperitoneal lymph node dissection. Gynecol Oncol 2008;2(Suppl):S66 9. ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG 253