Paraaortic Lymph Node Dissection

Transcription

1 Paraaortic Lymph Node Dissection 가천의대 임소이

2 Pelvic & paraaortic lymph node dissection Major surgical staging procedure Endometrial cancer, ovarian cancer Cervical cancer: clinical staging Surgical and oncologic goals Define extent of disease Guide further treatment Therapeutic role? Papdia et al. J Am Assoc Gynecol Laparosc 2004 Cosin et al. Cancer 1998 Goff et al. Gynecol Oncol 1999 Somashekhar et al. Best Practice & Res Clin Obstet Gynecol 2015 Chan et al. Cancer 2006

3 Definition and terminology KGOG surgical manual Systematic dissection all fat and nodal tissues surrounding aorta, IVC from renal vessels to mid CIA Sampling sentinel node suspicious node random sampling Debulking Lee et al. J Gynecol Oncol 2017 Pomel et al. BJOG 2011

4 Definition of PALND Over distal vena cava from IMA to mid Rt.CIA Between aorta and left ureter from IMA to mid Lt. CIA GOG Surgical Procedure Manual From textbook of TeLinde s Operative Gynecoogy, 11 th edition

5 Lymph node dissection classification by KGOG surgical manual Paraaortic - infrarenal Paraaortic- infra-ima Common iliac (presacral) External, internal iliac Level 4 Level 3 Level 2 Level 1 Lee et al. J Gynecol Oncol 2017 From textbook of TeLinde s Operative Gynecoogy, 11 th edition

6 Defining anatomical region LN Site Precaval Paracaval Retrocaval Aortocaval Preaortic Paraaortic Retroaortic Panici et al. Obstet Gynecol 1992

7 Paraaortic LN count LNs/ normal adult body >250 in abdomen & pelvis About 81 LNs between: Pelvis 50 Aortic area 31 Node group Median Range Paracaval Precaval Retrocaval Intercavoaortic-superficial Intercavoaortic-deep Preaortic Paraaortic Retroaortic Panici et al. Obstet Gynecol 1992

8 Anatomy From textbook of TeLinde s Operative Gynecoogy, 11 th edition

9 Anatomy Retroperitoneal space Kidneys, ureters, bladder, great vessels, lymphatic channels, lymph nodes, nerves, muscles Anatomy of the retroperitoneum Optimal exposure Panici et al. Gynecol Oncol 2007

10 Lymphatic system Step-wise fashion 3 main route of uterus Fundus, superior uterine body ovarian vessel aortic LN round ligament superficial inguinal LN Most of uterine body broad ligament external iliac LN Cervix uterine vessel internal iliac LN utero sacral ligament sacral LN Ovaries, tubes Pelvic & aortic LN From textbook of TeLinde s Operative Gynecoogy, 11 th edition

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12 Incidence of PLN and ALN metastasis in cervical, endometrial and ovarian carcinoma N No. positive node patients PLN Both PLN ALN ALN alone *PA/(PA+P) **PA/(PA+A) CC 76 25(33%) 16 (64%) 9(36%) 0 (0%) 9/25 (36%) 9/9 (100%) EC (25%) 7 (26%) 18 (67%) 2 (7%) 18/25(72%) 18/20 (90%) OC (37%) 10 (17%) 36 (62%) 12 (21%) 36/46(78%) 36/48 (75%) * Incidence of ALN mets in pt with PLN mets **Incidence of PLN mets in pt with ALN mets CC: primarily to PLN OC: almost equally to both PLN and ALN EC: directly to both PLN and ALN with dominant PLN mets Matsumoto et al. Cancer Letters 2002

13 Cervical cancer Stage IB-IIB Mostly pelvic LN mets Sakuragi et al. Cancer 1999

14 Endometrial cancer

15 Endometrial cancer Pelvic or paraaortic or both region metastasis Metastatic site of PALN relative to IMA Above IMA Pelvic only Pelvic +PALN PALN only Mariani et al. Gynecol Oncol 2008

16 Endometrial cancer Todo et al. J Gynecol Oncol 2017

17 Endometrial cancer Todo et al. J Gynecol Oncol 2017

18 Ovarian cancer Panici et al. Res Clin Obs Gynecol 2002

19 Ovarian cancer Pelvic & paraaortic LN mets in early stage ovarian cancer Pelvic & paraaortic LN mets in advanced stage ovarian cancer Panici et al. Res Clin Obs Gynecol 2002

20 Extent of PALND Cervical ca: PLND, low PALND Endometrial ca: PLND, low PALND Ovarian ca: PLND, high PALND

21 Approach Transperitoneal greater space, familiar landmarks requires bowel mobilization. Extraperitoneal operative feasibility in spite of previous abdominal surgery, risk of bowel injury, bowel adhesion. Disadvantages: small working space, limited landmark, risk of disorientation Both ways of approaches By abdominal incision or laparoscopically.

22 Minimal invasive surgery Benefits fewer complications, lesser adhesion, shorter hospital stay, maintenance of QOL, reduced analgesics, earlier return to normal activities. Limited surgical space, technical problems, especially in PALND Many barriers surgical field learning curve technique

23 Robotic surgery Facilitate minimal invasive surgery, 3D vision, intuitive control, wristed instruments Limitations in arm mobility Prohibit both in pelvis & upper abdomen Robotic column reposition Additional trocar Kim et al. J Gynecol Oncol 2015

24 Operation technique and points of caution Opening retroperitoneum at level of peritoneum above Rt.CIA. ureter should be identified carefully. common iliac vein injury. Ao RCI LCI From textbook of Atlas of Procedures in Gynecologic Oncology

25 Approach through paracolic gutter From textbook of Critical Operative Maneuvers in Urologic Surgery

26 Right paracaval dissection From left to right or right to left Not directly over vena cava.

27 Fellow s vein Small perforating vein located anterior to vena cava during clipping to avoid massive bleeding

28 Ovarian veins right renal vein right ovarian vein Zivanovic et al. Gynecol Oncol 2008 From textbook of TeLinde s Operative Gynecoogy, 11 th edition

29 Accessory renal artery Sometimes, accessory renal artery is then exposed crossing in front of vena cava.

30 Lumbar vessels From textbook of Critical Operative Maneuvers in Urologic Surgery Zivanovic et al. Gynecol Oncol 2008

31 Vena cava tear 4-0 Prolene suture From textbook of Critical Operative Maneuvers in Urologic Surgery

32 Low paraaortic node dissection Endometrial cancer at level of IMA Ovarian cancer up to renal vessel Identify IMA prior to starting LND

33 IMA (inferior mesenteric artery) 1 st major vessel during PALND 3-4cm above the aortic bifurcation D- colon, rectum supply No significant complication after ligation

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35 High paraaortic lymph node dissection Right side between aorta and Rt. ureter from IMA to entry of Rt. Ovarian vein Left side between aorta and Lt. ureter from IMA to entry of Lt.ovarian vein

36 High paraaortic lymph node dissection

37 Left ovarian vein should be ligated first avoid to dissect accessory renal vein

38 Retrocaval/retroaortic lymph node dissection Not routinely performed in surgery for gynecologic malignancy care for injury to lumbar vessels Zivanovic et al. Gynecol Oncol 2008

39 Retrocaval/retroaortic lymph node dissection

40 PALND in Gil Hospital Ovarian cancer, endometrial cancer (n=161) Cytoreductive surgery/surgical staging Laparotomy/laparoscopy PALND/PALNS/PLND/PLNS

41 PALND in Gil Hospital Ovarian cancer/tubal cancer/ppc* (N=119) Endometrial cancer (N=42) Age, mean (range) 55 (26-78) 57 (29-74) Stage I: 42 II: 9 III: 42 IV: 26 I: 36 II:3 III:3 Laparoscopic surgery 2 15 Retrieved PLN 30.8 (1-72) 18.6 (5-56) Retrieved PALN 15.3 (1-57) 5.2 (1-13) Metastatic PLN 3 (1-43) 0.5 (1-5) Metastatic PALN 1.6 (1-40) 0.3 (1-9) *PPC: primary peritoneal carcinoma

42 PALND in Gil Hospital Complications N =161 (%) Intraoperative vessel injury 1 (0.6) Ureter injury 4 (2.5) Lymphocyst 44 (27.3) Lymphedema 13 (8.1)

43 Complications of PALND Lymphatic fluid-drainage related Lymphedema Most common, within the first year progresses to a chronic disease Vulvar cancer 9-70%, cervical cancer %, endometrial cancer % Postop. irradiation, greater extent of LND No association with age, weight, BMI, stage, type of hysterectomy, duration closed suction drainage, lymphocyst formation Abu-Rustum et al. Gynecol Oncol 2006 JH Kim et al. IJGC 2012

44 Management of lymphedema Early recognition Compression stockings referred to a physical therapist specialized in lymphedema Abu-Rustum et al. Gynecol Oncol 2006 JH Kim et al. IJgc 2012

45 Lymphocyst Incidence 20% Left pelvic side wall- most common Often asymptomatic Resolve spontaneously management Sclerotherapy iodine, doxycycline, alcohol instillation Laparoscopic marsupialization Zicman et al. Gynceol Oncol 2015 Ghezzi et al. Ann Surg Oncol 2012

46 Electronic devices Monopolar electrosurgical device Can increase lymphocele formation due to incomplete sealing of the lymphatic ducts. USS, EBVSD (Ligasure ) helps to decrease lymphocele. Portet et al. Am J Surg 1998 Matthey-Gie et al. Ann Surg Oncol 2016 Tsuda et al. J Gynecol Oncol 2014

47 Thromboembolism Incidence 2-5% procedures >45 minutes in duration moderate risk prophylactic pharmacologic anticoagulation Kumar et al. Gynecol Oncol 2013 Matsuura et al. Int J Gynecol Cancer 2006

48 Chylous ascites Incidence 1-9% mostly after paraaortic lymph node dissection. PALN>14 Kaas et al. Eur J Surg 2001 Solmaz et al. Int J Surg 2016

49 Chylous ascites Conservative management Drain placement, paracenetesis High protein/low fat diet TPN alone or with diet Median chain fatty acid diet Somatostatin analogues Surgical correction Level of left renal vein Upper limit of infrarenal lymphadenectomy Coagulation & cut with a clip Kaas et al. Eur J Surg 2001 Solmaz et al. Int J Surg 2016

50 Lumbar vessels Massive bleeding, difficult repair Lumbar artery injury Infarction of spinal cord.

51 Abdominal aortic nerve plexus On sides and front of aorta Between origins of SMA & IMA Contraction of internal urethral sphincter Male: ejaculation function Female: incontinence

52 L2 L3 Ovarian artery 5-6cm Lt.Renal vein L2 L3 L4 IMA 3-4cm L4 L5 L5

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54 Summary

55 경청해주셔서감사합니다.