How accurate is frozen section histology of pelvic lymph nodes in patients with endometrial cancer?

OBJECTIVE: Recent prospective data support the trend towards systematic retroperitoneal lymphadenectomy in patients with high-risk endometrial cancer. Because para-aortic node involvement in the absence of pelvic node involvement is uncommon, a reliable finding of negative pelvic lymph nodes (PLN) at intraoperative frozen section examination might allow omitting para-aortic dissection. We analyzed the diagnostic accuracy of frozen section examination of PLN in patients with endometrial cancer. METHODS: We reviewed 131 patients with endometrial cancer who underwent surgery including systematic pelvic lymphadenectomy (n=101) or pelvic and para-aortic lymphadenectomy (n=27). Intraoperative frozen section examination of PLN was performed in 72 (55%) patients. Results of frozen section examination were compared with those of final histopathology and the diagnostic accuracy of frozen section examination of PLN was calculated. One pathologist measured the diameters of PLN metastases retrospectively. RESULTS: A total of 1063 and 2666 PLN were analyzed by frozen section examination and by final histopathology, respectively. PLN metastases were found in 7 cases (10%) at frozen section examination, and in 17 cases (24%) at final histopathology (false negative rate, 59%). No false positive cases were noted. The mean diameter of all PLN metastases at final histopathology was 4.3 mm, as compared to 9.0 mm for the metastases detected at frozen section analyses. The mean diameter of PLN metastases missed at frozen section examination was 2.0 mm. CONCLUSION: In this review at a single institution, intraoperative frozen section histology missed nearly two of three endometrial cancer patients with positive nodes. These results do not support tailoring the extent of lymphadenectomy according to the results of frozen section examination.

Assessment of risk factors for survival of neonates born after second-trimester PPROM.

OBJECTIVE: Assess fetal risk factors which impact survival of infants delivered after second-trimester PPROM. STUDY DESIGN: Clinical records of 87 patients, who all had second-trimester rupture of membranes between 14+0 and 24+6 weeks of gestation treated January 1998 to July 2005 were reviewed regarding perinatal outcome. This study is based on 25 surviving infants. RESULTS: 13 of these 25 infants died in the hospital. Survivors had a higher birth weight (p=0.008) and higher Apgar scores after 5 min (p=0.005) than those infants dying. No differences in UA pH, the need of catecholamines and no association between histological verified chorioamnionitis and early onset sepsis were seen between survivors and nonsurvivors. CONCLUSION: Higher gestational age at birth, higher birth weight, the absence of histologically verified chorioamnionitis and 5 min Apgar scores of >or= than 6 have positive prognostic value for survival of neonates delivered preterm after second-trimester PPROM.

Neonatal outcome and two-year follow-up after expectant management of second trimester rupture of membranes.

OBJECTIVE: To assess neonatal outcome and 2-year follow-up of pregnancies complicated by second trimester preterm premature rupture of membranes (PPROM). METHODS: A retrospective review of obstetric and neonatal records for 87 pregnancies (56 singletons, 6 twins, 1 triplet) with PPROM between 14+0 and 24+6 weeks of gestation. Patients received antibiotics and steroids for fetal lung maturity once they reached 24 weeks of gestation. Placentas were examined histopathologically. Surviving infants were followed-up at 2 years of age. RESULTS: Median latency from PPROM to delivery was 4 days. Survival rate of 56 singletons was 45% (25/56); and 13 died in hospital. Survival rate of infants discharged from hospital was 23% (12/56). Chorioamnionitis was seen histologically in 42% (5/12) of surviving infants compared with 92% (12/13) of those that died in hospital. Of the 12 surviving infants, 50% had a normal neurological and developmental outcome at 2 years of age. CONCLUSION: Gestational age, birth weight, and histologic chorioamnionitis have prognostic importance in pregnancies complicated by PPROM. Surviving infants have a 50% chance of achieving an adequate health status at 2 years of age.

Where to look for the sentinel lymph node in cervical cancer.

OBJECTIVE: The aim of this study was to analyze lymphatic spread to pelvic, parametrial, and paraaortic lymph nodes in patients with cervical cancer. STUDY DESIGN: We reviewed 619 patients with invasive cervical cancer treated by radical abdominal hysterectomy and systematic pelvic or pelvic and paraaortic lymphadenectomy between 1971 and 2005. The present study included 61 patients with one positive lymph node (10%) and 59 patients with two positive lymph nodes (10%) at any location. RESULTS: The external iliac (43%) and obturator (26%) regions and the parametrium (21%) were the most commonly involved pelvic lymph node sites with solitary metastases. Isolated metastases to common iliac, presacral (internal iliac), and paraaortic nodes were found in 7%, 1%, and 1% of patients, respectively. Patients with 2 positive nodes had 1 parametrial and 1 pelvic node involved (32%), 2 ipsilateral positive nodes (31%), 1 positive lymph node on both sides of the pelvis (27%), and 2 positive nodes within the parametrium (10%). CONCLUSIONS: In cervical cancer patients with only 1 positive lymph node, this node is most frequently located within the external iliac and obturator regions and the parametrium. Sentinel node identification should primarily address these lymph node sites. If 1 positive lymph node is found, further metastases are unpredictable within pelvic and parametrial lymph node sites. Paraaortic spread without pelvic node involvement is rare.

Long-term follow-up after neoadjuvant chemotherapy for high-risk cervical cancer during pregnancy.

BACKGROUND: We report on a patient with a high-risk cervical cancer during pregnancy treated with neoadjuvant chemotherapy (NACT) followed by radical surgery. CASE: A 38-year-old woman was diagnosed with FIGO stage IIA cervical cancer at 19 weeks' gestation. She received four cycles of cisplatin (50 mg/m2) and vincristine (1 mg/m2) at 3-week intervals starting at 23 weeks' gestation. A cesarean section with radical hysterectomy and pelvic lymphadenectomy was performed at 33 weeks, delivering a 1920 g male newborn. Histology showed a poorly differentiated squamous cell carcinoma with lymph vascular invasion and pelvic lymph node metastases. The patient received three further cycles of chemotherapy. Both mother and child are healthy at 80 months after the primary diagnosis. CONCLUSION: NACT followed by radical surgery may be effective in selected patients with invasive cervical cancer during pregnancy.

Is intraoperative frozen section analysis of pelvic lymph nodes accurate after neoadjuvant chemotherapy in patients with cervical cancer?

OBJECTIVE: Intraoperative frozen section examination of pelvic lymph nodes is frequently used in patients with cervical cancer, some of whom have received neoadjuvant chemotherapy (NACT). However, NACT can cause necrosis, fibrosis, or keratinization of tumor deposits in extirpated lymph nodes, and it is unclear whether intraoperative frozen section analysis of extirpated nodes is accurate after NACT. We analyzed the accuracy of frozen section examination of pelvic lymph nodes in patients after NACT for cervical cancer. METHODS: We reviewed 134 patients with invasive cervical cancer who underwent surgery including systematic pelvic lymphadenectomy with intraoperative frozen section examination of pelvic lymph nodes. Results of frozen section examination were related to definitive histology and compared between patient groups of NACT and primary surgery. RESULTS: A total of 1670 pelvic lymph nodes were evaluated intraoperatively by frozen section examination, and 6689 pelvic lymph nodes were analyzed by final histopathology. Overall frozen section analysis had nine false negative results among 53 patients with positive lymph nodes (false negative rate, 16.9%). After NACT, there were two false negative diagnoses in twelve patients with node metastases (false negative rate, 16.7%). No false positive cases were noted. The sensitivity and negative predictive value of frozen section examination were 83% and 82%, respectively, in patients after NACT, and 83% and 91% at primary surgery. CONCLUSION: NACT does not appear to compromise the diagnostic accuracy of intraoperative frozen section examination of pelvic lymph nodes in patients with cervical cancer.

Isolated recurrence at the residual uterine cervix after abdominal radical trachelectomy for early cervical cancer.

BACKGROUND: We report an isolated recurrence at the residual cervix shortly after abdominal radical trachelectomy for cervical cancer. CASE: A 34-year-old woman underwent radical abdominal trachelectomy and pelvic lymphadenectomy for FIGO stage IB1 squamous cell cervical cancer. The tumor measured 10 mm in maximum diameter with 4 mm of invasion. Histology showed lymph vascular space involvement with no infiltration of adjacent structures and no pelvic lymph node metastases. Tumor-free resection margins exceeded 15 mm. At the 6-month follow-up examination, cervical cytology showed cells suspicious for recurrent cervical cancer. Abdominal hysterectomy was performed and histology showed an isolated 3-mm recurrence in the residual cervix. The patient is free of disease 8 months after hysterectomy. CONCLUSION: Recurrence at the residual cervix is a potential risk of abdominal trachelectomy for early cervical cancer. Patients should be counseled accordingly and followed closely.

Ectopic (pelvic) kidney mimicking bulky lymph nodes at pelvic lymphadenectomy.

BACKGROUND: Ectopic (pelvic) kidney is the most common congenital renal anomaly with an incidence of 1 in 500 to 1 in 2000. A pelvic kidney can be encountered at pelvic or paraaortic lymphadenectomy. CASE REPORTS: In two patients undergoing pelvic lymphadenectomy, lobulated tumors near the pelvic brim were initially interpreted as bulky lymph node conglomerates. Further dissection showed the ureter to originate from the masses, leading to a diagnosis of pelvic kidney. CONCLUSION: Pelvic kidneys mistaken for bulky lymph nodes are a potential intraoperative pitfall in patients with gynecologic malignancies. Keys to recognition include an index of suspicion, identifying the course of the ureter and origin of the renal vessels, and confirming absence of a kidney at the normal location.

Placement of a retropubic drain with the tension-free vaginal tape operation.

Intraoperative bleeding and postoperative hematomas are recognized complications of the tension-free vaginal tape (TVT) operation. We devised a connector to attach a drain to the end of the TVT needle. The drain is pulled upward with the tape itself and is left in the space of Retzius in the tract created by the needle. The drain connector provides a simple method to place a drain in the space of Retzius during the TVT operation.

T1 breast cancer: identification of patients at low risk of axillary lymph node metastases.

OBJECTIVE: The status of the axillary lymph nodes is one of the most important prognostic factors in patients with breast cancer. A panel of molecular markers of tumor aggressiveness in addition to conventional clinical and histopathologic features were analyzed in an attempt to identify a subgroup of patients with a low risk of axillary lymph node metastases. MATERIAL AND METHODS: Data from 358 patients with T1 breast cancer who underwent level I/II axillary lymph node dissection (ALND) were investigated. Hormone receptor status, Ki-67, S-phase fraction, DNA ploidy, HER-2/neu, p53, epidermal growth factor receptor, urokinase type plasminogen activator, plasminogen activator inhibitor-1, bone marrow micrometastases as well as patient age, menopausal status, tumor site, tumor size, histologic type, tumor grade, carcinoma in situ, multifocality, and lymph vascular invasion (LVI) were studied to predict axillary lymph node status. RESULTS: In a multivariate logistic regression analysis LVI (present v.s. not present), Ki-67 (> or = 18% v.s. < 18%), tumor size (1.1-2 cm v.s. < or = 1 cm), and histologic grade (G3 v.s. G1/2) were identified as independent predictive factors of axillary lymph node metastases. Approximately 13% of patients (n = 47) with well or moderately differentiated tumors less than or equal to 1 cm, no lymph vascular invasion, and a low Ki-67 staining were identified as having a low risk of axillary lymph node metastases of 4.3%. However, 20 patients with all four unfavorable predictive factors had a 75% incidence of axillary lymph node involvement. CONCLUSION: Primary tumor characteristics can be used to identify a subgroup of patients with a low risk of axillary lymph node metastases in T1 breast cancer. Preoperative risk assessment might be used to omit routine ALND in those patients at low risk of axillary lymph node metastases.

[The tension-free vaginal tape operation for the treatment of stress incontinence]. / Die Tension-free-vaginal-tape-Operation zur Behandlung der Stressinkontinenz.

The tension-free vaginal tape (TVT) operation and similar procedures are the newest development in the surgical treatment of female stress incontinence. In contrast to the Burch colposuspension and abdominovaginal sling procedures, the operation aims at supporting the midurethra and not the bladder neck. The only ongoing prospective randomized trial comparing TVT with the Burch colposuspension, conducted by the UK and Ireland TVT Trial Group, shows comparable 2-year results. The TVT operation is a technically simple procedure with a low rate intraoperative and postoperative complications. This and the good cure rates may make this procedure and similar methods the standard operation for the treatment of primary and recurrent stress incontinence.

Groin recurrence after micrometastasis in a sentinel lymph node in a patient with vulvar cancer.

BACKGROUND: The sentinel lymph node concept is attractive in vulvar cancer because of the potential to avoid the morbidity associated with formal groin dissection. CASE: An 84-year-old patient with a T2 carcinoma of the anterior vulva underwent surgery including bilateral sentinel node excision after identification with technetium-labeled nanocolloid. Frozen section histology showed a tumor deposit <1 mm in diameter in a left groin node whereas four nodes in the right groin were apparently negative. Completion lymphadenectomy was performed only for the left groin. Final histology including serial sectioning showed a micrometastasis in one of seven nodes from the right groin; no further treatment was given. Sixteen months postoperatively the patient developed a recurrence in the right groin; the left groin was free of tumor. CONCLUSION: This case indicates that groins with a micrometastasis detected by sentinel lymph node excision require further treatment.