Pelvic and Paraaortic Lymphadenectomy in Gynecologic Cancers

Pelvic and paraaortic lymphadenectomy in gynecologic cancers - UpToDate 17/10/16 8:57 p.m.
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www.uptodate.com 2016 UpToDate
Pelvic and paraaortic lymphadenectomy in gynecologic cancers
Authors: Jeffrey M Fowler, MD, Floor J Backes, MD

Section Editors: Barbara Goff, MD, Tommaso Falcone, MD, FRCSC, FACOG
Deputy Editor: Sandy J Falk, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2016. | This topic last updated: May 27, 2016.
INTRODUCTION Pelvic and paraaortic lymph node evaluation is a major component of the surgical staging
procedure for several gynecologic malignancies, including endometrial and ovarian carcinoma [1]. Cervical
cancer is clinically staged, but assessment of pelvic and paraaortic lymph nodes is performed with
lymphadenectomy and/or imaging.
The surgical and oncologic goals of the lymph node dissection are to define the extent of disease, and thereby,
to guide further treatment. Lymphadenectomy may also have a therapeutic goal in conditions in which removing
nodes harboring metastatic disease improves survival [2-5].
The role of the pelvic and paraaortic lymph node dissection for women diagnosed with a gynecologic malignancy
has evolved since the 1990s. For each tumor site, there is controversy about the extent of dissection (complete
lymphadenectomy versus lymph node sampling) and the anatomic level of dissection that is required (ie, pelvic
with or without paraaortic nodes).
Techniques for pelvic and paraaortic lymphadenectomy in gynecologic malignancies are reviewed here. Staging
of individual tumor sites are discussed separately. (See "Invasive cervical cancer: Staging and evaluation of
lymph nodes" and "Endometrial carcinoma: Pretreatment evaluation, staging, and surgical treatment" and
"Cancer of the ovary, fallopian tube, and peritoneum: Staging and initial surgical management".)
ANATOMY
Retroperitoneal space The retroperitoneal space is a potential space that is accessed via a transperitoneal
incision, or directly via an extraperitoneal approach. The kidneys, ureters, bladder, great vessels, lymphatic
channels, lymph nodes, nerves, and muscles lie underneath the peritoneum and are enveloped in loose areolar
connective tissue. Knowledge of the anatomy of the retroperitoneum and the surgical ability to dissect and
develop these potential spaces greatly facilitates radical gynecologic surgery and pelvic and paraaortic lymph
node dissection. The pararectal and paravesical pelvic spaces and the retroperitoneum of the lower abdomen
are developed by the surgeon in order to define the boundaries of the lymph nodes and facilitate the surgical
dissection.
Lymphatic system The lymphatic system transports excess intracellular fluid that will be recirculated or
excreted. It is able to drain larger sized debris compared with the vascular system. Small lymphatic capillaries
https://www-uptodate-com.bdigital.ces.edu.co:2443/contents/pelvicaraaortic-lymphadenectomy-in-gynecologic-cancers&languageCode=en Pgina 1 de 31
drain organs and merge into larger vessels that eventually drain into lymph nodes. The ultimate destination of
this drainage and filtration system is the thoracic duct, which empties into the venous system.
Malignant tumor can invade the lymphatic endothelium, creating emboli that may be transported to regional or
distant lymph nodes [6]. The lymph nodes of interest in a pelvic and paraaortic dissection lie along, upon, or in
between the great vessels of the pelvis and abdomen (figure 1). Lymph nodes are divided into regions based
upon arbitrary anatomic boundaries for the purpose of staging of cancers and for defining the boundaries of
surgical dissection.
Lymphatic drainage from the pelvic viscera may proceed in a step-wise fashion from the pelvic to the lower and
then upper aortic lymph nodes; however, lymphatic channels from the ovaries, fallopian tubes, and uterus may
also drain directly into the lower and upper paraaortic nodes.
Pelvic lymph nodes The pelvic lymph nodes include the lower portion of the common iliac, external and
internal iliac, obturator, sacral, and pararectal nodes (figure 2). It is uncommon for the sacral and pararectal
nodes to be included in a lymph node dissection for a gynecologic malignancy.
According to the Gynecologic Oncology Group Surgical Procedures Manual, pelvic node dissection includes
bilateral removal of nodal tissue from the distal one-half of each common iliac artery, the anterior and medial
aspect of the proximal half of the external iliac artery and vein, and the distal half of the obturator fat pad anterior
to the obturator nerve [7]. Most of the pelvic lymph nodes lie anterior, medially, and posteriorly to the external and
internal iliac vessels and the obturator nerve. There are a few nodes that lie lateral to these structures, between
the vessels and the pelvic sidewall, and these are generally removed in a complete dissection [8].
Paraaortic lymph nodes According to the Gynecologic Oncology Group Surgical Procedures Manual,
paraaortic node dissection consists of resection of nodal tissue over the distal vena cava from the level of the
inferior mesenteric artery to the mid right common iliac artery and between the aorta and the left ureter from the
inferior mesenteric artery to the left mid common iliac artery (figure 3) [7].
By convention, many staging protocols limit the superior extent of dissection for gynecologic malignancies to the
level of the inferior mesenteric artery. However, uterine fundal, fallopian tube, and ovarian lymphatics can drain
directly to the paraaortic nodes above the level of the inferior mesenteric artery. The lymphatic drainage from
pelvic viscera to the paraaortic nodes is complex and involves both ipsilateral and contralateral connections in
addition to direct lymphatic channels that may bypass the pelvic drainage basin.
It is not uncommon for the surgeon to encounter anatomic vascular anomalies of the arteries and veins during a
paraaortic lymphadenectomy. Accessory renal arteries are likely the most common arterial anomaly, and many
types of venous abnormalities exist [9-11].
Extent of lymph node evaluation A lymph node dissection (also referred to as lymphadenectomy) is
intended to clear all lymph nodes from a specified area defined by anatomic boundaries and is the most accurate
technique for defining the surgical stage in a patient with a gynecologic malignancy.
Selective or random sampling of nodes from the pelvis and/or the paraaortic region has been described and is
less thorough or complete compared with a lymph node dissection (lymphadenectomy). If selective node
sampling is performed, nodes are typically visualized and palpated and sampled if they are suspicious for
metastatic disease (eg, enlarged to >1 cm, rounded instead of oval, hard, fall apart when dissected). Selective or
random sampling is generally of little value except when performed as part of a formal sentinel node identification
procedure.
In the staging of gynecologic cancers, the extent of lymphadenectomy varies by type of cancer and node chain
(pelvic or paraaortic). The approach to evaluation of lymph nodes for each tumor site is discussed in detail
separately. (See "Invasive cervical cancer: Staging and evaluation of lymph nodes" and "Endometrial carcinoma:
Pretreatment evaluation, staging, and surgical treatment" and "Cancer of the ovary, fallopian tube, and
peritoneum: Staging and initial surgical management".)
TUMOR SITES The use of pelvic and paraaortic lymphadenectomy in gynecologic malignancies is
summarized here briefly. The evaluation of lymph node status for each tumor site is discussed in detail
separately. (See "Invasive cervical cancer: Staging and evaluation of lymph nodes" and "Endometrial carcinoma:
Pretreatment evaluation, staging, and surgical treatment" and "Cancer of the ovary, fallopian tube, and
peritoneum: Staging and initial surgical management".)
Cervical cancer Cervical cancer is clinically staged based upon physical examination, biopsy, endoscopy (eg,
cystoscopy), and plain film radiographs (table 1). Evaluation for pelvic and paraaortic lymph node metastases
impacts prognosis and treatment decisions, but is not part of clinical staging. Thus, pelvic and/or paraaortic
lymph node dissection is regularly incorporated into the management of patients with early-stage disease and in
selected patients with locally advanced-stage disease [2,12].
In early-stage cervical cancer, information regarding lymph node involvement helps to guide whether the primary
therapy will be radical hysterectomy or chemoradiation, and if adjuvant chemoradiation should be given. In
addition, the information impacts the anatomic level chosen for volume-directed radiation therapy in both early-
and advanced-stage disease.
It is controversial whether debulking grossly enlarged positive lymph nodes is therapeutic in cervical cancer [2-4],
but some centers routinely remove bulky nodes in women with advanced cervical cancer prior to definitive
treatment with radiation and concurrent chemotherapy.
Lymph node evaluation in cervical cancer is discussed in detail separately. (See "Invasive cervical cancer:
Staging and evaluation of lymph nodes", section on 'Surgical evaluation of lymph nodes' and "Management of
early-stage cervical cancer", section on 'Approach to treatment' and "Management of locally advanced cervical
cancer", section on 'Treatment of para-aortic nodes'.)
Endometrial cancer Endometrial cancer is surgically staged (table 2). One of the most important prognostic
factors for endometrial carcinoma is the presence of extrauterine disease, particularly pelvic and paraaortic
lymph node metastases. Evaluation of pelvic and paraaortic lymph nodes is required as part of staging, but there
is ongoing controversy about the mode of evaluation, particularly in women presumed to have early-stage
disease. Possible approaches include pelvic and paraaortic node palpation and sampling, selective
lymphadenectomy based on frozen section criteria (grade, tumor size, and depth of invasion), complete
lymphadenectomy, or sentinel node evaluation. The extent of lymph node dissection, ie, whether paraaortic
lymphadenectomy should be performed and to what anatomic level, is also a topic of debate. Endometrial cancer
remains the least uniformly managed gynecologic malignancy, even among gynecologic oncologists [13].
The presence of pelvic and/or paraaortic lymph node metastases determines whether postoperative radiation
and/or chemotherapy is indicated and to what level the radiation may possibly be given. (See "Endometrial
carcinoma: Pretreatment evaluation, staging, and surgical treatment" and "Approach to adjuvant treatment of
endometrial cancer", section on 'Definition of risk based on histology and stage'.)
Ovarian cancer Ovarian cancer is surgically staged (table 3). Unfortunately, 75 percent of patients diagnosed
with epithelial ovarian cancer present with stage II or higher disease [14]. In those patients, a lymph node
dissection is less useful prognostically and to guide treatment decisions than for the patient diagnosed with
disease confined to the ovaries. However, it is important to remove suspicious or grossly enlarged nodes in
patients with advanced disease undergoing tumor debulking with the goal of optimal cytoreductive surgery
[15,16]. For women who have no apparent disease outside the ovaries, 15 to 20 percent will have lymph node
involvement, with histologic grade being the most significant risk factor [17,18]. (See "Cancer of the ovary,
fallopian tube, and peritoneum: Staging and initial surgical management", section on 'Lymph node sampling'.)
Chemotherapy is indicated for patients with stage IC or higher disease, so lymph node metastases are not the
sole indication for postoperative therapy. However, the absence of lymph node involvement is clinically significant
for subsets of women with surgically staged low-risk epithelial, germ cell, and stromal ovarian malignancies, who
may be candidates for observation without adjuvant chemotherapy [15,16]. Some data suggest that lymph node
dissection is therapeutic in a portion of patients with obvious advanced-stage disease [19-22]. (See "Cancer of
the ovary, fallopian tube, and peritoneum: Staging and initial surgical management", section on 'Lymph node
sampling' and "Adjuvant therapy of early stage (stage I and II) epithelial ovarian, fallopian tubal, or peritoneal
cancer" and "First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tubal, and
peritoneal cancer".)
PREOPERATIVE PREPARATION
Preoperative evaluation Preoperative preparation for pelvic or paraaortic lymphadenectomy as a standalone

procedure should include appropriate evaluation based on tumor site, medical comorbidities, and performance
status. General principles of preoperative evaluation and preparation and specific requirement for patients with
cervical, endometrial, or ovarian cancer is discussed in detail separately. (See "Overview of preoperative
evaluation and preparation for gynecologic surgery" and "Invasive cervical cancer: Staging and evaluation of
lymph nodes" and "Endometrial carcinoma: Pretreatment evaluation, staging, and surgical treatment" and
"Cancer of the ovary, fallopian tube, and peritoneum: Staging and initial surgical management".)
Prophylactic antibiotics There are no guidelines or data regarding whether antibiotic prophylaxis to prevent
surgical site infection is indicated for pelvic or paraaortic lymphadenectomy when performed as a standalone
procedure. In our experience, many surgeons do give antibiotics for these procedures to cover for skin flora, but
as a clean procedure, antibiotics are not indicated.
Thromboprophylaxis Women with gynecologic malignancy and those undergoing procedures that are >45
minutes in duration have at least a moderate risk of venous thromboembolism, and many patients are at high
risk, and should receive prophylactic pharmacologic anticoagulation (table 4). (See "Prevention of venous
thromboembolic disease in surgical patients", section on 'Surgical risk groups'.)
LYMPHADENECTOMY PROCEDURE
Surgical access The surgical approach used for a lymphadenectomy procedure in gynecologic oncology is
typically determined by the best approach for the total procedure, since procedures for endometrial and ovarian,
fallopian tubal, and peritoneal cancer include full surgical staging with hysterectomy, bilateral salpingo-
oophorectomy, and cytoreduction.
For women with locally advanced cervical cancer (stages IB2 to IVA) who undergo pelvic and paraaortic
lymphadenectomy for evaluation prior to primary chemoradiation, the lymphadenectomy procedure is often
performed as a standalone procedure. For these patients, in our practice, we use a robotic transperitoneal
approach, although others prefer the extraperitoneal laparoscopic approach.
Laparoscopy In current practice, most laparoscopic gynecologic oncology procedures are performed
using robotic surgery.
Robotic laparoscopy The port site setup for robotic surgery is different than for conventional
laparoscopic procedures, as ports are generally placed above the umbilicus (figure 4) [23,24]. Most gynecologic
oncologists will use four 8 mm robotic ports and two additional laparoscopic ports to be controlled by the bedside
assistant. This port setup and surgical approach is effective for most situations requiring hysterectomy with pelvic
and paraaortic lymph node dissection up to the level of the inferior mesenteric artery (IMA). Adequate exposure
to the paraaortic nodes is more likely with the robotic technique compared with laparoscopic; however, obesity
and surgeon experience are still potential limiting factors, especially if the goal is dissection of nodes above the
level of the IMA.
Surgical techniques have been described to improve the ability to dissect the higher-level paraaortic lymph
nodes [25-27]. Using such techniques, surgical ports are placed below the level of the umbilicus and the robot is
docked from the head of the table [26]. This technique likely improves access to the higher paraaortic nodes, but
does not allow access to the pelvis. Therefore, these techniques are best in patients where the goals of the
surgery are limited to information related to the paraaortic nodes such as surgical staging for advanced cervical
cancer.
Conventional laparoscopy The precise location of laparoscopic ports is not standardized and is highly
dependent on the procedure, anatomic level of the paraaortic lymph node dissection, surgeon, and whether the
laparoscopic approach is transperitoneal or extraperitoneal [28-30]. The most common port setup is a "diamond-
like" pattern with the camera port at the umbilicus and three operative ports paced suprapubically and laterally in
the left and right lower quadrants (picture 1) [31,32]. Additional ports are often added to retract bowel and
enhance exposure.
Laparotomy Historically, all gynecologic oncology procedures were performed via laparotomy. In current
practice, full staging procedures (including hysterectomy, bilateral salpingo-oophorectomy, cytoreduction) may be
performed using either laparotomy or laparoscopy. Pelvic or paraaortic lymphadenectomy as a standalone
procedure is typically performed via a minimally invasive approach (robotic or conventional laparoscopic).
If pelvic lymphadenectomy is performed via laparotomy, either a vertical midline or a variety of transverse
incisions (eg, Pfannenstiel, Maylard) can be utilized. A midline incision that extends above the level of the
umbilicus tends to be the most reliable for exposure to the paraaortic nodes, especially if a node dissection
above the level of the IMA is planned or needed. (See "Incisions for open abdominal surgery".)
Transperitoneal versus extraperitoneal Pelvic and/or paraaortic lymphadenectomy for gynecologic

oncology procedures is typically done as part of a complete staging procedure, as noted above. In terms of
access to the nodes, these are performed via laparotomy or laparoscopy and thus are transperitoneal
procedures; that is, the peritoneal is incised at the abdominal incision and then again posteriorly to access the
nodes in the retroperitoneum.
The main exception to this is for women with cervical cancer, in whom lymph node dissection is performed as a
standalone procedure, however, there are several options for surgical access to the retroperitoneum [2-4,29]. In
our practice, we perform these procedures with a robotic, transperitoneal approach, if feasible. If this is not
feasible, we perform a laparotomy. Based on the available evidence, for an open procedure, we suggest an
extraperitoneal rather than a transperitoneal approach.
The two approaches to the retroperitoneum each have advantages and disadvantages:
A transperitoneal approach gives excellent access to the pelvic nodes and variable access to the
paraaortic nodes. Access to the paraaortic nodes is primarily dependent on whether the patient is obese and
the experience of the surgeon. Paraaortic lymphadenectomy is more difficult in obese patients because the
bowel and omentum store a great deal of fat. These structures need to be mobilized and retracted out of the
field of dissection to access the paraaortic nodes.
An extraperitoneal approach provides excellent exposure to the paraaortic nodes, even in obese patients.
A pelvic lymph node dissection below the level of the common iliac nodes is not possible, however, unless
additional port sites are placed.
Transperitoneal laparotomy for lymph node dissection prior to radiation therapy in this patient population appears
to result in a higher frequency of some post-irradiation regional enteric complications, presumably secondary to
adhesion formation. The data regarding this are mainly based on one retrospective study, a Gynecologic
Oncology Group study of 284 women [33]. This is discussed in detail separately. (See "Invasive cervical cancer:
Staging and evaluation of lymph nodes", section on 'Lymph node dissection'.)
When a laparoscopic approach is planned, the factors differ from laparotomy regarding the choice of a
transperitoneal versus extraperitoneal approach. There is less risk of adhesion formation, so this is a less
important factor. Extraperitoneal laparotomy was designed as an alternative to transperitoneal laparotomy to
avoid intraperitoneal adhesions prior to definitive radiation therapy for advanced cervical cancer. However,
transperitoneal laparoscopy is associated with a lower risk of intraperitoneal adhesions than transperitoneal
laparotomy. Blinded studies in animal models reveal a similar rate and severity of adhesions between
transperitoneal laparoscopic lymph node dissection and extraperitoneal laparotomy; however, transperitoneal
laparoscopic lymphadenectomy is associated with significantly fewer adhesions compared with transperitoneal
laparotomy [34,35].
A systematic review of robotic extraperitoneal paraaortic lymphadenectomy included five studies and 88 patients
(72 percent with cervical cancer) and found that the mean (SD) number of para-aortic node yielded was 15.4
(standard deviation 4.7) nodes [36]. Blood transfusion and intraoperative complication rates were 2 and 6
percent, respectively. Six (6 percent) and 4 (4 percent) patients had conversion to other minimally invasive
procedures and open surgery, respectively.
The procedure for an extraperitoneal approach to paraaortic lymphadenectomy is detailed below. (See
'Extraperitoneal laparoscopic access' below.)
Pelvic lymphadenectomy Transperitoneal pelvic lymph node dissection is performed via a retroperitoneal
incision. The steps of the procedure include:
The retroperitoneum is accessed by incising the peritoneum along the psoas muscle lateral to the level of
the pelvic vessels. On the left side, any adhesions of the sigmoid colon are divided sharply.
The round ligaments are transected; this usually allows for improved exposure of the obturator fossa and the
distal external iliac vessels.
The pararectal and paravesical spaces are then developed with a combination of sharp and blunt dissection.
A useful landmark is the obliterated umbilical artery, which is usually visualized as a discrete fold on either
side of the bladder. Developing the area between the obliterated umbilical artery and the external iliac
vessels exposes the paravesical space medially and the obturator fossa laterally.
The ureter is identified along the medial peritoneal fold. This is typically retracted medially during the entire
procedure.
The pararectal space can be developed in the area between the ureter medially and the origin of the
hypogastric vessels laterally.
The pelvic lymph node dissection is then initiated by dissecting the lateral nodal tissue away from the psoas
muscle. Care is taken to identify and isolate the genitofemoral nerve, which can easily be misidentified as a
lymphatic channel. The external iliac vessels can be gently retracted medially; the space between the
vessels and the psoas muscle is developed. As the dissection is carried caudad, the assistant places an
instrument into the paravesical space for medial retraction. The dissection continues until the circumflex iliac
vein is clearly visualized.
At this point, the fibrofatty tissue surrounding the external iliac vessels is elevated. The fibrous sheath
overlying the external iliac artery is incised in order to mobilize the specimen. The surgeon then grasps the
specimen and retracts it medially.
Any adhesions to the medial portion of the external iliac artery can then be incised. The space between the
external iliac artery and vein is sharply and bluntly developed. Next, the tissue adherent to the external iliac
vein is gently dissected free.
The surgeon then dissects within the obturator fossa. The fibrofatty tissue of the lymph node bundle is
retracted medially, and a plane is created underneath the external iliac vein. Sharp and blunt dissection is
performed within the fossa until the obturator nerve is visualized; this nerve can be isolated along its entire
course within the obturator fossa. Accessory vessels in this space often arise from the undersurface of the
external iliac vein; these can be clipped or cauterized only after the obturator nerve is clearly delineated and
the ureter is safely retracted out of the field of dissection. Particular care must be taken at the proximal
aspect of the fossa, where the bifurcation of the common iliac artery is found and the lymph nodes may be
more adherent to the hypogastric vessels.
Paraaortic lymphadenectomy Paraaortic lymphadenectomy may be performed using either a

transperitoneal or extraperitoneal approach.
Extraperitoneal laparoscopic access Extraperitoneal paraaortic lymphadenectomy is performed

laparoscopically, either by conventional or robotic laparoscopy [25,26,29,30,37,38].
In terms of patient setup, for the robotic approach, the bed is placed at a different angle for the paraaortic
lymphadenectomy procedure than for the hysterectomy and pelvic lymphadenectomy procedure, so the bed will
need to be rotated (or the robot redocked).
Briefly, a small incision is made in the left flank of the mid abdomen. The fascia is transected, taking care not to
enter the peritoneal space. The retroperitoneal space is developed using blunt finger dissection until the psoas
muscle is palpated. The laparoscopic port is placed and the space is then insufflated with carbon dioxide gas (10
to 15 mmHg). Two additional ports are then placed (figure 5) [26,29,30,39]. On the left side, the areolar tissues
are transected to separate the mesentery from the lymph node bundle, and the left common iliac artery and aorta
are identified. A laparoscopic retractor may be used to hold up the peritoneal sac that forms the roof of the
extraperitoneal space, as needed. The ureter is identified in the mesentery (lifted up by the insufflation), and the
gonadal vein is followed to its entry into the left renal vein. The lymph nodes to the left of the aorta are then
dissected using a sharp and blunt dissection.
To remove the right paraaortic nodes, the dissection is continued laterally over the aorta to reach the right aortic
lymph nodes covering the inferior vena cava. The right ureter is identified and the lymph node bundle over the
inferior vena cava is then carefully dissected.
For laparoscopic pelvic lymph nodes, the ports are advanced from extraperitoneally (for the aortic lymph nodes)
to intraperitoneally (for the pelvic lymph nodes), and the steps are as described above.
Setup and positioning for laparoscopic surgery is discussed in detail separately. (See "Abdominal access
techniques used in laparoscopic surgery" and "Nerve injury associated with pelvic surgery", section on
'Prevention of nerve injury'.)
Procedure The procedure for paraaortic lymphadenectomy regardless of the technique used to access the
retroperitoneum is as follows:
Left side The procedure for left-side paraaortic lymphadenectomy is as follows:
An incision is made in the peritoneum over the right common iliac artery and is extended cephalad along the
aorta to the level of the duodenum.
Next, the bifurcation of the aorta is identified, and the peritoneum over the left common iliac artery is incised.
The mesentery of the sigmoid colon is retracted anteriorly. The areolar tissue between the left common iliac
artery (and aorta) and the mesentery of the sigmoid colon is opened with a combination of blunt and sharp
dissection until the left psoas muscle is identified.
The left ureter is also identified and retracted laterally so that it is safely out of the field of dissection. The
degree of difficulty in obtaining this critical exposure is dependent on the ability to "pack" the small bowel
into the upper abdomen above the level of the IMA and to avoid redundancy of the sigmoid colon. It is very
important to identify the IMA prior to starting the lymph node dissection to avoid cutting into the mesentery of
the sigmoid colon.
Once adequate exposure has been achieved, the surgeon grasps the nodal bundle adjacent to either the
aorta or proximal left common iliac artery and lifts anteriorly while dissecting the plane between the great
vessels and the lymph nodes that lie adjacent to them. The dissection is then extended in a cephalad
direction with blunt and sharp dissection and with electrosurgery and with scissors as needed.
The nodal chain is then transected at the cephalad end near the IMA. The cephalad border of dissection is
usually the IMA, unless there are suspicious nodes above this or a higher dissection is indicated.
Right side The procedure for right side paraaortic lymphadenectomy is as follows:
To obtain exposure for the right-sided paraaortic lymph node dissection, the assistant lifts the previously
incised peritoneum overlying the vena cava and the right common iliac artery. Elevation of this peritoneal
window permits lateral retraction of the ureter out of the operative field and visualization of the vena cava
and aorta.
The surgeon sharply dissects within the areolar plane between the lymph nodes and the peritoneum.
The right-side paraaortic lymphadenectomy is then performed with the use of monopolar cautery and/or
hemoclips for hemostasis and sealing of lymphatic channels. The dissection is begun over the aorta and
proceeds in a medial to lateral direction. Thin pedicles are created prior to transection so that perforating
veins can be identified.
Infrarenal nodes The infrarenal nodes are the nodes between the IMA and the renal vessels. These
are superior paraaortic nodes and are removed if indicated; however, exposure is more difficult to obtain in this
region.
The procedure for infrarenal lymphadenectomy is as follows:
The peritoneum between the IMA and along the duodenum is incised. This incision may be carried out
toward the left along the mesentery of the descending colon, often until encountering the inferior mesenteric
vein.
After adequate cephalad exposure is obtained, the nodal dissection may begin.
On the left side, the plane of dissection is over the anterior surface of the aorta. It is important to identify the
left renal and ovarian veins as well as the ovarian artery. Exposure is facilitated by dissecting the areolar
tissue beneath the duodenum and then gently retracting it cephalad. The ureter is retracted laterally by the
assistant. The left ovarian artery is often sacrificed to improve access to the nodes. The left nodal bundle is
transected near the level of the left renal vein.
On the right side, exposure is not as difficult and the lower paraaortic dissection is carried up to the level
between the ovarian vein and the right renal vein. The right renal vein is often not visualized.
SENTINEL NODE EVALUATION A sentinel node (SLN) is defined as a lymph node that has a direct
connection to the primary tumor through a lymphatic channel and represents the lymph node(s) most likely to
first receive metastases from the primary tumor. SLN detection is becoming much more common in the treatment
of both endometrial and cervical cancer. A few centers are performing SLN outside research protocols; however,
comparisons of cost effectiveness, complications, and overall survival between women who have had SLN
versus traditional lymphadenectomy or lymph node sampling have not been completed.
The rationale for SLN mapping is to identify patients with lymph node metastases and avoid the morbidity of a full
lymphadenectomy in patients with negative SLNs. In addition, SLN mapping may also be considered a technique
that may identify occult metastatic disease not otherwise identified by a standard lymphadenectomy. This may
occur if the node lies outside of the usual boundaries of pelvic or paraaortic lymph node dissection. Also, the
SLN evaluation process typically includes ultra-section of the SLN and immunohistochemical staining, which may
be more sensitive than the traditional hematoxylin and eosin evaluation.
The most common technique for identification of sentinel nodes is the injection of vital blue dyes (eg, isosulfan
blue) and/or indocyanine green (detectable with near infrared immunofluorescent light) and/or radioisotope (eg,
Technetium-99) around the tumor. These techniques are relatively well established for patients diagnosed with
vulvar and cervical carcinoma. This injection can be performed intraoperatively with or without preoperative
lymphoscintigraphy, and hand-held and laparoscopic instruments (gamma-probe) are available.
Sentinel node evaluation for specific gynecologic tumor sites is discussed in detail separately. (See "Invasive
cervical cancer: Staging and evaluation of lymph nodes", section on 'Sentinel lymph node biopsy' and
"Endometrial carcinoma: Pretreatment evaluation, staging, and surgical treatment" and "Squamous cell
carcinoma of the vulva: Staging and surgical treatment", section on 'Sentinel node biopsy'.)
POSTOPERATIVE CARE There are no postoperative management issues unique to the pelvic or paraaortic
lymphadenectomy. Patients undergoing pelvic and paraaortic lymphadenectomy are managed based on the type
of surgical approach (laparotomy, laparoscopy) and extent of surgery (eg, lymph node dissection alone or full
surgical staging) [40,41].
Leaving a drain in place to drain the lymph node dissection basin has fallen out of favor and is not indicated [42].
COMPLICATIONS Surgical complications in women undergoing a pelvic and paraaortic lymph node
dissection are multifactorial and usually related to the patient age, existing patient comorbidities, surgical
approach, operative duration, and concurrent surgical procedures. Laparoscopic procedures in general result in
less morbidity than laparotomy, including pain and wound complications [43-45].
The incidence of major organ and vessel injury related to lymphadenectomy is low [46,47].
Women undergoing lymphadenectomy for gynecologic malignancy are at least at a moderate risk of venous
thromboembolism. It is not clear that the risk of deep vein thrombosis is higher with or without lymph node
dissection. The incidence of thromboembolic disease has been reported in 2 to 5 percent of cases among all
women undergoing lymph node dissection for endometrial cancer staging [47-49].
Lymph node drainage issues Complications related to lymphatic drainage are specific to the lymph node
dissection.
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Lymphedema is the most common complication of pelvic and paraaortic lymphadenectomy, reported in 1.5 to 28
percent of patients. This is likely lower than the actual incidence, since this complication is likely to be
underreported in retrospective reports [50,51]. Postoperative irradiation and a greater extent of lymph node
dissection increase the risk of this complication. Presentation of lymphedema can be quite variable. Some
patients only notice some increased ankle swelling, but edema can extend from the feet to the abdominal wall as
well as in more atypical places such as the mons pubis and upper thighs only, and a fluctuating course is not
uncommon. Sixty percent of patients reported it affected their daily activities and noted exacerbating factors such
as prolonged standing, heat, and walking [52]. Physical and mental quality of life was lower in women with lower
leg swelling compared with those without lower leg swelling [53,54]. Early recognition is paramount for control of
the disease. Patients with lymphedema are recommended to wear compression stockings as much as possible
and should be referred to a physical therapist specialized in lymphedema therapy. Other options include
elevation of the legs, and there are some early data on lymphatic venous anastomosis [55,56]. (See "Clinical
features and diagnosis of peripheral lymphedema" and "Clinical staging and conservative management of
peripheral lymphedema".)
Another potential complication is lymphocele. In a prospective study of 800 women who underwent solo pelvic
and/or paraaortic lymphadenectomy for gynecologic cancer, the rate of lymphocele was 20 percent, and the rate
of symptomatic lymphocele was 6 percent [57]. The most common location was the left pelvic sidewall. In
another series of 138 women with endometrial cancer, lymphocele was reported in 1 percent of patients after
laparoscopy and in 15 percent after laparotomy [58]. Lymphoceles are often asymptomatic but can present as
pelvic pressure or pain, they may cause hydronephrosis secondary to external compression of the ureter, and
often will be palpable as a rounded smooth mass that can be slightly compressed along the pelvic sidewall. They
may resolve spontaneously over time, but if there are secondary consequences (pain, lymphedema,
hydronephrosis), they may require image-guided drainage. If drain output continues to be high after several
weeks (>50 to 100 mL/day), sclerotherapy with instillation of alcohol, iodine, doxycycline, or talc directly into the
cystic collection can be considered [59]. Alternatively, a laparoscopic marsupialization is another option [60].
Many patients may have drainage of lymphatic fluid (lymphorrhea) from the vagina in the immediate
postoperative period. This typically resolves within a few weeks [48]. If there is no improvement in drainage, a
vesicovaginal or ureterovaginal fistula should be considered.
The risk of lymphatic fistula and chylous ascites has been reported but is quite uncommon [61-68]. Chylous
ascites after gynecologic surgery mostly occur after paraaortic lymph node dissection. Often it will resolve with
conservative management, but drain placement, median chain fatty acid diet, somatostatin analogues, or
surgical correction may be required.
SUMMARY AND RECOMMENDATIONS
Pelvic and paraaortic lymph node dissection is a key part of surgical staging for women with cervical,
uterine, or ovarian, fallopian tubal, or peritoneal cancers. (See 'Introduction' above.)
The pelvic lymph nodes include the lower portion of the common iliac, external and internal iliac, obturator,
sacral, and pararectal nodes (figure 2). Pelvic node dissection includes bilateral removal of nodal tissue from
the distal one-half of each common iliac artery, the anterior and medial aspect of the proximal half of the
external iliac artery and vein, and the distal half of the obturator fat pad anterior to the obturator nerve. (See
'Pelvic lymph nodes' above.)
Paraaortic node dissection consists of resection of nodal tissue over the distal vena cava from the level of
the inferior mesenteric artery to the mid right common iliac artery, and between the aorta and the left ureter
from the inferior mesenteric artery to the left mid common iliac artery (figure 3). (See 'Paraaortic lymph
nodes' above.)
The surgical approach used for a lymphadenectomy procedure in gynecologic oncology is typically
determined by the best approach for the total procedure, since procedures for endometrial and ovarian,
fallopian tubal, and peritoneal cancer include full surgical staging with hysterectomy, bilateral salpingo-
oophorectomy, and cytoreduction. However, for women with locally advanced cervical cancer (stages IB2 to
IVA) who undergo pelvic and paraaortic lymphadenectomy for evaluation prior to primary chemoradiation,
the lymphadenectomy procedure is often performed as a standalone procedure. (See 'Surgical access'
above.)
For women with locally advanced cervical cancer (stages IB2 to IVA) who undergo pelvic and paraaortic
lymphadenectomy for evaluation prior to primary chemoradiation, in our practice, we use robotic approach if
feasible, and use transperitoneal access. For women who undergo pelvic and paraaortic lymphadenectomy
as a standalone procedure via laparotomy, we suggest an extraperitoneal rather than a transperitoneal
approach (Grade 2C). (See 'Transperitoneal versus extraperitoneal' above.)
Lymphedema is the most common complication of pelvic and paraaortic lymphadenectomy, reported in 1.5
to 28 percent of patients. This is likely lower than the actual incidence, since this complication is likely to be
underreported in retrospective reports. Postoperative irradiation and a greater extent of lymph node
dissection increase the risk of this complication. Early recognition is paramount for control of the disease.
Patients with lymphedema are recommended to wear compression stockings as much as possible and
should be referred to a physical therapist specialized in lymphedema therapy. (See 'Lymph node drainage
issues' above.)
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Topic 3182 Version 8.0
GRAPHICS
Lymph node groups in women
The green dots indicate the location of lymph nodes, which are found throughout the
body.
Graphic 52298 Version 4.0
Female pelvic lymphadenectomy
Image
Lymph node dissection is begun by sharply and bluntly mobilizing the tissue
lateral to the external iliac artery and vein, and moving this tissue until the
external iliac artery can be identified. The dissection should be kept close to the
artery to facilitate the resection. Using Metzenbaum scissors and forceps, the
lymphatic tissue is then sharply dissected off the surface of the external and
common iliac arteries, and reflected medially. With lateral traction at this time,
the external iliac vein and obturator fossa can be identified.
Courtesy of William J Mann, Jr, MD.
Female pelvic and paraaortic lymph nodes
The pelvic and paraaortic lymph nodes and their relationship to the female
pelvic organs and the major retroperitoneal blood vessels.
Reproduced with permission from: Berek JS, Hacker NF. Practical Gynecologic
Oncology, Fourth Edition. Philadelphia: Lippincott Williams & Wilkins, 2005. Copyright
2005 Lippincott Williams & Wilkins.
Staging cervical cancer (TNM and International Federation of Gynecology and

Obstetrics [FIGO])
Primary tumor (T)
TNM FIGO
Definition
categories stages
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis* Carcinoma in situ (preinvasive carcinoma)
T1 I Cervical carcinoma confined to uterus (extension to corpus should be disregarded)
T1a IA Invasive carcinoma diagnosed only by microscopy. Stromal invasion with a maximum depth of 5.0
mm measured from the base of the epithelium and a horizontal spread of 7.0 mm or less. Vascular
space involvement, venous or lymphatic, does not affect classification.
T1a1 IA1 Measured stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread
T1a2 IA2 Measured stromal invasion more than 3.0 mm and not more than 5.0 mm in depth with a horizontal
spread 7.0 mm or less
T1b IB Clinically visible lesion confined to the cervix or microscopic lesion greater than T1a/IA2
T1b1 IB1 Clinically visible lesion 4.0 cm or less in greatest dimension
T1b2 IB2 Clinically visible lesion more than 4.0 cm in greatest dimension
T2 II Cervical carcinoma invades beyond uterus but not to pelvic wall or to lower third of vagina
T2a IIA Tumor without parametrial invasion or involvement of the lower one-third of the vagina [1,2]
T2a1 IIA1 Clinically visible lesion 4.0 cm or less in greatest dimension with involvement of less than the upper
two-thirds of the vagina
T2a2 IIA2 Clinically visible lesion more than 4.0 cm in greatest dimension with involvement of less than the
upper two-thirds of the vagina
T2b IIB Tumor with parametrial invasion
T3 III Tumor extends to pelvic wall and/or involves lower third of vagina, and/or causes
hydronephrosis or nonfunctioning kidney
T3a IIIA Tumor involves lower third of vagina, no extension to pelvic wall
T3b IIIB Tumor extends to pelvic wall and/or causes hydronephrosis or nonfunctioning kidney
T4 IVA Tumor invades mucosa of bladder or rectum, and/or extends beyond true pelvis (bullous
edema is not sufficient to classify a tumor as T4)
Regional lymph nodes (N)
TNM FIGO
Definition
categories stages
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Regional lymph node metastasis
Distant metastasis (M)
TNM FIGO Definition
categories stages
M0 No distant metastasis
M1 IVB Distant metastasis (including peritoneal spread, involvement of supraclavicular,

mediastinal, or paraaortic lymph nodes, lung, liver, or bone)
Anatomic stage/prognostic groups
Stage 0* Tis N0 M0
Stage I T1 N0 M0
Stage IA T1a N0 M0
Stage IA1 T1a1 N0 M0
Stage IA2 T1a2 N0 M0
Stage IB T1b N0 M0
Stage IB1 T1b1 N0 M0
Stage IB2 T1b2 N0 M0
Stage II T2 N0 M0
Stage IIA T2a N0 M0
Stage IIA1 T2a1 N0 M0
Stage IIA2 T2a2 N0 M0
Stage IIB T2b N0 M0
Stage III T3 N0 M0
Stage IIIA T3a N0 M0
Stage IIIB T3b Any N M0
T1-3 N1 M0
Stage IVA T4 Any N M0
Stage IVB Any T Any N M1
NOTE: cTNM is the clinical classification, pTNM is the pathologic classification.
* FIGO no longer includes Stage 0 (Tis).

All macroscopically visible lesions-even with superficial invasion-are T1b/IB.
References:
1. Pecorelli S. Revised FIGO staging for carcinoma of the cervix. Int J Gynecol Obstet 2009; 105:107.
2. Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynecol Obstet
2009; 105:103.
Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for
this material is the AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer New York, Inc.
Staging uterine carcinoma* (TNM and International Federation of Gynecology and

Obstetrics [FIGO])
Primary tumor (T) (surgical-pathologic findings)
TNM FIGO
Definition
categories stages
Tis Carcinoma in situ (preinvasive carcinoma)
T1 I Tumor confined to corpus uteri
T1a IA Tumor limited to endometrium or invades less than one-half of the myometrium
T1b IB Tumor invades one-half or more of the myometrium
T2 II Tumor invades stromal connective tissue of the cervix but does not extend beyond uterus
T3a IIIA Tumor involves serosa and/or adnexa (direct extension or metastasis)
T3b IIIB Vaginal involvement (direct extension or metastasis) or parametrial involvement
T4 IVA Tumor invades bladder mucosa and/or bowel mucosa (bullous edema is not sufficient to
classify a tumor as T4)
TNM FIGO
Definition
categories stages
N1 IIIC1 Regional lymph node metastasis to pelvic lymph nodes
N2 IIIC2 Regional lymph node metastasis to para-aortic lymph nodes, with or without positive
pelvic lymph nodes
TNM FIGO
Definition
categories stages
M1 IVB Distant metastasis (includes metastasis to inguinal lymph nodes intraperitoneal disease, or
lung, liver, or bone. It excludes metastasis to para-aortic lymph nodes, vagina, pelvic
serosa, or adnexa.)
Carcinomas*
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage IA T1a N0 M0
Stage IB T1b N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
Stage IIIB T3b N0 M0
Stage IIIC1 T1-T3 N1 M0
Stage IIIC2 T1-T3 N2 M0
Stage IVA T4 Any N M0
Stage IVB Any T Any N M1
* Carcinosarcomas should be staged as carcinoma.

FIGO no longer includes Stage 0 (Tis).
Endocervical glandular involvement only should be considered as Stage I and not as Stage II.
Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for
this material is the AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer New York, Inc.
Staging ovarian, fallopian tubal, and peritoneal cancer (TNM and International
Federation of Gynecology and Obstetrics [FIGO])
Primary tumor (T)
TNM FIGO
Definition
categories stages
T1 I Tumor confined to ovaries or fallopian tubes

T1a IA Tumor limited to one ovary (capsule intact) or fallopian tube; no tumor on ovarian or fallopian
tube surface; no malignant cells in ascites or peritoneal washings
T1b IB Tumor limited to both ovaries (capsules intact) or fallopian tubes; no tumor on ovarian or
fallopian tube surface; no malignant cells in ascites or peritoneal washings
T1c IC Tumor limited to one or both ovaries or fallopian tubes, with any of the following:
IC1 Surgical spill
IC2 Capsule ruptured before surgery or tumor on ovarian or fallopian tube surface
IC3 Malignant cells in the ascites or peritoneal washings
T2 II Tumor involves one or both ovaries or fallopian tubes with pelvic extension (below pelvic
brim) or peritoneal cancer*
T2a IIA Extension and/or implants on uterus and/or tube(s) and/or ovaries
T2b IIB Extension to other pelvic intraperitoneal tissues
T3 III Tumor involves one or both ovaries or fallopian tubes, or peritoneal cancer, with
cytologically or histologically confirmed spread to the peritoneum outside the pelvis
and/or metastasis to the retroperitoneal lymph nodes
T3a IIIA Positive retroperitoneal lymph nodes and/or microscopic metastasis beyond pelvis
IIIA1 Positive retroperitoneal lymph nodes only (cytologically or histologically proven)
IIIA1 (i) Metastasis up to 10 mm in greatest dimension
IIIA1 (ii) Metastasis more than 10 mm in greatest dimension
IIIA2 Microscopic extrapelvic (above the pelvic brim) peritoneal involvement, with or without positive
retroperitoneal lymph nodes
T3b IIIB Macroscopic peritoneal metastasis beyond pelvis up to 2 cm in greatest dimension, with or
without positive retroperitoneal lymph nodes
T3c IIIC Macroscopic peritoneal metastasis beyond pelvis more than 2 cm in greatest dimension (includes
extension of tumor to capsule of liver and spleen without parenchymal involvement of either
organ), with or without positive retroperitoneal lymph nodes
TNM FIGO
Definition
categories stages
N1 III Regional lymph node metastasis
TNM FIGO
Definition
categories stages
M1 IV Distant metastasis (excludes peritoneal metastasis)
IVA Pleural effusion with positive cytology
IVB Parenchymal metastases and metastases to extra-abdominal organs (including inguinal

lymph nodes and lymph nodes outside the abdominal cavity)
pTNM pathologic classification. The pT, pN, and pM categories correspond to the T, N, and M categories.
Stage I T1 N0 M0
Stage IA T1a N0 M0
Stage IB T1b N0 M0
Stage IC T1c N0 M0
Stage II T2 N0 M0
Stage IIA T2a N0 M0
Stage IIB T2b N0 M0
Stage IIC T2c N0 M0
Stage III T3 N0 or N1 M0
T3a N1
Stage IIIB T3b N0 or N1 M0
Stage IIIC T3c N0 or N1 M0
Stage IV Any T Any N M1
* Dense adhesions with histologically proven tumor cells justify upgrading to stage II.
Transmural bowel infiltration or umbilical deposit are stage IVB.
References:
1. The American Joint Committee on Cancer, AJCC Cancer Staging Manual, Seventh Edition, New York: Springer,
2010.
2. Prat J. Staging classification for cancer of the ovary, fallopian tube, and peritoneum. Int J Gynaecol Obstet 2014;
124:1.
Modified Caprini risk assessment model for VTE in general surgical patients
Risk score
1 point 2 points 3 points 5 points
Age 41 to 60 years Age 61 to 74 years Age 75 years Stroke (<1 month)
Minor surgery Arthroscopic surgery History of VTE Elective arthroplasty
BMI >25 kg/m 2 Major open surgery (>45 Family history of VTE Hip, pelvis, or leg fracture
minutes)
Swollen legs Laparoscopic surgery (>45 Factor V Leiden Acute spinal cord injury
minutes) (<1 month)
Varicose veins Malignancy Prothrombin 20210A
Pregnancy or postpartum Confined to bed (>72 Lupus anticoagulant

hours)
History of unexplained or Immobilizing plaster cast Anticardiolipin antibodies

recurrent spontaneous
abortion
Oral contraceptives or Central venous access Elevated serum

hormone replacement homocysteine
Sepsis (<1 month) Heparin-induced

thrombocytopenia
Serious lung disease, Other congenital or

including pneumonia (<1 acquired thrombophilia
month)
Abnormal pulmonary
function
Acute myocardial
infarction
Congestive heart failure

(<1 month)
History of inflammatory
bowel disease
Medical patient at bed rest
Interpretation
Estimated VTE risk in

the absence of
Surgical risk category* Score pharmacologic or
mechanical prophylaxis
(percent)
Very low (see text for 0 <0.5

definition)
Low 1 to 2 1.5
Moderate 3 to 4 3.0
High 5 6.0
VTE: venous thromboembolism; BMI: body mass index.

* This table is applicable only to general, abdominal-pelvic, bariatric, vascular, and plastic and reconstructive surgery.
See text for other types of surgery (eg, cancer surgery).
From: Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic
therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practical
guidelines. Chest 2012; 141:e227S. Copyright 2012. Reproduced with permission from the American College of Chest
Physicians.
Port sites for robotic-assisted laparoscopy in gynecology
Position of abdominal ports for laparascopic

lymphadenectomy
Image
Courtesy of Ken Hatch, MD.
Extraperitoneal laparoscopic pelvic and paraaortic lymphadenectomy:

Placement of ports
Schematic illustrating port placement in the left flank. The lowermost port (10 mm) is located two
fingerbreadths medial to, and three to six fingerbreadths superior to, the left anterior superior
iliac spine. The remaining trocars are triangulated one finger's length from the initial incision. The
second, more posterior trocar is 10 mm. The third, most cephalad 5 mm trocar is located just
inferior to the costal margin.
Reproduced from: Dowdy SC, Aletti G, Cilby WA, et al. Extra-peritoneal laparoscopic para-aortic
lymphadenectomy - A prospective cohort study of 293 patients with endometrial cancer. Gynecol Oncol
2008; 111:418. Illustration used with the permission of Elsevier Inc. All rights reserved.
Contributor Disclosures
Jerey M Fowler, MD Nothing to disclose Floor J Backes, MD Nothing to disclose Barbara Go,
MD Consultant/Advisory Boards: Roche Diagnostics [Biomarkers for ovarian cancer (HE4)]. Employment
(Spouse): Lilly [General oncology (Gemcitabine, pemetrexed)]. Tommaso Falcone, MD, FRCSC,
FACOG Nothing to disclose Sandy J Falk, MD, FACOG Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
Conflict of interest policy

Pelvic and Paraaortic Lymphadenectomy in Gynecologic Cancers - UpToDate

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Pelvic and Paraaortic Lymphadenectomy in Gynecologic Cancers - UpToDate

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Pelvic and paraaortic lymphadenectomy in gynecologic cancers - UpToDate 17/10/16 8:57 p.m.

Official reprint from UpToDate

Authors: Jeffrey M Fowler, MD, Floor J Backes, MD

Preoperative evaluation Preoperative preparation for pelvic or paraaortic lymphadenectomy as a standalone

Transperitoneal versus extraperitoneal Pelvic and/or paraaortic lymphadenectomy for gynecologic

Paraaortic lymphadenectomy Paraaortic lymphadenectomy may be performed using either a

Extraperitoneal laparoscopic access Extraperitoneal paraaortic lymphadenectomy is performed

Left side The procedure for left-side paraaortic lymphadenectomy is as follows:

The procedure for infrarenal lymphadenectomy is as follows:

SUMMARY AND RECOMMENDATIONS

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Topic 3182 Version 8.0

Lymph node groups in women

Graphic 52298 Version 4.0

Female pelvic lymphadenectomy

Courtesy of William J Mann, Jr, MD.

Graphic 75242 Version 3.0

Female pelvic and paraaortic lymph nodes

Graphic 54775 Version 2.0

Staging cervical cancer (TNM and International Federation of Gynecology and

Primary tumor (T)

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis* Carcinoma in situ (preinvasive carcinoma)

T1 I Cervical carcinoma confined to uterus (extension to corpus should be disregarded)

T1b1 IB1 Clinically visible lesion 4.0 cm or less in greatest dimension

T2b IIB Tumor with parametrial invasion

Regional lymph nodes (N)

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Regional lymph node metastasis

Distant metastasis (M)

TNM FIGO Definition

M1 IVB Distant metastasis (including peritoneal spread, involvement of supraclavicular,

Anatomic stage/prognostic groups

Stage IA1 T1a1 N0 M0

Stage IA2 T1a2 N0 M0

Stage IB1 T1b1 N0 M0

Stage IB2 T1b2 N0 M0

Stage IIA T2a N0 M0

Stage IIA1 T2a1 N0 M0

Stage IIA2 T2a2 N0 M0

Stage IIB T2b N0 M0

Stage IIIA T3a N0 M0

Stage IIIB T3b Any N M0

Stage IVA T4 Any N M0

Stage IVB Any T Any N M1

NOTE: cTNM is the clinical classification, pTNM is the pathologic classification.

* FIGO no longer includes Stage 0 (Tis).

Graphic 79282 Version 20.0

Staging uterine carcinoma* (TNM and International Federation of Gynecology and

Primary tumor (T) (surgical-pathologic findings)

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ (preinvasive carcinoma)

T1 I Tumor confined to corpus uteri

T1b IB Tumor invades one-half or more of the myometrium

T3b IIIB Vaginal involvement (direct extension or metastasis) or parametrial involvement

Regional lymph nodes (N)

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 IIIC1 Regional lymph node metastasis to pelvic lymph nodes

Distant metastasis (M)