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Metastasis to Para-Aortic Lymph Nodes Cephalad to the Renal Veins in Patients with Ovarian Cancer

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Metastasis to Para-Aortic Lymph Nodes Cephalad to the Renal Veins in Patients with Ovarian Cancer Komiyama et al. World Journal of Surgical Oncology (2020) 18:64 https://doi.org/10.1186/s12957-020-01841-8 RESEARCH Open Access Metastasis to para-aortic lymph nodes cephalad to the renal veins in patients with ovarian cancer Shinichi Komiyama1,2*, Masaru Nagashima1, Tomoko Taniguchi1, Takayuki Rikitake1 and Mineto Morita1,2 Abstract Background: In patients with epithelial ovarian cancer, whether metastasis to para-aortic lymph nodes located cephalad to the renal veins (supra-renal PAN) should be classified as regional lymph node metastasis or distant metastasis remains controversial. This study was a preliminary retrospective evaluation of the pattern of supra-renal PAN metastasis in patients with epithelial ovarian cancer. Methods: The subjects were 25 patients with epithelial ovarian cancer, primary peritoneal cancer, or fallopian tube cancer who underwent systematic dissection of the para-aortic nodes, including the supra-renal PAN, and pelvic lymph nodes (PLN). Patient factors, perioperative factors, the number of dissected lymph nodes, and pathological lymph node metastasis were investigated. Results: Supra-renal PAN metastasis was found in 4/25 patients (16.0%). None of the 14 patients with pT1 or pT2 disease had supra-renal PAN metastasis, while 4/11 patients (36.4%) with pT3 or ypT3 disease had such metastases. None of the patients had isolated supra-renal PAN metastasis, while patients with supra-renal PAN metastasis also had multiple metastases to the infra-renal PAN and PLN. Conclusions: In patients with epithelial ovarian cancer, supra-renal PAN metastases might be considered to be distant rather than regional metastases. Further studies are needed to better define the clinical significance of supra-renal PAN metastasis. Keywords: Epithelial ovarian cancer, Supra-renal para-aortic node metastasis, Extended PAN dissection, FIGO stage Introduction inferior mesenteric artery and nodes located between the The para-aortic lymph nodes (PANs) are located around inferior mesenteric artery and the aortic bifurcation [1]. the abdominal aorta and inferior vena cava and are the In patients with epithelial ovarian cancer, primary regional lymph nodes of the intraperitoneal organs. peritoneal cancer, or fallopian tube cancer, the clinical These nodes can be broadly classified into supra-renal implications of supra-renal PAN metastasis are unclear. PANs located cephalad (superior) to the renal veins and According to the International Federation of Gynecology infra-renal PANs located caudad (inferior) to the renal and Obstetrics (FIGO) staging classification, the supra- veins, while the infra-renal PANs can be further classi- renal PANs are classified as regional lymph nodes, but it fied into nodes located between the renal veins and the is stated that there is controversy regarding whether supra-renal PAN metastasis should be considered as re- * Correspondence: [email protected] gional lymph node metastasis (stage III) or distant me- 1Department of Obstetrics and Gynecology, Toho University Faculty of Medicine, 6-11-1, Omori-nishi, Ota-ku, Tokyo 143-8541, Japan tastasis (stage IV), and this issue should be investigated 2Department of Gynecology, Toho University Ohashi Medical Center, Tokyo, further in the future [2]. The chief reason why the Japan © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Komiyama et al. World Journal of Surgical Oncology (2020) 18:64 Page 2 of 10 clinical significance of supra-renal PAN metastasis re- preserve fertility, (6) borderline malignant tumor, and mains unclear in patients with epithelial ovarian cancer, (7) active double cancer. including primary peritoneal cancer and fallopian tube The chest and abdomen, including the supra-renal cancer, is that metastasis to these nodes has received lit- PANs, were examined carefully by computed tomog- tle attention in the past. raphy (CT) before surgery. Staging laparotomy was per- It is possible that supra-renal PAN metastases have formed in patients with a clinical diagnosis of early not been assessed in many previous studies because cancer, while primary debulking surgery (PDS) was done these nodes lie dorsal to the pancreas and dissection is in patients with a clinical diagnosis of advanced cancer difficult due to this anatomic location. In addition, the in whom it was considered that primary surgery would target region for systematic PAN dissection is below the achieve an optimal outcome. In addition, interval renal veins in patients with ovarian cancer and dissec- debulking surgery (IDS) was performed after 3–4 cycles tion of the supra-renal PANs is unusual. of neoadjuvant chemotherapy (NAC) with taxanes, plat- However, the supra-renal PANs can be sites of metas- inum, and bevacizumab in patients with clinically sus- tasis or recurrence in patients with advanced ovarian pected advanced cancer in whom it was considered that cancer. To determine the optimal surgical management primary surgery would not be optimal. for patients with supra-renal PAN involvement, we have tried various approaches to supra-renal PAN dissection, Surgical procedure and we have developed a safe method for dissection of After pelvic lymph node dissection was completed, the entire PAN region, including the supra-renal PANs Komiyama’s maneuver for extended PAN dissection was (extended PAN dissection). This method involves carried out as follows (Fig. 1). complete mobilization of the entire small intestine (in- (1) The ascending colon was displaced from the right cluding the duodenum) and the right hemicolon to ex- paracolic gutter toward the left side. A retroperitoneal pose the inferior vena cava and abdominal aorta below incision was made from the ileocecal region in the ceph- the epiploic foramen on the inferior surface of the liver. alic direction along the so-called Monk’s white line on Consequently, it is possible to expand the para-aortic re- the dorsal side of the ascending colon. At this site, Gero- gion located cephalad to the renal artery, and it is easy ta’s fascia, the ascending mesocolon, and the retroperito- to dissect the supra-renal PANs. Our method is a modi- neum coalesce to form the so-called fusion fascia, which fication of Kocher’s maneuver for duodenal mobilization continues to the mesentery on the right side of the sec- and has been named Komiyama’s maneuver for dissec- ond part of the duodenum and ends superiorly at the tion of high para-aortic lymph nodes [3]. epiploic foramen on the inferior surface of the left lobe We performed the present study to evaluate the pat- of the liver. The fusion fascia was incised through the tern of supra-renal PAN metastasis and the feasibility of medial side of Gerota’s fascia toward the root of the performing extended PAN dissection in patients with right renal vein to separate the right kidney from the as- epithelial ovarian cancer, primary peritoneal cancer, or cending colon, which was mobilized to expose the region fallopian tube cancer. from the anterior surface of the inferior vena cava (IVC) to the left side of the abdominal aorta. The right ovarian Materials and methods vein runs through the fusion fascia and then through the Patients pelvic cavity toward the midpoint of the IVC, and the The subjects of this study were patients with an initial right ureter also runs through the fusion fascia, allowing diagnosis of epithelial ovarian cancer, primary peritoneal both structures to be easily identified by incising the cancer, or fallopian tube cancer who underwent ex- fascia. After identifying the right ovarian vein, it was tended PAN dissection and pelvic lymph node dissection transected to expose the IVC below the renal vein (Fig. at Toho University Ohashi Medical Center. 1a–c). The eligibility criteria for our surgical procedure were (2) Kocher’s maneuver was performed for mobilization as follows: (1) preoperative Eastern Cooperative Oncol- of the duodenum. The second part of the duodenum ogy Group (ECOG) Performance Status of 0–1; (2) ad- was displaced toward the left side and the incision in the equate major organ function as evaluated by hematology fusion fascia, which was at the root of the right renal tests, biochemical tests, coagulation tests, chest and ab- vein, was extended to the epiploic foramen. Then, con- dominal X-ray examination, and electrocardiography; nective tissues were stripped from around the duode- and (3) written informed consent to surgery provided by num, and it was mobilized to completely expose the IVC the patient. Patients who met any of the following cri- below the inferior surface of the left lobe of the liver teria were excluded: (1) a history of intestinal obstruc- (Fig. 1d, e). tion, (2) uncontrolled diabetes or hypertension, (3) deep (3) A retroperitoneal incision was commenced near venous thrombosis, (4) pancreatic disease, (5) a desire to the bifurcation of the abdominal aorta into the common Komiyama et al. World Journal of Surgical Oncology (2020) 18:64 Page 3 of 10 Fig. 1 Surgical procedure of Komiyama’s maneuver for extended PAN dissection.
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