Antoine El Asmar

Deep epigastric lymph node involvement in patients with ovarian and colorectal peritoneal metastasis: A prospective pilot study

The inferior deep epigastric lymph node basin has been described as a lymphatic pathway for systemic cancer dissemination from the intra-abdominal cavity. This study aimed to determine the incidence and conditions of involvement of this basin in patients with peritoneal metastases of ovarian and colorectal cancer. This single-center prospective pilot trial conducted over 3 years (from December 10, 2020, to September 1, 2023) included patients with peritoneal metastases of ovarian and colorectal cancer presenting for cytoreductive surgery. For each patient, bilateral inferior deep epigastric lymph node harvesting and histologic analysis was performed. This study enrolled 40 patients, 20 with peritoneal metastases of ovarian cancer and 20 with peritoneal metastases of colorectal cancer. Of the 20 patients with peritoneal metastases of ovarian cancer, 6 (30%) had positive inferior deep epigastric lymph nodes, including 5 with high peritoneal cancer index (31, 28, 25, 17, 16). Of the patients with peritoneal metastases of colorectal cancer, 2 had positive inferior deep epigastric lymph nodes (10%) with peritoneal cancer index of 25 and 15, respectively. The inferior deep epigastric lymph node basin represents a drainage route for the peritoneum and provided an alternative pathway for systemic dissemination in 30% of patients with peritoneal metastases of ovarian cancer and 10% of patients with peritoneal metastases of colorectal cancer. Inferior deep epigastric lymph nodes were positive in patients with high-grade disease, high peritoneal cancer index, and extensive pelvic peritoneal disease.

Deep epigastric lymph nodes implication in patients’ recurrence pattern after cytoreductive surgery in ovarian peritoneal metastases

Although complete cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) offers a good prognosis in patients with peritoneal metastasis of ovarian cancer (PMOC), recurrences are quite common. These recurrences can be intra-abdominal or systemic in nature. Our objective was to study and illustrate the global recurrence pattern in patients operated for PMOC, shedding light on a previously overlooked lymphatic basin at the level of the epigastric artery, the deep epigastric lymph nodes (DELN) basin. This was a retrospective study including patients with PMOC who underwent surgery with curative-intent, from 2012 until 2018, at our cancer center, and who presented with any type of disease recurrence on follow-up. CT-scans, MRIs and PET-scans were reviewed in order to determine solid organs and lymph nodes (LN) recurrences. During the study period, 208 patients underwent CRS ± HIPEC, 115 (55.3%) presented with organ or lymphatic recurrence over a median follow-up of 81 months. Sixty percent of these patients had radiologically enlarged LN involvement. The pelvis/pelvic peritoneum was the most common intra-abdominal organ recurrence site (47%), while the retroperitoneal LN was the most common lymphatic recurrence site (73.9%). Previously overlooked DELN were found in 12 patients, with 17.4% implication in lymphatic basin recurrence patterns. Our study revealed the potential role of the DELN basin, previously overlooked in the systemic dissemination process of PMOC. This study sheds light on a previously unrecognized lymphatic pathway, as an intermediate checkpoint or relay, between the peritoneum, an intra-abdominal organ, and the extra-abdominal compartment.

Inferior epigastric artery lymph nodes: A pathway for systemic dissemination from peritoneal carcinomatosis?

AbstractBackground and ObjectivesWe report, for the first time in the literature, a metastatic lymphatic pathway along the inferior epigastric vessels, through the inferior epigastric lymph nodes (IELNs), in patients with peritoneal carcinomatosis (PC). Interestingly, these lymph nodes (LNs) in the anterior retroperitoneum were not detectable on preoperative imaging. They may, however, represent a pertinent systemic dissemination pathway for PC.Patients and MethodsIn patients undergoing indocyanine green‐fluorescence imaging during cytoreductive surgery for PC, an incidental finding of a hyperfluorescent LN, harboring metastatic tumorous cells, around the inferior epigastric artery was made.ResultsIn three out of five patients with clear fluorescent hotspot, the harvested LN was harboring metastatic cancerous cells. None of these nodes, whether negative or positive, was visible on any preoperative imaging modalities. A protocol to sample, in a systematic manner, the IELN in patients with PC, is currently being devised at our institution.ConclusionThese lymphatic nodes basin and channels might reveal to be a potential passage from peritoneal metastasis to the extraperitoneal lymphatic compartment, representing an independent pathway for cancerous cell dissemination. This will bring us to further investigate the prevalence and the prognostic significance of these LNs.

Deep Epigastric Lymph Node Harvesting in Patients with Peritoneal Metastases of Colorectal and Ovarian Cancer Origin