Anatomical and pathological study of retroperitoneal nodes in epithelial ovarian cancer

Contribution of the cadaveric recirculation system in the anatomical study of lymphatic drainage of the ovary: applications in the management of ovarian cancer

PURPOSE

The present knowledge about lymphatic drainage of the ovary is based on carcinological studies, but it has only rarely been studied under physiological conditions. However, it is one of the preferential routes of dissemination in ovarian cancer, and understanding it is therefore vital for optimal carcinological management.Our purpose was to evaluate the feasibility of an innovative technique to study the lymphatic drainage territories of the ovary using a recirculation module on the cadaveric model.

METHODS

We injected patent blue into the cortex of twenty "revascularised" cadaver ovaries with the Simlife recirculation model. We observed the migration of the dye live and described the drainage territories of each ovary.

RESULTS

We observed a staining of the lymphatic vessels and migration of the dye in all the subjects, systematically ipsilateral to the injected ovary. We identified a staining of the lumbo-aortic territory in 65% of cases, with a preferential lateral-caval involvement (60%) for the right ovary and lateral-aortic territory (40%) for the left ovary. A common iliac involvement was observed in only 10% of cases. In 57% of cases, the staining of the lumbo-aortic territory was associated with a staining of the suspensory ligament. The pelvic territory was involved in 50% of cases, with an external iliac staining in 25% of cases and internal in 20%.

CONCLUSION

Our study provides for a better understanding of lymphatic drainage of the ovary using a new detection method, and allows the possibility of improving the teaching for operators with a realistic model. Continuation of this work could lead to considering more targeted and thus less morbid lymph node sampling for lymph node staging in early-stage ovarian cancer.

CUP-syndrome: Inguinal high grade serous ovarian carcinoma lymph node metastases with unknown primary origin – a case report and literature review

Objective

High-grade serous ovarian carcinoma (HGSC) often presents lymph node involvement. According to the paths of lymphatic drainage, the most common site of nodal metastasis is in the aortic area. However, pelvic lymph nodes are also involved and inguinal metastases are less frequent.

Methods

Our report concerns the case of a 78-year-old woman with an inguinal lymph node relapse of HGSC, with the prior positivity of a right inguinal lymph node, after the primary surgery. Ovaries and tubes were negative on histological examination. A comprehensive search of the literature published from January 2000 to October 2021 was conducted on PubMed and Scopus. The papers were selected following the PRISMA guidelines. Nine retrospective studies were evaluated.

Results

Overall, 67 studies were included in the initial search. Applying the screening criteria, 36 articles were considered eligible for full-text reading of which, after applying the exclusion criteria, 9 studies were selected for the final analysis and included in the systematic review. No studies were included for a quantitative analysis. We divided the results according to the relapse location: loco-regional, abdominal, and extra-abdominal recurrence.

Conclusions

Inguinal node metastasis is a rare but not unusual occurrence in HGSC. A reasonable level of suspicion should be maintained in patients with inguinal adenopathy and high CA125 values, especially in women with a history of gynecologic surgery, even in the absence of negative imaging for an ovarian origin.

Feasibility of sentinel lymph node mapping in ovarian tumors: A systematic review and meta-analysis of the literature

Purpose of the report

Since the presence of lymph node metastases upstages the disease and to reduce the morbidity of total lymphadenectomy, sentinel lymph node (SLN) mapping in ovarian mass has been the focus of extensive research. This study aims to review all the literature associated with ovarian SLN mapping and assess the feasibility of ovarian SLN mapping.

Materials and methods

PubMed and Scopus were searched using the following keywords: (Sentinel lymph node) AND (Ovary OR Ovarian) AND (Tumor OR Neoplasm OR Cancer). All studies with information regarding sentinel node biopsy in ovaries were included. Different information including mapping material, injection sites, etc., was extracted from each study. In total, two indices were calculated for included studies: detection rate and false-negative rate. Meta-analysis was conducted using Meta-MUMS software. Pooled detection rate, sensitivity, heterogeneity, and publication bias were evaluated. Quality of the studies was evaluated using the Oxford center for evidence-based medicine checklist.

Results

Overall, the systematic review included 14 studies. Ovarian SLN detection rate can vary depending on the type of tracer, site of injection, etc., which signifies an overall pooled detection rate of 86% [95% CI: 75-93]. The forest plot of detection rate pooling is provided (Cochrane Q-value = 31.57, p = 0.003; I2 = 58.8%). Trim and fill method resulted in trimming of 7 studies, which decreased the pooled detection rate to 79.1% [95% CI: 67.1-87.5]. Overall, pooled sensitivity was 91% [59-100] (Cochrane Q-value = 3.93; p = 0.41; I2 = 0%). The proportion of lymph node positive patients was 0-25% in these studies with overall 14.28%.

Conclusion

Sentinel lymph node mapping in ovarian tumors is feasible and seems to have high sensitivity for detection of lymph node involvement in ovarian malignant tumors. Mapping material, injection site, and previous ovarian surgery were associated with successful mapping. Larger studies are needed to better evaluate the sensitivity of this procedure in ovarian malignancies.

Utility of Intraoperative Fluorescence Imaging in Gynecologic Surgery: Systematic Review and Consensus Statement

BACKGROUND

This study aimed to review the current knowledge on the utility of intraoperative fluorescence imaging in gynecologic surgery and to give evidence-based recommendations to improve the quality of care for women who undergo gynecologic surgery.

METHODS

A computer-based systematic review of the MEDLINE, CENTRAL, Pubmed, EMBASE, and SciSearch databases as well as institutional guidelines was performed. The time limit was set at 2000-2019. For the literature search, PRISMA guidelines were followed. A modified-Delphi method was performed in three rounds by a panel of experts to reach a consensus of conclusions and recommendations.

RESULTS

Indocyanine green (ICG) is used primarily in gynecology for sentinel node-mapping. In endometrial and cervical cancer, ICG is a feasible, safe, time-efficient, and reliable method for lymphatic mapping, with better bilateral detection rates. Experience in vulvar cancer is more limited, with ICG used together with Tc-99 m as a dual tracer and alone in video endoscopic inguinal lymphadenectomy. In early ovarian cancer, results are still preliminary but promising. Indocyanine green fluorescence imaging also is used for ureteral assessment, allowing intraoperative ureteral visualization, to reduce the risk of ureteral injury during gynecologic surgery.

CONCLUSIONS

For most gynecologic cancers, ICG fluorescence imaging is considered the tracer of choice for lymphatic mapping. The use of this new technology expands to a better ureteral assessment.

Lymphadenectomy in Ovarian Cancer: Is It Still Justified?

PURPOSE OF REVIEW

The aim of this review is to determine, in the light of recent evidences, the role of lymphadenectomy in ovarian cancer.

RECENT FINDINGS

The lymphadenectomy in ovarian neoplasms (LION) trial reports no better outcomes and higher complication and mortality rates associated with lymphadenectomy. Even if performed by expert hands, lymphadenectomy has a cost in terms of longer operative time, blood loss, higher rates of transfusions, and intensive unit care. If on the one hand retroperitoneal staging is not correlated to survival benefits both in early and advanced ovarian cancer, on the other hand it is associated with an increased surgery-related morbidity. Surgical treatment of isolated nodal recurrences seems to be feasible and associated with survival benefits.

Feasibility of sentinel lymph node mapping of the ovary: a systematic review

Pelvic and para-aortic lymphadenectomy is routinely performed in early ovarian cancer to define the stage of the disease. However, it may be associated with increased blood loss, operative time, and length of hospitalization. The sentinel lymph node technique has been shown to be safe and feasible in vulvar, uterine, and cervical cancer. Data detailing feasibility and outcomes of sentinel lymph node mapping in ovarian cancer are scarce.

To summarize the studies evaluating the feasibility of sentinel lymph node detection from the ovary, examining the technique and detection rate.

A systematic search of the literature was performed using PubMed and Embase from June 1991 to February 2019. Studies describing the sentinel lymph node technique and lymphatic drainage of the ovaries were incorporated in this review. Ten articles were selected, comprising a total of 145 patients. A variety of agents were used, but the primary markers were technetium-99m radiocolloid (Tc-99m), patent blue, or indocyanine green, and the most common injection site was the ovarian ligaments.

The overall sentinel lymph node detection rate was 90.3%.

We propose a standardized technique sentinel lymph node mapping in ovarian cancer, using indocyanine green, or Tc-99m and blue dye as alternative tracers, injected in both the suspensory and the infundibulopelvic ligament of the ovary.

Endometrioid Carcinoma of the Ovary: A Retrospective Analysis of 106 Cases

Aims and background

This report retrospectively analyzes 106 cases of endometrioid carcinoma of the ovary treated at the National Cancer Institute of Milan from 1974 through December 1993. In 12 of the 106 cases (11.3%) a synchronous carcinoma of the uterine body was observed.

Methods and study design

Only patients who had previously untreated disease were included in the study. Patients with synchronous tumors were staged according to their ovarian cancer and treated according to the stage of that disease.

Results

Thirty-nine patients (36.8%) had stage I, 17 (16.0%) stage II, 43 (40.6%) stage III, and 7 (6.6%) stage IV disease. Moderately plus poorly differentiated tumors were present in 76 of the 106 cases (71.7%). Considering the 67 patients with advanced disease, residual tumor was absent in 27 cases (40.3%), ≤ 2 cm in 17 (25.4%), and > 2 cm in 23 (34.3%) cases. Systematic pelvic and para-aortic lymphadenectomy was performed in 60 patients (56.6%); selective sampling was carried out in 23 cases (21.7%). After surgery, 77 patients underwent various chemotherapy regimens.

Conclusion

Using univariate analysis, FIGO stage, tumor grade, residual disease after surgery, lymph node status, and platinum in the chemotherapy regimen significantly influenced 5-year survival. However, when all these variables were included in a multivariate analysis only FIGO stage still had a significant impact on survival. Survival analysis also showed a trend towards longer survival in patients with synchronous tumors.

Tumor Laterality in Early Ovarian Cancer: Influence on Left-Right Asymmetry of Pelvic Lymph Nodes

Aim and background

To determine whether left-right asymmetry was present in cases of early ovarian cancer and whether or not the difference between number of removed lymph nodes on both sides of the pelvis is associated with tumor laterality.

Methods and study design

We extracted from the medical data base cases of early ovarian cancer with lymphadenectomy who had been treated between 1994 and 2008. The sample was divided in three groups according to the left-right laterality of the tumor in the pelvis (bilateral, left sided, right sided). For each case, we subtracted the number of dissected lymph nodes on the left side from the number of dissected lymph nodes on the right side of the pelvis (NRightside - NLeftside). We used one sample t test to determine whether the mean of differences for each group was different from zero.

Results

We extracted 48 cases with early ovarian cancer who had undergone lymphadenectomy. The average number of dissected lymph nodes was 24 (SD, 12). In 3 cases, we confirmed the presence of lymph node metastasis (6.3%). In 2 of the up-staged cases, tumor and involved lymph nodes were on the right side of the pelvis. In the third case, the tumor was on the left side, whereas involved lymph nodes were on both sides of the pelvis. For bilateral tumors, tumors on the left, and those on the right side of the pelvis, the mean difference was −0.5 (95% CI, −9.9 to 8.9; t, −0.137; P= 0.90), 0.32 (95% CI, −3.8 to 4.5; t, 0.16; P = 0.87) and 3.5 (95% CI, 0.03 to 7.01; t, 2.09; P = 0.048), respectively.

Conclusions

When the tumor was on the left or on both sides of the pelvis, there was no significant difference in the number of removed lymph nodes. In contrast, when the tumor was on the right side, the number of removed lymph nodes was significantly higher on the right hemipelvis than on the left hemipelvis. Free full text available at www.tumorionline.it

What is the role of retroperitoneal exploration in optimally debulked stage IIIC epithelial ovarian cancer? An NRG Oncology/Gynecologic Oncology Group ancillary data study

BACKGROUND

The purpose of this study was to determine the effect of retroperitoneal (RP) exploration on progression-free survival (PFS) and overall survival (OS) in epithelial ovarian cancer (EOC) patients with stage IIIC disease who underwent optimal debulking surgery.

METHODS

Data were collected from records of the Gynecologic Oncology Group 182 (GOG-182) study of stage IIIC EOC patients cytoreduced to no gross residual disease (R0) or minimal gross residual (<1 cm) disease (MGRD) at primary surgery. Patients with stage IIIC disease by intraperitoneal (IP) tumor were included and divided into 3 groups: 1) > 2 cm IP tumor without lymph node involvement (IP/RP-), 2) > 2 cm IP tumor with lymph node involvement (IP/RP+), and 3) > 2 cm IP tumor with no RP exploration (IP/RP?). The effects of disease distribution and RP exploration on PFS and OS were assessed using Kaplan-Meier and proportional hazards methods.

RESULTS

There were 1871 stage IIIC patients in GOG-182 who underwent optimal primary debulking surgery. Of these, 689 (36.8%) underwent RP exploration with removal of lymph nodes from at least 1 para-aortic site, and 1182 (63.2%) did not. There were 269 patients in the IP/RP- group, 420 patients in the IP/RP + group, and 1182 patients in the IP/RP? group. Improved PFS (18.5 vs 16.0 months; P < .0001) and OS (53.3 vs 42.8 months; P < .0001) were associated with RP exploration versus no exploration. Patients with MGRD had improved PFS (16.8 vs 15.1 months, P = 0.0108) and OS (44.9 vs 40.5 months, P = 0.0076) versus no exploration.

CONCLUSIONS

RP exploration at the time of primary surgery in patients with optimally debulked stage IIIC EOC is associated with a survival benefit. Cancer 2017;123:985-93. © 2016 American Cancer Society.

Incidence of Lymph Node Metastases in Apparent Early-Stage Low-Grade Epithelial Ovarian Cancer: A Comprehensive Review

Objectives

This study aimed to determine the incidence of lymph node (LN) metastases in presumed stage I-II low-grade epithelial ovarian cancer (EOC).

Methods

Eligible studies were identified from MEDLINE and EMBASE (time frame, 2015–1975), that analyzed patients with clinical or radiologic presumed early-stage EOC who underwent a complete pelvic and para-aortic lymphadenectomy as part of their surgical staging. The number and site of dissected and involved LNs and the correlation with overall outcome are analyzed. The termlow gradeand also the older termwell differentiatedwere used.

Results

Thirteen of 978 identified studies were selected, and 13 of 75 studies were identified as eligible. A total of 1403 patients were analyzed in these 13 retrospective studies. The final International Federation of Gynecology and Obstetrics staging after completed surgical staging was I to II in 912 patients (65%). A total of 338 patients (24%) had grade 1 tumors whereas 473 patients (34%) had grade 2, and 502 patients (36%) had grade 3 tumors. Systematic lymphadenectomy was performed in 1159 patients (83%), whereof 1142 (82%) were pelvic and para-aortic LN dissections.

In 185 patients (13%), an upstaging from an apparent clinical stage I-II to IIIC occurred because of LN involvement: 64 (35%) of the patients had only pelvic LNs metastases, 69 (37%) had only para-aortic LNs metastasis, and 51 (28%) had both a pelvic and para-aortic LN involvement. When analyzing only the patients with low-grade (grade 1 as the old classification) presumed early-stage disease (n = 273), only 8 patients (2.9%; range, 0–6.2) were identified with LNs metastases present.

Conclusions

The incidence of occult LN metastases in apparent early-stage low-grade EOC is 2.9% in a metaanalysis of retrospective studies. Future larger-scale prospectively assessed studies with established surgical quality of the LN dissection are warranted to establish the true incidence of LN metastasis in presumed early low-grade disease.

Understanding Lymphatic Drainage Pathways of the Ovaries to Predict Sites for Sentinel Nodes in Ovarian Cancer

Supplemental digital content is available in the text.

Objective

In ovarian cancer, detection of sentinel nodes is an upcoming procedure. Perioperative determination of the patient’s sentinel node(s) might prevent a radical lymphadenectomy and associated morbidity. It is essential to understand the lymphatic drainage pathways of the ovaries, which are surprisingly up till now poorly investigated, to predict the anatomical regions where sentinel nodes can be found. We aimed to describe the lymphatic drainage pathways of the human ovaries including their compartmental fascia borders.

Methods

A series of 3 human female fetuses and tissues samples from 1 human cadaveric specimen were studied. Immunohistochemical analysis was performed on paraffin-embedded transverse sections (8 or 10 μm) using antibodies against Lyve-1, S100, and α-smooth muscle actin to identify the lymphatic endothelium, Schwann, and smooth muscle cells, respectively. Three-dimensional reconstructions were created.

Results

Two major and 1 minor lymphatic drainage pathways from the ovaries were detected. One pathway drained via the proper ligament of the ovaries (ovarian ligament) toward the lymph nodes in the obturator fossa and the internal iliac artery. Another pathway drained the ovaries via the suspensory ligament (infundibulopelvic ligament) toward the para-aortic and paracaval lymph nodes. A third minor pathway drained the ovaries via the round ligament to the inguinal lymph nodes. Lymph vessels draining the fallopian tube all followed the lymphatic drainage pathways of the ovaries.

Conclusions

The lymphatic drainage pathways of the ovaries invariably run via the suspensory ligament (infundibulopelvic ligament) and the proper ligament of the ovaries (ovarian ligament), as well as through the round ligament of the uterus. Because ovarian cancer might spread lymphogenously via these routes, the sentinel node can be detected in the para-aortic and paracaval regions, obturator fossa and surrounding internal iliac arteries, and inguinal regions. These findings support the strategy of injecting tracers in both ovarian ligaments to identify sentinel nodes.

Preferential Allele Expression Analysis Identifies Shared Germline and Somatic Driver Genes in Advanced Ovarian Cancer

Identifying genes where a variant allele is preferentially expressed in tumors could lead to a better understanding of cancer biology and optimization of targeted therapy. However, tumor sample heterogeneity complicates standard approaches for detecting preferential allele expression. We therefore developed a novel approach combining genome and transcriptome sequencing data from the same sample that corrects for sample heterogeneity and identifies significant preferentially expressed alleles. We applied this analysis to epithelial ovarian cancer samples consisting of matched primary ovary and peritoneum and lymph node metastasis. We find that preferentially expressed variant alleles include germline and somatic variants, are shared at a relatively high frequency between patients, and are in gene networks known to be involved in cancer processes. Analysis at a patient level identifies patient-specific preferentially expressed alleles in genes that are targets for known drugs. Analysis at a site level identifies patterns of site specific preferential allele expression with similar pathways being impacted in the primary and metastasis sites. We conclude that genes with preferentially expressed variant alleles can act as cancer drivers and that targeting those genes could lead to new therapeutic strategies.

Identifying genes that contribute to cancer biology is complicated partly because cancers can have dozens of somatic mutations and thousands of germline variants. Somatic mutations are gene variants that arise after conception in an organism while germline variants are gene variants present at conception in an organism. Most methods to identify cancer drivers have focused on determining somatic mutations. In this study we attempt to identify, from a tumor sample, important germline and somatic variants by determining if a variant is expressed (made into RNA) more than expected from the amount of the variant in the genome. The preferred expression of a variant could benefit cancer cells. When applying our analysis to ovarian cancer samples we found that despite the apparent heterogeneity, different patients frequently share the same genes with preferentially expressed variants. These genes in many cases are known to affect cancer processes such as DNA repair, cell adhesion and cell signaling and are targetable with known drugs. We therefore conclude that our analysis can identify germline and somatic gene variants that contribute to cancer biology and can potentially guide individualized therapies.

The Safety and Feasibility of Robotic-Assisted Lymph Node Staging in Early-Stage Ovarian Cancer

Objectives

The purpose of this study was to report on the safety and feasibility of robotic-assisted systematic lymph node staging in the management of early-stage ovarian cancer.

Methods

We retrospectively reviewed the charts of presumed early-stage (International Federation of Gynecology and Obstetrics (FIGO) stages I and II) ovarian cancer patients who underwent robotic-assisted surgery that incorporated a systematic pelvic and para-aortic lymphadenectomy from January 2009 until December 2013. Patient demographics, operative characteristics, pathology, lymph node counts, surgical complications, and hospital stay were evaluated.

Results

A total of 26 early-stage ovarian cancer patients were identified. The mean operating time was 2.90 hours, and the estimated blood loss was 63 mL; there were no intraoperative complications although 1 patient’s surgery was significantly prolonged due to pelvic adhesions. The mean number of pelvic and para-aortic lymph nodes removed was 14.6 (2.3% incidence of pelvic lymph node metastases) and 5.8 (3.3% incidence of para-aortic lymph node metastases), respectively. The patients’ mean duration of hospital stay was 18.4 hours, and 2 patients were readmitted for either a postoperative wound infection or vaginal dehiscence.

Conclusions

The results from this study suggest that robotic-assisted surgical staging in the management of presumed early-stage ovarian cancer is both feasible and associated with a minimal patient complication rate. We encountered a low incidence of lymph node metastases, and the readmission rate was favorable. Nevertheless, because the prevalence of lymph node metastases can approach 20% in select patients, physicians should consider a systematic lymph node resection to confer an optimal clinical assessment.

Prognostic relevance of celiac lymph node involvement in ovarian cancer

OBJECTIVE

The aim of the study was to report on the oncologic outcome of the disease spread to celiac lymph nodes (CLNs) in advanced-stage ovarian cancer patients.

METHODS

All patients who had CLN resection as part of their cytoreductive surgery for epithelial ovarian, fallopian, or primary peritoneal cancer were identified. Patient demographic data with particular emphasis on operative records to detail the extent and distribution of the disease spread, lymphadenectomy procedures, pathologic data, and follow-up data were included.

RESULTS

The median follow-up was 26.3 months. The median overall survival values in the group with positive CLNs and in the group with negative CLNs were 26.9 months and 40.04 months, respectively. The median progression-free survival values in the group with metastatic CLNs and in the group with negative CLNs were 8.8 months and 20.24 months, respectively (P = 0.053). Positive CLNs were associated with progression during or within 6 months after the completion of chemotherapy (P = 0.0044). Tumor burden and extensive disease distribution were significantly associated with poor progression-free survival, short-term progression, and overall survival. In multivariate analysis, only the CLN status was independently associated with short-term progression.

CONCLUSIONS

Disease in the CLN is a marker of disease severity, which is associated to a high-risk group of patients with presumed adverse tumor biology, increased risk of lymph node progression, and worst oncologic outcome.

Correlation between the extent of intraperitoneal disease and nodal metastasis in node-positive ovarian cancer patients

AIMS

To investigate correlations between extent of disease (ED), frequency and location of nodal metastases in node-positive EOC patients.

METHODS

Data were collected from 116 consecutive patients who underwent systematic lymphadenectomy during primary surgery. Patients were grouped in ED1 (disease confined in pelvis), ED2 (disease extended to abdomen), and ED3 (distant metastases). Univariate and multivariate analysis were performed for overall survival and progression-free survival (PFS).

RESULTS

Correspondence analysis revealed associations between ED1 and negative nodes, ED2 and positive aortic/pelvic nodes, and ED3 and positive external and common iliac nodes. The most representative group for nodal metastases in ED1 was aortic nodes (77.8%). The number of positive pelvic nodes increased with ED; the RR was 0.58 for ED2 and 0.25 for ED3 (p = 0.004). The RR for positive external iliac nodes was 0.66 in ED2 and 0.31 in ED3 (p = 0.002); the RR for positive common iliac nodes was 0.76 and 0.17, respectively (p = 0.001). Multivariate analysis revealed that aortic nodal metastasis was associated with PFS (p = 0.03; HR, 1.95).

CONCLUSION

Distribution and percentage of nodal metastases varied with ED. The risk of pelvic nodal metastasis, increased with ED. Location of positive nodes was correlated with PFS.

The role of pelvic and aortic lymphadenectomy at second look surgery in apparent early stage ovarian cancer after inadequate surgical staging followed by adjuvant chemotherapy

BACKGROUND

Systematic aortic and pelvic lymphadenectomy (SAPL) is a milestone procedure in the treatment of early stage ovarian cancer. It defines staging and prognosis and helps in tailoring adjuvant chemotherapy. Only limited data are available about SAPL at second look surgery in patients with apparent early stage ovarian cancer who underwent inadequate surgical staging and adjuvant platinum based chemotherapy.

METHODS

From January 1991 through January 2013, 66 patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA-IIA epithelial ovarian carcinoma suboptimally surgically staged and treated with adjuvant chemotherapy, were referred to our center and underwent second look surgery including SAPL.

RESULTS

Twenty-two women underwent bilateral and 44 unilateral SAPL. A total of 2168 nodes were removed and analyzed. The median number of lymph nodes dissected was 29 (range 14-73); in particular it was 29 (range 14-60) in case of unilateral and 37 (range 17-73) in case of bilateral SAPL. Only one woman had nodal metastasis (1.5%). After a median follow-up of 78 months, 10 women (15.2%) relapsed and 5 (7.6%) died of progressive disease. The 5-year disease-free survival and overall survival are 91.7% and 96%.

CONCLUSION

The risk of nodal metastases in stage I-IIA unstaged ovarian cancer after adjuvant chemotherapy is negligible. Our study suggests that SAPL at second look is not indicated in this subset of women.

Lymph node metastasis in patients with epithelial ovarian cancer macroscopically confined to the ovary: review of a single-institution experience

BACKGROUND

To evaluate the patterns of lymphatic spread in epithelial ovarian cancer (EOC) macroscopically confined to the ovary and to determine risk factors for lymph node metastasis.

MATERIALS AND METHODS

All patients with clinically apparent stage IA/B/C EOCs who underwent staging surgery between January 2003 and February 2013 were retrospectively identified.

RESULTS

Two hundred and thirty-six (n = 236) consecutive patients were operated for primary epithelial ovarian carcinoma. Sixty-two of these patients (26.2 %) who underwent a comprehensive staging procedure including pelvic and paraaortic lymphadenectomy were diagnosed with tumors confined to one or two ovaries (stage IA/B/C). Of these 62 patients, 17 (27.4 %) had upstaged disease and 8 (12.9 %) had lymph node metastasis. Tumor histology was serous in 25 patients (40.3 %), mucinous in 23 patients (37 %), endometrioid in 9 patients (14.5 %), and clear cell in 5 patients (8 %). Positive lymph node status was found in 20 % (5/25) of those with serous histology while this rate was only 8.1 % (3/37) in those with non-serous disease. Although the presence of ascites was not associated with an increased risk of lymph node involvement (p = 0.24), positive peritoneal cytology (p = 0.001) and grade 3 disease (p = 0.001) were significant predictors of lymph node involvement.

CONCLUSION

All patients diagnosed with EOC macroscopically confined to the ovary should be considered for comprehensive staging surgery including pelvic and paraaortic lymphadenectomy.

The impact of pelvic retroperitoneal invasion and distant nodal metastases in epithelial ovarian cancer

BACKGROUND

The absence of disease after debulking surgery is the most important prognostic factor in the treatment of advanced epithelial ovarian cancer (EOC). Occasionally, the presence of extra-abdominal disease complicates the ability to obtain a complete surgery, considering some locations of the metastatic disease as unresectable. The objective of the study was to estimate the survival impact of pelvic retroperitoneal invasion and extrapelvic and aortic distant nodal metastases in EOC patients. The anatomical landmarks of primary cytoreductive surgery will be discussed.

MATERIAL AND METHODS

We reviewed data from 116 consecutive Mayo Clinic patients with epithelial ovarian cancer (EOC) stage IIIC and IV, undergoing primary cytoreduction surgery between 1996 and 2000. Univariate and multivariate analysis for patients with positive distant nodes and pelvic retroperitoneal invasion was performed, including 57 patients with no residual disease after surgery. Kaplan-Meier curves were used to estimate the probability of survival.

RESULTS

The median patient's age was 65 years (range 24-87 years). The 5 years overall survival was 44.8% (range 30.1-57.9 months) and the median length of survival was 39.9 months (range 0.13-60 months, 95% confidence interval: 30.1-57.9). Pelvic retroperitoneal invasion was present in 22 EOC patients (18.9%) and distant positive nodes were noted in 11 (9.5%): suprarenal/celiac (5.2%), inguinal (4.3%) and supraclavicular (0.9%). Univariate and multivariate Cox regression analysis, identified distant positive lymph nodes and pelvic retroperitoneal invasion as factors statistically associated with overall survival (p = 0.002 and p = 0.025, respectively).

CONCLUSIONS

Metastatic distant nodes and pelvic retroperitoneal invasion are independent prognostic factors for survival in patients with advanced EOC.

Sentinel node in ovarian cancer: study protocol for a phase 1 study

Background

The concept of sentinel lymph node surgery is to determine whether the cancer has spread to the very first lymph node or sentinel node. If the sentinel node does not contain cancer, then there is a high likelihood that the cancer has not spread to other lymph nodes. The sentinel node technique has been proven to be effective in different types of cancer. In this study we want to determine whether a sentinel node procedure in patients with ovarian cancer is feasible when the tracers are injected into the ovarian ligaments.

Methods/Design

Patients with a high likelihood of having an ovarian malignancy in whom a median laparotomy and a frozen section analysis is planned and patients with endometrial cancer in whom a staging laparotomy is planned will be included.

Before starting the surgical staging procedure, blue dye and radioactive colloid will be injected into the ligamentum ovarii proprium and the ligamentum infundibulo-pelvicum. In the analysis we calculate the percentage of patients in whom it is feasible to identify sentinel nodes. Other study parameters are the anatomical localization of the sentinel node(s) and the incidence of false negative lymph nodes.

Trial registration

Approval number: NL40323.068.12

Name: Medical Ethical Committee Maastricht University Hospital, University of Maastricht

Affiliation: Maastricht University Hospital

Board Chair Name: Medisch Ethische Commissie azM/UM

Elevated expression of MAC30 predicts lymph node metastasis and unfavorable prognosis in patients with epithelial ovarian cancer

Meningioma-associated protein (MAC30), first described to be overexpressed in meningiomas, exhibits altered expression in certain human tumors. The definite role of MAC30 is not clear now, and few studies have documented the value of MAC30 in epithelial ovarian cancer (EOC). The aim of this study was to investigate the expression of MAC30 in EOC and to evaluate its clinical significance in patients with EOC. A total of 266 patients with EOC who undergone complete cytoreductive surgery from November 2003 to September 2006 were eligible for this study. The expression of MAC30 in epithelial ovarian tumor tissues was examined immunohistochemically. High expression of MAC30 was observed in 66.17 % of EOC. The high MAC30 expression group had more advanced stages, poorer histological grade, lymph node metastasis, and recurrence than those with low MAC30 expression. Moreover, the presence of lymph node metastasis was significantly associated with MAC30 expression (OR 2.888, 95 % CI 1.428-5.838, P = 0.003). In addition, it was also shown that high MAC30 expression significantly correlated with poorer overall survival and progression-free survival (both P < 0.001). Multivariate Cox regression analysis revealed that MAC30 expression status was an independent prognostic factor for both overall survival and progression-free survival (P = 0.001 and P = 0.002, respectively) of patients with EOC. Our study provides evidence that patients with expression of MAC30 in EOC have high malignant potential, and MAC30 may serve as a new molecular marker to predict the lymph node metastasis and prognosis of patients with EOC in the clinic.

Systematic lymphadenectomy in ovarian cancer at second-look surgery: a randomised clinical trial

Background:

The role of systematic aortic and pelvic lymphadenectomy (SAPL) at second-look surgery in early stage or optimally debulked advanced ovarian cancer is unclear and never addressed by randomised studies.

Methods:

From January 1991 through May 2001, 308 patients with the International Federation of Gynaecology and Obstetrics stage IA–IV epithelial ovarian carcinoma were randomly assigned to undergo SAPL (n=158) or resection of bulky nodes only (n=150). Primary end point was overall survival (OS).

Results:

The median operating time, blood loss, percentage of patients requiring blood transfusions and hospital stay were higher in the SAPL than in the control arm (P<0.001). The median number of resected nodes and the percentage of women with nodal metastases were higher in the SAPL arm as well (44% vs 8%, P<0.001 and 24.2% vs 13.3%, P:0.02). After a median follow-up of 111 months, 171 events (i.e., recurrences or deaths) were observed, and 124 patients had died. Sites of first recurrences were similar in both arms. The adjusted risk for progression and death were not statistically different (hazard ratio (HR) for progression=1.18, 95% confidence interval (CI)=0.87–1.59; P=0.29; 5-year progression-free survival (PFS)=40.9% and 53.8% HR for death=1.04, 95% CI=0.733–1.49; P=0.81; 5-year OS=63.5% and 67.4%, in the SAPL and in the control arm, respectively).

Conclusion:

SAPL in second-look surgery for advanced ovarian cancer did not improve PFS and OS.

Systematic para-aortic and pelvic lymphadenectomy in early stage epithelial ovarian cancer: a prospective study

BACKGROUND

Lymphadenectomy is important in the surgical treatment of apparent early epithelial ovarian cancers (eEOC); however, its extent is not well defined. We evaluated the role of systematic lymphadenectomy, the risk factors related with lymph node metastases, the implications, and the morbidity of comprehensive surgical staging.

METHODS

We prospectively recruited 124 patients diagnosed with apparent eEOC [International Federation of Gynecology and Obstetrics (FIGO) stage I and II] between January 2003 and January 2011. Demographics, surgical procedures, morbidities, pathologic findings, and correlations with lymph node metastases were assessed.

RESULTS

A total of 111 patients underwent complete surgical staging, including lymphadenectomy, and were therefore analyzed. A median of 23 pelvic and 20 para-aortic nodes were removed. Node metastases were found in 15 patients (13.5 %). The para-aortic region was involved in 13 (86.6 %) of 15 cases. At univariate analysis, age, menopause, FIGO stage, grading, and laterality were found to be significant factors for lymph node metastases, while CA125 of >35 U/ml and positive cytology were not. No lymph node metastases were found in mucinous histotypes. At multivariate analysis, only bilaterality (p = 0.018) and menopause (p = 0.032) maintained a statistically significant association with lymph node metastases. Lymphadenectomy-related complications (lymphocyst formation and lymphorrhea) were found in 14.4 % patients.

CONCLUSIONS

The data of this prospective study demonstrate the prognostic value of lymphadenectomy in eEOC. Menopause, age, bilaterality, histology, and tumor grade are identifiable factors that can help the surgeon decide whether to perform comprehensive surgical staging with lymph node dissection. These parameters may be used in planning subsequent treatment.

Should stage IIIC ovarian cancer be further stratified by intraperitoneal vs. retroperitoneal only disease?: a Gynecologic Oncology Group study

OBJECTIVE

To examine whether clinical outcomes varied with intraperitoneal (IP) and/or retroperitoneal (RP) involvement in stage IIIC epithelial ovarian cancer (EOC) patients with microscopic residual disease after cytoreduction.

METHODS

Retrospective review was performed for EOC patients enrolled in Gynecologic Oncology Group (GOG)-182 who underwent primary cytoreduction to microscopic residual disease. Patients were divided into 3 groups: stage IIIC by lymphadenopathy with <2 cm IP spread (RP); >2 cm IP spread and negative nodes (IP/RP-); and >2 cm IP dissemination and positive lymphadenopathy (IP/RP+). Product-limit and multivariate proportional hazards modeling were used.

RESULTS

Analyses included 417 stage IIIC women who underwent primary cytoreduction with lymphadenectomy to microscopic residual. There were 203, 123, and 91 in the RP, IP/RP-, and IP/RP+ groups, respectively. IP/RP+ and IP/RP- were associated with worse progression-free survival (PFS) (Hazard Ratio (HR) 1.68, 95% confidence interval (CI) 1.23-2.30; HR 1.38, 95% CI 1.04-1.84) vs. RP only. IP/RP+ was associated with worse overall survival (OS) (HR 1.79, 95% CI 1.24-2.57) while IP/RP- trended towards worse OS (HR 1.21, 95% CI 0.85-1.73) vs. RP only. Median PFS for IP/RP+ and IP/RP- groups was 21 and 29 months, respectively, vs. 48 months in the RP group (p=0.0007) and median OS of 63 and 79 months vs. "not reached," respectively (p=0.0038).

CONCLUSIONS

Among EOC patients surgically cytoreduced to microscopic residual disease, those upstaged to IIIC by retroperitoneal involvement demonstrated significant improvement in PFS and OS compared to patients with intraperitoneal tumor, suggesting that these women may represent a unique subset of FIGO stage IIIC patients.

Celiac lymph node resection and porta hepatis disease resection in advanced or recurrent epithelial ovarian, fallopian tube, and primary peritoneal cancer

INTRODUCTION

Prognostic value of complete macroscopic resection of primary disease has been reported and confirmed in several publications. Published data indicate that extensive upper abdominal disease involving the hepatic pedicle and celiac trunk is associated with an abortion of the surgical procedure or with suboptimal residual disease.

METHODS

All patients who had disease at the porta hepatis or celiac lymph node resection as part of cytoreductive surgery were included. Medical and operative records with particular emphasis on extent and distribution of disease spread, number of peritonectomy procedures, visceral resections, and lymphadenectomy procedures were examined.

RESULTS

A total of 28 patients who underwent some kind of celiac lymph node resection or resection of metastatic involvement of the porta hepatis were included. Median preoperative serum Ca-125 level was 78U/ml (range, 30-2950U/ml), and median ascites volume was 1900ml (range, 0-10,000ml). Of the 28 patients, 23 underwent supra-radical surgery for diffuse peritoneal carcinomatosis. Median operative time was 252minutes (range, 100-540minutes). Complete cytoreduction to CCO was achieved in all except one case, who was cytoreduced to millimetric residue. Fifteen patients had positive celiac nodes and nineteen patients had peritoneal disease in the porta hepatis region.

DISCUSSION

Resection of enlarged nodes and metastatic disease to the porta hepatis is feasible with an acceptable morbidity. The decision to undergo an aggressive cytoreductive surgery is based on appropriate patient selection depending on the extension of surgical procedure, on medical comorbidities, and on the potential to tolerate an extensive procedure, rather than on specific anatomic locations.

Frequency and Distribution of Lymph Node Metastases in Epithelial Ovarian Cancer: Significance of Serous Histology

Background:

The aim of this retrospective study was to evaluate the incidence and distribution of nodal metastases in relation to the serous versus nonserous histological subtypes of epithelial ovarian cancer.

Methods:

Patients were treated primarily with upfront surgery, including pelvic and para-aortic systematic lymphadenectomy, up to the level of the left renal vein, before any kind of chemotherapy administration. Patients were classified according the tumor histology into 2 groups: serous (including the cases of mixed histology with a serous component) and nonserous group.

Results:

A total of 173 patients fulfilled the inclusion criteria; 76 and 97 patients had serous and nonserous ovarian carcinoma, respectively. Positive lymph nodes were found in 59.3% (45/76) and 14.4% (14/97) of patients in the serous and nonserous histology groups, respectively. There was no difference in positive node distribution in 3 regions (pelvic and para-aortic regions, below and above the inferior mesenteric artery) between these 2 groups. Early spread including 1 or 2 positive lymph nodes was predominantly found in the para-aortic region in both groups, serous and nonserous, whereas distribution of positive nodes in patients with 3 or more lymph nodes shows equal presence in pelvic and para-aortic regions.

Conclusions:

Serous ovarian carcinomas are much more prone to metastasize to lymph nodes than nonserous histological types. However, the pattern of lymph node distribution did not differ between these 2 groups and was similar in the pelvic and para-aortic regions.

Lymph node metastasis in grossly apparent clinical stage Ia epithelial ovarian cancer: Hacettepe experience and review of literature

Background

Lymphadenectomy is an integral part of the staging system of epithelial ovarian cancer. However, the extent of lymphadenectomy in the early stages of ovarian cancer is controversial. The objective of this study was to identify the lymph node involvement in unilateral epithelial ovarian cancer apparently confined to the one ovary (clinical stage Ia).

Methods

A prospective study of clinical stage I ovarian cancer patients is presented. Patient's characteristics and tumor histopathology were the variables evaluated.

Results

Thirty three ovarian cancer patients with intact ovarian capsule were evaluated. Intraoperatively, neither of the patients had surface involvement, adhesions, ascites or palpable lymph nodes (supposed to be clinical stage Ia). The mean age of the study group was 55.3 ± 11.8. All patients were surgically staged and have undergone a systematic pelvic and paraaortic lymphadenectomy. Final surgicopathologic reports revealed capsular involvement in seven patients (21.2%), contralateral ovarian involvement in two (6%) and omental metastasis in one (3%) patient. There were two patients (6%) with lymph node involvement. One of the two lymph node metastasis was solely in paraaortic node and the other metastasis was in ipsilateral pelvic lymph node. Ovarian capsule was intact in all of the patients with lymph node involvement and the tumor was grade 3.

Conclusion

In clinical stage Ia ovarian cancer patients, there may be a risk of paraaortic and pelvic lymph node metastasis. Further studies with larger sample size are needed for an exact conclusion.

Pattern of retroperitoneal dissemination of primary peritoneum cancer: basis for rational use of lymphadenectomy

INTRODUCTION

The rationale for lymphadenectomy in primary peritoneal cancer (PPC) is unclear. We sought to define the pattern of lymphatic metastasis in PPC and propose evidence-based rationale for lymphadenectomy in relevant cases.

METHODS

Patients with PPC undergoing primary surgery at Mayo Clinic were identified. Demographics, tumor characteristics, procedures performed and follow up were analyzed.

RESULTS

Forty eight patients with PPC were identified; 39 had stage IIIC (81.2%) and 9 (18.8%) had stage IV. Residual disease (RD) after primary surgery was microscopic in 6 cases (12.5%), less than 1 cm in 33 (68.8%), more than 1 cm in 9 patient (18.7%) with median survivals of 5.8, 3.2 and 1.3 years, respectively. Overall, 24 patients had lymphadenectomy performed (pelvic (PND) or paraortic (PAND) or both). Pelvic nodes were involved in 12/23 (52.7%) cases, while para-aortic nodes were involved in 5/21 (23.8%) of cases. The rate of simultaneously positive pelvic and para-aortic nodes was 20% (4/20). Nodal involvement was a poor prognostic factor with 5 year overall survival 63% vs. 25% (p=0.014) in node positive vs. negative cases. Compared to patients with primary ovarian cancer (OC), OC cases had a higher rate of positive para-aortic nodes (57.6%: 77/132; p=0.004).

CONCLUSIONS

Retroperitoneal lymph nodes are a common site of metastases in PPC, therefore it is logically consistent to perform PND and PAND if a patient can be cytoreduced to microscopic RD in other sites or remove grossly positive nodes in patients with RD<1 cm.

Stage IIIC epithelial ovarian cancer classified solely by lymph node metastasis has a more favorable prognosis than other types of stage IIIC epithelial ovarian cancer

OBJECTIVE

To verify whether it can be justified to classify patients to stage IIIC epithelial ovarian cancer based on nodal involvement only.

METHODS

This study included all consecutive patients with stage IIIC epithelial ovarian cancer who underwent upfront cytoreductive surgery according to the FIGO guideline followed by platinum based chemotherapy from September 1989 to September 2006 at Asan Medical Center.

RESULTS

During the study period, a total of 272 patients met the inclusion criteria. Optimal cytoreduction was achieved in 213 patients, and complete cytoreduction was achieved in 85 patients. Median follow-up time was 37 months (range, 6-181 months). The 5-year disease free survival (DFS) and overall survival (OS) rate of all patients were 23% and 57%, respectively. Forty-one patients were allocated to stage IIIC by positive nodes only. Patients with stage IIIC disease due to positive nodes only had significantly longer DFS and OS compared to other stage IIIC patients (p<0.001 and p<0.001). The DFS and OS of these patients was significantly better than those of other stage IIIC patients who achieved complete or optimal cytoreduction (p<0.001 and p<0.001). The outcome was even better than that of stage IIIA and IIIB patients (p<0.05 and p<0.05).

CONCLUSION

Patients with stage IIIC epithelial ovarian cancer due to positive nodes only had a more favorable prognosis compared to other stage IIIC patients. Therefore, reevaluation of the current FIGO staging system for stage IIIC epithelial ovarian cancer is required.

[Not Available]

D. Salet-Lizée, S. Alsary Ovarian cancer often invades regional lymph nodes but the patterns of involvement are variable; spread to para-aortic and pelvic lymph nodes can be unilateral, contralateral or bilateral. For staging purposes, complete lymph node dissection seems more reasonable and effective than simple lymph node sampling. In early stage disease, lymph node dissection has both diagnostic and therapeutic value allowing identification and optimal management of Stage IIIc tumors with retroperitoneal spread; it may also have direct therapeutic value by removing retroperitoneal micrometastatic disease including cell clones which may be resistant to chemotherapy. Therefore, complete lymph node dissection is recommended in early-stage disease with the exception of stage I mucinous ovarian cancer. In advanced-stage disease, lymph node involvement is an additional factor of poor prognosis correlating with increased tumor aggressivity. Optimal debulking resection of all visible tumor offers the best chance for a prolonged disease-free interval if patient condition permits and morbidity can be limited. Survival benefit for complete lymph node dissection has not been evaluated by randomized controlled trials; but several non-randomized studies and two long-term prospective trials have shown objective improvement in disease-free survival and improved quality of life when debulking surgery leaves no residual tumor larger than 1 cm.

[Not Available]

D. Salet-Lizée, S. Alsary Ovarian cancer often invades regional lymph nodes but the patterns of involvement are variable; spread to para-aortic and pelvic lymph nodes can be unilateral, contralateral or bilateral. For staging purposes, complete lymph node dissection seems more reasonable and effective than simple lymph node sampling. In early stage disease, lymph node dissection has both diagnostic and therapeutic value allowing identification and optimal management of Stage IIIc tumors with retroperitoneal spread; it may also have direct therapeutic value by removing retroperitoneal micrometastatic disease including cell clones which may be resistant to chemotherapy. Therefore, complete lymph node dissection is recommended in early-stage disease with the exception of stage I mucinous ovarian cancer. In advanced-stage disease, lymph node involvement is an additional factor of poor prognosis correlating with increased tumor aggressivity. Optimal debulking resection of all visible tumor offers the best chance for a prolonged disease-free interval if patient condition permits and morbidity can be limited. Survival benefit for complete lymph node dissection has not been evaluated by randomized controlled trials; but several non-randomized studies and two long-term prospective trials have shown objective improvement in disease-free survival and improved quality of life when debulking surgery leaves no residual tumor larger than 1 cm.

Outcomes of fertility-sparing surgery for invasive epithelial ovarian cancer: oncologic safety and reproductive outcomes

OBJECTIVE

Younger patients with invasive epithelial ovarian cancer (EOC) frequently want to preserve their fertility, but the role of fertility-sparing surgery in EOC has not been well defined. We therefore assessed tumor recurrence, patient survival and pregnancy outcomes in patients with invasive EOC who underwent fertility-sparing surgery.

METHODS

Records of 62 patients with invasive EOC who underwent fertility-sparing surgery, defined as the preservation of ovarian tissue in one or both adnexa and the uterus, between May 1990 and October 2006, were retrospectively reviewed.

RESULTS

Of the 62 EOCs, 36 were stage IA, 2 were stage IB, 21 were stage IC, and 1 each was stage IIB, IIIA, and IIIC; 48 were grade I, 5 were grade II, and 9 were grade III. Forty-eight patients received platinum-based adjuvant chemotherapy (mean 4.6 cycles, range 1-9 cycles). At a median follow-up of 56 months (range, 6-205 months), 11 patients had tumor recurrence, 6 died of disease, 2 were alive with disease, and 54 were alive without disease. Patients with stage >IC (p=0.0014) or grade III (p=0.0002) tumors had significantly poorer survival. Nineteen women attempted to conceive, and there were 22 term pregnancies, with no congenital anomalies in any of the offspring.

CONCLUSION

Fertility-sparing surgery can be considered in young patients with stages IA-C and grades I-II EOCs who desire to preserve their fertility.

The prevalence and prognostic impact of lymph node metastasis in malignant germ cell tumors of the ovary

BACKGROUND

The purpose of this study is to report the prevalence and prognostic importance of lymph node metastasis in malignant germ cell tumors of the ovary (OGCT).

METHODS

Demographic and clinicopathologic information were abstracted from the Surveillance, Epidemiology, and End Results Program (SEER) from 1988 to 2004. Patients with a histologic diagnosis of OGCT after surgical resection were included. The study population was divided into Cohort A (lymph node metastasis absent) and Cohort B (lymph node metastasis present). Statistical analysis using Fisher's Exact Test, Kaplan-Meier survival methods, and Cox regression proportional hazards were performed.

RESULTS

In 613 patients with lymphadenectomy, the prevalence of lymphnode metastasis was 18.1% (111/613). In dysgerminoma, malignant teratoma and mixed germ cell tumors including pure non-dysgerminoma histology, the lymphnode metastasis was present in 28%, 8% and 16% patients respectively (p<0.05). Age, race, grade and extent of lymph node dissection influenced lymph node involvement but this was statistically not significant. Five year survival in Cohort A was 95.7% compared to 82.8% in Cohort B (p<0.001). After controlling for age, race, stage, grade and histology, multivariate analysis revealed the presence of lymph node involvement as an independent predictor of poor survival with a hazards ratio of 2.87 (95% CI 1.439-5.725; p<0.05).

CONCLUSIONS

Prevalence of lymph node metastasis varies according to histology in OGCT and is an independent predictor of poor survival in these patients. These findings highlight the value of lymphadenectomy and may be helpful in creating risk stratification models for individualization of adjuvant therapies.

Skin metastases revealing a bilateral ovarian invasive micropapillary serous carcinoma

Skin involvement is a late complication that rarely occurs in ovarian cancer patients. This event invariably carries a bad prognosis in the course of an advanced stage ovarian carcinoma which is usually of the conventional serous type. Micropapillary serous carcinoma (MPSC) was recently recognized as a distinct neoplasm that seems to be less aggressive than conventional serous ovarian carcinoma. Indeed, a few cases of stage IV MPSC have been reported. Herein, we describe an unusual case of ovarian invasive MPSC occurring in a young woman, particularly by its mode of presentation as multiple subcutaneous nodules that were subsequently diagnosed as metastatic lesions. This case demonstrates the potential of MPSC for aggressive clinical behaviour.

Should pelvic and para-aortic lymphadenectomy be different depending on histological subtype in epithelial ovarian cancer?

BACKGROUND

The aim of this study was to determine the influence of the different histological subtypes (serous versus non-serous) on the location of nodal metastases in patients undergoing pelvic and para-aortic lymphadenectomies during the initial management of epithelial ovarian tumors.

METHODS

We carried out a retrospective analysis of data concerning patients fulfilling the following inclusion criteria: (1) an epithelial ovarian tumor; (2) a complete pelvic and bilateral para-aortic lymphadenectomy up to the level of the left renal vein; (3) surgical procedures including lymphadenectomies performed before adjuvant chemotherapy; and (4) a description of the distribution of positive nodes removed between pelvic and para-aortic areas. Patients were classified into two groups according to the histological subtypes: serous (group 1) and non-serous (group 2) tumors.

RESULTS

Of patients treated between 1989 and 2005, 148 fulfilled the inclusion criteria: 73 had a serous tumor and 75 a non-serous tumor. Positive nodes were observed in 70 (47%) patients-47 (64%) in group 1 and 23 (31%) in group 2 (P < 0.05). But the distribution of involved nodes between pelvic and para-aortic areas in patients with positive nodes was not statistically different between the two groups. In both groups, the most common site for positive nodes in the para-aortic area was the left para-aortic group: 74% in group 1 and 61% in group 2 (NS).

CONCLUSIONS

This series suggests that the histological subtype has no impact on the distribution of positive nodes in pelvic and para-aortic areas in patients with epithelial ovarian tumors.

Pattern and clinical predictors of lymph node metastases in epithelial ovarian cancer

Para-aortic lymphadenectomy is part of staging in early epithelial ovarian cancer (EOC) and could be part of therapy in advanced EOC. However, only a minority of patients receive therapy according to guidelines or have attendance to a specialized unit. We analyzed pattern of lymphatic spread of EOC and evaluated if clinical factors and intraoperative findings reliably could predict lymph node involvement, in order to evaluate if patients could be identified in whom lymphadenectomy could be omitted and who should not be referred to a center with capacity of performing extensive gynecological operations. Retrospective analysis was carried out of all patients with EOC who had systematic pelvic and para-aortic lymphadenectomy during primary cytoreductive surgery. One hundred ninety-five patients underwent systematic pelvic and para-aortic lymphadenectomy. Histologic lymph node metastases were found in 53%. The highest frequency was found in the upper left para-aortic region (32% of all patients) and between vena cava inferior and abdominal aorta (36%). Neither intraoperative clinical diagnosis nor frozen section of pelvic nodes could reliably predict para-aortic lymph node metastasis. The pathologic diagnosis of the pelvic nodes, if used as diagnostic tool for para-aortic lymph nodes, showed a sensitivity of only 50% in ovarian cancer confined to the pelvis and 73% in more advanced disease. We could not detect any intraoperative tool that could reliably predict pathologic status of para-aortic lymph nodes. Systematic pelvic and para-aortic lymphadenectomy remains part of staging in EOC. Patients with EOC should be offered the opportunity to receive state-of-the-art treatment including surgery

Radiological staging of ovarian cancer: imaging findings and contribution of CT and MRI

Ovarian cancer is the most lethal among the gynecologic malignancies with approximately 70% of patients presenting with advanced tumor stage. The prognosis of patients with ovarian cancer is directly related to the tumor stage and residual tumor burden after cytoreductive surgery. Exploratory laparotomy has been the cornerstone in the management of ovarian cancer, as it offers staging and tumor debulking. Understaging at initial laparotomy, however, is a problem in up to 30%, mainly due to insufficient technique and unexpected peritoneal spread outside the pelvis. Sites difficult to assess intraoperatively including the posterior aspect of the liver and the dome of the diaphragm can be well demonstrated with multiplanar imaging. CT and alternatively MRI have been accepted as adjunct imaging modalities for preoperative staging ovarian cancer. Of these, multidetector CT is the imaging modality of choice for staging ovarian cancer. In a multidisciplinary team approach patient management may be guided towards an individualized treatment plan. The contribution of imaging includes (1) surgery planning including referral practice, (2) selection of candidates for primary chemotherapy by demonstration of non (optimally) resectable disease, and (3) tissue sampling in peritoneal carcinomatosis.

Management of retroperitoneal lymph nodes in the treatment of ovarian cancer

The mechanisms and clinical significance of lymph node involvement in ovarian cancer have been revealed since the International Federation of Gynaecology and Obstetrics (FIGO) introduced a new clinical staging including retroperitoneal lymph node status. The multiple directions of the lymph drainage pathway in ovarian cancer have been recognized. The incidence and pattern of lymph node involvement depends on the extent of disease progression and the histological type. Thus, it is difficult to specify a single node as the sentinel node. As a surgical approach, systemic lymphadenectomy is necessary to obtain accurate clinical stage, and it has obvious diagnostic value. Nevertheless, a recent large randomized trial in patients with advanced ovarian cancer revealed that systemic lymphadenectomy had no impact on survival compared with removing only macroscopic lymph nodes. Other factors, such as chemosensitivity, histological grade, and the size of residuals have also influenced survival in ovarian cancer. From the viewpoint of adverse effects and survival benefit, the efficacy of lymphadenectomy remains controversial. Therefore, further accumulation of clinical data is needed to establish the indications for lymph node dissection; when this procedure is done, it should be performed by experienced gynecologic oncologists at selected institutions.

Ovarian Carcinoma Presenting With Isolated Contralateral Inguinal Lymph Node Metastasis: A Case Report

Introduction: Ovarian carcinoma usually presents at an advanced stage with diffuse intraabdominal manifestations. We report a patient who presented with a right groin swelling. Clinical Picture: The only clinical abnormality was an enlarged right inguinal lymph node (3 x 2 cm), for which excision biopsy revealed metastatic adenocarcinoma. A computed tomography (CT) scan showed an enlarged left ovarian lesion (9.0 x 6.4 cm). Treatment and Outcome: Laparotomy with total hysterectomy, bilateral salpingo-oophrectomy and partial omentectomy were performed. Histology confirmed left ovarian adenocarcinoma, consistent with the earlier histology of the right inguinal lymph node. There were no other sites of involvement. Postoperatively, the patient received adjuvant chemotherapy for treatment of FIGO Stage IIIc ovarian carcinoma and is clinically disease free 13 months after surgery. Conclusions: Ovarian cancer presenting with inguinal lymph node metastases is uncommon. Ovarian cancer which manifests solely as a contralateral inguinal lymph node metastasis has not been previously reported. This case illustrates a rare presentation of ovarian carcinoma, and underscores the need to consider ovarian carcinoma in the differential diagnosis of women with inguinal lymphadenopathy. Key words: Inguinal lymph node metastasis, Ovarian adenocarcinoma