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AlMahdy AM, Elassall GM, Abdelbadee AY, Abd-Elkariem AY, Atef F, Ahmed IA, Sayed EG, Salah MA, Ali AK, Ragab EY, Abd Elazeem HAS, Saad MM, Shazly SA. Prognostic value of systematic lymphadenectomy in patients with ovarian cancer: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2021; 267:179-185. [PMID: 34814044 DOI: 10.1016/j.ejogrb.2021.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/17/2020] [Accepted: 02/09/2021] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To appraise clinical outcomes of systematic lymphadenectomy in women with ovarian cancer based on stage, control group and type of chemotherapy. STUDY DESIGN A literature search was conducted on SCOPUS, PUBMED, COCHRANE, MEDLINE, and WEB OF SCIENCE databases. All comparative studies that assess outcomes of systematic lymphadenectomy in patients with ovarian cancer were eligible. Overall survival was analyzed by pooling log hazard ratio (HR) and standard error of multivariable Cox regression models. MOGGE Meta-analysis Matrix is a novel illustration tool that was used to demonstrate multiple subgroup analyses of included studies. RESULTS Twenty-two studies were eligible. Systematic lymphadenectomy was associated with better overall survival, that was close to significance, compared to control group (HR 0.93, 95 %CI 0.86-1.00). Among women treated with adjuvant chemotherapy, overall survival improved in women with stage IIB-IV who underwent systematic lymphadenectomy (HR 0.91, 95 %CI 0.84-0.99) and was most significant among patients with stage III to IV (HR 0.85, 95 %CI 0.73-0.99). Systematic lymphadenectomy did not improve survival in women who received neoadjuvant chemotherapy (HR 0.97, 95 %CI 0.73-1.29). Systematic lymphadenectomy was associated with improved progress-free survival compared to control group (HR 0.88, 95 %CI 0.79-0.99). CONCLUSION Although data from clinical trials do not support role of systematic lymphadenectomy in advanced ovarian cancer, overall data conveys stage-specific survival benefit. Further clinical trials may be warranted to assess substage survival outcomes in women with advanced stages.
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Affiliation(s)
- AlBatool M AlMahdy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Gena M Elassall
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed Y Abdelbadee
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed Y Abd-Elkariem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Fatma Atef
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Islam A Ahmed
- Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Esraa G Sayed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mohamed Ashraf Salah
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed K Ali
- Department of Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Esraa Y Ragab
- Department of Anaesthesia, Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Mahmoud M Saad
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Sherif A Shazly
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt.
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2
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Armstrong DK, Alvarez RD, Bakkum-Gamez JN, Barroilhet L, Behbakht K, Berchuck A, Chen LM, Cristea M, DeRosa M, Eisenhauer EL, Gershenson DM, Gray HJ, Grisham R, Hakam A, Jain A, Karam A, Konecny GE, Leath CA, Liu J, Mahdi H, Martin L, Matei D, McHale M, McLean K, Miller DS, O'Malley DM, Percac-Lima S, Ratner E, Remmenga SW, Vargas R, Werner TL, Zsiros E, Burns JL, Engh AM. Ovarian Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19:191-226. [PMID: 33545690 DOI: 10.6004/jnccn.2021.0007] [Citation(s) in RCA: 331] [Impact Index Per Article: 110.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States and is the country's fifth most common cause of cancer mortality in women. A major challenge in treating ovarian cancer is that most patients have advanced disease at initial diagnosis. These NCCN Guidelines discuss cancers originating in the ovary, fallopian tube, or peritoneum, as these are all managed in a similar manner. Most of the recommendations are based on data from patients with the most common subtypes─high-grade serous and grade 2/3 endometrioid. The NCCN Guidelines also include recommendations specifically for patients with less common ovarian cancers, which in the guidelines include the following: carcinosarcoma, clear cell carcinoma, mucinous carcinoma, low-grade serous, grade 1 endometrioid, borderline epithelial, malignant sex cord-stromal, and malignant germ cell tumors. This manuscript focuses on certain aspects of primary treatment, including primary surgery, adjuvant therapy, and maintenance therapy options (including PARP inhibitors) after completion of first-line chemotherapy.
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Affiliation(s)
| | | | | | | | | | | | - Lee-May Chen
- 7UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | - Heidi J Gray
- 12Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | | | | | | | | | - Joyce Liu
- 19Dana-Farber/Brigham and Women's Cancer Center
| | - Haider Mahdi
- 20Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Lainie Martin
- 21Abramson Cancer Center at the University of Pennsylvania
| | - Daniela Matei
- 22Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - David M O'Malley
- 26The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | - Roberto Vargas
- 20Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
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3
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Widschwendter P, Blersch A, Friedl TWP, Janni W, Kloth C, de Gregorio A, de Gregorio N. CT Scan in the Prediction of Lymph Node Involvement in Ovarian Cancer - a Retrospective Analysis of a Tertiary Gyneco-Oncological Unit. Geburtshilfe Frauenheilkd 2020; 80:518-525. [PMID: 32435068 PMCID: PMC7234823 DOI: 10.1055/a-1079-5158] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/06/2019] [Accepted: 12/07/2019] [Indexed: 12/28/2022] Open
Abstract
Background
The prognostic value of lymph node removal in ovarian cancer varies depending on the tumor stage. While in the advanced stage the removal of clinically normal lymph nodes does not improve the prognosis, this is still unclear in the early stages. Evaluation of the lymph nodes based on preoperative imaging influences the surgical procedure.
Methods
This retrospective analysis was performed by analyzing data from 114 patients with ovarian cancer, treated in our university hospital in the years 2000 – 2012. Diagnostic performance of imaging by computer tomography with respect to the correct prediction of lymph node status was analyzed in terms of sensitivity, specificity, positive predictive value and negative predictive value.
Results
Imaging by computer tomography showed a rather limited diagnostic performance with regard to the detection of lymph node metastases in ovarian cancer, with a sensitivity of 40.7%, a specificity of 89.1%, a positive predictive value of 80.0%, and a negative predictive value of 58.3%. A separate analysis for pelvic and paraaortic lymph node involvement showed a better diagnostic performance of computer tomography for the detection of positive paraaortic lymph nodes (41.2, 93.1, 84.0, and 64.3% for sensitivity, specificity, positive predictive value and negative predictive value, respectively) as compared to the detection of positive pelvic lymph nodes (25.6, 91.8, 62.5, and 69.8%).
Conclusion
The preoperative prediction of lymph node status by computer tomography is limited. A decision for or against lymphadenectomy should not be made solely on the basis of this approach.
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Affiliation(s)
| | - Alexandra Blersch
- Department of Gynecology and Obstetrics, University of Ulm, Ulm, Germany
| | - Thomas W P Friedl
- Department of Gynecology and Obstetrics, University of Ulm, Ulm, Germany
| | - Wolfgang Janni
- Department of Gynecology and Obstetrics, University of Ulm, Ulm, Germany
| | - Christopher Kloth
- Department of Diagnostic and Interventional Radiology, University Hospital Ulm, Ulm, Germany
| | - Amelie de Gregorio
- Department of Gynecology and Obstetrics, University of Ulm, Ulm, Germany
| | - Niko de Gregorio
- Department of Gynecology and Obstetrics, University of Ulm, Ulm, Germany
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4
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Ferron G, Narducci F, Pouget N, Touboul C. [Surgery for advanced stage ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]. ACTA ACUST UNITED AC 2019; 47:197-213. [PMID: 30792175 DOI: 10.1016/j.gofs.2019.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Indexed: 01/10/2023]
Abstract
Debulking surgery is the key step of advanced stage ovarian cancer treatment with chemotherapy. The quality of surgical resection is the main prognosis factor, thus a complete resection must be achieved (grade A) in an expert center (grade B). Surgery for stage IV is possible and has a benefit in case of complete peritoneal resection (LoE3). Pelvic and aortic lymphadenectomies are recommended in case of clinical or radiological suspicious lymph nodes (grade B). In absence of clinical or radiological suspicious lymph nodes and in case of complete peritoneal resection during initial debulking surgery, lymphadenectomy can be omitted because it won't change nor medical treatment nor overall survival (grade B). Neoadjuvant chemotherapy can be proposed in case of: impossibility to perform initial complete surgical resection (grade B) ; alteration of general state or co-morbidities or elderly patient (in order to decrease morbidity and increase quality of life) (grade B); stage IV with multiple intra-hepatic or pulmonary metastasis or important ascites with miliary (grade B). In case of stage III or IV ovarian cancer diagnosed on a biopsy during prior laparotomy, a neoadjuvant chemotherapy and interval debulking surgery should be preferred (gradeC). In case of palliative surgery or peroperative impossibility to perform a complete resection, no data regarding the type of surgery to perform influencing survival or quality of life is available. Peritoneal carcinosis description before resection and residual disease at the end of the surgery should be reported (size, location and reason of non-extirpability) (grade B). A score of peritoneal carcinosis such as Peritoneal Carcinosis Index (PCI) should be used in order to objectively evaluate the tumoral burden (gradeC). A standardized operative report is recommended (gradeC).
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Affiliation(s)
- G Ferron
- Inserm CRCT 19, département de chirurgie oncologique, institut Claudius Regaud, institut universitaire du cancer, 31000 Toulouse, France
| | - F Narducci
- Inserm U1192, département de chirurgie oncologique, centre Oscar Lambret, 59000 Lille, France
| | - N Pouget
- Département de chirurgie oncologique, chirurgie gynécologique et mammaire, institut Curie, site Saint-Cloud, 75005 Paris, France
| | - C Touboul
- IMRB, U955 Inserm, service de gynécologie obstétrique et médecine de la reproduction, centre hospitalier intercommunal de Créteil, institut Mondor de recherche biomédicale, 94000 Créteil, France.
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5
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Association of lymphadenectomy and survival in epithelial ovarian cancer. Curr Probl Cancer 2018; 43:151-159. [PMID: 30149960 DOI: 10.1016/j.currproblcancer.2018.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/01/2018] [Indexed: 11/23/2022]
Abstract
PURPOSE Lymph node metastasis has a significant contribution to the prognosis of epithelial ovarian cancer but the role of lymph node dissection in treatment is not clear. In this study, we aimed to retrospectively determine the effect of the number and localization of lymph nodes removed and the number of metastatic lymph nodes on survival. METHODS In this study, we retrospectively reviewed the data of 378 patients (210 patients with lymph node dissection and 168 patients with no dissection) who underwent primary surgery between 2004 and 2014 in various centers with epithelial ovarian cancer diagnosis and followed up in our medical oncology clinic. Demographic and histopathologic features, stage, Ca 125 levels, chemotherapy responses of these patients were examined and survival analyzes were performed. RESULTS The median age of the patients was 52 years (range 16-89) and median follow-up duration was 39 months (range 1-146). During the analysis, 156 patients (41%) died and 222 patients (59%) were alive. Patients who underwent lymphadenectomy had significantly improved progression free survival (PFS) (18 vs 31 months, P < 0.05) and overall survival (OS) (57 vs 92 months, P < 0.05). OS was longer in patients with >10 lymph nodes removed compared to patients with 1-10 lymph nodes removed (P = 0.005). Survival was found to be longer in patients with pelvic and paraaortic lymph node dissection compared to patients with only pelvic lymph node dissection (P < 0.05). Patients in stage I-II had no difference in PFS and OS. Patients in stage III-IV had no difference in PFS but there was a significant difference in OS (P = 0.02). CONCLUSION It may be a therapeutic effect of lymphadenectomy in advanced stage ovarian cancer. The number of lymph nodes removed and the removal of the paraaortic lymph nodes may also contribute to the treatment.
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6
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Lupi G, Fontanelli R, Jin R, Grosso G. Second Surgical Treatment of Retroperitoneal Persistent Disease in Epithelial Ovarian Cancer. TUMORI JOURNAL 2018; 82:81-4. [PMID: 8623513 DOI: 10.1177/030089169608200118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background This report retrospectively analyzes 9 cases of epithelial ovarian cancer with persistent retroperitoneal metastasis after intraperitoneal surgery (without systematic lymphadenectomy) and chemotherapy. Methods All 9 patients were diagnosed as FIGO stage I to IV at the time of primary surgery. They received combined postoperative chemotherapy (8 cases with a cisplatin-based regimen and 1 with adriamycin and endoxan). They were submitted to pelvic and paraaortic lymphadenectomy at the National Cancer Institute of Milan during the period 1990-1994. Results All patients presented no evidence of disease in the abdominal cavity but retroperitoneal metastasis, which was the unique metastatic site. Chemotherapy was administered as adjuvant therapy after lymphadenectomy. Six patients were free of disease for 14 to 61 months. One patient with vaginal recurrence at the 18th month was treated with radiotherapy and chemotherapy, but died of widespread disease 25 months after lymphadenectomy. Two patients with massive positive lymph nodes died of brain and lung metastasis 20 and 6 months later, respectively. Conclusions We conclude that retroperitoneal metastasis may be the only site of persistent disease and that systematic lymphadenectomy technically feasible in this situation to increase the opportunity for local disease control and to obtain a good result.
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Affiliation(s)
- G Lupi
- Surgical Gynecologic Oncology, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
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7
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Khalid N, Dessai SB, Anilkumar B, Dharmarajan A, Yadav P, Arvind S, Satheeshan B. Clinical Significance of Nodal Positivity Following Neoadjuvant Chemotherapy in Epithelial Ovarian Cancer. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2017. [DOI: 10.1007/s40944-017-0158-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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8
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Pu T, Xiong L, Liu Q, Zhang M, Cai Q, Liu H, Sood AK, Li G, Kang Y, Xu C. Delineation of retroperitoneal metastatic lymph nodes in ovarian cancer with near-infrared fluorescence imaging. Oncol Lett 2017; 14:2869-2877. [PMID: 28928826 PMCID: PMC5588176 DOI: 10.3892/ol.2017.6521] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 03/14/2017] [Indexed: 02/01/2023] Open
Abstract
Lymph node metastasis occurs in early-stage and late-stage ovarian cancers. Systematic lymphadenectomy is frequently conducted in an attempt to prevent disease progression. However, this method is associated with multiple complications. Therefore, it is necessary to develop a less invasive and more sensitive method for detecting lymphatic metastasis in ovarian cancer. The aim of the present study was to develop an appropriate fluorescent label for the analysis of lymphatic metastasis in vivo. To this end, epithelial ovarian cancer cells with high potential for lymph node metastasis were labeled using mCherry fluorescence. The cells were then imaged in vitro to determine the expression of mCherry, and in a mouse xenograft model in vivo. The data demonstrated the successful identification of metastatic retroperitoneal lymph nodes by co-localization with lymph nodes labeled by near-infrared fluorescence nanoparticles in vivo. These data provided important insights into the further development of methods for intra-operative identification of lymphatic metastasis and the mechanisms underlying lymphatic metastasis.
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Affiliation(s)
- Tao Pu
- Department of Obstetrics and Gynecology, Shanghai Medical School, Fudan University, Shanghai 200032, P.R. China
| | - Liqin Xiong
- School of Biomedical Engineering, Med-X Research Institute, Shanghai Jiao Tong University, Shanghai 200030, P.R. China
| | - Qiyu Liu
- Department of Obstetrics and Gynecology, Shanghai Medical School, Fudan University, Shanghai 200032, P.R. China
| | - Minxing Zhang
- Department of Obstetrics and Gynecology, Shanghai Medical School, Fudan University, Shanghai 200032, P.R. China
| | - Qingqing Cai
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai 200011, P.R. China
| | - Haiou Liu
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai 200011, P.R. China
| | - Anil K Sood
- Department of Gynecologic Oncology and Reproductive Medicine, Center for RNAi and Non-Coding RNA, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA.,Department of Cancer Biology, Center for RNAi and Non-Coding RNA, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | - Guiling Li
- Department of Obstetrics and Gynecology, Shanghai Medical School, Fudan University, Shanghai 200032, P.R. China.,Department of Integrated Traditional Chinese and Western Medicine, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, P.R. China
| | - Yu Kang
- Department of Obstetrics and Gynecology, Shanghai Medical School, Fudan University, Shanghai 200032, P.R. China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai 200011, P.R. China
| | - Congjian Xu
- Department of Obstetrics and Gynecology, Shanghai Medical School, Fudan University, Shanghai 200032, P.R. China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai 200011, P.R. China.,Department of Integrated Traditional Chinese and Western Medicine, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, P.R. China
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Hacker NF, Rao A. Surgery for advanced epithelial ovarian cancer. Best Pract Res Clin Obstet Gynaecol 2016; 41:71-87. [PMID: 27884789 DOI: 10.1016/j.bpobgyn.2016.10.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 10/12/2016] [Indexed: 10/20/2022]
Abstract
Cytoreductive surgery for patients with advanced epithelial ovarian cancer has been practised since the pioneering work of Tom Griffiths in 1975. Further research has demonstrated the prognostic significance of the extent of metastatic disease pre-operatively, and of complete cytoreduction post-operatively. Patients with advanced epithelial ovarian cancer should be referred to high volume cancer units, and managed by multidisciplinary teams. The role of thoracoscopy and resection of intrathoracic disease is presently investigational. In recent years, there has been increasing use of neoadjuvant chemotherapy and interval cytoreductive surgery in patients with poor performance status, which is usually due to large volume ascites and/or large pleural effusions. Neoadjuvant chemotherapy reduces the post-operative morbidity, but if the tumour responds well to the chemotherapy, the inflammatory response makes the surgery more difficult. Post-operative morbidity is generally tolerable, but increases in older patients, and in those having multiple, aggressive surgical procedures, such as bowel resection or diaphragmatic stripping. Primary cytoreductive surgery should be regarded as the gold standard for most patients until a test is developed which would allow the prediction of platinum resistance pre-operatively.
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Affiliation(s)
- Neville F Hacker
- Gynaecological Cancer Centre, Royal Hospital for Women, Randwick NSW 2031, Australia; School of Women's and Children's Health, University of New South Wales, Kensington NSW 2031, Australia.
| | - Archana Rao
- Gynaecological Cancer Centre, Royal Hospital for Women, Randwick NSW 2031, Australia.
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10
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Zhou J, Shan G, Chen Y. The effect of lymphadenectomy on survival and recurrence in patients with ovarian cancer: a systematic review and meta-analysis. Jpn J Clin Oncol 2016; 46:718-26. [PMID: 27272175 DOI: 10.1093/jjco/hyw068] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 05/06/2016] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Our objective was to perform a meta-analysis examining the effectiveness of lymphadenectomy in patients with ovarian cancer. METHODS PubMed and CENTRAL databases were searched on 15 November 2015 using the terms 'lymphadenectomy', 'ovarian cancer', 'dissection', 'para-aortic', 'pelvic' and survival. Prospective and retrospective studies comparing the outcomes of surgery with or without lymphadenectomy were included. Outcomes were 5-year overall survival, progression-free survival and recurrence rate. RESULTS Of the 556 studies identified, 3 randomized controlled trials and 11 retrospective studies were included. Lymphadenectomy was associated with greater 5-year overall survival than no lymphadenectomy (pooled odds ratio = 1.58, 95% confidence interval: 1.41-1.77, p < 0.001). There was no difference in progression-free survival between the groups (pooled overall survival = 1.62, 95% confidence interval: 0.82-3.21, p = 0.168). Lymphadenectomy was associated with greater progression-free survival in randomized clinical trials (pooled overall survival = 1.57, 95% confidence interval: 1.11-2.21, p = 0.010), but not in retrospective studies. Lymphadenectomy was associated with a significantly lower recurrence rate (pooled overall survival = 0.51, 95% confidence interval: 0.30-0.85, p = 0.011). Lymphadenectomy was associated with greater 5-year overall survival in patients with both early and advanced stage cancer, but was associated with greater progression-free survival and lower recurrence rate only in patients with advanced stage cancer. CONCLUSION Lymphadenectomy is associated with greater 5-year overall survival in patients with early and advanced stage ovarian cancer, but an effect on progression-free survival and recurrence rate was only found in patients with advanced stage ovarian cancer.
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Affiliation(s)
- Jinhong Zhou
- Department of Gynecologic Tumor, Zhejiang Cancer Hospital, Hangzhou, Zhejiang Province, China
| | - Guoping Shan
- Department of Gynecologic Tumor, Zhejiang Cancer Hospital, Hangzhou, Zhejiang Province, China
| | - Yiwen Chen
- Statistics with Applications in Medicine, University of Southampton, Southampton, UK
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11
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Bae J, Choi JS, Lee WM, Koh AR, Jung US, Ko JH, Lee JH. Feasibility and efficacy of laparoscopic restaging surgery for women with unexpected ovarian malignancy. Eur J Obstet Gynecol Reprod Biol 2015; 193:46-50. [PMID: 26232726 DOI: 10.1016/j.ejogrb.2015.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 06/09/2015] [Accepted: 06/30/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate the feasibility, surgical outcomes and complications of laparoscopic restaging surgery for women with unexpected ovarian malignancy. STUDY DESIGN We conducted a retrospective chart review of 14 women with unexpected ovarian malignancy who underwent laparoscopic restaging surgery including peritoneal washing cytology, laparoscopic pelvic and paraaortic lymphadenectomy up to the left renal vein level, omentectomy, and multiple peritoneal biopsies, and hysterectomy except three fertility saving surgery. RESULTS The median age and median body mass index women were 49 years (range, 22-63) and 24.2m/kg(2) (range, 18.9-25.3), respectively. The median operating time was 230min (range, 155-370). The median numbers of harvested pelvic and paraaortic lymph nodes were 26 (range, 6-41) and 18 (range, 2-40), respectively. The median return of bowel activity was 28h (range, 21-79). Four of the women were upstaged from the initial presumed stage. There were two intraoperative complications, laceration of the inferior vena cava and cisterna chyli rupture. There was one postoperative complication, port-site metastasis. There was no conversion to laparotomic surgery. The median follow-up period was 33 months. Thirteen of the patients have no evidence of recurrences, however one patient died after 22 months after the surgery. CONCLUSION Laparoscopic restaging surgery, performed by a specialized laparoscopic oncologist with sufficient laparoscopic experience and a well-trained operating team, is both feasible and effective in the management of unexpected ovarian malignancies.
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Affiliation(s)
- Jaeman Bae
- Division of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Joong Sub Choi
- Division of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Hanyang University College of Medicine, Seoul, Republic of Korea.
| | - Won Moo Lee
- Division of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - A Ra Koh
- Division of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Un Suk Jung
- Division of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Jung Hwa Ko
- Department of Obstetrics and Gynecology, Kangwon National University Hospital, Chuncheon, Republic of Korea
| | - Jung Hun Lee
- Department of Obstetrics and Gynecology, MizMedi Hospital, Eulji University School of Medicine, Seoul, Republic of Korea
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12
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Somashekhar SP. Does debulking of enlarged positive lymph nodes improve survival in different gynaecological cancers? Best Pract Res Clin Obstet Gynaecol 2015; 29:870-83. [PMID: 26043964 DOI: 10.1016/j.bpobgyn.2015.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 04/20/2015] [Accepted: 04/28/2015] [Indexed: 11/26/2022]
Abstract
Lymph-node-positive gynaecological cancers remain a pharmacotherapeutic challenge, and patients with lymph-node-positive gynaecological cancers have poor survival. The purpose of this review is to determine whether a survival advantage arises from surgical debulking of enlarged positive lymph nodes in different types of gynaecological cancers. Information from studies published on the survival benefits from debulking lymph nodes in gynaecological cancers was investigated. Pertaining to therapeutic lymphadenectomy, survival benefit can be analysed in two ways, direct survival benefit following therapeutic lymphadenectomy of bulky positive metastatic lymph nodes and indirect survival benefit, which results after a sequela of systematic lymphadenectomy, proper, accurate staging of disease and stage migration and tailor-made adjuvant treatment. The direct hypothesis of therapeutic lymphadenectomy and survival benefit has been prospected in cervical cancers and vulval cancers and in post-chemotherapy residual paraarotic nodal mass in germ cell ovarian cancer. The indirect survival benefit of therapeutic paraarotic lymphadenectomy in high-risk endometrial cancers and advanced epithelial ovarian cancers needs to be tested in randomized controlled trials. More randomized controlled trials are required to investigate this research question. Further, indirect benefit due to tailor-made adjuvant treatment, secondary to accurate staging achieved as a sequela of systematic lymphadenectomy, needs to be analysed in future trials.
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Affiliation(s)
- S P Somashekhar
- Manipal Comprehensive Cancer Center, Manipal Hospital, Bangalore 560017, India.
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Jeong HJ, Kim HJ, Lee EH, Lee HW, Kim MK. Perimenopausal ovarian carcinoma patient with subclavian node metastasis proven by immunohistochemistry. J Menopausal Med 2014; 20:43-6. [PMID: 25371892 PMCID: PMC4217566 DOI: 10.6118/jmm.2014.20.1.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 10/22/2013] [Accepted: 11/14/2013] [Indexed: 11/05/2022] Open
Abstract
Ovarian cancer is the seventh most common cancer in the world and the fifth most common cause of death from cancer; it is responsible for over half of all deaths related to gynecological cancers. The presence of lymphatic metastasis is an important prognostic factor in ovarian cancer. Nodal metastases to the pelvic and the para-aortic lymph nodes are common, particularly in an advanced of the disease (stages III-IV). The finding of distant nodal metastasis, especially subclavian lymph node metastasis, from ovarian carcinoma is very uncommon. 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) or FDG-PET/computed tomography (CT) provides an improved imaging for detecting metastatic lymph nodes in patients with ovarian cancer. Immunohistochemically, ovarian carcinoma cells are positive for estrogen receptor, progesterone receptor, cancer antigen 125, Wilms' tumor 1 protein, and p53; they are negative for thyroid transcription factor (TTF-1) and caudal-related homeobox 2 (CDX-2). This report describes a Korean woman diagnosed with ovarian cancer with subclavian lymph node metastasis revealed by FDG PET/CT and verified by an immunohistochemical staining. Differentiating between the primary ovarian lesion and the metastatic lesion will allow the initiation of an appropriate treatment and help predict the prognosis.
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Affiliation(s)
- Hee Jeong Jeong
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Hyun Joo Kim
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Eun Hee Lee
- Division of Gynecologic Oncology, Department of Pathology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Hyoun Wook Lee
- Division of Gynecologic Oncology, Department of Pathology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Min Kyu Kim
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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Nagano H, Muraoka M, Takagi K. Recurrent ovarian cancer with multiple lymph nodes metastases successfully treated with lymphadenectomy as secondary cytoreductive surgery: A case report. Int J Surg Case Rep 2014; 5:412-5. [PMID: 24880887 PMCID: PMC4064423 DOI: 10.1016/j.ijscr.2014.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 04/02/2014] [Accepted: 04/12/2014] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Occasionally, lymph node metastases represent the only component at the time of recurrence of ovarian cancer. Here we report the case of a 78-year-old Japanese female who underwent successful surgery for recurrent ovarian cancer with multiple lymph node metastases. PRESENTATION OF CASE The patient was referred to our institution with recurrent disease accompanied by chemoresistant multiple retroperitoneal lymph node metastases five years after the initial therapy for stage IIIc serous adenocarcinoma of the ovary. Positron emission tomography/computed tomography (PET/CT) revealed the involvement of two para-aortic nodes and two pelvic nodes, with no other positive site. The patient underwent systematic para-aortic and pelvic lymphadenectomy, and the metastatic nodes were completely resected. Histopathological examination revealed metastatic high-grade adenocarcinoma in four of 63 dissected lymph node specimens. The patient has been in clinical remission for over four years without any further additional therapies. DISCUSSION In our case, the metastatic nodes predicted by PET/CT completely corresponded to the actual metastatic nodes; however, PET/CT often fails to identify microscopic disease in pathological positive nodes. We cannot reliably predict whether lymph node metastasis will persist in the limited range. Therefore, systematic lymphadenectomy with therapeutic intent should be performed, although it does not always mean that we remove all cancer cells. CONCLUSION The findings from this case suggest that, even if used as secondary cytoreductive surgery in the context of a recurrent disease, systematic aortic and pelvic node dissection might sometimes contribute to the control if not cure of ovarian cancer.
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Affiliation(s)
- Hiroaki Nagano
- Department of Obstetrics and Gynecology, Tokyo Women's Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo 116-8567, Japan.
| | - Mitsue Muraoka
- Department of Obstetrics and Gynecology, Tokyo Women's Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo 116-8567, Japan
| | - Koichiro Takagi
- Department of Obstetrics and Gynecology, Tokyo Women's Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo 116-8567, Japan
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Hacker N. State of the art of surgery in advanced epithelial ovarian cancer. Ann Oncol 2013; 24 Suppl 10:x27-32. [DOI: 10.1093/annonc/mdt465] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Chang SJ, Bristow RE, Ryu HS. Prognostic significance of systematic lymphadenectomy as part of primary debulking surgery in patients with advanced ovarian cancer. Gynecol Oncol 2012; 126:381-6. [DOI: 10.1016/j.ygyno.2012.05.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 05/08/2012] [Accepted: 05/10/2012] [Indexed: 01/23/2023]
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Systematic lymphadenectomy in ovarian cancer at second-look surgery: a randomised clinical trial. Br J Cancer 2012; 107:785-92. [PMID: 22864456 PMCID: PMC3425968 DOI: 10.1038/bjc.2012.336] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
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.
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Diagnosis and management of peritoneal metastases from ovarian cancer. Gastroenterol Res Pract 2012; 2012:541842. [PMID: 22888339 PMCID: PMC3408715 DOI: 10.1155/2012/541842] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 05/12/2012] [Indexed: 02/08/2023] Open
Abstract
The management and the outcome of peritoneal metastases or recurrence from epithelial ovarian cancer are presented. The biology and the diagnostic tools of EOC peritoneal metastasis with a comprehensive approach and the most recent literatures data are discussed. The definition and the role of surgery and chemotherapy are presented in order to focuse on the controversial points. Finally, the paper discusses the new data about the introduction of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of advanced epithelial ovarian cancer.
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Fagotti A, De Iaco P, Fanfani F, Vizzielli G, Perelli F, Pozzati F, Perrone AM, Turco LC, Scambia G. Systematic Pelvic and Aortic Lymphadenectomy in Advanced Ovarian Cancer Patients at the Time of Interval Debulking Surgery: A Double-Institution Case–Control Study. Ann Surg Oncol 2012; 19:3522-7. [DOI: 10.1245/s10434-012-2400-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Indexed: 11/18/2022]
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Sakai K, Kajiyama H, Umezu T, Shibata K, Mizuno M, Suzuki S, Kawai M, Nagasaka T, Kikkawa F. Is there any association between retroperitoneal lymphadenectomy and survival benefit in advanced stage epithelial ovarian carcinoma patients? J Obstet Gynaecol Res 2012; 38:1018-23. [DOI: 10.1111/j.1447-0756.2011.01826.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Laparoscopic Lymphadenectomy for Isolated Lymph Node Recurrence in Gynecologic Malignancies. J Minim Invasive Gynecol 2012; 19:188-95. [DOI: 10.1016/j.jmig.2011.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2011] [Revised: 10/22/2011] [Accepted: 10/27/2011] [Indexed: 10/14/2022]
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Gouy S, Goetgheluck J, Uzan C, Duclos J, Duvillard P, Morice P. Prognostic factors for and prognostic value of mesenteric lymph node involvement in advanced-stage ovarian cancer. Eur J Surg Oncol 2012; 38:170-5. [DOI: 10.1016/j.ejso.2011.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 10/10/2011] [Indexed: 01/09/2023] Open
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Mahdi H, Thrall M, Kumar S, Hanna R, Seward S, Lockhart D, Morris RT, Swensen R, Munkarah AR. The prognostic impact of the ratio of positive lymph nodes on survival of epithelial ovarian cancer patients. J Surg Oncol 2011; 103:724-9. [PMID: 21241015 DOI: 10.1002/jso.21869] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 12/21/2010] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES To study the prognostic significance of ratio of positive to examined lymph nodes (LNR) on survival of patients with node positive epithelial ovarian cancer (NPEOC). METHODS Data were obtained from Surveillance, Epidemiology, and End Results Program (SEER) from 1988 to 2006, and analyzed using Kaplan-Meier survival and Cox regression proportional hazard methods. Patients were divided into: stage IIIC group 1 (no macroscopic peritoneal disease), stage IIIC group 2 (macroscopic peritoneal disease), and stage IV. RESULTS A total of 6,310 women were included. The 5-year survival for stage IIIC groups 1, 2, and stage IV was 55.4%, 35.5%, and 20.3%, respectively (P < 0.001). Increasing LNR (<10%, 10-50%, and >50%) was associated with decreased survival from 51.5% to 38.1% to 27.0%, respectively, (P < 0.001). On multivariate analysis, LNR was an independent prognostic factor for survival after adjusting for extent of peritoneal disease, stage, grade, race, age, extent of lymphadenectomy and absolute number of positive nodes. CONCLUSIONS The impact of increasing LNR was strongly related to survival, especially in patients with no macroscopic peritoneal disease. Stratification of this subpopulation of node positive EOC based on nodal burden provides a significant prognostic value that may be considered in future staging and aid in management decisions.
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Affiliation(s)
- Haider Mahdi
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA.
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Frequency and Distribution of Lymph Node Metastases in Epithelial Ovarian Cancer: Significance of Serous Histology. Int J Gynecol Cancer 2011. [DOI: 10.1097/igc.0b013e31820575db] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
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Abe A, Furumoto H, Irahara M, Ino H, Kamada M, Naka O, Sasaki M, Kagawa T, Okitsu O, Kushiki N. The impact of systematic para-aortic and pelvic lymphadenectomy on survival in patients with optimally debulked ovarian cancer. J Obstet Gynaecol Res 2010; 36:1023-30. [DOI: 10.1111/j.1447-0756.2010.01274.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Rouzier R, Bergzoll C, Brun JL, Dubernard G, Selle F, Uzan S, Pomel C, Daraï E. The role of lymph node resection in ovarian cancer: analysis of the surveillance, epidemiology, and end results (SEER) database. BJOG 2010; 117:1451-8. [DOI: 10.1111/j.1471-0528.2010.02633.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Berek JS. Lymph Node-Positive Stage IIIC Ovarian Cancer: A Separate Entity? Int J Gynecol Cancer 2009; 19 Suppl 2:S18-20. [DOI: 10.1111/igc.0b013e3181bf8111] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction:Ovarian cancer spreads via the retroperitoneal lymphatics, and these lymph nodes frequently contain metastasis. A subset of patients whose disease was classified as stage IIIC has retroperitoneal lymph node metastases in the pelvic and/or para-aortic lymph nodes without intraperitoneal carcinomatosis and was upstaged from stage I to IIIB diseases based on these findings. Patients undergoing cytoreductive surgery for advanced-stage ovarian cancer undergo concomitant retroperitoneal lymphadenectomy in an effort to improve their survival.Methods:Stratification of patients with stage IIIC ovarian cancer by lymph node status and presence and extent of metastatic disease in the peritoneal cavity has been performed. Studies have determined the impact on disease-free and overall survivals of the resection of retroperitoneal lymph nodes as part of primary and secondary cytoreductive operations.Results:The overall survival of patients with stage IIIC ovarian cancer based on retroperitoneal lymph node metastasis without peritoneal carcinomatosis is 58% to 84% compared with 18% to 36% for those with macroscopic peritoneal carcinomatosis. Although the performance of a pelvic and para-aortic lymphadenectomy in patients with stage IIIC to IV diseases has been reported to prolong survival, an international randomized study did not confirm this finding. Patients who undergo secondary resection of isolated recurrent lymph node metastasis have a better survival than those with more extensive recurrent disease.Conclusions:These data support the stratification of patients with stage IIIC ovarian cancer based on the finding of metastasis to the retroperitoneal lymph nodes without peritoneal carcinomatosis versus those who have peritoneal carcinomatosis. The International Federation of Gynecology and Obstetrics Committee should consider modifying the ovarian cancer staging system by further stratifying stage III disease. Although systematic lymphadenectomy during primary cytoreductive surgery does not appear to improve overall survival, resection of isolated lymph node metastasis and recurrences in lymph nodes may be associated with a survival benefit.
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Marth C, Hiebl S, Oberaigner W, Winter R, Leodolter S, Sevelda P. Influence of Department Volume on Survival for Ovarian Cancer: Results From a Prospective Quality Assurance Program of the Austrian Association for Gynecologic Oncology. Int J Gynecol Cancer 2009; 19:94-102. [DOI: 10.1111/igc.0b013e31819915cb] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective:The Austrian Association for Gynecologic Oncology initiated in 1998 a prospective quality assurance program for patients with ovarian cancer. The aim of this study was to evaluate factors predicting overall survival especially under consideration of department volume.Methods:All Austrian gynecological departments were invited to participate in the quality assurance program. A questionnaire was sent out that included birth date, histology, date of diagnosis, stage, and basic information on primary treatment. Description of comorbidity was not requested. Patient life status was assessed in a passive way. We did record linkage between each patient's name and birth date and the official mortality data set collected by Statistics Austria. No data were available on progression-free survival. Patients treated between January 1, 1999 and December 31, 2004 were included in the analysis. Mortality dates were available to December 31, 2006. Data were analyzed by means of classical statistical methods. Cut-off point for departments was 24 patients per year.Results:A total of 1948 patients were evaluable. Approximately 75% of them were treated at institutions with fewer than 24 new patients per year. Patient characteristics were grossly similar for both department types. Multivariate analysis confirmed established prognostic factors such as International Federation of Gynecologists and Obstetricians (FIGO) stage, lymphadenectomy, age, grading, and residual disease. In addition, we found small departments (<24 patients per year) to have a negative effect on overall survival (hazards ratio, 1.38: 95% confidence interval, 1.2-1.7; and P < 0.001).Conclusions:The results indicate that in Austria, rules prescribing minimum department case load can further improve survival for patients with ovarian cancer.
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Salet-Lizée D, Alsary S. [Not Available]. ACTA ACUST UNITED AC 2008; 145S4:12S45-9. [PMID: 22793985 DOI: 10.1016/s0021-7697(08)74722-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Salet-Lizée D, Alsary S. [Not Available]. ACTA ACUST UNITED AC 2008; 145:12S45-9. [PMID: 22794072 DOI: 10.1016/s0021-7697(08)45009-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
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.
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Ryo E. Diagnostic value of intraoperative ultrasonography to assess para-aortic lymph nodes in women with ovarian and uterine corpus malignancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 32:91-96. [PMID: 18570237 DOI: 10.1002/uog.5366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To examine the ability of intraoperative ultrasonography to detect enlarged para-aortic lymph nodes, and to assess its potential use in reducing the number of unnecessary para-aortic lymphadenectomies performed in women with ovarian and uterine corpus malignancies. METHODS Computed tomography (CT), palpation during surgery, and intraoperative ultrasonography were used to assess whether para-aortic lymph nodes were enlarged in 163 women with ovarian and uterine corpus malignancy. All the women underwent para-aortic lymphadenectomy, and nodes were assessed for metastasis. RESULTS Thirty-five women had pathological para-aortic node metastasis. The sensitivity, specificity, and positive and negative predictive values of CT for the diagnosis of metastasis were 42.9, 96.1, 75.0 and 86.0%, respectively. These values were 60.0, 82.0, 47.7 and 88.2% for palpation, and 91.4, 69.5, 45.1 and 96.7% for intraoperative ultrasonography, respectively. If para-aortic lymphadenectomy had been performed only when enlarged lymph nodes were detected on CT then the number performed would have been reduced from 163 to 20 (12.3%); however, node metastasis would have been missed in 20 out of 35 women. On the same basis, the number of lymphadenectomies performed would have been 44 (27.0%) and metastasis would have been missed in 14 women on palpation during surgery, and 71 lymphadenectomies (43.6%) would have been performed and metastasis would have been missed in three women on intraoperative ultrasonography. CONCLUSIONS Intraoperative ultrasonography is a highly sensitive tool with which to diagnose lymph node metastasis. Its high negative predictive value allows avoidance of unnecessary para-aortic lymphadenectomy in women with ovarian and uterine corpus malignancy.
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Affiliation(s)
- E Ryo
- Department of Obstetrics and Gynecology, Teikyo University, Kaga, Tokyo, Japan.
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Hacker NF, Valmadre S, Robertson G. Management of retroperitoneal lymph nodes in advanced ovarian cancer. Int J Gynecol Cancer 2008; 18 Suppl 1:7-10. [DOI: 10.1111/j.1525-1438.2007.01097.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Autopsy studies have demonstrated a very high incidence of positive retroperitoneal lymph nodes in patients with advanced ovarian cancer, but the clinical management of these nodes has only recently been investigated. Several institutional studies had suggested an advantage to systematic removal of pelvic and paraaortic nodes in patients whose tumor was optimally cytoreduced in the peritoneal cavity. However, the only randomized prospective study revealed a 7-month benefit in progression-free survival for patients having systematic lymphadenectomy, but no benefit in terms of overall survival. Unless a future randomized trial shows evidence to the contrary, removal of clinically normal nodes should not be considered part of the standard care for patients with advanced ovarian cancer. Bulky nodes should be removed as part of the surgical aim of removing all macroscopic residual disease
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Prognosis in epithelial ovarian cancer: Clinical analysis of 287 pelvic and para-aortic lymphadenectomy. ACTA ACUST UNITED AC 2007. [DOI: 10.1007/s10330-007-0092-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Benedetti Panici P, Perniola G, Angioli R, Zullo MA, Manci N, Palaia I, Bellati F, Plotti F, Calcagno M, Basile S. Bulky lymph node resection in patients with recurrent epithelial ovarian cancer: impact of surgery. Int J Gynecol Cancer 2007; 17:1245-51. [PMID: 17425680 DOI: 10.1111/j.1525-1438.2007.00929.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The aim of this study was to evaluate the role of systematic lymphadenectomy, feasibility, complications rate, and outcome in epithelial ovarian cancer (EOC) patients with recurrent bulky lymph node disease. A prospective observational study of EOC patients with pelvic/aortic lymph node relapse was conducted between January 1995 and June 2005. After a clinical and laparoscopic staging, secondary cytoreduction, including systematic lymphadenectomy, were performed. The eligibility criteria were as follows: disease-free interval ≥6 months, radiographic finding suggestive of bulky lymph node recurrence, and patients' consent to be treated with chemotherapy. Forty-eight EOC patients with lymph node relapse were recruited. Twenty-nine patients were amenable to cytoreductive surgery. Postoperatively, all patients received adjuvant treatment. The median numbers of resected aortic and pelvic nodes were 15 (2–32) and 17 (8–47), respectively. The median numbers of resected aortic and pelvic positive lymph nodes were 4 (1–18) and 3 (1–17), respectively. The mean size of bulky nodes was 3.3 cm. Four patients (14%) experienced one severe complication. No treatment-related deaths were observed. After a median follow-up of 26 months, among cytoreduced patients, 18 women were alive with no evidence of disease, nine were alive with disease. Among the 11 patients not amenable to surgery, five women were alive with persistent disease, six patients died of disease, at a median follow-up of 18 months. Estimated 5-year overall survival and disease-free interval for operated women were 87% and 31%, respectively. In conclusion, patients with bulky lymph node relapse can benefit from systematic lymphadenectomy in terms of survival. The procedure is feasible with an acceptable morbidity rate
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Affiliation(s)
- P Benedetti Panici
- Department of Obstetrics and Gynecology, University La Sapienza of Rome, Rome, Italy.
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Ushijima K. Management of retroperitoneal lymph nodes in the treatment of ovarian cancer. Int J Clin Oncol 2007; 12:181-6. [PMID: 17566840 DOI: 10.1007/s10147-007-0672-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Kimio Ushijima
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan.
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Chan JK, Urban R, Hu JM, Shin JY, Husain A, Teng NN, Berek JS, Osann K, Kapp DS. The potential therapeutic role of lymph node resection in epithelial ovarian cancer: a study of 13918 patients. Br J Cancer 2007; 96:1817-22. [PMID: 17519907 PMCID: PMC2359970 DOI: 10.1038/sj.bjc.6603803] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The aim of the study is to determine the role of lymphadenectomy in advanced epithelial ovarian cancer. The data were obtained from the Surveillance, Epidemiology and End Results (SEER) program reported between 1988 and 2001. Kaplan–Meier estimates and Cox proportional hazards regression models were used for analysis. Of 13 918 women with stage III–IV epithelial ovarian cancer (median age: 64 years), 87.9% were Caucasian, 5.6% African Americans, and 4.4% Asians. A total of 4260 (30.6%) underwent lymph node dissections with a median number of six nodes reported. For all patients, a more extensive lymph node dissection (0, 1, 2–5, 6–10, 11–20, and >20 nodes) was associated with an improved 5-year disease-specific survival of 26.1, 35.2, 42.6, 48.4, 47.5, and 47.8%, respectively (P<0.001). Of the stage IIIC patients with nodal metastases, the extent of nodal resection (1, 2–5, 6–10, 11–20, and >20 nodes) was associated with improved survivals of 36.9, 45.0, 47.8, 48.7, and 51.1%, respectively (P=0.023). On multivariate analysis, the extent of lymph node dissection and number of positive nodes were significant independent prognosticators after adjusting for age, year at diagnosis, stage, and grade of disease. The extent of lymphadenectomy is associated with an improved disease-specific survival of women with advanced epithelial ovarian cancer.
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Affiliation(s)
- J K Chan
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco School of Medicine, 1600 Divisadero Street, Box 1702, San Francisco, CA 94143, USA.
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Aletti GD, Dowdy S, Podratz KC, Cliby WA. Role of lymphadenectomy in the management of grossly apparent advanced stage epithelial ovarian cancer. Am J Obstet Gynecol 2006; 195:1862-8. [PMID: 17132488 DOI: 10.1016/j.ajog.2006.06.068] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2006] [Revised: 05/09/2006] [Accepted: 06/17/2006] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the factors that are related to the performance of lymph node assessment and its impact on prognosis in ovarian cancer. STUDY DESIGN This was a retrospective analysis of stage IIIC/IV epithelial ovarian cancer in patients who had undergone primary surgery between 1994 and 1998. Simple statistics and univariate and multivariable analysis were performed. RESULTS Two hundred nineteen patients met the inclusion criteria; lymph node assessment was performed for 93 of these patients (41%). Sixty-one patients (65.5%) underwent complete pelvic and para-aortic lymphadenectomy, and 32 patients (34.5%) underwent a more limited lymph node sampling. In patients with residual disease >1 cm, lymph node assessment was an independent predictor of outcome. In this same subgroup, lymphadenectomy appeared to be superior to lymph node sampling (5-year overall survival, 50% (lymphadenectomy) vs 33% (lymph node sampling) vs 29% (no lymph node assessment); P = .01). Considering survival of the subgroup who underwent lymph node assessment, we observed a significantly worse outcome for those with lymphatic involvement (5-year overall survival, 31.5% [positive for nodal metastases] vs 54% [negative for nodal metastases]; P = .003). Although multiple factors were correlated with the decision to perform lymph node assessment in univariate analysis, only the surgeon (P < .001), low residual disease (P = .004), American Society of Anesthesiology 1 or 2 (P = .004), and the absence of carcinomatosis (P = .0002) were independent factors in the multivariable analysis. Further, if lymph node assessment was performed, the decision to do lymphadenectomy versus lymph node sampling was associated independently with the surgeon (P < .001), low residual disease (P < .001), and patient age of <65 years (P < .001). CONCLUSION Removal of obviously involved lymph nodes in patients with residual disease near 1 cm and lymphadenectomy for patients with complete or near complete resection of abdominal disease appears to be justified. A lack of standard recommendation in advanced ovarian cancer results in wide variations that are based on individual preference in addition to logical factors.
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Affiliation(s)
- Giovanni D Aletti
- Department of Obstetrics and Gynecology, Mayo Clinic and Foundation, Rochester, MN 55905, USA
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Kumpulainen S, Kuoppala T, Leminen A, Penttinen J, Puistola U, Pukkala E, Sankila R, Mäkinen J, Grénman S. Surgical treatment of ovarian cancer in different hospital categories – A prospective nation-wide study in Finland. Eur J Cancer 2006; 42:388-95. [PMID: 16414260 DOI: 10.1016/j.ejca.2005.09.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2005] [Revised: 09/28/2005] [Accepted: 09/28/2005] [Indexed: 10/25/2022]
Abstract
This prospective nation-wide study was performed to evaluate the effect of hospital category and subspeciality training on surgical treatment of ovarian cancer. Data were obtained from a questionnaire filled in by the operating unit, and from the surgical and histopathology reports. The survey included 307 patients. Half of them were operated in the university hospitals where gynaecologic oncologists performed 72% of the operations. This was the case in only 4% and 19% in the central and district hospitals, respectively. In university hospitals, pelvic lymphadenectomy was performed in 88%, and para-aortic lymphadenectomy in 73%, of the patients with stage I disease. The corresponding figures ranged from 11% to 21% in central and district hospitals. For stage III patients operated by gynaecologic oncologists, the estimated odds ratio for no macroscopic tumour was 3.0 times higher (95% CI 1.2-7.5) than for those operated by general gynaecologists. These results favour centralisation of surgical treatment of ovarian cancer.
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Affiliation(s)
- Salla Kumpulainen
- Department of Obstetrics and Gynaecology, Turku University Hospital, PL 52, Kiinanmyllynkatu 4-8, 20521 Turku, Finland
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Takeshima N, Hirai Y, Umayahara K, Fujiwara K, Takizawa K, Hasumi K. Lymph node metastasis in ovarian cancer: Difference between serous and non-serous primary tumors. Gynecol Oncol 2005; 99:427-31. [PMID: 16112718 DOI: 10.1016/j.ygyno.2005.06.051] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2005] [Revised: 06/15/2005] [Accepted: 06/23/2005] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate the lymph node sites most susceptible to involvement relative to primary tumor histology in ovarian cancer. METHODS The locations of metastatic lymph nodes were investigated in 208 patients with primary ovarian cancer who underwent systemic lymphadenectomy covering both the pelvic and para-aortic regions. RESULTS Lymph node metastasis was present in 12.8% (20/156) of patients with stage I (pT1M0), 48.6% (18/37) with stage II (pT2M0), and 60% (9/15) with stage III (pT3M0) disease, thus in 22.6% (47/208) of all study patients. Isolated para-aortic nodal involvement was present in 23.3% (14/60) of patients with serous tumor and 4.1% (6/148) of those with non-serous tumor (P = 0.00002). In an analysis of 35 positive nodes from 25 patients with up to 3 positive nodes, 86.4% (19/22) of metastatic lymph nodes from patients with serous tumor were found in the para-aortic region, with 14 positive nodes located above the inferior mesenteric artery (IMA) and 5 below it, whereas metastasis to para-aortic lymph nodes accounted for 53.8% (7/13) of metastatic lymph nodes from patients with non-serous tumor (P = 0.0334). CONCLUSIONS The locations of metastatic lymph nodes in ovarian cancer depend upon the histologic type of the primary cancer. In cases of serous tumor, the para-aortic region, particularly above the IMA, is the prime site for the earliest lymph node metastasis. However, the likelihood of pelvic node involvement is almost equal to that of para-aortic node involvement in cases of non-serous tumor.
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Affiliation(s)
- Nobuhiro Takeshima
- Department of Gynecology, Cancer Institute Hospital, 3-10-6, Ariake, Koto-ku, Tokyo 135-8550, Japan.
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Ayhan A, Gultekin M, Taskiran C, Celik NY, Usubutun A, Kucukali T, Yuce K. Lymphatic metastasis in epithelial ovarian carcinoma with respect to clinicopathological variables. Gynecol Oncol 2005; 97:400-4. [PMID: 15863136 DOI: 10.1016/j.ygyno.2005.01.038] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2004] [Revised: 01/20/2005] [Accepted: 01/31/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the prognostic factors, and the patterns of lymphatic metastasis in EOC patients who were treated with systematic pelvic and paraaortic lymphatic dissection. METHODS A total of 420 EOC patients was retrospectively evaluated. Clinical factors available were evaluated for a possible significance in terms of lymphatic metastasis and paraaortic involvement. RESULTS Two-hundred and three patients were found to have lymphatic metastasis. In multivariable analysis, stage (P < 0.001), histology (P < 0.01 for serous; P = 0.02 for mixed, and P = 0.04, for Brenner), and Ca-125 level higher than 500 U/ml (P = 0.04) were found to be significantly related with the lymphatic involvement. Age and grade were significant factors for paraaortic metastasis both in univariable and multivariable analysis (P = 0.003 and P = 0.02, respectively). Most of the patients with unilateral tumors had contralateral pelvic and/or paraaortic metastasis. There were eleven patients with lymphatic metastasis in stage I-II disease, and five had paraaortic metastasis while an additional five patients had contralateral pelvic nodal metastasis. However, there was no lymphatic involvement in Stage IA, Grade I-II disease (0/63). Survival analysis revealed no significant difference by the number of metastatic lymph nodes. CONCLUSION In multivariable analysis, lymphatic involvement was predicted independently by stage, histology, and Ca-125 level. In apparently stage I-II disease, a considerable part of patients were upstaged due to lymphatic involvement. Although routine systematic lymphadenectomy is suggested for patients with early stage disease, further series are needed for a definite regimen in patients with stage IA G1-2 disease since we did not detect any lymphatic involvement in this unique group.
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Affiliation(s)
- Ali Ayhan
- Hacettepe University Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Naci Cakir Mah. 1. Cadde, Kubra Apt. 1/1 Dikmen, Sihhiye, Ankara, Turkey
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Panici PB, Maggioni A, Hacker N, Landoni F, Ackermann S, Campagnutta E, Tamussino K, Winter R, Pellegrino A, Greggi S, Angioli R, Manci N, Scambia G, Dell'Anna T, Fossati R, Floriani I, Rossi RS, Grassi R, Favalli G, Raspagliesi F, Giannarelli D, Martella L, Mangioni C. Systematic aortic and pelvic lymphadenectomy versus resection of bulky nodes only in optimally debulked advanced ovarian cancer: a randomized clinical trial. J Natl Cancer Inst 2005; 97:560-6. [PMID: 15840878 DOI: 10.1093/jnci/dji102] [Citation(s) in RCA: 295] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The role of systematic aortic and pelvic lymphadenectomy in patients with optimally debulked advanced ovarian cancer is unclear and has not been addressed by randomized studies. We conducted a randomized clinical trial to determine whether systematic aortic and pelvic lymphadenectomy improves progression-free and overall survival compared with resection of bulky nodes only. METHODS From January 1991 through May 2003, 427 eligible patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIB-C and IV epithelial ovarian carcinoma were randomly assigned to undergo systematic pelvic and para-aortic lymphadenectomy (n = 216) or resection of bulky nodes only (n = 211). Progression-free survival and overall survival were analyzed using a log-rank statistic and a Cox multivariable regression analysis. All statistical tests were two-sided. RESULTS After a median follow-up of 68.4 months, 292 events (i.e., recurrences or deaths) were observed, and 202 patients had died. Sites of first recurrences were similar in both arms. The adjusted risk for first event was statistically significantly lower in the systematic lymphadenectomy arm (hazard ratio [HR] = .75, 95% confidence interval [CI] = 0.59 to 0.94; P = .01) than in the no-lymphadenectomy arm, corresponding to 5-year progression-free survival rates of 31.2 and 21.6% in the systematic lymphadenectomy and control arms, respectively (difference = 9.6%, 95% CI = 1.5% to 21.6%), and to median progression-free survival of 29.4 and 22.4 months, respectively (difference = 7 months, 95% CI = 1.0 to 14.4 months). The risk of death was similar in both arms (HR = 0.97, 95% CI = 0.74 to 1.29; P = .85), corresponding to 5-year overall survival rates of 48.5 and 47%, respectively (difference = 1.5%, 95% CI = -8.4% to 10.6%), and to median overall survival of 58.7 and 56.3 months, respectively (difference = 2.4 months, 95% CI = -11.8 to 21.0 months). Median operating time was longer, and the percentage of patients requiring blood transfusions was higher in the systematic lymphadenectomy arm than in the no-lymphadenectomy arm (300 versus 210 minutes, P<.001, and 72% versus 59%; P = .006, respectively). CONCLUSION Systematic lymphadenectomy improves progression-free but not overall survival in women with optimally debulked advanced ovarian carcinoma.
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Chambers SK. Systematic Lymphadenectomy in Advanced Epithelial Ovarian Cancer: Two Decades of Uncertainty Resolved. ACTA ACUST UNITED AC 2005; 97:548-9. [PMID: 15840870 DOI: 10.1093/jnci/dji123] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Dubernard G, Morice P, Rey A, Camatte S, Pautier P, Lhommé C, Duvillard P, Castaigne D. Lymph node spread in stage III or IV primary peritoneal serous papillary carcinoma. Gynecol Oncol 2005; 97:136-41. [PMID: 15790449 DOI: 10.1016/j.ygyno.2004.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2004] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study was to determine the rates and topography of pelvic and para-aortic nodal involvement in patients with stage III or IV primary peritoneal serous papillary carcinoma (PSPC). METHODS Retrospective review of 19 women who underwent a systematic bilateral pelvic and para-aortic lymphadenectomy. RESULTS The overall frequency of lymph node involvement was 63% (12/19). Eighteen patients underwent complete resection of peritoneal disease. Only 4 patients underwent this procedure as part of their initial surgery (before chemotherapy). The frequency of pelvic and para-aortic metastases was 58% (11/19) and 58% (11/19), respectively. When para-aortic nodes were involved, the left para-aortic chain above the level of the inferior mesenteric artery was the site most frequently involved (72%). The event-free survival of the 18 patients without macroscopic disease at the end of debulking surgery was significantly correlated with the nodal status. None of the patients with positive nodes developed recurrent disease in abdominal nodes. CONCLUSIONS The rate of nodal involvement in patients with PSPC is high. The topography of nodal spread is similar to that of ovarian cancer. Lymphadenectomy has a prognostic value.
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Affiliation(s)
- Gil Dubernard
- Service de Chirurgie, Institut Gustave Roussy, 39 rue Camille Desmoulins, 94805 Villejuif Cedex, France
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Uzan C, Morice P, Rey A, Pautier P, Camatte S, Lhommé C, Haie-Meder C, Duvillard P, Castaigne D. Outcomes After Combined Therapy Including Surgical Resection in Patients with Epithelial Ovarian Cancer Recurrence(s) Exclusively in Lymph Nodes. Ann Surg Oncol 2004; 11:658-64. [PMID: 15197013 DOI: 10.1245/aso.2004.11.023] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The aim was to study the prognosis for and survival of patients treated with combined therapy (including surgical resection) for nodal recurrences from epithelial ovarian cancer (EOC). METHODS This was a retrospective study of a group of 12 patients with a recurrence from EOC, a priori, exclusively located in lymph node(s). All patients underwent surgical resection of nodal metastases, followed by adjuvant therapy. RESULTS The median age of patients was 51 (range, 42-71) years. The initial disease stages were as follows: stage IA, n = 5; stage IIA, n = 1; and stage IIIC, n = 6. The median interval between the end of initial treatment and the nodal relapse was 21 (range, 6-72) months. The recurrence was located in the abdominal nodes in 10 patients (pelvic and/or para-aortic area) and was extra-pelvic in one patient, and the last patient had concomitant para-aortic and supraclavicular nodal involvement. Ten patients received postoperative chemotherapy and two had radiation therapy (one patient received both treatments). Eight patients relapsed and four did not. To date, three patients have died of the disease, three are alive with persistent disease, and six are alive and disease-free (including two patients who were treated by surgical resection after relapses twice in abdominal nodes). Five-year overall survival from the time of treatment of recurrent disease is 71% (confidence interval, 41%-90%). CONCLUSIONS The prognosis of patients with an a priori isolated nodal recurrence from EOC was good in this group of treated with surgical resection followed by chemoradiation or radiation therapy. This finding argues in favor of proposing surgical resection in such patients.
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Affiliation(s)
- Catherine Uzan
- Department of Surgery, Institut Gustave Roussy, 39 rue Camille Desmoulins, 94805 Villejuif Cedex, France
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Joulie F, Morice P, Rey A, Thoury A, Camatte S, Pautier P, Lhommé C, Haie-Meder C, Duvillard P, Castaigne D. Les métastases ganglionnaires du cancer épithélial de l'ovaire sont-elles chimio-sensibles ? Étude comparative de la lymphadénectomie première ou après chimiothérapie. ACTA ACUST UNITED AC 2004; 32:502-7. [PMID: 15217565 DOI: 10.1016/j.gyobfe.2004.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2004] [Accepted: 04/06/2004] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of this study is to compare the rates of nodal involvement in epithelial ovarian cancer (EOC) in patients who underwent initial lymphadenectomy (before chemotherapy/group 1) and patients who underwent lymphadenectomy after chemotherapy (during interval debulking surgery/group 2 or second-look surgery/group 3). PATIENTS AND METHODS The rates of nodal involvement in 205 patients with EOC who underwent complete pelvic and paraaortic lympadenectomy were compared. One hundred and five patients underwent this surgical procedure at the end of chemotherapy (group 3) or during chemotherapy (group 2) for 28 patients (with three courses of a platinum-based regimen containing paclitaxel) and were compared to 100 patients who underwent initial lymphadenectomy (group 1). RESULTS In patients with stage I and II disease the rate of nodal involvement in group 1 and 3 were similar (respectively 19% vs. 21% and 50% vs. 33% in stage I or II disease-NS). In patients with stage III disease, the rates of nodal involvement in patients treated with initial surgery, interval debulking surgery (with paclitaxel-based regimen) and second-look surgery were respectively: 53%, 58% and 48% (NS). Adding to the platinum-based regimen does not seem to improve node sterilization rates. DISCUSSION AND CONCLUSIONS The rates of nodal involvement seem to be similar in patients treated before or after chemotherapy but the comparison of groups is difficult because the presence of several bias (particularly in early stage disease). Such results suggest that nodal metastases are not totally sterilized by chemotherapy. However, further studies are needed to evaluate the therapeutic value of lymphadenectomy in patients with nodal involvement.
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Affiliation(s)
- F Joulie
- Département de chirurgie oncologique gynécologique, institut Gustave-Roussy, 39, rue Camille-Desmoulins, 94805 Villejuif, France
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Ryo E, Nagasaka T, Yasugi T, Kozuma S, Taketani Y. Assessment of para-aortic lymph nodes by intraoperative sonography in gynecological malignancies: a preliminary report. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2003; 22:622-626. [PMID: 14689536 DOI: 10.1002/uog.928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To investigate the usefulness of intraoperative sonography for the assessment of para-aortic lymph nodes in gynecological malignancies. METHODS The assessment of para-aortic lymph node swelling by computed tomography (CT), palpation during surgery and intraoperative sonography was performed in 43 women with a gynecological malignancy. The sensitivity, specificity and predictive values of each technique for assessment of node metastasis were examined in the 33 women who underwent para-aortic lymphadenectomy. For each of the three assessment techniques, the number of para-aortic lymphadenectomies that would have been performed and the number of women who would have had missed metastasis were evaluated assuming a para-aortic lymphadenectomy would be performed only when swollen nodes were detected. RESULTS Para-aortic nodes were assessed to be swollen by CT, palpation, and intraoperative sonography, respectively, in one, six and 10 of 43 women in total, and in one, six and nine of the 33 women who underwent para-aortic lymphadenectomy. The sensitivity and negative predictive value of intraoperative sonography were 100%, while the specificity and positive predictive value of CT were 100%. If para-aortic lymphadenectomy had been performed only when swollen nodes were detected by intraoperative sonography, the number performed would have decreased from 33 to nine without missing lymph-node metastasis. CONCLUSION Intraoperative sonography has potential for the assessment of para-aortic lymph nodes in gynecological malignancies.
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Affiliation(s)
- E Ryo
- Musashino Red Cross Hospital, Tokyo, Japan.
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Morice P, Joulie F, Camatte S, Atallah D, Rouzier R, Pautier P, Pomel C, Lhommé C, Duvillard P, Castaigne D. Lymph node involvement in epithelial ovarian cancer: analysis of 276 pelvic and paraaortic lymphadenectomies and surgical implications. J Am Coll Surg 2003; 197:198-205. [PMID: 12892797 DOI: 10.1016/s1072-7515(03)00234-5] [Citation(s) in RCA: 169] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The purpose was to determine the factors influencing nodal involvement and topography of pelvic and paraaortic node involvement in ovarian carcinoma. STUDY DESIGN Between 1985 and 2001, 276 women with epithelial ovarian carcinoma underwent systematic bilateral pelvic and paraaortic lymphadenectomy. RESULTS The overall frequency of lymph node involvement was 44% (122 of 276). The frequency of pelvic and paraaortic metastases were 30% (82 of 276) and 40% (122 of 276), respectively. The frequency of lymph node metastases according to the stage of the disease (stages I, II, and III + IV) were: 20% (17 of 85), 40% (6 of 15), and 55% (99 of 176), respectively. In patients with stage IA, IB, and IC disease, the rates of nodal involvement were 13% (8 of 60), 33% (4 of 12), and 38% (5 of 13), respectively. None of 15 patients with stage IA grade 1 disease had nodal involvement. None of the 20 patients with mucinous tumors confined to the ovary(ies) (stage I disease) had nodal involvement. When paraaortic nodes were involved, the left paraaortic chain above the level of the inferior mesenteric artery was the most frequently involved site (70 patients, 63%). One of nine patients (11%) with a macroscopic stage I unilateral tumor and paraaortic involvement had contralateral metastases. CONCLUSIONS Lymphadenectomy should be performed even in patients with stage IA disease. This procedure could be omitted in patients with mucinous apparent stage I disease and stage I grade 1 tumor. Lymphadenectomy should involve the whole pelvic and paraaortic chain up to the level of the left renal vein. A bilateral dissection should be performed even in cases of patients with a unilateral tumor.
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Affiliation(s)
- Philippe Morice
- Department of Surgery, Institut Gustave Roussy, Villejuif, France
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Tangjitgamol S, Manusirivithaya S, Sheanakul C, Leelahakorn S, Sripramote M, Thawaramara T, Kaewpila N. Can we rely on the size of the lymph node in determining nodal metastasis in ovarian carcinoma? Int J Gynecol Cancer 2003; 13:297-302. [PMID: 12801259 DOI: 10.1046/j.1525-1438.2003.13192.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study endeavored to determine whether lymph node size is a reliable indicator in determining lymph node metastasis in common epithelial ovarian cancer. We reviewed pathologic sections of pelvic and para-aortic lymph nodes removed from 104 ovarian carcinoma patients who underwent either primary surgical staging or secondary surgery from January 1994 to July 2001. All sections of each individual node were measured in two dimensions. The different sizes of nodes were studied statistically to determine the optimal sensitivity and specificity in predicting cancer metastasis. A nodal size of 10 mm was a specific point of interest. Of 2069 total nodes obtained, 110 nodes (5.3%) had metastatic cancer. More than half (55.4%) of these positive nodes had a nodal long axis of 10 mm and less. The sensitivity and specificity of nodal size at 10 mm were 44.5% and 81.1%, respectively. We conclude that lymph node size is not a good indicator in determining epithelial ovarian cancer metastasis. Mere sampling of only the enlarged nodes does not reflect the true positive incidence of nodal metastasis. To avoid inaccurate staging and improper management, complete lymph node dissection is proposed as part of surgical staging for ovarian cancer.
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Affiliation(s)
- S Tangjitgamol
- Department of Obstetrics and Gynecology, Bangkok Metropolitan Administration Medical College and Vajira Hospital, Bangkok, Thailand
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Abstract
BACKGROUND AND OBJECTIVES Our knowledge regarding the pathologic lymphatic spread pattern of primary peritoneal carcinoma (PPC) is limited. The aim of this study was to compare the incidence and the pathologic patterns of pelvic and para-aortic lymph node metastases among women with PPC and those with papillary serous ovarian carcinoma (PSOC). METHODS We conducted a prospective study over the last 4 years among women with FIGO stage III and IV PPC and PSOC who had optimal primary cytoreductive surgery (<1 cm residual). The same surgeon performed pelvic and para-aortic lymphadenectomy on all the patients using a similar technique. The same pathologist reviewed all lymph nodes and recorded nodal involvement with cancer, diameter of the largest nodal tumor, capsular integrity, and pattern of immune response (lymphocyte predominant, germinal cell predominant, unstimulated, or lymphocyte depletion). Both groups were compared in their characteristics, FIGO stage, tumor grade, number of lymph nodes, proportion of lymph nodes with metastases, and the pathologic characteristics of the positive lymph nodes. RESULTS Eleven women had PPC and 27 had PSOC. Patients with PPC were older than those with PSOC (mean age: 63.2 years +/- 11.0 vs. 57.4 +/- 13.4, P = 0.181). There was no difference in FIGO stage or tumor grade between both groups. There was no difference among the mean numbers of pelvic and para-aortic lymph nodes between women with PPC and those with PSOC (10.8 +/- 7.3 vs. 11.0 +/- 6.7 and 3.0 +/- 3.3 vs. 3.4 +/- 2.1, P = 0.768 and 0.706, respectively). The incidences of pelvic, para-aortic, and pelvic and/or para-aortic lymph node metastases were similar among women with PPC and those with PSOC (72.7% vs. 66.6%, P = 0.701, 72.7% vs. 48.1%, P = 0.172, and 72.7% vs. 77.8%, P = 0.736, respectively). Similarly, pelvic and para-aortic nodal tumor size, capsular integrity, and immune response were similar in both groups. The incidence of significant complications related to lymphadenectomy was low among women with PPC and those with PSOC (9.1% vs. 7.4%, respectively). CONCLUSIONS PPC and PSOC exhibit similar pathologic lymphatic spread patterns. Pelvic and para-aortic lymphadenectomy should be considered among women with PPC in whom the tumor could be optimally cytoreduced.
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Affiliation(s)
- Gamal H Eltabbakh
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Vermont College of Medicine, Burlington, Vermont 05403, USA.
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