Risks and benefits of systematic lymphadenectomy during interval debulking surgery for advanced high grade serous ovarian cancer

Questionnaire-based survey on the extent of lymph node dissection during interval debulking surgery after neoadjuvant chemotherapy for patients with advanced ovarian cancer in the Gynecologic Cancer Study Group of JCOG

BACKGROUND

The significance of lymph node dissection (LND) in primary debulking surgery (PDS) for advanced ovarian cancer was demonstrated in the LION trial. However, the role and the current practices of LND during interval debulking surgery (IDS) remains unclear. We aimed to conduct a survey of the current LND practices.

METHODS

A questionnaire-based survey regarding the criteria and extent of LND for advanced ovarian cancer was conducted by the Gynecologic Cancer Study Group of the Japan Clinical Oncology Group (JCOG). We defined enlarged lymph nodes as 10 mm or more in the short axis on imaging.

RESULTS

This study included data from 51 institutions. Factors contributing to the decision regarding the extent of LND included performance status, completeness of cytoreductive surgery excluding the lymph nodes, and age. Regarding PDS cases with enlarged lymph nodes, 90% of all institutions opted for systematic LND (SyLND) or removal of only the enlarged lymph nodes (SeLND). In IDS cases with enlarged lymph nodes after neoadjuvant chemotherapy (NACT), 15 (29%) and 35 (69%) institutions opted for SyLND and SeLND, respectively. In contrast, in IDS cases in which enlarged lymph nodes were reduced after NACT, approximately half the institutions opted for no LND.

CONCLUSION

This study found no established standard treatment for LND during IDS in patients with enlarged lymph nodes among the JCOG institutions. Thus, further prospective studies comparing the prognostic outcomes with or without LND are warranted.

Role of systematic lymphadenectomy at the time of interval debulking surgery for patients with advanced-stage epithelial ovarian carcinoma who achieved complete gross resection

OBJECTIVE

To evaluate the role of systematic lymphadenectomy at the time of interval cytoreductive surgery for patients with advanced-stage epithelial ovarian carcinoma who achieved complete gross resection.

METHODS

The National Cancer DataBase was accessed, and patients diagnosed between 2010 and 2015 with advanced-stage ovarian carcinoma who underwent interval cytoreductive surgery and achieved complete gross resection were identified. Patients who did not undergo lymphadenectomy and those who underwent systematic lymphadenectomy (defined as at least 20 lymph nodes removed) were selected for further analysis. Median overall survival was compared with the log-rank test and controlled for a priori selected confounders.

RESULTS

A total of 1060 patients were identified. Systematic lymphadenectomy was performed for 125 (11.8%) patients with a median of 29 lymph nodes (range 20-72) removed. Rate of lymph node metastasis was 62.4%. Patients who underwent systematic lymphadenectomy had higher rate of unplanned readmission (8.9% vs 1.6%, p<0.001), and median hospital stay (6 vs 4 days, p<0.001). Median overall survival for patients who did and did not undergo systematic lymphadenectomy was 44.2 and 40.4 months, respectively, p=0.40. After controlling for confounders, performance of systematic lymphadenectomy was not associated with better survival (HR=0.98, 95% CI 0.80 to 1.19).

CONCLUSION

Systematic lymphadenectomy is rarely performed at the time of interval cytoreductive surgery and not associated with a survival benefit for patients who achieved complete gross resection.

Hyperthermic Intraperitoneal Chemotherapy (HIPEC): New Approaches and Controversies on the Treatment of Advanced Epithelial Ovarian Cancer-Systematic Review and Meta-Analysis

BACKGROUND

Hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery has been extensively studied in patients with peritoneal carcinomatosis, and it holds promise as a therapeutic strategy, but its role remains elusive. The aim of this study was to assess the existing evidence for the use or not of HIPEC in primary debulking surgery (PDS), interval debulking surgery (IDS), and recurrent ovarian cancer (ROC), evaluated in terms of survival rates and post-surgical morbidity.

METHODS

Medline, Pubmed, Cochrane, and Medscape were systematically searched for any article comparing the use of HIPEC treatment with any other therapy in patients with ovarian cancer in PDS, IDS, and ROC. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were followed. We only considered English-language published studies.

RESULTS

We included 14 studies, including two RCTs with a total of 1813 women, published between 2003 and 2023 with a recruitment period between 1998 and 2020. In PDS, there were no differences in progression-free survival (PFS) between HIPEC and controls [MD -5.53 months [95% CI -19.91 to 8.84 months]; I2 = 96%]. Conversely, in patients treated with NACT, pooled results showed a significant survival advantage in terms of progression-free survival (PFS) and overall survival (OS) in the combined HIPEC plus IDS group rather than surgery alone [PFS: MD 4.68 months (95% CI 3.49 to 5.86 months, I2 = 95%); OS: MD 11.81 months (95% CI 9.34 to 14.27 months); I2 = 97%]. Concerning ROC patients, pooled MD did not show either a significant PFS difference between intervention and controls [MD 2.68 months (95% CI 433 to 9.70 months); I2 = 95%], and OS significant difference (MD 6.69 months [95% CI -9.09 to 22.47 months]; I2 = 98%). Severe post-operative complications (≥grade 3) were available in 10 studies, accounting for 1108 women. Overall, there was a slightly but significantly increased risk with the combined approach compared to controls [RR 1.26 (95% CI 1.02 to 1.55); I2 = 0%].

CONCLUSIONS

The combination of HIPEC with cytoreductive surgery prolongs OS and PFS in advanced epithelial ovarian cancer after NACT with acceptable morbidity. However, additional trials are still needed to determine the effectiveness of HIPEC in primary and recurrence settings. In the era of personalized medicine, the correlation between the efficacy of HIPEC and biological and molecular findings represents a challenge for the future of ovarian cancer.

Prognostic Value of Lymph Node Parameters in Elderly Patients With Stage III Serous Ovarian Cancer Based on Competing Risk Model

OBJECTIVES

Competing risk models were used in this study. The purpose of this study was to assess the predictive usefulness of lymph node characteristics in elderly patients with stage III serous ovarian cancer.

METHODS

We conducted a retrospective analysis on 148,598 patients from 2010 to 2016 using the surveillance, epidemiology, and end results database. Lymph node characteristics were collected and examined, including the number of lymph nodes retrieved the number of lymph nodes examined (ELN) and the number of positive lymph nodes (PN). Using competing risk models, we evaluated the connection between these variables and overall survival (OS) and disease-specific survival (DSS).

RESULTS

This study included a total of 3457 ovarian cancer patients. Multivariate analysis using the COX proportional hazards model found that ELN>22 was an independent predictive factor for both OS (hazard ratio [HR] [95% CI]=0.688 [0.553 to 0.856], P <0.05) and DSS (HR [95% CI]=0.65 [0.512 to 0.826], P <0.001), PN>8 was identified as a significant risk factor for both OS (HR [95% CI]=0.908 [0.688 to 1.199], P =0.497) and DSS (HR [95% CI]=0.926 [0.684 to 1.254], P =0.62). Subsequently, using the competing risk model, ELN>22 was found to be an independent protective factor for DSS (HR [95% CI]=0.738 [0.574 to 0.949], P =0.018), while PN>8 was identified as a risk factor for DSS (HR [95% CI]=0.999 [0.731 to 1.366], P =1).

CONCLUSIONS

Our findings demonstrate the robustness of the competing risk model to evaluate the results of the COX proportional hazards model analysis.

Prediction for 2-year mortality of metastatic ovarian cancer patients based on surveillance, epidemiology, and end results database

Aim

To establish prediction models for 2-year overall survival of ovarian cancer patients with metastasis.

Methods

In total, 4,929 participants from Surveillance, Epidemiology, and End Results (SEER) database were randomly divided into the training set (n = 3,451) and the testing set (n = 1,478). Univariate and multivariable regression were conducted in the training set to identify predictors for 2-year overall survival of metastatic ovarian cancer patients. The C-index was calculated for assessing the performance of the models. The nomogram for the model was plotted. The prediction value of the model was validated in the testing set. Subgroup analysis were performed concerning surgery and chemotherapy status of patients and the metastatic site of ovarian cancer in the testing set. The calibration curves were plotted and the decision curve analysis (DCA) were conducted.

Results

At the end of follow-up, 2,587 patients were survived and 2,342 patients were dead within 2 years. The 2-year survival rate was 52.5%. The prediction models were constructed based on predictors including age, radiation, surgery and chemotherapy, CA125, and bone, liver, and lung metastasis. The prediction model for 2-year overall survival of ovarian cancer patients with metastasis showed good predictive ability with the C-index of the model of 0.719 (95% CI: 0.706–0.731) in the training set and 0.718 (95% CI: 0.698–0.737) in the testing set. In terms of patients with bone metastasis, the C-index was 0.740 (95% CI: 0.652–0.828) for predicting the 2-year overall survival of ovarian cancer patients. The C-index was 0.836 (95% CI: 0.694–0.979) in patients with brain metastasis, 0.755 (95% CI: 0.721–0.788) in patients with liver metastasis and 0.725 (95% CI: 0.686–0.764) in those with lung metastasis for predicting the 2-year overall survival of ovarian cancer patients.

Conclusion

The models showed good predictive performance for 2-year overall survival of metastatic ovarian cancer patients.

Systematic lymph node dissection during interval debulking surgery for advanced epithelial ovarian cancer: a systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of systematic lymph node dissection (SyLND) at the time of interval debulking surgery (IDS) for advanced epithelial ovarian cancer (AEOC).

METHODS

Systematic literature review of studies including AEOC patients undergoing SyLND versus selective lymph node dissection (SeLND) or no lymph node dissection (NoLND) after neoadjuvant chemotherapy (NACT). Primary endpoints included progression-free survival (PFS) and overall survival (OS). Secondary endpoints included severe postoperative complications, lymphocele, lymphedema, blood loss, blood transfusions, operative time, and hospital stay.

RESULTS

Nine retrospective studies met the eligibility criteria, involving a total of 1,660 patients: 827 (49.8%) SyLND, 490 (29.5%) SeLND, and 343 (20.7%) NoLND. The pooled estimated hazard ratios (HR) for PFS and OS were, respectively, 0.88 (95% confidence interval [CI]=0.65-1.20; p=0.43) and 0.80 (95% CI=0.50-1.30; p=0.37). The pooled estimated odds ratios (ORs) for severe postoperative complications, lymphocele, lymphedema, and blood transfusions were, respectively, 1.83 (95% CI=1.19-2.82; p=0.006), 3.38 (95% CI=1.71-6.70; p<0.001), 7.23 (95% CI=3.40-15.36; p<0.0001), and 1.22 (95% CI=0.50-2.96; p=0.67).

CONCLUSION

Despite the heterogeneity in the study designs, SyLND after NACT failed to demonstrate a significant improvement in PFS and OS and resulted in a higher risk of severe postoperative complications.

TRIAL REGISTRATION

PROSPERO Identifier: CRD42022303577.

Differences in Treatment Modalities and Prognosis of Elderly Patients with Ovarian Cancer: A Two-Center Propensity Score-Matched Study

Background: The prognosis of older patients with ovarian cancer is poor. We evaluated the effect of chronological age and different treatment characteristics on the prognosis of older patients with ovarian cancer; Methods: The study retrospectively analyzed patients aged over 60 years who underwent cytoreduction followed by platinum-based adjuvant chemotherapy between January 2011 and December 2019 in two national centers in China. Propensity score matching (PSM, 1:1) was performed to stratify the comorbidity- and treatment-related factors. The Kaplan−Meier method was employed to estimate progression-free survival (PFS) in the original cohort and the cohort after PSM; Results: A total of 324 patients were evaluated. The Age ≥ 70 group often received more neoadjuvant chemotherapy (62.3% vs. 31.2%, p < 0.001), more discontinuation of adjuvant chemotherapy (31.2% vs. 10.8%, p < 0.001), and had more severe chemotherapy-related toxicity (45.6% vs. 34.2%, p = 0.040) than the Age < 70 group. After matching, the PFS of the Age < 70 group was not significantly different from the Age ≥ 70 group (median PFS = 12.4 and 11.9 months, respectively, p = 0.850). Furthermore, the advanced FIGO stage, non-R0 cytoreduction, and discontinuation of adjuvant chemotherapy were all found to be poor prognostic factors. Serum albumin level <40 g/L (HR = 2.441, p = 0.018) and age ≥ 70 years (HR = 2.639, p = 0.008) led to more severe chemotherapy-related toxicity. Additionally, poor renal function (HR = 5.128, p = 0.002) was in association with discontinuation of adjuvant chemotherapy; Conclusions: The chronological age of older patients cannot be seen as a poor prognostic factor. Older patients may benefit most from R0 cytoreduction followed by the completion of chemotherapy. Postoperative poor renal function and serum albumin level <40 g/L may help predict the discontinuation of adjuvant chemotherapy.