Is complete surgical staging necessary in patients with stage I mucinous epithelial ovarian tumors?

Outcomes of patients with early stage mucinous ovarian carcinoma: a Dutch population-based cohort study comparing expansile and infiltrative subtypes

OBJECTIVE

This study aimed to assess the outcomes of patients with early stage mucinous ovarian carcinoma based on subtype (expansile vs infiltrative).

METHODS

We retrospectively analyzed all surgically treated patients with mucinous ovarian carcinoma in the Netherlands (2015-2020), using data from national registries. Subtypes were determined, with any ambiguities resolved by a dedicated gynecologic pathologist. Patients with International Federation of Gynecology and Obstetrics (FIGO) stage I were categorized into full staging, fertility-sparing, or partial stagings. Outcomes were overall survival and recurrence free survival, and recurrence rates.

RESULTS

Among 409 identified patients, 257 (63%) had expansile and 152 (37%) had infiltrative tumors. Patients with expansile tumors had FIGO stage I more frequently (n=243, 95% vs n=116, 76%, p<0.001). For FIGO stage I disease, patients with expansile and infiltrative tumors underwent similar proportions of partial (n=165, 68% vs n=78, 67%), full (n=32, 13% vs n=23, 20%), and fertility-sparing stagings (n=46, 19% vs n=15, 13%) (p=0.139). Patients with expansile FIGO stage I received less adjuvant chemotherapy (n=11, 5% vs n=24, 21%, p<0.001), exhibited better overall and recurrence free survival (p=0.006, p=0.012), and fewer recurrences (n=13, 5% vs n=16, 14%, p=0.011). Survival and recurrence rates were similar across the expansile extent of staging groups. Patients undergoing fertility-sparing staging for infiltrative tumors had more recurrences compared with full or partial stagings, while recurrence free survival was similar across these groups. Full staging correlated with better overall survival in infiltrative FIGO stage I (p=0.022).

CONCLUSIONS

While most patients with FIGO stage I underwent partial staging, those with expansile had better outcomes than those with infiltrative tumors. Full staging was associated with improved overall survival in infiltrative, but not in expansile FIGO stage I. These results provide insight for tailored surgical approaches.

Update on Prognostic and Predictive Markers in Mucinous Ovarian Cancer

This review includes state-of-the-art prognostic and predictive factors of mucinous ovarian cancer (MOC), a rare tumor. Clinical, pathological, and molecular features and treatment options according to prognosis are comprehensively discussed. Different clinical implications of MOC are described according to the The International Federation of Gynecology and Obstetrics (FIGO) stage: early MOC (stage I-II) and advanced MOC (stage III-IV). Early MOC is characterized by a good prognosis. Surgery is the mainstay of treatment. Fertility-sparing surgery could be performed in patients who wish to become pregnant and that present low recurrence risk of disease. Adjuvant chemotherapy is not recommended, except in patients with high-risk clinical and pathological features. Regarding the histological features, an infiltrative growth pattern is the major prognostic factor of MOC. Furthermore, novel molecular biomarkers are emerging for tailored management of early-stage MOC. In contrast, advanced MOC is characterized by poor survival. Radical surgery is the cornerstone of treatment and adjuvant chemotherapy is recommended, although the efficacy is limited by the intrinsic chemoresistance of these tumors. Several molecular hallmarks of advanced MOC have been described in recent years (e.g., HER2 amplification, distinct methylation profiles, peculiar immunological microenvironment), but target therapy for these rare tumors is not available yet.

Outcome and prognostic factors of unexpected ovarian carcinomas

BACKGROUND

We investigated risk factors influencing the outcome of unexpected ovarian carcinomas.

METHODS

We reviewed the ovarian carcinoma patients treated at atertiary medical institution between 2000 and 2017 and analyze the clinico-pathological characteristics, treatment strategies, recurrence status, and outcome.

RESULTS

A total of 112 women (65 primary laparoscopic surgery [LSC] and 47 laparotomic surgery [LAPA]) were included in the analysis. The LSC group had smaller ovarian tumors (10.5 ± 7.3 cm vs. 16.6 ± 8.7 cm, p = 0.031) and higher incidence of subsequent staging surgery (56.9% vs. 25.5%, p = 0.0001) compared to the LAPA group. There were 98/112 (86.6%) of early stages (I/II) diseases. The difference between the recurrent rate (27.7% vs. 31.9%), disease-free survival (DFS), and overall survival (OS) were not significant among surgical groups. In the multivariate analysis, FIGO stage (stage II hazard ratio [HR] 6.61, p = 0.007; stage III HR 8.40, p = 0.002) was the only prognostic factor for DFS. FIGO stage (stage II HR 20.78, p = 0.0001; stage III HR 7.99, p = 0.017), histological type (mucinous HR 12.49, p = 0.036), and tumor grade (grade 3 HR 35.01, p = 0.003) were independent prognostic factors for OS, while women with latency >28 days from primary to staging surgery had significantly poorer OS (p = 0.008). Women with latency >28 days between primary surgery and adjuvant chemotherapy had similar DFS (p = 0.31) and a trend of poorer OS (p = 0.064).

CONCLUSIONS

The prognosis of unexpected ovarian cancer is independent from the primary surgical procedure and comprehensive staging surgery should be performed at close proximity after the diagnosis of unexpected ovarian malignancy.

Surgical treatment for clinical early-stage expansile and infiltrative mucinous ovarian cancer: can staging surgeries safely be omitted?

PURPOSE OF REVIEW

Mucinous ovarian cancers (MOCs) are categorized into infiltrative and expansile subtypes. These subtypes have different characteristics and prognoses. Patients with clinical early-stage disease of both subtypes currently undergo surgical staging (peritoneal washing, biopsies, omentectomy). Peritoneal and lymph node metastases of expansile MOC are rare, but whereas lymph node sampling (LNS) is omitted in these patients, peritoneal staging is not. Therefore, we collected all available MOC data to determine whether staging surgeries could safely be omitted in clinical early-stage expansile and infiltrative MOC.

RECENT FINDINGS

Current literature confirms that peritoneal metastases are rare in expansile MOC: more than 90% of patients have early-stage disease. Only 3.4% of the patients with clinical early-stage expansile MOC had positive peritoneal washings at surgical staging. Patients with infiltrative MOC were diagnosed more frequently with advanced-stage disease (21-54%). Moreover, upstaging clinical early-stage infiltrative MOC based on positive cytology, peritoneum and omentum metastases occurred in 10.3% of the patients. Therefore, we recommend that patients with early-stage infiltrative MOC undergo peritoneal staging and LNS. However, in addition to omitting LNS, we can also safely recommend omitting peritoneal staging in patients with clinical early stage expansile MOC.

SUMMARY

Peritoneal metastases are rare in clinical early-stage expansile MOC and peritoneal staging can therefore safely be omitted.

Feasibility and safety of fertility-sparing surgery in epithelial ovarian cancer with dense adhesion: a long-term result from a single institution

OBJECTIVE

We investigated the feasibility and safety of fertility-sparing surgery (FSS) in patients with epithelial ovarian cancer (EOC) with dense adhesions.

METHODS

Patients were divided into cases with and without dense adhesions in this retrospective study.

RESULTS

Of the 95 eligible patients, 29 patients had dense adhesions. Mean age, proportion of staging procedure, distribution of histologic type, and co-presence of endometriosis were different (p=0.003, 0.033, 0.011, and 0.011, respectively). The median follow-up period was 57.8 (0.4-230.0) months. There were no differences in the rates of recurrence (21.2% vs. 20.7%, p=1.000) or death (16.7% vs. 6.9%, p=0.332) between the 2 groups. There was no difference in the pattern of recurrence or in disease-free survival (DFS) and overall survival (OS) between the 2 groups. In multivariate analysis, pretreatment cancer antigen-125 >35 U/mL and International Federation of Gynecology and Obstetrics stage IC were significant factors of worse DFS and OS, while dense adhesion was not a prognostic factor for both DFS (hazard ratio [HR]=0.9; 95% confidence interval [CI]=0.3-2.7; p=0.792) and OS (HR=0.2; 95% CI=0.1-1.8; p=0.142), nor were age, proportion of staging procedure, histologic type, and co-presence of endometriosis. Moreover, the distribution of those 2 significant prognostic factors was not different between the 2 groups. Dense adhesions were subgrouped into non-tumor and tumor associated dense adhesions for further analysis and the results were same.

CONCLUSION

FSS is feasible and safe in EOC, regardless of the presence of dense adhesions.

Predicting Lymph Node Involvement in Borderline Ovarian Tumors with a Quantitative Model and Nomogram: A Retrospective Cohort Study

Purpose

This study aimed to establish a predictive model for lymph node involvement (LNI) in patients with borderline ovarian tumor (BOT) using clinicopathological factors.

Patients and Methods

We collected clinical data from consecutive patients who underwent lymphadenectomy for BOT between 2001 and 2018 and analyzed their clinicopathological features. Multivariate logistic regression was used to identify all independent risk factors associated with LNI; these were then incorporated into the prediction model.

Results

In total, we included 248 patients with BOT who were undergoing lymphadenectomy. These were divided into a training cohort (n=174) and a validation cohort (n=74). When considering histopathological data, 16 and 5 patients were identified to have LNI in the training and validation cohorts, respectively. Overall, 13.5% (21/156) patients with serous BOT had LNI while 0% (0/92) patients with non-serous BOT had LNI. We identified several predictors of LNI: the largest tumor being ≥ 12.2cm in diameter, the presence of lesions on the ovarian surface, and the presence of pelvic or abdominal lesions. We created a prediction model and nomogram that incorporated these three risk factors for serous BOT. The model achieved good discriminatory abilities of 0.951 and 0.848 when predicting LNI in the training and validation cohorts, respectively. The LNI-predicting nomogram had an area under curve (AUC) of 0.951 and generated well-fitted calibration curves.

Conclusion

Non-serous BOT may not require lymphadenectomy as part of surgical staging. The individual risk of LNI in patients with serous BOT can be accurately estimated using our prediction model and nomogram. The use of LNI criteria provides a practical way to support the clinician in making an optimal decision relating to surgical scope for patients with BOT.

Lymphadenectomy for early-stage mucinous ovarian carcinoma

OBJECTIVES

There is evidence to suggest that the rate of lymph node metastases in patients with ovarian mucinous tumors is rare. The objective of this study was to investigate the prevalence of regional lymph node metastases among patients with apparent stage IA and IC mucinous ovarian carcinoma.

METHODS

A retrospective cohort study was performed and included patients from the National Cancer Database with apparent stage IA and IC mucinous ovarian tumors who underwent surgery between January 1, 2004 and December 31, 2015. Data collected included demographics, surgical procedures, and pathologic characteristics. The primary outcome was the effect of tumor stage, grade, and size on the risk of lymph node metastases. Categorical and continuous variables were compared using the χ² and Mann-Whitney U tests, respectively.

RESULTS

A total of 4379 patients were identified: 3088 and 1213 with stage IA and IC disease, respectively, with an additional 78 patients who were stage I Not Otherwise Specified (NOS). Lymphadenectomy was performed in 70.6% of patients with stage IA and 70.3% of patients with stage IC cancers. Stratifying by grade, 68.4%, 71.3%, and 72.8% of patients with grades 1, 2, and 3 tumors underwent a lymphadenectomy, respectively. Furthermore, lymphadenectomy was performed in 64.9% of patients with tumors <10 cm and 72.4% with tumors >10 cm. Lymph node metastases were identified in 1.2% and 1.6% of patients with stage IA and IC disease, respectively (p=0.063). Additionally, metastases were present in 0.6% of patients with grade 1 tumors, 1.1% of patients with grade 2 tumors, and 5.3% of patients with grade 3 tumors (p<0.001). Lastly, 0.9% of patients with tumors <10 cm and 1.4% of patients with tumors >10 cm had lymph node metastases (p=0.19).

CONCLUSIONS

Among patients with mucinous ovarian carcinoma, lymph node metastases are rare. However, metastases are significantly more common in patients with higher grade tumors. These factors may be considered when making decisions regarding the need for lymphadenectomy in early-stage mucinous ovarian tumors.

Ovarian mucinous neoplasms, intestinal type, in premenopausal patients, develop in abnormal ovaries

Although several studies have addressed different aspects of mucinous neoplasms arising in the ovary, such as their clinicopathologic features, immunohistochemical profile, and molecular characteristics, no study has presented an analysis of the ovarian tissue where these neoplasms arise. In this study, we included 196 cases of intestinal-type ovarian mucinous neoplasms in premenopausal patients. Our main goal was to perform a rigorous examination of the ovarian tissue surrounding these neoplasms. We also reviewed the clinicopathologic features of these cases. For comparison, the background ovarian tissue in 85 cases of ovarian serous neoplasm and in 29 cases of metastatic neoplasms to the ovary, as well as 57 normal ovaries, was examined. All the patients in this study, which included those with mucinous and with serous neoplasms primary in the ovary, those with metastatic tumors to the ovaries, and those with normal ovaries, were also premenopausal. Patients affected by ovarian mucinous neoplasms ranged in age from 13 to 52 years (median = 36 years). Nulligravidity was seen in 50%, 32%, and 22% of patients with mucinous carcinomas, mucinous borderline neoplasms, and mucinous cystadenomas, respectively. Ovarian mucinous intestinal neoplasms arise in abnormal ovaries characterized by two important features: (1) an abnormal ovarian cortex, seen in 95% of the cases, which is hypocellular or with no distinction between the cellular cortex and medulla, and (2) a remarkable paucity of primordial follicles. The abnormalities detected in the background ovarian tissue might provide insights into the tumorigenesis of these neoplasms and might facilitate their distinction from metastasis to the ovary, in premenopausal patients.

Low value of staging in detecting extraovarian occult metastasis in mucinous borderline ovarian tumors

OBJECTIVES

Staging procedure in borderline ovarian tumors is a topic of controversy. Upstaging in non-serous borderline ovarian tumors that are confined to the ovary is rare. The aim of this study was to assess the impact of surgical staging on clinical outcomes in mucinous borderline ovarian tumors.

METHODS

This was a retrospective study conducted at the Asan Medical Center, Seoul, Korea between January 1990 and December 2015, that included 432 patients with mucinous borderline ovarian tumors and at least 6 months follow-up. These patients were divided into a 'staging group' and 'unstaged group'. The staging group referred to patients who, in addition to hysterectomy and/or adnexal surgery, underwent at least one of the following: cytology, omental biopsy/omentectomy, peritoneal biopsy, lymph node biopsy/lymphadenectomy, or appendectomy. The unstaged group referred to patients who did not undergo any staging procedure but underwent adnexal surgery (cystectomy or oophorectomy).

RESULTS

Median patient age was 40 (range 9-87) years. A total of 367 patients (85%) underwent a staging procedure (staging group) and 65 (15.0%) patients did not (unstaged group). Among the staging group, 258, 4, 100, and 5 patients were FIGO stage IA, IB, IC, or II-III, respectively. Overall recurrence was confirmed in 15 patients and median time to recurrence was 13.4 (range 0.4-127.3) months. One patient was in the unstaged group and had borderline recurrence. Fourteen were in the staging group, and 11 of them had borderline and three had invasive recurrence. Extraovarian disease was found at recurrence only in two patients. There was no significant difference in recurrence-free survival (p=0.39) and in overall survival between the staging group and the unstaged group (p=0.40). In total, 16 (4.4%) of 367 patients who underwent a staging procedure were upstaged.

CONCLUSION

Staging in mucinous borderline ovarian tumors may be omitted if there is no obvious evidence of gross extraovarian disease.

Significance of lymph node ratio on survival of women with borderline ovarian tumors

PURPOSE

To assess the qualitative and quantitative measures of the effect of pelvic lymph node involvement on survival of women with borderline ovarian tumors (BOTs).

METHODS

This is a retrospective study examining the Surveillance, Epidemiology, and End Results Program between 1988 and 2003. Women with stage T1-3 BOTs who had results of pelvic lymph node status at surgery were included. The effect of lymph node involvement on cause-specific survival (CSS) was evaluated using multivariable analysis with the following approaches: (1) any involvement, (2) involvement of multiple nodes (≥ 2 nodes), and (3) lymph node ratio (LNR), defined as the ratio of the number of tumor-containing lymph nodes to the total number of harvested lymph nodes.

RESULTS

A total of 1524 women were examined for analysis. Median count of sampled nodes was 8 (interquartile range 3-15), and there were 81 (5.3%, 95% confidence interval [CI] 4.2-6.4) women who had lymph node involvement. Median follow-up was 15.8 (interquartile range 13.8-18.9) years, and 83 (5.4%) women died of BOTs. After controlling for age, histology, stage, and tumor size, only LNR remained an independent prognostic factor for decreased CSS (adjusted hazard ratio [HR] per percentage unit 1.015, 95% CI 1.003-1.026, P = 0.014), whereas any involvement (adjusted HR 1.700, 95% CI 0.843-3.430, P = 0.138) and involvement of multiple nodes (adjusted HR 1.644, 95% CI 0.707-3.823, P = 0.249) did not. On cutoff analysis, LNR ≥ 13% had the largest magnitude of significance on multivariable analysis of CSS (adjusted HR 2.399, 95% CI 1.163-4.947, P = 0.018).

CONCLUSION

Our study suggests that high pelvic LNR may be a prognostic factor associated with decreased CSS in women with BOTs.

Impact of surgical restaging on recurrence in patients with borderline ovarian tumors: A meta-analysis

OBJECTIVE

The benefits of restaging surgery for patients with a borderline ovarian tumor (BOT) discovered on initial surgery are debatable. We performed a meta-analysis to evaluate the role of restaging surgery on recurrence in patients with BOTs.

STUDY DESIGN

We systematically reviewed published studies comparing restaging surgery and incomplete surgery in BOT patients from January 1985 to December 2017. Endpoints were recurrence and mortality rates. Study design features that possibly affected participant selection, reporting of recurrence and death, and manuscript publication were assessed. For pooled estimates of the effect of restaging surgery on recurrence, fixed-effect meta-analytical models were used.

RESULTS

Of the 577 articles initially selected, four retrospective observational studies (Restaging group: 166 patients; Non-Restaging group: 394 patients) met our research criteria. No significant differences in terms of recurrence between the two groups were observed (pooled Peto Odds Ratio [OR] = 0.88; 95 % confidence interval [CI]: 0.41-1.92). The number of deaths was insufficient for statistical analysis.

CONCLUSIONS

This meta-analysis based on retrospective studies, suggests that restaging surgery does not significantly reduce recurrence in patients with BOT.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Epidemiology and Risk Factors of Relapse, Follow-up and Interest of a Completion Surgery]

OBJECTIVE

To provide clinical practice guidelines from the French college of obstetrics and gynecology (CNGOF) based on the best evidence available, concerning epidemiology of recurrence, the risk or relapse and the follow-up in case of borderline ovarian tumor after primary management, and evaluation of completion surgery after fertility sparing surgery.

MATERIAL AND METHODS

English and French review of literature from 2000 to 2019 based on publications from PubMed, Medline, Cochrane, with keywords borderline ovarian tumor, low malignant potential, recurrence, relapse, follow-up, completion surgery. From 2000 up to this day, 448 references have been found, from which only 175 were screened for this work.

RESULTS AND CONCLUSION

Overall risk of recurrence with Borderline Ovarian Tumour (BOT) may vary from 2 to 24% with a 10-years overall survival>94% and risk of invasive recurrence between 0.5 to 3.8%. Age<40 years (level of evidence 3), advanced initial FIGO stage (LE3), fertility sparing surgery (LE2), residual disease after initial surgery for serous BOT (LE2), implants (invasive or not) (LE2) are risk factors of recurrence. In case of conservative treatment, serous BOT had a higher risk of relapse than mucinous BOT (LE2). Lymphatic involvement (LE3) and use of mini invasive surgery (LE2) are not associated with a higher risk of recurrence. Scores or Nomograms could be useful to assess the risk of recurrence and then to inform patients about this risk (gradeC). In case of serous BOT, completion surgery is not recommended, after conservative treatment and fulfillment of parental project (grade B). It isn't possible to suggest a recommendation about completion surgery for mucinous BOT. There is not any data to advise a frequency of follow-up and use of paraclinic tools in general case of BOT. Follow-up of treated BOT must be achieved beyond 5 years (grade B). A systematic clinical examination is recommended during follow-up (grade B), after treatment of BOT. In case of elevation of CA-125 at diagnosis use of CA-125 serum level is recommended during follow-up of treated BOT (grade B). When a conservative treatment (preservation of ovarian pieces and uterus) of BOT is performed, endovaginal and transabdominal ultrasonography is recommended during follow-up (grade B). There isn't any sufficient data to advise a frequency of these examinations (clinical examination, ultrasound and CA-125) in case of treated BOT.

CONCLUSION

Risk of relapse after surgical treatment of BOT depends on patients' characteristics, type of BOT (histological features) and modalities of initial treatment. Scores and nomogram are useful tools to assess risk of relapse. Follow-up must be performed beyond 5 years and in case of peculiar situations, use of paraclinic evaluations is recommended.

Comparison of Laparoscopic and Open Surgery for Patients With Borderline Ovarian Tumors

OBJECTIVES

The aim of this study was to compare surgical and oncologic outcomes of open and laparoscopic surgery in patients with borderline ovarian tumors (BOTs).

MATERIALS AND METHODS

This study included patients with BOTs who underwent open (n = 433) or laparoscopic (n = 210) surgery between 1990 and 2015. Surgical outcomes, perioperative morbidity, and disease-free survival and overall survival were compared.

RESULTS

There was no significant difference in age, histologic type of tumor, and laterality of tumor. However, body mass index was slightly higher for the open surgery group (P = 0.046). The open surgery group had a higher serum cancer antigen 125 level (P < 0.001), larger tumor size (P < 0.001), more frequent radical surgery (P = 0.001), higher stage (P = 0.034), and higher incidence of invasive implants (P = 0.035). The operative time (P < 0.001), time interval to return of bowel movement (P < 0.001), and length of postoperative hospital stay (P < 0.001) were significantly shorter and estimated blood loss was significantly less (P < 0.001) in the laparoscopic group. Perioperative complications were documented in 5 (2.4%) patients in the laparoscopic surgery group and 17 (3.9%) in the open surgery group (P = 0.064). Twenty-three (5.3%) patients in the open surgery group and 9 (4.3%) in the laparoscopic surgery group had recurrence (P = 0.902) at a median follow-up of 57 months. The 10-year disease-free survival was 96% and 97% for the open and laparoscopic groups, respectively (P = 0.851), with no significant difference between the groups after adjusting for independent factors (odds ratio, 1.0; 95% confidence interval, 0.4-2.4; P = 0.999). The 10-year overall survival was 99% for both groups, respectively (P = 0.441).

CONCLUSIONS

Laparoscopic surgery and open surgery showed similar survival outcomes in BOTs. The surgical outcomes of laparoscopic surgery were more favorable.

An Evaluation of Frozen Section and Lymph Node Dissection Results for Mucinous Ovarian Tumors

OBJECTIVES

Intraoperative frozen section has greater than 90% accuracy for ovarian tumors; however, mucinous histology has been shown to be associated with increased frozen section inaccuracy. Recent data demonstrate that primary ovarian mucinous carcinomas have no lymph node involvement, even when extraovarian disease is present, and therefore may not require lymph node dissection. Our primary objective is to evaluate the accuracy of identifying mucinous histology on frozen section.

METHODS/MATERIALS

A cross-sectional review of mucinous ovarian tumors in surgical patients at one institution from 2006 to 2016 was performed. Cases reporting a mucinous ovarian tumor on frozen section or final pathology were identified. Frozen section results were compared with final diagnosis to calculate concordance rates. Analyses with χ and t tests were performed to identify variables associated with pathology discordance.

RESULTS

A total of 126 mucinous ovarian tumors were identified. Of these, 106 were reported as mucinous on frozen section and 103 (97.2%) were concordant on final pathology. Discordant cases included 2 serous and 1 clear cell tumor. Among the 103 mucinous tumors, classification as malignant, borderline, or benign was concordant in 74 (71.8%) of 103 cases, whereas 22 (21.4%) of 103 were discordant and 7 (6.8%) were deferred to final pathology. Lymph node dissection was performed in 33 cases; the only case with lymph node metastasis was a gastrointestinal mucinous adenocarcinoma. Discordance between frozen section and final pathology was associated with larger tumor size and diagnosis other than benign: discordant cases had a mean tumor size of 21.7 cm compared with 14.4 cm for concordant cases (P < 0.001), and 93.5% of discordant cases were borderline or malignant, compared with 30.5% of concordant cases (P < 0.001).

CONCLUSIONS

Intraoperative identification of mucinous histology by frozen section is reliable with a concordance rate to final pathology of 97.2%. No lymph node metastases were present in any malignant or borderline primary ovarian cases.

Survival Benefit of Adjuvant Radiotherapy: An Analysis of Low-Stage Invasive Ovarian Mucinous Carcinomas

OBJECTIVE

Our aim was to evaluate the population-based outcomes of stages I and II invasive ovarian mucinous carcinomas (MCs) treated with adjuvant platinum-based chemotherapy and abdominopelvic radiotherapy (XRT).

METHODS

International Federation of Gynecology and Obstetrics stage I/II MC cases referred to the British Columbia Cancer Agency between 1984 and 2014 were reviewed. Chemotherapy (minimum of 3 cycles) and XRT were the institutional policy for stages IA/B (grade 2/3) and IC/II (any grade). Physician patterns of practice determined XRT use in eligible patients, allowing for the comparison of outcomes based on receipt of XRT treatment on disease-free survival (DFS) and overall survival (OS).

RESULTS

We identified 129 patients. Univariate analyses on substages IA, IC no rupture, IC with intraoperative rupture, and IC with preoperative rupture demonstrated 10-year DFS rates of 67%, 67%, 67%, and 27% (P = 0.004), respectively, and OS rates of 72%, 72%, 67%, and 38% (P = 0.01), respectively. For all patients, adjuvant XRT demonstrated improved 10-year DFS (78% vs 36%, P = 0.05) and OS (83% vs 36%, P = 0.02). Subgroup analysis did not detect a benefit of adjuvant therapy for stage IA grade 1/2. Multivariate analysis confirmed the benefit of XRT on DFS (hazard ratio, 0.14; 95% confidence interval, 0.02-0.98; P = 0.047) and a trend to improved OS (hazard ratio, 0.12; 95% confidence interval, 0.009-1.64; P = 0.11), whereas decision tree analysis demonstrated a reduced rate of relapse (33% vs 77%) and death (20% vs 46%) with the use of XRT, exclusive of patients with preoperative rupture.

CONCLUSIONS

This population-based retrospective study is the first to demonstrate that the use of adjuvant abdominopelvic XRT after chemotherapy can improve survival in patients diagnosed as having stage I/II MC. Patients with stage IA grade 1 and grade 2 MC can have adjuvant therapy omitted.

Staging surgery in early-stage ovarian mucinous tumors according to expansile and infiltrative types

The aim of this study is to determine the value of surgical staging for the two histologic types (expansile or infiltrative) of apparent stage I mucinous ovarian carcinoma. We retrospectively analyzed patients treated from 1976 and 2016 for apparent macroscopic stage I ovarian mucinous carcinoma. Extra-ovarian disease and tumors that metastasized to the ovaries were excluded. Two expert pathologists performed pathologic reviews of tumor data, according to 2014 WHO classification criteria. Tumors were typed as expansile or infiltrative and clinical and histologic characteristics were studied. The value of staging procedures (peritoneal and nodal) was based on the rate of microscopic involvement in macroscopically normal specimens.

Of 114 cases reviewed, 46 were excluded (26 with macroscopic stage > I; 20 inaccessible for pathologic review). Of 68 patients included, 29 had expansile and 39 had infiltrative types. 27 patients received one-step surgery and 41 received restaging surgery. 52 patients received “complete” peritoneal surgical staging (including cytology, peritoneal biopsies, and an omentectomy or large omental biopsies). 24 underwent appendectomies and 31 underwent lymphadenectomies (8 expansile and 23 infiltrative). Before histologic analyses of staging specimens, 35 had “initial” stage IA and 33 had IC disease. After histologic analyses of lymph nodes, 4 cases (17%, all infiltrative) had nodal involvement, and 2 showed microscopic peritoneal disease (1 omentum and 1 right diaphragm peritoneum). Three patients were upstaged based on isolated positive peritoneal cytology.

To conclude, peritoneal staging procedures are required for both types of mucinous ovarian carcinoma. Lymphadenectomy could be omitted in expansile, but required in infiltrative type.

•

Interest of staging procedures according to both subtypes of mucinous ovarian cancer are studied.

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52 patients underwent peritoneal surgical staging and 31 a lymphadenectomies.

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After lymphadenectomy 4 cases (all infiltrative) had nodal involvement and 5 peritoneal disease.

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Peritoneal staging procedures are required for both types of mucinous ovarian carcinoma.

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Lymphadenectomy could be omitted in expansile subtype.

Is lymphadenectomy necessary in mucinous ovarian cancer? A single institution experience

BACKGROUND

According to the International Federation of Gynecology and Obstetrics (FIGO) guidelines, every patient diagnosed with ovarian cancer (OC) should undergo a complete staging procedure to adequately assess tumor spread. The role of lymphadenectomy in the initial management of primary early mucinous ovarian cancer (MOC) remains unclear.

OBJECTIVE

To describe the prevalence of pelvic and para-aortic node metastases in MOC.

MATERIALS AND METHODS

The records of patients with MOC treated at our Institute during January 2005 to December 2011 were assessed. A descriptive and comparative analysis was conducted. Overall survival (OS) and diseases-free period (DFP) were calculated with the Kaplan-Meier method and were compared with the log-rank test.

RESULTS

Of 31 patients with MOC, 14 (45.16%) underwent lymphadenectomy, obtaining 190 pelvic nodes, with a median of 9 pelvic lymph nodes removed per patient (interquartile range = 15). There was no evidence of metastatic disease in the dissected pelvic nodes.

CONCLUSION

These results suggest that complete surgical staging with lymph node dissection has no effect on recurrence, disease-free period, and overall survival of patients with early stage MOC.

Surgical lymph node assessment in mucinous ovarian carcinoma staging: a systematic review and meta-analysis

BACKGROUND

The proportion of women with mucinous ovarian carcinoma in whom nodal metastases are identified during staging remains unclear.

OBJECTIVES

To review the literature on surgical lymph node assessment during staging of women diagnosed with mucinous ovarian carcinoma.

SEARCH STRATEGY

A systematic search using synonyms of 'mucinous ovarian carcinoma' and 'lymph node assessment' was conducted in PubMed, Scopus, Embase and the Cochrane Library.

SELECTION CRITERIA

When they covered ten or more mucinous ovarian carcinoma cases, staging surgery and minimally one of the following outcomes: prevalence of metastases, stage shift or survival data.

DATA COLLECTION AND ANALYSIS

Studies were quality evaluated with the Cochrane risk-of-bias assessment tool for non-randomised studies of interventions. Outcomes were pooled using an inverse variance weighted random effects model.

MAIN RESULTS

Sixteen studies were included. In 278 women with mucinous ovarian cancer suspected to be stage I-II, a pooled proportion of 0.8% (95% CI <0.1-2.9%) had lymph node metastases and were upstaged. In those suspected of stage I (n = 184), this proportion was 0.7% (95% CI <0.1-3.8%). No difference (P = 0.287) was found in metastases between sampling at 0.0% (95% CI 0.0-3.3%) and complete pelvic and/or para-aortic lymph node dissection at 1.2% (95% CI <0.1-4.2%). One study directly compared the survival of patients staged with and without lymph node dissection and reported no significant difference.

CONCLUSIONS

Surgical lymph node assessment in women suspected of stage I-II mucinous ovarian carcinoma rarely identifies nodal metastases and consequently has no significant impact on staging.

TWEETABLE ABSTRACT

Surgical lymph node assessment in women with stage I-II mucinous ovarian cancer rarely has staging consequences.

Fertility-sparing surgery in epithelial ovarian cancer

Since the last two decades, the feasibility of fertility-sparing surgery in early-stage epithelial ovarian cancer has been explored by several teams. Despite the impossibility of conducting a randomized trial to validate this management, evidence-based data suggest that in selected cases, the preservation of the uterus and at least one part of the ovary does not lead to a high risk of relapse. Conservative surgery maintains organ function, enables patients of childbearing age to preserve their fertility and improves their quality of life. In this review, we analyze the main series in the literature on this topic in order to highlight the selected criteria for conservative management and to summarize oncological and fertility outcomes.

Epithelial Tumors of the Ovary in Children and Teenagers: A Prospective Study from the Italian TREP Project

STUDY OBJECTIVE

To report the clinical findings and treatment results of a series of patients with epithelial tumors of the ovary, registered and treated prospectively in a multi-institutional Italian network (TREP project) on rare tumors in children and adolescent between 2000 and 2014.

DESIGN, SETTING, AND PARTICIPANTS

Data on 16 patients, aged 22 to 206 months, from 7 centers were reviewed. All patients were grouped on the basis of the results of the first surgical approach, according to the Children Oncology Group staging system.

RESULTS

The most frequent symptom was abdominal pain; 3 patients were hospitalized for acute pain after ovarian torsion. Initial surgical treatment was complete in 15 of 16, and a biopsy was performed in 1 of 16. The histology examination revealed 8 benign tumors (7 mucinous cystadenomas and 1 serous cystadenoma) and 8 borderline tumors (2 serous and 6 mucinous). Fifteen of 16 patients maintained the complete remission after surgical treatment alone; 1 affected by Proteus syndrome died consequent to the progression of a synchronous Wilms tumor, after a delayed incomplete surgery.

CONCLUSION

Our analysis documented the rarity of these tumors in children and adolescents. No malignant histologies were found. Surgery alone was effective to cure the majority of patients. Considering the rarity of malignant entities, ovary-sparing surgery may be planned when an epithelial tumor is suspected on the basis of the preoperative work-up and intraoperative findings.

Management of Borderline Ovarian Tumors Based on Patient and Tumor Characteristics

BACKGROUND

Borderline ovarian tumors are staged similarly to invasive ovarian tumors.

AIMS

We wanted to better understand which tumors were associated with disease recurrence.

METHODS

We performed a retrospective cohort analysis at a single institution between 1984 and 2005. Cases were confirmed by pathology report. Multivariate analysis was done to evaluate factors associated with recurrence.

RESULTS

143 cases were identified. Mean follow-up was 73.5 months. The overall risk of recurrence was 12%. The hazard ratio for risk of recurrence was highest among seromucinous tumors at 4.04 and lowest among mucinous tumors at 0.53. Only 4% of mucinous tumors, 15.5% of serous tumors and 28.6% of seromucinous tumors recurred. 2% of mucinous tumors had an appendix positive for metastasis. No mucinous tumor had nodal disease.

CONCLUSIONS

Based on our data, a low rate of appendiceal or lymph node involvement was observed in mucinous tumors, as was a low risk of recurrence. Less aggressive staging may be considered if a mucinous tumor is identified on frozen section with a normal-appearing appendix in the absence of pseudomyxoma peritonei. In patients with a serous or a seromucinous tumor, complete surgical staging is recommended. © 2015 S. Karger AG, Basel.

Mucinous tumors of the ovary: current thoughts on diagnosis and management

Mucinous tumors of the ovary represent a spectrum of neoplastic disorders, including benign mucinous cystadenoma, pseudomyxoma peritonei, mucinous tumors of low malignant potential (borderline), and invasive mucinous ovarian carcinoma. These tumors are related closely to each other and are distinct from other histologic subtypes of epithelial ovarian neoplasms from a clinical, histologic, and molecular standpoint. A continuum appears to be present from benign to borderline to malignant, which is different from other types of epithelial ovarian cancer. Mutational profiles are also distinct, as KRAS mutations are common, but p53 and BRCA mutations are infrequent. These characteristics lead to specific biologic behavior and guide both clinical management and research efforts in patients with mucinous ovarian tumors.

Safety of fertility-sparing surgery in primary mucinous carcinoma of the ovary

Purpose

The aim of this study is to evaluate the safety of fertility-sparing surgery as the treatment for patients with primary mucinous epithelial ovarian cancer.

Materials and Methods

A retrospective study of patients with mucinous ovarian cancer between 1991 and 2010 was performed. The demographics and survival outcomes were compared between patients who underwent fertility-sparing surgery and those who underwent radical surgery.

Results

A total of 110 patients underwent primary surgery. At the time of surgery, tumors appeared to be grossly confined to the ovaries in 90 patients, and evidence of metastasis was definite in 20 patients. Of the 90 patients with tumors that appeared to be grossly confined to the ovaries at surgical exploration, 35 (38.9%) underwent fertility-sparing surgery. The Kaplan- Meier curve and the log rank test showed no difference in either recurrence-free survival (p=0.792) or disease-specific survival (p=0.706) between the two groups. Furthermore, there was no significant difference in recurrence-free survival (p=0.126) or disease-specific survival (p=0.377) between the two groups, even when the analysis was limited to women below the age of 40. In a multivariate Cox model, fertility-sparing surgery had no effect on either recurrence-free survival (recurrence hazard ratio [HR], 1.20; 95% confidence interval [CI], 0.25 to 5.71) or disease-specific survival (death HR, 0.88; 95% CI, 0.17 to 4.60).

Conclusion

Fertility-sparing surgery in primary mucinous cancer grossly confined to the ovaries may be a safe option and one not associated with an increase in recurrence or mortality.

Simplified staging laparotomy in FIGO stage 1 epithelial ovarian cancer: follow-up and outcomes in south Wales, U.K

We have conducted a retrospective analysis of FIGO stage 1 ovarian cancer patients in south Wales, who underwent a simplified staging laparotomy without routine nodal sampling and peritoneal biopsies. Patient records from January 2004 to December 2010 were analysed. A total of 116 patients were included in the final analysis. Adjuvant chemotherapy was offered to patients with risk factors for relapse (grade > 1, clear cell histology, or stage > Ia); overall, 89 patients (76.7%) received adjuvant single agent carboplatin (n = 54, 46.5%) or combination chemotherapy (n = 35, 30.2%). After a median follow up of 41 months (range 12-95), 18 patients have relapsed (15.5%), of these 17 had risk factors and 16 had received adjuvant chemotherapy. Eighteen patients have died, of whom 6 of non-cancer related causes without prior relapse. 5-year overall and relapse free survival were 80%. In conclusion, in situations where there are limited resources and operating time constraints, our data suggest that a simplified staging laparotomy approach may be a reasonable compromise in apparently early stage ovarian cancer: this may result in a more aggressive use of chemotherapy, but survival outcomes seem comparable to other series.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Management of a suspicious adnexal mass: a clinical practice guideline

QUESTIONS

What is the optimal strategy for preoperative identification of the adnexal mass suspicious for ovarian cancer? What is the most appropriate surgical procedure for a woman who presents with an adnexal mass suspicious for malignancy?

PERSPECTIVES

In Canada in 2010, 2600 new cases of ovarian cancer were estimated to have been diagnosed, and of those patients, 1750 were estimated to have died, making ovarian cancer the 7th most prevalent form of cancer and the 5th leading cause of cancer death in Canadian women. Women with ovarian cancer typically have subtle, nonspecific symptoms such as abdominal pain, bloating, changes in bowel frequency, and urinary or pelvic symptoms, making early detection difficult. Thus, most ovarian cancer cases are diagnosed at an advanced stage, when the cancer has spread outside the pelvis. Because of late diagnosis, the 5-year relative survival ratio for ovarian cancer in Canada is only 40%. Unfortunately, because of the low positive predictive value of potential screening tests (cancer antigen 125 and ultrasonography), there is currently no screening strategy for ovarian cancer. The purpose of this document is to identify evidence that would inform optimal recommended protocols for the identification and surgical management of adnexal masses suspicious for malignancy.

OUTCOMES

Outcomes of interest for the identification question included sensitivity and specificity. Outcomes of interest for the surgical question included optimal surgery, overall survival, progression-free or disease-free survival, reduction in the number of surgeries, morbidity, adverse events, and quality of life.

METHODOLOGY

After a systematic review, a practice guideline containing clinical recommendations relevant to patients in Ontario was drafted. The practice guideline was reviewed and approved by the Gynecology Disease Site Group and the Report Approval Panel of the Program in Evidence-based Care. External review by Ontario practitioners was obtained through a survey, the results of which were incorporated into the practice guideline.

PRACTICE GUIDELINE

These recommendations apply to adult women presenting with a suspicious adnexal mass, either symptomatic or asymptomatic. IDENTIFICATION OF AN ADNEXAL MASS SUSPICIOUS FOR OVARIAN CANCER: Sonography (particularly 3-dimensional sonography), magnetic resonance imaging (mri), and computed tomography (ct) imaging are each recommended for differentiating malignant from benign ovarian masses. However, the working group offers the following further recommendations, based on their expert consensus opinion and a consideration of availability, access, and harm: Where technically feasible, transvaginal sonography should be the modality of first choice in patients with a suspicious isolated ovarian mass.To help clarify malignant potential in patients in whom ultrasonography may be unreliable, mri is the most appropriate test.In cases in which extra-ovarian disease is suspected or needs to be ruled out, ct is the most useful technique.Evaluation of an adnexal mass by Doppler technology alone is not recommended. Doppler technology should be combined with a morphology assessment.Ultrasonography-based morphology scoring systems can be used to differentiate benign from malignant adnexal masses. These scoring systems are based on specific ultrasound parameters, each with several scores base on determined features. All evaluated scoring systems were found to have an acceptable level of sensitivity and specificity; the choice of scoring system may therefore be made based on clinician preference.As a standalone modality, serum cancer antigen 125 is not recommended for distinguishing between benign and malignant adnexal masses.Frozen sections for the intraoperative diagnosis of a suspicious adnexal mass is recommended in settings in which availability and patient preference allow. SURGICAL PROCEDURES FOR AN ADNEXAL MASS SUSPICIOUS FOR MALIGNANCY: To improve survival, comprehensive surgical staging with lymphadenectomy is recommended for the surgical management of patients with early-stage ovarian cancer. Laparoscopy is a reasonable alternative to laparotomy, provided that appropriate surgery and staging can be done. The choice between laparoscopy and laparotomy should be based on patient and clinician preference. Discussion with a gynecologic oncologist is recommended. Fertility-preserving surgery is an acceptable alternative to more extensive surgery in patients with low-malignant-potential tumours and those with well-differentiated surgical stage i ovarian cancer. Discussion with a gynecologic oncologist is recommended.

Clinical outcomes of fertility-sparing treatments in young patients with epithelial ovarian carcinoma

OBJECTIVE

To assess the clinical outcomes of fertility-sparing treatments in young patients with epithelial ovarian carcinoma (EOC).

METHODS

A retrospective study of young EOC inpatients (≤40 years old) was performed during January 1994 and December 2010 in eight institutions.

RESULTS

Data were analyzed from 94 patients treated with fertility-sparing surgery with a median follow-up time of 58.7 months. As histologic grade increased, overall survival (OS) and disease-free survival (DFS) of patients receiving fertility-sparing surgery declined. Neither staging surgery nor laparoscopy of early stage EOC with conservative surgery had a significant effect on OS or DFS. Normal menstruation recommenced after chemotherapy in 89% of the fertility-sparing group. Seventeen pregnancies among twelve patients were achieved by the end of the follow-ups.

CONCLUSIONS

Fertility-sparing treatment for patients with EOC Stage I Grade 1 could be cautiously considered for young patients. The surgical procedure and surgical route might not significantly influence the prognosis. Standard chemotherapy is not likely to have an evident impact on ovarian function or fertility in young patients.

Borderline tumors of the ovary: clinical course and prognostic factors

BACKGROUND

The prognosis in borderline tumors of the ovary (BOT) is generally favorable. However, some patients experience recurrence, and mortalities occur. There is a need to better characterize prognostic factors to be considered for individualized treatment planning.

PATIENTS AND METHODS

The data of 158 consecutive patients who underwent surgery for BOT at a tertiary referral center for gynecologic oncology between 1997 and 2008 were retrospectively analyzed.

RESULTS

Most patients had early stage disease, and advanced stages FIGO II/III only occurred in 23.4%. Serous histology was most frequent (68%), followed by mucinous histology (22%). All patients received surgery as initial treatment with no adjuvant systemic therapy. 37 patients (40.7% of the patients under the age of 50) had fertility-sparing surgery (FSS). Recurrent disease occurred in 18 (11.4%) patients, and 4 (2.5%) patients died. Independent risk factors for recurrence were FIGO stages > I (hazard ratio (HR) 37.1; 95% confidence interval (CI) 4.5-155.5), tumor rupture (HR 12.4; 95% CI 1.5-61.5), incomplete staging (HR 5.9; 95% CI 1.6-21.3), and FSS in patients < 50 years (HR 8.0; 95% CI 2.0-31.6).

CONCLUSION

Intraoperative tumor rupture, incomplete staging, and FSS - all influenced by the surgeon - may impose a substantial recurrence risk. Therefore, careful counseling and balancing of risk and benefit are mandatory before therapy is applied, especially if FSS is planned.

Recommendations of the Fertility Task Force of the European Society of Gynecologic Oncology about the conservative management of ovarian malignant tumors

In young patients with borderline ovarian tumor a conservative treatment approach does not seem to have a significant impact on survival, and the outcome regarding fertility is good in general. It can be considered even if noninvasive peritoneal implants are discovered at the time of the initial surgery. In contrast, in patients with epithelial ovarian cancer, conservative surgery should be considered only in adequately staged patients, with a stage IA grade 1 (and probably 2) serous, mucinous or an endometrioid tumor, including a careful follow-up. Such an approach could also probably be discussed in stage IC grade 1 disease.In patients with nonepithelial malignant ovarian tumors, conservative surgery is also feasible, particularly in patients with malignant germ cell tumors because of their high chemosensitivity leading to an excellent prognosis in general.

[Pregnancy after conservative surgical treatment of ovarial mucinous adenocarcinoma]

BACKGROUND

Epithelial ovarian cancer (EOC) accounts for 25% of all malignancies in the female genital tract and it is the most common cause of death among women who develop gynecologic malignancies. According to recent reports at least 20% of EOC are diagnosed at stage I of the disease. Because women tend to give birth to their first child at an older age, and due to the usage of more sensitive diagnostic procedures, the diagnosis of EOC during reproductive age has become more frequent. Therefore, the demand for fertility-sparing surgery in early-stage of EOC is increased.

CASE REPORT

We presented the case of accomplished reproduction at 41 after the conservative treatment of mucinous ovarian cancer. In the absence of a complete surgical staging, her decision was to spare her fertility capacities opposed to the treatment recommendations of the oncological council. The bottom-line of this report was to give its contribution to the ongoing controversies in the decision to recommend the conservative surgical treatment of the EOC and also to reveal the need of reconsideration of the necessity of a complete surgical staging in patients with stage I of mucinous ovarian cancer.

CONCLUSION

The profile of EOC cases in which a conservative surgical approach is the appropriate one has not yet been defined. Correct surgical staging is still an indispensable guideline for that kind of clinical decision. In the case of stage I of mucinous ovarian cancer with the low tumor grade, the necessity of a complete surgical staging should be reconsidered.

Prognostic factors of a large retrospective series of mucinous borderline tumors of the ovary (excluding peritoneal pseudomyxoma)

BACKGROUND

To determine the prognosis and prognostic factors in a large series of mucinous borderline tumors of the ovary (MBOT).

MATERIALS AND METHODS

A retrospective review of patients with MBOT treated or referred to our institution. Three inclusion criteria were defined: (1) centralized histological review by our expert pathologist, (2) exclusion of peritoneal pseudomyxoma and any synchronous malignant tumor in the abdominal cavity, and (3) available data on the management and outcomes of patients.

RESULTS

From 1997 to 2004, 97 patients fulfilled inclusion criteria (95 stage I and 2 stage II disease). Of these, 9 patients had endocervical-like subtypes, 8 patients had stromal microinvasion, and 24 had intraepithelial carcinoma. Radical and conservative surgeries were performed, respectively, in 28 and 69 patients. After a median follow-up of 48 months, 13 patients had developed 14 recurrences: 7 were borderline and 7 were invasive lesions. The probability of recurrence in the form of carcinoma 5 and 10 years after the diagnosis was, respectively, 9 and 13%. The only prognostic factor for recurrence attaining statistical significance was the use of a cystectomy (compared with other surgeries relative risk [RR] = 5.6; P = 0.003; compared with salpingo-oophorectomy RR = 5.5; P = 0.012).

CONCLUSIONS

In the present series of 97 MBOT, mainly early-stage disease and excluding peritoneal pseudomyxoma, the cumulative risk of recurrence in the form of invasive carcinoma at 10 years was 13%. MBOT do not appear to be such a "safe" disease. The only prognostic factor for recurrence was the use of a cystectomy, suggesting that a salpingo-oophorectomy should be preferred in cases of conservative treatment.

Prevalence of lymph node metastasis in primary mucinous carcinoma of the ovary

OBJECTIVE

To estimate the prevalence of lymph node involvement in women with primary mucinous ovarian carcinomas.

METHODS

A retrospective study was performed of patients with primary mucinous ovarian carcinomas evaluated at a single institution between 1985 and 2007. A gynecologic oncology pathologist evaluated all cases. Patients with tumors of low malignant potential and mucinous carcinomas metastatic to the ovary from other primary sites were excluded.

RESULTS

Patients with primary mucinous ovarian carcinomas were identified (n=107). All patients underwent primary surgery. At time of surgery, 93 patients (87%) had tumors that grossly appeared to be confined to the ovary, and 14 patients (13%) had evidence of extraovarian disease. Of the 93 patients with tumors that grossly appeared to be confined to the ovary at surgical exploration, 51 (55%) underwent lymphadenectomy (n=27 pelvic and paraaortic, n=19 pelvic only, n=5 paraaortic only). Of these 51 patients, none had metastatic disease to the pelvic or paraaortic lymph nodes. In addition, there were no significant differences in progression-free survival and overall survival rates between the patients who underwent lymphadenectomy and those who did not.

CONCLUSION

There were no cases of isolated lymph node metastases among women with primary mucinous carcinoma grossly confined to the ovary, suggesting that routine lymphadenectomy may be omitted in these patients.

LEVEL OF EVIDENCE

III.

Unmasking the complexities of mucinous ovarian carcinoma

OBJECTIVE

Most collaborative studies for the treatment of primary and recurrent ovarian cancer have grouped all epithelial ovarian cancers together, leading to a common therapeutic approach to all the different subtypes. Emerging data, however, support the hypothesis that primary mucinous ovarian cancers are unique histologically, molecularly, and clinically from other epithelial subtypes. The objective of our review was to identify and synthesize the most current information on mucinous ovarian carcinoma with regard to pathologic, molecular, and clinical distinctions.

METHODS

We searched PubMed for English-language articles with the MeSH term "mucinous ovarian carcinoma" published between 1990 and 2009.

RESULTS

On pathologic examination, primary invasive mucinous ovarian cancer often can be seen next to areas of benign and borderline mucinous histology, suggesting a continuum to malignant progression not observed in the other epithelial ovarian lesions. When compared to serous ovarian tumors, primary mucinous ovarian tumors have a significantly higher prevalence of KRAS mutations and a lower frequency of BRCA and p53 abnormalities. In addition, metastatic primary disease and recurrent mucinous cancers have a substantially worse prognosis than other epithelial ovarian cancers and are largely platinum and taxane resistant.

CONCLUSIONS

Primary mucinous ovarian cancer should be considered separate from the other epithelial ovarian cancers. Ongoing clinical trials in this disease will likely offer improvements in chemotherapeutic agents used to treat women with primary and recurrent mucinous ovarian cancer.

The role of serum CA-125 levels in early-stage epithelial ovarian cancer on preoperative CT and MRI

BACKGROUND

We sought to identify the role of serum CA-125 levels in early-stage epithelial ovarian cancer (EOC) on preoperative CT and MRI.

METHODS

Clinical data of 101 patients with early-stage EOC on preoperative CT and MRI were collected between January 2000 and December 2007. Clinical stage I (n=59) was defined as tumor limited to the ovaries with or without ascites, whereas clinical stage II (n=42) was defined as tumor within the pelvis with or without ascites. The primary endpoint was to investigate the efficacy of serum CA-125 levels for the prediction of advanced-stage disease, and secondary endpoints were to evaluate the accuracy of preoperative CT and MRI, and to examine the role of serum CA-125 levels as a prognostic factor for survival.

RESULTS

The results of preoperative CT and MRI were concordant with no peritoneal implants outside the pelvis in 50/101 (50%) and no lymph node metastasis in 71/101 (70%) patients. The receiver operating characteristic curves showed that best cut-off values of serum CA-125 levels were 320 U/ml (71% sensitivity, 84% specificity) and 510 U/ml (67% sensitivity, 80% specificity) for the prediction of peritoneal implants outside the pelvis and lymph node metastasis. The serum CA-125 level (> or =320 U/ml) was a significant factor for the prediction of advanced-stage disease (adjusted OR, 7.43; 95% CI, 2.39-23.04). However, it was not an independent prognostic factor for survival.

CONCLUSIONS

Serum CA-125 levels may be very useful for the prediction of advanced-stage disease in early-stage EOC on preoperative CT and MRI.

[Not Available]

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

[Not Available]

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopy in the treatment of ovarian tumours of low malignant potential

Laparoscopy is increasingly used by gynaecologists for the investigation of adnexal masses. Uncertainty exists whether ovarian tumours of low malignant potential can effectively be treated by laparoscopy, whether staging bears a benefit for all patients, whether port-site metastases are a problem and how long patients need to be followed up after surgery. This review summarises the evidence to address these important questions.