Improved 5-year disease-free survival for FIGO stage I epithelial ovarian cancer patients without tumor rupture during surgery

Is There a Survival Benefit of Adjuvant Chemotherapy in Stage IC1 Epithelial Ovarian Cancer Patients? A Meta-Analysis

The purpose of the present systematic review is to clarify whether adjuvant chemotherapy improves survival rates in women with stage IC1 ovarian cancer. We searched Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar. We considered comparative observational studies and randomized trials that investigated survival outcomes (progression-free (PFS) and overall survival (OS)) among women with intraoperative rupture of early-stage epithelial ovarian cancer who received adjuvant chemotherapy and those that did not. Eleven studies, which recruited 7556 patients, were included. The risk of bias was defined as moderate after assessment with the Risk of Bias in non-Randomized Trials tool. Meta-analysis was performed with RStudio. Seven studies investigated the impact of adjuvant chemotherapy on recurrence-free survival of patients experiencing intraoperative cyst rupture for otherwise stage I ovarian cancer. The outcome was not affected by the use of adjuvant chemotherapy as the effect estimate was not significant (HR 1.24, 95% CI 0.74, 2.04). The analysis of data from 5 studies similarly revealed that overall survival rates were comparable among the two groups (HR 0.75, 95% CI 0.54, 1.05). This meta-analysis did not detect any benefit from adjuvant chemotherapy for stage IC ovarian cancer patients with cyst rupture. However, conclusions from this investigation are limited by a study population which included multiple histologic subtypes, high and low grade tumors and incompletely staged patients.

Minimally invasive surgery for suspected early-stage ovarian cancer; a cost-effectiveness study

OBJECTIVE

While there are a number of benefits to minimally invasive surgery (MIS) for women with ovarian cysts, there is an increased risk of ovarian capsule rupture during the procedure, which could potentially seed the abdominal cavity with malignant cells. We developed a decision model to compare the risks, benefits, effectiveness and cost of MIS versus laparotomy in women with ovarian masses.

DESIGN

Cost-effectiveness study POPULATION: Hypothetical cohort of 10 000 women with ovarian masses who were undergoing surgical management.

METHODS

The initial decision point in the model was performance of surgery via laparotomy or a MIS approach. Model probabilities, costs and utility values were derived from published literature and administrative data sources. Extensive sensitivity analyses were conducted to assess the robustness of the findings.

MAIN OUTCOME MEASURES

The primary outcome was the cost-effectiveness of MIS versus laparotomy for women with a pelvic mass measured by incremental cost-effectiveness ratios (ICERs).

RESULTS

MIS was the least costly strategy at $7,732 per women on average, compared with $17,899 for laparotomy. In our hypothetical cohort of 10 000 women, there were 64 cases of ovarian rupture in the MIS group and 53 in the laparotomy group, while there were 26 cancer-related deaths in the MIS group and 25 in the laparotomy group. MIS was more effective than laparotomy (188 462 QALYs for MIS versus 187 631 quality adjusted life years [QALYs] for laparotomy). Thus, MIS was a dominant strategy, being both less costly and more effective than laparotomy. These results were robust in a variety of sensitivity analyses.

CONCLUSION

MIS constitutes a cost-effective management strategy for women with suspicious ovarian masses.

TWEETABLE ABSTRACT

MIS is a cost-effective management strategy for women with suspicious ovarian masses.

Intraoperative Rupture of the Ovarian Capsule in Early-Stage Ovarian Cancer: A Meta-analysis

OBJECTIVE

To examine the effects of intraoperative ovarian capsule rupture on progression-free survival and overall survival in women who are undergoing surgery for early-stage ovarian cancer.

DATA SOURCES

MEDLINE using PubMed, EMBASE (Elsevier), ClinicalTrials.gov, and Scopus (Elsevier) were searched from inception until August 11, 2020.

METHODS OF STUDY SELECTION

High-quality studies reporting survival outcomes comparing ovarian capsule rupture to no capsule rupture among patients with early-stage epithelial ovarian cancer who underwent surgical management were abstracted. Study quality was assessed with the Newcastle-Ottawa Scale, and studies with scores of at least 7 points were included.

TABULATION, INTEGRATION, AND RESULTS

The data were extracted independently by multiple observers. Random-effects models were used to pool associations and to analyze the association between ovarian capsule rupture and oncologic outcomes. Seventeen studies met all the criteria for inclusion in the meta-analysis. Twelve thousand seven hundred fifty-six (62.6%) patients did not have capsule rupture and had disease confined to the ovary on final pathology; 5,532 (33.7%) patients had intraoperative capsule rupture of an otherwise early-stage ovarian cancer. Patients with intraoperative capsule rupture had worse progression-free survival (hazard ratio [HR] 1.92, 95% CI 1.34-2.76, P<.001), with moderate heterogeneity (I2=41%, P=.07) when compared with those without capsule rupture. Pooled results from these studies showed a worse overall survival (HR 1.48, 95% CI 1.15-1.91, P=.003), with moderate heterogeneity (I2=53%, P=.02) when compared with patients without intraoperative capsule rupture. This remained significant in a series of sensitivity analyses.

CONCLUSION

This systematic review and meta-analysis of high-quality observational studies shows that intraoperative ovarian capsule rupture results in decreased progression-free survival and overall survival in women with early-stage ovarian cancer who are undergoing initial surgical management.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021216561.

Comparison of perioperative outcomes of single-port laparoscopy, three-port laparoscopy and conventional laparotomy in removing giant ovarian cysts larger than 15 cm

Background

Although conventional laparoscopy has gradually accepted as a surgical treatment for ovarian cancer, reducing the port numbers of laparoscopy still has great challenge for larger ovarian tumors. Thus, this study aims to explore the surgical outcomes of single-port laparoscopy for removing giant ovarian cysts (≥ 15 cm) and compare with laparotomy and three-port laparoscopy.

Methods

This study enrolled 95 patients with giant ovarian cysts (> 15 cm) who underwent single-port laparoscopy, three-port laparoscopy or laparotomy. Their medical records, perioperative surgical outcomes, and postoperative pain score and complications were analyzed and compared retrospectively.

Results

Single-port laparoscopy showed better perioperative outcomes and less postoperative pain than three-port laparoscopy and laparotomy. The time between post-surgery and getting out of bed in single-port laparoscopy was significant shorter than that in the laparotomy and three-port laparoscopy (17.53 ± 7.26 vs 29.40 ± 9.57 vs 24.56 ± 7.76, P < 0.01). The length of hospital stay in single-port laparoscopy was significantly shorter than that in other two groups (4.06 ± 0.5 vs 5.46 ± 1.63 vs 4.81 ± 0.83, P < 0.001). In addition, single-port laparoscopy had the lowest postoperative pain scores than in the laparotomy and three-port laparoscopy. There were no significant differences of total hospital cost, postoperative complications and time until gas passing among the three surgical groups. Importantly, in the removal of giant ovarian cysts, the proportion of cyst rupture in single-port laparoscopy was far lower than that in three-port laparoscopy (3.0 vs 22.2%).

Conclusions

For giant ovarian cysts, single-port laparoscopy is still a safe and efficient technique with the advantages of short operation time, less estimated blood loss, short hospital stay, lower spillage rate, and less postoperative pain.

Impact of incomplete surgery and adjuvant chemotherapy for the intraoperative rupture of capsulated stage I epithelial ovarian cancer: a multi-institutional study with an in-depth subgroup analysis

Objective

The aim of the present study was to examine the effects of incomplete surgery and adjuvant chemotherapy on the prognosis of patients with intraoperative rupture of capsulated stage I epithelial ovarian cancer (OvCa).

Methods

A regional retrospective study was conducted between 1986 and 2019. Among 4,730 patients with malignant ovarian tumors, 534 women with International Federation of Gynecology and Obstetrics stage IA and IC1 epithelial OvCa were eligible. Differences in survival outcomes were examined between patients with stage IA and IC1 tumors and the effects of uterine preservation, complete-staging lymphadenectomy, and adjuvant chemotherapy were investigated by an in-depth subgroup analysis. To analyze therapeutic effects, baseline imbalances were adjusted using propensity score (PS).

Results

The prognosis of patients with stage IC1 tumors was worse than those with stage IA. Surgical spill did not affect the site of recurrence. In the PS-adjusted subgroup analysis, uterine preservation (hazard ratio [HR]=1.669; 95% confidence interval [CI]=1.052–2.744), incomplete-staging lymphadenectomy (HR=1.689; 95% CI=1.211–2.355), and the omission of adjuvant chemotherapy (HR=3.729; 95% CI=2.090–6.653) significantly increased the HR of recurrence for patients with stage IC1 tumors compared to those with stage IA tumors. Adjuvant chemotherapy decreased the impact of rupture with uterine preservation (HR=0.159; 95% CI=0.230–1.168) or incomplete-staging lymphadenectomy (HR=0.987; 95% CI=0.638–1.527).

Conclusion

The present results suggest intraoperative rupture of capsulated stage I epithelial OvCa is associated with a poor prognosis. When chemotherapy is given for patients receiving incomplete surgery, there is no longer an increased risk of recurrence observed with the rupture.

Rho GTPases in Gynecologic Cancers: In-Depth Analysis toward the Paradigm Change from Reactive to Predictive, Preventive, and Personalized Medical Approach Benefiting the Patient and Healthcare

Rho guanosine triphospatases (GTPases) resemble a conserved family of GTP-binding proteins regulating actin cytoskeleton dynamics and several signaling pathways central for the cell. Rho GTPases create a so-called Ras-superfamily of GTPases subdivided into subgroups comprising at least 20 members. Rho GTPases play a key regulatory role in gene expression, cell cycle control and proliferation, epithelial cell polarity, cell migration, survival, and apoptosis, among others. They also have tissue-related functions including angiogenesis being involved in inflammatory and wound healing processes. Contextually, any abnormality in the Rho GTPase function may result in severe consequences at molecular, cellular, and tissue levels. Rho GTPases also play a key role in tumorigenesis and metastatic disease. Corresponding mechanisms include a number of targets such as kinases and scaffold/adaptor-like proteins initiating GTPases-related signaling cascades. The accumulated evidence demonstrates the oncogenic relevance of Rho GTPases for several solid malignancies including breast, liver, bladder, melanoma, testicular, lung, central nervous system (CNS), head and neck, cervical, and ovarian cancers. Furthermore, Rho GTPases play a crucial role in the development of radio- and chemoresistance e.g. under cisplatin-based cancer treatment. This article provides an in-depth overview on the role of Rho GTPases in gynecological cancers, highlights relevant signaling pathways and pathomechanisms, and sheds light on their involvement in tumor progression, metastatic spread, and radio/chemo resistance. In addition, insights into a spectrum of novel biomarkers and innovative approaches based on the paradigm shift from reactive to predictive, preventive, and personalized medicine are provided.

Predictive factors of recurrence in patients with early-stage epithelial ovarian cancer

OBJECTIVE

To identify predictive factors of recurrence and survival in patients with early-stage epithelial ovarian cancer (eEOC).

METHODS

We retrospectively searched the medical records of all women undergoing optimal surgical staging for eEOC (stage I-II) at the National Cancer Institute of Milan, Italy, between January 1, 1974, and December 31, 2014.

RESULTS

During the study period, 429 patients underwent primary surgery followed by either adjuvant chemotherapy or observation alone for apparent eEOC. In multivariable analysis, International Federation for Gynecology and Obstetrics (FIGO) stage greater than 1 (hazard ratio [HR] 2.49, 95% CI 1.24-4.99) was the only prognostic factor for lower disease-free survival. Multivariate analysis showed that age at diagnosis (HR 1.68, 95% CI 1.14-2.47) and stage (HR 2.29, 95% CI 1.01-6.39) were independent predictive factors for poorer overall survival (OS).

CONCLUSIONS

FIGO stage is the most important prognostic factor for recurrence and survival in patients with eEOC. Furthermore, age at diagnosis was identified as a factor that negatively influenced OS. Our data for oncologic outcomes are similar to those reported in previous studies.

[Surgery in early-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]

Early stage ovarian epithelial cancer (stage I according to the FIGO classification, i.e. limited to ovaries) affects 20% to 33% of patients with ovarian cancer. This chapter only describes data on these presumed early stages. The rate of occult epiploic metastases varies from 2% to 4%, and leads to over-staging in stage III A of 3% to 11% of patients. Performing an omentectomy does not result in a change in survival in this situation (NP4). The rate of appendix metastasis ranges from 0% to 26.7% (NP4). In the mucinous subtype, this rate can reach 53% if the appendix is macroscopically abnormal (NP2). The rate of positive peritoneal cytology ranges from 20.9% to 27%. Positive peritoneal cytology is responsible for over-staging of patients in 4.3% to 52% of cases and appears as a poor prognostic factor on survival (NP4). The rate of occult peritoneal metastases varies from 1.1% to 16%. Performing these peritoneal biopsies results in over-staging of 4% to 7.1% (NP4). In the management of ovarian cancers at a presumed early stage, it is recommended to perform: omentectomy, peritoneal biopsies, cytology, appendectomy (grade C). In case of incomplete or incomplete initial staging, restaging including omentectomy, peritoneal biopsies and appendectomy (if not explored) is recommended; especially in the absence of a reported indication of chemotherapy. The lymph node invasion rate ranges from 6.3% to 22%. It is 4.5% to 18% for stages I and 17.5% to 31% in stages II. Between 8.5% and 13% of patients with suspected early stage ovarian cancer are reclassified to stage IIIA1 following the completion of lymphadenectomy (NP3). Pelvic and lumbo-aortic lymphadenectomy improves the survival of patients with ovarian cancer at a presumptive early stage (NP2). Pelvic and lumbo-aortic lymphadenectomy is recommended for presumed early ovarian stages (grade B). In case of initial treatment of early-stage ovarian cancer without lymph node staging, restadification including lymphadenectomy is recommended; especially in the absence of a stated indication of chemotherapy (grade B). No studies have shown any laparoscopic disadvantage compared to laparotomy for feasibility, safety, or postoperative rehabilitation (NP3) in surgical staging of patients with early-stage ovarian cancer. For the initial surgical management of these patients, the choice between laparoscopy or laparotomy depends on local conditions (tumor size) and surgical expertise. If complete surgery without risk of tumor rupture is possible, the laparoscopic approach is preferred (grade C). In the opposite case, median laparotomy is recommended. As part of surgical restadification, the laparoscopic approach is recommended (grade C). Intraoperative tumor rupture leads to a decrease in disease free survival (hazard ratio=2.28) and overall survival (hazard ratio=3.79) (NP2). It is recommended that all precautions be taken to avoid perioperative ovarian tumor rupture, including the intraoperative decision of laparoconversion (grade C). There is no specific study to answer the question of the feasibility of a one-time or two-time surgery during an extemporane diagnosis of an early stage ovarian cancer. The high sensitivity and specificity of this extemporane examination in this situation makes it possible to consider a surgical management of staging during the same operating time.

Fertility sparing surgery in gynecologic cancer

Fertility preservation is one of the major concerns of young patients diagnosed with gynecological cancer. With newer treatment regimens and better surgical techniques, survival rates after cancer treatment have improved, hence preservation of fertility has recently become an important issue in the treatment of gynecological cancers. Fertility sparing surgery may be an option for early-stage cervical cancer with the development of loop excision techniques and radical trachelectomy which allows a radical approach to cervix cancer at the same time preserving the uterus and thus fertility. Fertility preservation is possible in Stage 1 epithelial ovarian cancers, germ cell ovarian tumors, and borderline cancers. Hormonal therapy with progestin agents is effective in early endometrial cancer. In patients desiring future pregnancy, fertility sparing options must be explored before starting treatment for gynecologic cancers.

Napsin A as a marker of clear cell ovarian carcinoma

BACKGROUND

Clear cell carcinomas are aggressive tumors with a distinct biologic behaviour. In a genome-wide screening for genes involved in chemo-resistance, NAPA was over-expressed in cisplatin-resistant cells. The NAPA (protein) Napsin A was described to promote resistance to cisplatin by degradation of the tumor suppressor p53.

METHODS

Totally 131 patients were included in this study all in FIGO-stages I-II; 16 were clear cell tumors which were compared with 40 Type I tumors and 75 type II tumors according to the markers Napsin A, p21, p53 and p27 and some clinical features. For detection of the markers tissue microarrays and immunohistochemistry were used.

RESULTS

Positivity for Napsin A was detected in 12 (80%) out of the 15 clear cell tumors available for analysis compared with 3 (4%) out of the Type I and II tumors in one group (p<0.001). Differences in p21 status, p53 status, and p21+p53- status were striking when clear cell tumors were compared with Type I, Type II, and Type I and II tumors in one group, respectively. The p21+p53-status was associated to positive staining of Napsin A (p=0.0015) and clear cell morphology (p=0.0003). In two separate multivariate logistic regression analyses with Napsin A as endpoint both clear cell carcinoma with OR=153 (95% C.I. 21-1107); (p<001) and p21+p53- status with OR=5.36 (95% C.I. 1.6-17.5); (p=0.005) were independent predictive factors. ROC curves showed that AUC for Napsin A alone was 0.882, for p21+p53- it was 0.720 and for p21+p53-Napsin A+AUC was 0.795. Patients with clear cell tumors had lower (p=0.013) BMI than Type I patients and were younger (p=0.046) at diagnosis than Type II patients. Clear cell tumors had a higher frequency (p=0.039) of capsule rupture at surgery than Type I and II tumors.

CONCLUSIONS

Positivity of Napsin A in an epithelial ovarian tumor might strengthen the morphological diagnosis of clear cell ovarian carcinoma in the process of differential diagnosis between clear cell ovarian tumors and other histological subtypes.

Sertoli-Leydig cell tumors: current status of surgical management: literature review and proposal of treatment

To identify the appropriate management we review the current literature on the diagnostic and different surgical procedures to which the patients affected by Sertoli-Leyding cell tumors (SLCTs) were submitted. Through the description of a case report we also propose an interdisciplinary diagnostic approach and a laparoscopic surgical staging, with a long-term follow-up. The analysis shows that pelvic ultrasound is primary diagnostic procedure, and only 36% of publications clearly describe to have performed more specific investigation. The hormone assessment is performed in the presence of specific endocrine symptoms. Laparoscopic approach is chosen by a few surgeon. Laparotomic surgery is preferred based in not recent recommendations for ovarian cancer treatment, although it is demonstrated the efficacy and safety of laparoscopy in the treatment of ovarian epithelial tumors. Different steps that are usually used for oncological ovarian cancer staging are not always performed. Conservative and fertility sparing surgery is commonly accepted, and even preferred due to the young age of patients. In the surgical treatment of SLCTs is necessary to adopt common guidelines, and evenly define the steps that the patient should be submitted. If are observed epithelial cancer oncological principles, laparoscopic surgery should be the approach of choice for these patients.

Prognostic Factors and Clinical Outcome of Patients With Recurrent Early-Stage Epithelial Ovarian Cancer: An Italian Multicenter Retrospective Study

Objective

The objective of this study was to assess the clinical outcome of patients with recurrent early-stage ovarian cancer.

Methods

The hospital records of 87 patients were reviewed. The median follow-up of survivors from recurrence was 87.6 months.

Results

The 25%, 50%, and 75% quantiles of time to recurrence were 15, 25, and 44 months, respectively. The pelvis was the most common site of failure (39.1%), followed by abdomen (18.3%) and retroperitoneal nodes (18.3%). Treatment at recurrence consisted of chemotherapy in 46 patients, surgery plus chemotherapy in 29, surgery in 3, surgery plus radiotherapy in 2, and other therapies in 7. A macroscopically complete cytoreduction was obtained in 29 (85.2%) of the 34 patients who underwent secondary surgery. Five- and 7-year survival rates after recurrence were 34.3% and 29.6%. By log-rank test, survival after recurrence was related to patient age (≤60 vs >60 years; P = 0.001), time to recurrence (>15 vs ≤15 months; P = 0.049), site of recurrence (retroperitoneum vs pelvis vs other; P = 0.004), and surgery at recurrence (yes vs not; P = 0.001), but not to substage, histotype, grade, prior adjuvant chemotherapy, examination that detected recurrence, and chemotherapy at recurrence. On multivariate analysis, patient age (hazard ratio, 1.836; 95% confidence interval, 1.060-3.180) and surgical treatment at recurrence (hazard ratio, 1.972; 95% confidence interval, 1.084–3.587) were independent prognostic variables for survival after recurrence.

Conclusions

Patient age and surgery at recurrence were independent prognostic variables for patients with recurrent early-stage ovarian cancer. When feasible, salvage surgery appears to give a survival advantage in this clinical setting.

The sonographic prediction of invasive carcinoma in unilocular-solid ovarian cysts in premenopausal patients: a pilot study

BACKGROUND

Unilocular-solid ovarian cysts are a rare but challenging pathology in young women, with a desire to spare their fertility. In these cases, the risks of borderline and invasive disease are around 10 and 20%, respectively. No ultrasound rule has yet demonstrated the ability to discriminate with high accuracy, a borderline tumor from a benign tumor or 'invasive tumor'. The aim of this study was to assess the predictive performance of different ultrasound parameters in differentiating benign and borderline tumors versus invasive malignant tumors in premenopausal patients with unilocular-solid ovarian masses.

METHODS

Women aged ≤ 50 years with unilocular-solid adnexal masses with a maximum diameter ≤ 10 cm, undergoing surgery in our department within 3 months from ultrasound examination, were included in this retrospective study. A standardized ultrasound examination technique and predefined definitions of ultrasound characteristics were used. The results of ultrasound examination using gray scale and color Doppler were compared with the histological examination of the respective surgical specimens.

RESULTS

The study included 51 patients. On histological examination, 36 (70%) lesions were classified as benign, 10 (20%) as borderline ovarian tumors and 5 (10%) as invasively malignant tumors. In receiver-operating characteristic curve analysis, the best cut-off for the largest solid component with regard to discriminating non-invasive (benign or borderline) from invasive tumors was 14 mm. A largest solid component >14 mm, the presence of papillation blood flow and the combination of the two parameters provided a sensitivity of 100% and a specificity of 63, 63 and 80%, respectively.

CONCLUSIONS

Transvaginal ultrasound examination seems to be able to discriminate between invasive and non-invasive tumors in the premenopausal patients with unilocular-solid adnexal masses. Because of the retrospective nature of the study, further prospective clinical trials are needed to confirm the accuracy of the selected sonographic parameters in discriminating the invasive and non-invasive adnexal tumors.