Mediastinal metastasis of ovarian carcinoma

Extra-abdominal cytoreductive techniques in ovarian cancer: how far can (should) we go?

Complex surgery is an essential component in the management of advanced ovarian cancer. Furthermore, achieving complete gross resection in cytoreductive surgery appears to be associated with significant survival benefits in patients with advanced ovarian cancer. The goal of this review is to demonstrate the advancement of surgical techniques in gynecologic oncology surgery, including resection of disease within the intrathoracic and inguinal regions. This progress has expanded the option of surgery to more patients, especially those who would have previously been deemed inoperable. In this review we describe the most notable studies and reports of surgical resection of ovarian cancer involving cardiophrenic/supradiaphragmatic lymph nodes, mediastinum, lung pleura or parenchyma, and the inguinal region. We also describe the growing role that video-assisted thoracic surgery has played in advanced ovarian cancer diagnosis and management. The studies, series, and reports described demonstrate that comprehensive surgical procedures outside of the abdomen or pelvis can be both safe and feasible in properly selected patients. They also suggest that resection of disease outside of the abdomen or pelvis may benefit appropriately selected patients. Future studies are necessary to identify which patients may benefit most from upfront surgery versus neoadjuvant chemotherapy when ovarian cancer metastasis is present in the thoracic or inguinal regions.

Survival impact and safety of intrathoracic and abdominopelvic cytoreductive surgery in advanced ovarian cancer: a systematic review and meta-analysis

Purpose

Achieving no residual disease is essential for increasing overall survival (OS) and progression-free survival (PFS) in ovarian cancer patients. However, the survival benefit of achieving no residual disease during both intrathoracic and abdominopelvic cytoreductive surgery is still unclear. This meta-analysis aimed to assess the survival benefit and safety of intrathoracic and abdominopelvic cytoreductive surgery in advanced ovarian cancer patients.

Methods

We systematically searched for studies in online databases, including PubMed, Embase, and Web of Science. We used Q statistics and I-squared statistics to evaluate heterogeneity, sensitivity analysis to test the origin of heterogeneity, and Egger's and Begg's tests to evaluate publication bias.

Results

We included 4 retrospective cohort studies, including 490 patients, for analysis; these studies were assessed as high-quality studies. The combined hazard ratio (HR) with 95% confidence interval (CI) for OS was 1.92 (95% CI 1.38-2.68), while the combined HR for PFS was 1.91 (95% CI 1.47-2.49). Only 19 patients in the four studies reported major complications, and 4 of these complications were surgery related.

Conclusion

The maximal extent of cytoreduction in the intrathoracic and abdominopelvic tract improves survival outcomes, including OS and PFS, in advanced ovarian cancer patients with acceptable complications.

Systematic Review Registration

PROSPERO, identifier CRD42023468096.

Extra-abdominal Lymph Node Metastases as the First Presentation in Ovarian and Fallopian Tube Carcinomas

Revision of ovarian and fallopian tube cancer presentation as extra-abdominal lymph nodes to understand the diagnostic challenges and prognostic features of these situations. Literature review in PubMed and Cochrane databases using the terms "ovarian cancer," "fallopian tube cancer," "extrapelvic lymph nodes," extra-abdominal lymph nodes," "distant lymph nodes," "initial presentation," "metastases," and "unusual presentation of ovarian cancer/unusual presentation of fallopian tube cancer" isolated and in conjunction. Articles in English were analyzed regarding revision's purpose, inclusion, and exclusion criteria and 65 were included in the final document. Statistical data was obtained with Microsoft Excel software analysis. Distant manifestations of ovarian cancer may occur through the lymphatic system and, less frequently, through hematogenous spread. These forms of spread may exist with almost no symptoms related to the primary cancer location and can justify distant disease at the initial presentation. Extra-abdominal lymph node involvement poses a clinical challenge for oncologists and oncologic gynecologists because it may occur with no or mild symptoms, and even in situations where no macroscopic disease is seen in the pelvic cavity. Histology and immunohistochemistry analyses together with a high level of suspicion are paramount to help in the diagnostic workup decisions and in finding a correct diagnosis when an extra-abdominal lymph node is the first manifested sign. Given its rarity and scarcity of information dispersed in a few case reports and small case series, further investigation is needed to understand the particularities of these tumors and their prognostic relevance.

Ovarian serous carcinoma in which mediastinal recurrence of the cancer was resected 16 years after surgery: A case report

We report a rare case of ovarian carcinoma in which a mediastinal recurrence was resected 16 years after the initial operation. A 72‐year‐old woman underwent hysterectomy with adnexectomy for stage IIIC ovarian serous carcinoma after neoadjuvant chemotherapy. Six courses of adjuvant chemotherapy were administered. Three years after surgery, left supraclavicular lymph node metastasis occurred, and radiotherapy and two courses of chemotherapy were administered. Six years before presentation, a metastasis at the right cardiophrenic lymph node was resected, and six courses of chemotherapy were administered. During follow‐up, a retrosternal tumour was found. The metastatic lesion in contact with the diaphragm was thought to result from pleuroperitoneal communication, and it increased in size. Although high‐grade serous carcinoma is aggressive, its sensitivity to chemotherapy may suppress early recurrence, contributing to good outcomes, but with late recurrence. Multidisciplinary therapy including surgery is required for improved long‐term prognosis for mediastinal metastasis of ovarian serous carcinoma.

Preoperative Prediction of Cardiophrenic Lymph Node Metastasis in Advanced Ovarian Cancer Using Computed Tomography

OBJECTIVE

The aim of this study was to determine whether the preoperative diameter of cardiophrenic lymph nodes (CPLNs) along the short and long axes, determined via computed tomography (CT), predicts CPLN metastasis in patients with advanced epithelial ovarian cancer.

METHODS

A total of 31 patients with primary advanced ovarian cancer who had CPLN dissection underwent preoperative CT that was reviewed twice by a radiologist blinded to the final pathology. An array of CT features and clinical factors [age, cancer antigen 125 (CA 125)] were compared between metastasis-positive and metastasis-negative CPLNs using the t test and Fisher's exact test. The optimal CPLN dimensions that best predicted metastasis were calculated using a receiver operating characteristic (ROC) curve, and were applied to find the correlation with other CT findings. Results were validated in an independent test set of nine patients by using the best cutoff value to predict metastasis.

RESULTS

Pathological evaluation revealed metastasis-positive CPLNs in 19 patients and metastasis-negative CPLNs in 12 patients. Metastasis-positive CPLNs had significantly reduced short axes than those of negative CPLNs (5.6 ± 1.7 and 7.8 ± 2.2, respectively; p < 0.001). ROC curve analysis showed that a cutoff value of 7 mm for the short axis demonstrated the largest area under the curve (0.789; p < 0.0007), with 63.16 % sensitivity and 83.33 % specificity. The presence of peritoneal metastasis and abdominopelvic adenopathy strongly related with CPLN adenopathy. Accuracies were 66.7 % (six of nine patients) based on the cutoff value in the independent test set.

CONCLUSIONS

The probability of detecting CPLN metastasis in patients with advanced ovarian cancer was approximately 85 % when the short axis of the CPLN was >7 mm in preoperative CT scans. Patients with CPLNs of this size may be candidates for CPLN dissection in order to confirm the pathological diagnosis.

A rare case of mediastinal metastasis of ovarian carcinoma diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a minimally invasive tool with excellent diagnostic accuracy and low risk of complications in the diagnosis of thoracic diseases, including lung cancers and primary mediastinal lesions. Occasionally, EBUS-TBNA may be useful in identifying thoracic metastasis from distant tumors. Here we report an interesting and rare case of mediastinal metastasis of ovarian carcinoma diagnosed by EBUS-TBNA.

A rare case of high-grade serous ovarian epithelial carcinoma presenting as an isolated cystic mediastinal mass: a case report and brief review of the literature

A 70-year-old woman presented with a 2-year history of increasing breathlessness. Computed tomography (CT) of the chest confirmed a well-defined cystic lesion abutting the mediastinum in the right hemi thorax measuring 8 x 6 cm. She underwent a right thoracotomy to excise the cystic lesion. Biopsies for histology demonstrated metastatic serous ovarian epithelial carcinoma. We report a very unusual primary presentation of ovarian epithelial carcinoma as a single cystic mediastinal mass. We also include a brief review of the literature.

Ovarian serous carcinoma presenting with mediastinal lymphadenopathy 20 months before the intraabdominal mass: Role of immunohistochemistry

INTRODUCTION

Metastatic involvement of the mediastinal lymph nodes is an extremely uncommon finding in epithelial ovarian cancers.

CASE REPORT

A 63-year-old woman was admitted to hospital for dyspnoea due to an anterior mediastinal mass. The surgical biopsy showed a 6-cm metastatic lymph node with a papillary pattern, scattered psammomas and immunoreactivity for WT1, Cytokeratin 7, EMA and negative for E-cadherin, GCFDP-15, Thyroglobulin, Cytokeratin 20, Cytokeratin 5/6, CEA, Vimentin, Calretinin, TTF1. After 20 months a follow-up CT identified an ovarian mass with the same histological pattern and immunoreactivity of the mediastinal nodule.

RESULTS

Immunohistochemistry, especially WT1, is useful in assessing the ovarian origin of an unusual metastasis particularly if it is the first presentation of the disease.

Recurrent ovarian cancer metastatic to the sternum, costae, and thoracic wall after prolonged treatment with platinum-based chemotherapy: a case report and review of the literature

Sternal and costal metastases from ovarian cancer are extremely rare. We present here a case of a 47-year-old woman with thoracic wall metastasis from serous-papillary ovarian carcinoma that occurred 3 years after the initial diagnosis, although the patient had received various regimens of intense platinum-based chemotherapy. Special emphasis is given to the effects of alkylating agents, such as cisplatin and carboplatin, on the pattern of tumor spread. We also discuss the possible mechanisms through which the biologic and metastatic behavior of this tumor is expressed.

Mediastinal node and diaphragmatic targeting after intracavitary injection of avidin/99mTc-blue-biotin-liposome system

A method for delivering drugs to sites of disease extension in mediastinal nodes is described. Mediastinal node and lymphatic distributions were determined after intracavitary injection of the avidin/biotin-liposome system in normal rats. The effect of the injected dose on lymphatic targeting of liposomes after intraperitoneal injection of (99m)Tc-blue-biotin-liposomes and intrapleural injection of avidin, and vice versa, is presented. Scintigraphic imaging was used to follow the movement of (99m)Tc-blue-biotin-liposomes to determine the pharmacokinetics and organ uptake. Tissue biodistribution studies were performed 22 h after injection of the (99m)Tc-blue-biotin-liposomes. Results indicated that independent of the cavity in which each agent was injected, a dose of 5.0 mg of each agent results in higher mediastinal node targeting (8%-10% ID/Organ) as compared with the injection of a 0.5 mg dose (2%-5% ID/Organ, p < 0.05). Targeting of diaphragm and associated lymphatics was observed when (99m)Tc-blue-biotin-liposomes were injected in peritoneum and avidin in pleural space. In contrast, pleural, and pericardial lymphatic targeting was observed when (99m)Tc-blue-biotin-liposomes were injected in pleural space and avidin in peritoneum. Intracavitary injection of the avidin/biotin-liposome system could potentially be used for the delivery of prophylactic drugs that could reduce tumor metastasis and infection spread to mediastinal nodes.

Multiple Mediastinal Metastasis of Ovarian Carcinoma

Secondary mediastinal tumours are rare. We present a case report of multiple mediastinal metastasis of ovarian cancer, a very rare occurrence with only two cases previously reported in the literature.

Pharmacokinetics and biodistribution of [111In]-avidin and [99mTc]-biotin-liposomes injected in the pleural space for the targeting of mediastinal nodes

Pharmacokinetics and mediastinal node uptake of [111In]-avidin and [99mTc]-biotin-liposomes following either intrapleural (pleural) or intraperitoneal (ip) injection were determined using scintigraphic imaging. Biodistribution results of [111In]-avidin at 44 h showed 3.3% uptake in mediastinal nodes by pleural injection vs 1.3% with ip injection. Mediastinal node accumulation with [99mTc]-biotin-liposomes was not different between injections (0.6% ip vs 0.5% pleural). This study demonstrates the potential of the pleural route as a technique for mediastinal node targeting using the avidin/biotin-liposome system.

A novel approach for the increased delivery of pharmaceutical agents to peritoneum and associated lymph nodes

A novel method for prolonging the retention of liposomes in the peritoneum while increasing liposome deposition in lymph nodes that drain the peritoneum is described. An aliquot (1 ml) of technetium-99m ((99m)Tc)-biotin-liposomes encapsulating blue dye was injected intraperitoneally in rats. Thirty minutes after administration of the (99m)Tc-blue-biotin-liposomes, five rats (experimental) were administered avidin (5 mg) intraperitoneally, whereas the remaining five rats served as controls. Scintigraphic images were acquired at baseline and 1 and 24 h after the liposome injection followed by a tissue biodistribution study. Images at 24 h clearly demonstrated very different distributions between the experimental and control animals. In experimental rats, most of the activity was visualized in the abdominal region, and in abdominal and mediastinal lymph nodes. The percentage of the injected dose (% ID) in the blood was significantly higher in the control group than in the experimental group (14.0 +/- 1.7 versus 0.17 +/- 0.03%; P < 0.001). The % ID in the spleen was also significantly greater for controls (23.3 +/- 3.9%) compared with the experimental group (0.78 +/- 0.8%; P = 0.001). Significant (99m)Tc activity was detected in blue-stained abdominal nodes (4.7%) and mediastinal nodes (2.3%) from the experimental animals, whereas no blue-stained nodes were detectable in the control animals. The intraperitoneal biotin-liposome/avidin delivery system described in this study could potentially be used for delivery of liposome-encapsulated drugs to disease processes that become disseminated in the peritoneum such as metastatic ovarian, gastric, and colorectal cancer, as well as infectious peritonitis.

A case report of recurrent epithelial ovarian cancer metastatic to the sternum, diaphragm, costae, and bowel managed by aggressive secondary cytoreductive surgery without postoperative chemotherapy

BACKGROUND

Ovarian epithelial cancer typically presents in advanced stage and has been traditionally managed by a combination of cytoreductive surgery followed by adjuvant systematic chemotherapy. The management of recurrent ovarian cancer has been individualized: surgical resection of intraabdominal and/or pelvic disease has been performed when technically feasible and usually followed with chemotherapy.

CASE

This case describes aggressive surgical management of recurrent ovarian cancer metastatic to the lower ribs, sternum, and diaphragm. A clear cell, Stage IIIA ovarian cancer was successfully resected in a 73-year-old female. The patient had total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy followed by six cycles of adjuvant chemotherapy, consisting of cyclophospamide and carboplatinum. A period of 8 years elapsed before recurrent disease was detected; there were two separate metastatic sites. A secondary cytoreductive surgery without further chemotherapy has been the mainstay of treatment. A combination of exploratory laparotomy and en bloc resection revealed the metastatic deposits, a 5-cm mass involving the diaphragm, the lower aspect of the manubrium sternum, and four right lower ribs. The second deposit was identified in the left paracolic gutter invading the sigmoid colon.

CONCLUSION

At 47 months of follow-up, the patient is alive and without any evidence of measurable disease by exam and confirmed by CT scans of chest, abdomen, and pelvis. To our knowledge, this is one of the few reported cases managed successfully by surgical approach and is recommended in selected patients with metastatic ovarian cancer.