Systematic pelvic and para-aortic lymphadenectomy in advanced ovarian cancer patients with no residual intraperitoneal disease

The role of systematic pelvic and para-aortic lymphadenectomy in the management of patients with advanced epithelial ovarian, tubal, and peritoneal cancer: A systematic review and meta-analysis

OBJECTIVE

To investigate whether systematic pelvic and para-aortic lymphadenectomy offers superior survival rates in patients with advanced epithelial ovarian cancer (EOC), tubal, or peritoneal cancer.

METHODS

We searched the electronic databases PubMed (from 1996), Cochrane Central Register of Controlled trials (from 1996), and Scopus (from 2004) to September 2021. We considered randomised controlled trials (RCTs) comparing systematic pelvic and para-aortic lymphadenectomy with no lymphadenectomy in patients with advanced EOC. Primary outcomes were overall survival and progression-free survival. Secondary outcomes were peri-operative morbidity and operative mortality. The revised Cochrane tool for randomised trials (RoB 2 tool) was utilised for the risk of bias assessment in the included studies. We performed time-to-event and standard pairwise meta-analyses, as appropriate.

RESULTS

Two RCTs with a total of 1074 patients were included in our review. Meta-analysis demonstrated similar overall survival (HR = 1.03, 95% CI [0.85-1.24]; low certainty) and progression-free survival (HR = 0.92, 95% CI [0.63-1.35]; very low certainty). Regarding peri-operative morbidity, systematic lymphadenectomy was associated with higher rates of lymphoedema and lymphocysts formation (RR = 7.31, 95% CI [1.89-28.20]; moderate certainty) and need for blood transfusion (RR = 1.17, 95% CI [1.06-1.29]; moderate certainty). No statistically significant differences were observed in regard to other peri-operative adverse events between the two arms.

CONCLUSIONS

Systematic pelvic and para-aortic lymphadenectomy is likely associated with similar overall survival and progression-free survival compared to no lymphadenectomy in optimally debulked patients with advanced EOC. Systematic lymphadenectomy is also associated with an increased risk for certain peri-operative adverse events. Further research needs to be conducted on whether we should abandon systematic lymphadenectomy in completely debulked patients during primary debulking surgery.

Survival benefits of retroperitoneal lymphadenectomy for optimally-resected advanced ovarian high-grade serous carcinoma: a multi-institutional retrospective study

Objective

The survival benefits of retroperitoneal lymphadenectomy (RLNA) for epithelial ovarian cancer (EOC) remain controversial because clinical behaviors differ among subtypes. The purpose of the present study was to clarify whether RLNA increases the survival rate of advanced high-grade serous carcinoma (HGSC).

Methods

This was a retrospective cohort analysis of 3,227 patients with EOC treated between 1986 and 2017 at 14 institutions. Among them, 335 patients with stage IIB-IV HGSC who underwent optimal cytoreduction (residual tumor of <1 cm) were included. Patients were divided into the RLNA group (n=170) and non-RLNA group (n=165). All pathological slides were assessed based on a central pathological review. Oncologic outcomes were compared between the two groups in the original and weighted cohorts adjusted with the inverse probability of treatment weighting.

Results

The median observation period was 49.8 (0.5–241.5) months. Overall, 219 (65%) out of 335 patients had recurrence or progression, while 146 (44%) died of the disease. In the original cohort, RLNA was a significant prognostic factor for longer progression-free survival (PFS) (hazard ratio [HR]=0.741; 95% confidence interval [CI]=0.558–0.985) and overall survival (OS) (HR=0.652; 95% CI=0.459–0.927). In the weighted cohort in which all variables were well balanced as standardized differences decreased, RLNA was also a significant prognostic factor for more favorable oncologic outcomes (PFS, adjusted HR=0.742; 95% CI=0.613–0.899) and OS, adjusted HR=0.620; 95% CI=0.488–0.787).

Conclusion

The present study demonstrated that RLNA for stage III-IV HGSC with no residual tumor after primary debulking surgery contributed to better oncologic outcomes.

Retroperitoneal lymphadenectomy for advanced-stage patients with ovarian high-grade serous carcinoma can improve oncologic outcomes. This multi-centered retrospective study was performed under the same chemotherapeutic protocol and criteria. Inverse probability of treatment weighting method was used to make weighted cohorts.

Prognostic value of systematic lymphadenectomy in patients with ovarian cancer: A systematic review and meta-analysis

OBJECTIVE

To appraise clinical outcomes of systematic lymphadenectomy in women with ovarian cancer based on stage, control group and type of chemotherapy.

STUDY DESIGN

A literature search was conducted on SCOPUS, PUBMED, COCHRANE, MEDLINE, and WEB OF SCIENCE databases. All comparative studies that assess outcomes of systematic lymphadenectomy in patients with ovarian cancer were eligible. Overall survival was analyzed by pooling log hazard ratio (HR) and standard error of multivariable Cox regression models. MOGGE Meta-analysis Matrix is a novel illustration tool that was used to demonstrate multiple subgroup analyses of included studies.

RESULTS

Twenty-two studies were eligible. Systematic lymphadenectomy was associated with better overall survival, that was close to significance, compared to control group (HR 0.93, 95 %CI 0.86-1.00). Among women treated with adjuvant chemotherapy, overall survival improved in women with stage IIB-IV who underwent systematic lymphadenectomy (HR 0.91, 95 %CI 0.84-0.99) and was most significant among patients with stage III to IV (HR 0.85, 95 %CI 0.73-0.99). Systematic lymphadenectomy did not improve survival in women who received neoadjuvant chemotherapy (HR 0.97, 95 %CI 0.73-1.29). Systematic lymphadenectomy was associated with improved progress-free survival compared to control group (HR 0.88, 95 %CI 0.79-0.99).

CONCLUSION

Although data from clinical trials do not support role of systematic lymphadenectomy in advanced ovarian cancer, overall data conveys stage-specific survival benefit. Further clinical trials may be warranted to assess substage survival outcomes in women with advanced stages.

Ovarian Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States and is the country's fifth most common cause of cancer mortality in women. A major challenge in treating ovarian cancer is that most patients have advanced disease at initial diagnosis. These NCCN Guidelines discuss cancers originating in the ovary, fallopian tube, or peritoneum, as these are all managed in a similar manner. Most of the recommendations are based on data from patients with the most common subtypes─high-grade serous and grade 2/3 endometrioid. The NCCN Guidelines also include recommendations specifically for patients with less common ovarian cancers, which in the guidelines include the following: carcinosarcoma, clear cell carcinoma, mucinous carcinoma, low-grade serous, grade 1 endometrioid, borderline epithelial, malignant sex cord-stromal, and malignant germ cell tumors. This manuscript focuses on certain aspects of primary treatment, including primary surgery, adjuvant therapy, and maintenance therapy options (including PARP inhibitors) after completion of first-line chemotherapy.

Intraoperative Clinical Examination for Assessing Pelvic and Para-Aortic Lymph Node Involvement in Advanced Epithelial Ovarian Cancer: A Systematic Review and Meta-Analysis

After the publication of the Lymphadenectomy in Ovarian Neoplasms (LION) trial results, lymphadenectomy in advanced epithelial ovarian cancer with primary complete cytoreductive surgery is considered indicated only for women with suspicious lymph nodes. The aim of this meta-analysis was to evaluate the diagnostic accuracy of intraoperative clinical examination for detecting lymph node metastases in patients with advanced epithelial ovarian cancer during primary complete cytoreductive surgery. MEDLINE, EMBASE, Web of Science and the Cochrane Library were searched for January 1990 to May 2019 for studies evaluating the diagnostic accuracy of intraoperative clinical examination for detecting lymph node metastases in patients with advanced epithelial ovarian cancer during primary complete cytoreductive surgery, with histology as the gold standard. Methodological quality was assessed by using the QUADAS-2 tool. Pooled diagnostic accuracy was calculated, and hierarchical summary receiver operating curve was constructed. The potential sources of heterogeneity were analyzed by meta-regression analysis. Deek’s funnel plot test for publication bias and Fagan’s nomogram for clinical utility were also used. This meta-analysis included five studies involving 723 women. The pooled sensitivity of intraoperative clinical examination for detecting lymph node metastases was 0.79, 95% CI (0.67–0.87), and its specificity 0.85, 95% CI (0.67–0.94); the area under the hierarchical summary receiver operating curve was 0.86, 95% CI (0.83–0.89). In the meta-regression analysis, patient sample size, mean age, and type of cancer included were significant covariates explaining the potential sources of heterogeneity. Deek’s funnel plot test showed no evidence of publication bias (p = 0.25). Fagan’s nomogram indicated that intraoperative clinical examination increased the post-test probability of lymph node metastases to 79% when it was positive and reduced it to 16% when negative. This meta-analysis shows that the diagnostic accuracy of intraoperative clinical examination during primary complete cytoreductive surgery for detecting lymph node metastases in advanced epithelial ovarian cancer is good.

Impact of Lymphadenectomy on Survival of Patients with Serous Advanced Ovarian Cancer After Neoadjuvant Chemotherapy: A French National Multicenter Study (FRANCOGYN)

Background: The population of interest to this study comprised individuals with advanced-stage ovarian carcinoma who were exposed to neoadjuvant chemotherapy (NAC) followed by interval debulking surgery (IDS). Those who had not received systematic lymphadenectomy (SL; Group 1) were compared to those who had received SL (Group 2). Outcome measures included progression-free survival (PFS), overall survival (OS), and surgical complications. Methods: This was a retrospective, multicenter cohort study in nine referral centers of France between January 2000 and June 2017. OS analysis using the multivariate Cox regression model was performed. PFS and surgery-related morbidity were analyzed. Results: Of the 255 patients included, 100 were in Group 1 and 155 in Group 2. Patient majority was, on average, younger and less comorbid, with predominant R0 surgery in Group 2. Dindo–Clavien score was similar between the two groups (p = 0.15). Median OS was 26.8 months in Group 2 and 27.6 months in Group 1. SL was not statistically significant on OS (p = 0.7). Median PFS was 18.3 months in Group 2 and 16.6 months in Group 1. SL had positive impact on PFS (p = 0.005). Conclusions: patients who had received SL (Group 2) had significantly higher PFS regardless of node-positivity status when compared to those who had not received SL (Group 1).

The relationship between retroperitoneal lymphadenectomy and survival in advanced ovarian cancer patients

BACKGROUND

Systematic retroperitoneal lymphadenectomy has been widely used in the surgical treatment of advanced ovarian cancer patients. Nevertheless, the corresponding therapeutic may not provide a survival benefit. The aim of this study was to assess the effect of systematic retroperitoneal lymphadenectomy in such patients.

METHODS

Patients with advanced ovarian cancer (stage III-IV, according to the classification presented by the International Federation of Gynecology and Obstetrics) who were admitted and treated in Zhejiang Cancer Hospital from January 2004 to December 2013 were enrolled and reviewed retrospectively. All patients were optimally or suboptimally debulked (absent or residual tumor < 1 cm) and divided into two groups. Group A (no-lymphadenectomy group, n = 170): patients did not undergo lymph node resection; lymph nodes resection or biopsy were selective. Group B (n = 240): patients underwent systematic retroperitoneal lymphadenectomy.

RESULTS

A total of 410 eligible patients were enrolled in the study. The patients' median age was 51 years old (range, 28-72 years old). The 5-year overall survival (OS) and 2-year progression-free survival (PFS) rates were 78 and 24% in the no-lymphadenectomy group and 76 and 26% in the lymphadenectomy group (P = 0.385 and 0.214, respectively). Subsequently, there was no significant difference in 5-year OS and 2-year PFS between the two groups stratified to histological types (serous type or non-serous type), the clinical evaluation of negative lymph nodes or with macroscopic peritoneal metastasis beyond pelvic (IIIB-IV). Multivariate Cox regression analysis indicated that systematic retroperitoneal lymphadenectomy was not a significant factor influencing the patients' survival. Patients in the lymphadenectomy group had a higher incidence of postoperative complications (incidence of infection treated with antibiotics was 21.7% vs. 12.9% [P = 0.027]; incidence of lymph cysts was 20.8% vs. 2.4% [P < 0.001]).

CONCLUSIONS

Our study showed that systematic retroperitoneal lymphadenectomy did not significantly improve survival of advanced ovarian cancer patients with residual tumor < 1 cm or absent after cytoreductive surgery, and were associated with a higher incidence of postoperative complications.

Should We Abandon Systematic Pelvic and Paraaortic Lymphadenectomy in Low-Grade Serous Ovarian Cancer?

BACKGROUND

Low-grade serous ovarian carcinoma (LGSOC) is a rare disease that accounts for 5% of all ovarian cancers and requires surgical complete debulking. To date, the prognostic value of pelvic and paraaortic lymphadenectomy remains unclear in this population.

PATIENTS AND METHODS

This retrospective cohort of patients with a diagnosis of LGSOC was registered in the Tumeurs Malignes Rares Gynécologiques national network, between January 2000 and July 2017, at 25 centers. All LGSOC were confirmed after pathological review and operated by primary debulking surgery (PDS) or interval debulking surgery after neoadjuvant chemotherapy (NACT-IDS). Primary endpoints were overall survival (OS) and progression-free survival (PFS).

RESULTS

A total of 126 patients were included, 86.1% were stage III/IV, and 74.6% underwent lymph node dissection (LND). According to the Completeness of Cancer Resection (CCR) score, 83.7% had complete resection. Median OS was 130 months, and median PFS was 41 months. Pelvic and paraaortic LND had no significant impact on OS (p = 0.78) or DFS (p = 0.93), and this was confirmed in subgroups (advanced stages FIGO III/IV, CCR score 0/1 or 2/3, and timing of surgery PDS or NACT-IDS). Histological positive paraaortic lymph nodes had a significant negative impact on PFS in the whole population (HR 2.21, 1.18-4.39, p = 0.02) and in the CC0/CC1 population (HR, 2.28, 1.13-4.59, p = 0.02).

CONCLUSIONS

Systematic pelvic and paraaortic LND in patients with LGSOC improved neither overall nor PFS. A prospective trial would be necessary to validate these results but would be difficult to conduct due to the rarity of this disease.

The impact of systematic retroperitoneal lymphadenectomy on long-term oncologic outcome of women with advanced ovarian clear-cell carcinoma

Objective

The impact of systematic retroperitoneal lymphadenectomy (SRL) remains controversial in patients with advanced ovarian clear-cell carcinoma (CCC) who are optimally debulked.

Methods

Between 1986 and 2017, a total of 3,227 women with epithelial ovarian carcinoma were analyzed in a multi-institutional study. Among them, 166 optimally debulked women with stage IIB–IV CCC were collected (residual tumor of <1 cm). All patients were divided into 2 groups: 1) Group I (n=112): underwent standard radical surgery with SRL, 2) Group II (n=54): underwent non-staging limited surgery. The pathological slides were assessed based on central pathological review. Oncologic outcomes were compared between the two groups using a propensity score (PS)-matching technique to adjust for various clinicopathologic factors.

Results

The median follow-up duration of all surviving women was 52.8 (1.6–184.2) months. Overall, 88 patients (53.0%) experienced recurrence and 68 patients (41.0%) died of the disease. In the original cohort, the 5-year overall survival (OS) rates of groups I and II were 57.9 and 64.9%, respectively (log-rank p=0.415). In the PS-adjusted cohort, the 5-year OS rates were 64.9 and 58.8% in women in groups I and II, respectively (p=0.453). Furthermore, in the PS-matched cohort after adjustment for multiple clinicopathologic factors, there was no significant difference in OS between the 2 groups (group I vs. group II; hazard ratio=1.170; 95% confidence interval=0.633–2.187; p=0.615).

Conclusions

This study suggests that the performance of SRL including radical surgery may not lead to a significant improvement in the oncologic outcome of advanced CCC patients with optimal cytoreduction.

A Randomized Trial of Lymphadenectomy in Patients with Advanced Ovarian Neoplasms

BACKGROUND

Systematic pelvic and paraaortic lymphadenectomy has been widely used in the surgical treatment of patients with advanced ovarian cancer, although supporting evidence from randomized clinical trials has been limited.

METHODS

We intraoperatively randomly assigned patients with newly diagnosed advanced ovarian cancer (International Federation of Gynecology and Obstetrics stage IIB through IV) who had undergone macroscopically complete resection and had normal lymph nodes both before and during surgery to either undergo or not undergo lymphadenectomy. All centers had to qualify with regard to surgical skills before participation in the trial. The primary end point was overall survival.

RESULTS

A total of 647 patients underwent randomization from December 2008 through January 2012, were assigned to undergo lymphadenectomy (323 patients) or not undergo lymphadenectomy (324), and were included in the analysis. Among patients who underwent lymphadenectomy, the median number of removed nodes was 57 (35 pelvic and 22 paraaortic nodes). The median overall survival was 69.2 months in the no-lymphadenectomy group and 65.5 months in the lymphadenectomy group (hazard ratio for death in the lymphadenectomy group, 1.06; 95% confidence interval [CI], 0.83 to 1.34; P = 0.65), and median progression-free survival was 25.5 months in both groups (hazard ratio for progression or death in the lymphadenectomy group, 1.11; 95% CI, 0.92 to 1.34; P = 0.29). Serious postoperative complications occurred more frequently in the lymphadenectomy group (e.g., incidence of repeat laparotomy, 12.4% vs. 6.5% [P = 0.01]; mortality within 60 days after surgery, 3.1% vs. 0.9% [P = 0.049]).

CONCLUSIONS

Systematic pelvic and paraaortic lymphadenectomy in patients with advanced ovarian cancer who had undergone intraabdominal macroscopically complete resection and had normal lymph nodes both before and during surgery was not associated with longer overall or progression-free survival than no lymphadenectomy and was associated with a higher incidence of postoperative complications. (Funded by Deutsche Forschungsgemeinschaft and the Austrian Science Fund; LION ClinicalTrials.gov number, NCT00712218.).

Role of systematic lymphadenectomy as part of primary debulking surgery for optimally cytoreduced advanced ovarian cancer: Reappraisal in the era of radical surgery

The prognostic significance of pelvic and para-aortic lymphadenectomy during primary debulking surgery for advanced-stage ovarian cancer remains unclear. This study aimed to evaluate the survival impact of lymph node dissection (LND) in patients treated with optimal cytoreduction for advanced ovarian cancer. Data from 158 consecutive patients with stage IIIC–IV disease who underwent optimal cytoreduction (<1 cm) were obtained via retrospective chart review. Patients were classified into two groups: (1) lymph node sampling (LNS), node count <20; and (2) LND, node count ≥20. Progression-free (PFS) and overall survival (OS) were analyzed using the Kaplan–Meier method. Among the included patients, 96 and 62 patients underwent LND and LNS as primary debulking surgery, respectively. There were no differences in the extent of debulking surgical procedures, including extensive upper abdominal surgery, between the groups. Patients who underwent LND had a marginally significantly improved PFS (P = 0.059) and significantly improved OS (P < 0.001) compared with those who underwent LNS. In a subgroup with negative lymphadenopathy on preoperative computed tomography scans, revealed LND correlated with a better PFS and OS (P = 0.042, 0.001, respectively). Follow-ups of subsequent recurrences observed a significantly lower nodal recurrence rate among patients who underwent LND. A multivariate analysis identified LND as an independent prognostic factor for PFS (hazard ratio [HR], 0.629; 95% confidence interval [CI], 0.400–0.989) and OS (HR, 0.250; 95% CI, 0.137–0.456). In conclusion, systematic LND might have therapeutic value and improve prognosis for patients with optimally cytoreduced advanced ovarian cancer.

The effect of lymphadenectomy in advanced ovarian cancer according to residual tumor status: A population-based study

BACKGROUND

We investigated the effect of lymphadenectomy on the survival outcomes of patients with advanced epithelial ovarian cancer in the Surveillance, Epidemiology, and End Results database according to residual disease status.

METHODS

We evaluated 3048 patients with International Federation of Gynecology and Obstetrics stage-IIIC-IV epithelial ovarian cancer. We assessed the effect of lymphadenectomy stratified by residual disease size on cause-specific survival (CSS).

RESULTS

A total of 1904 (62.5%) patients received lymphadenectomy, and 1355 (71.2%) patients had nodal metastases. Lymph-node status had no significant association with residual tumor size in the lymphadenectomy group. In multivariate analysis, lymphadenectomy was associated with a significantly better CSS and was an independent prognostic factor for CSS. Patients with >10 lymph nodes removed had better CSS compared with non-lymphadenectomy and 1-10 lymph nodes removed groups. Lymphadenectomy was associated with a significantly better CSS in patients with no gross residual tumor, but not in patients with residual tumor ≤1 cm or >1 cm.

CONCLUSIONS

Lymphadenectomy is significantly associated with a better survival outcome in patients advanced ovarian cancer, but its positive effect diminishes as residual tumor size increases.

Incidence and Impact of Lymph Node Metastases in Advanced Ovarian Cancer: Implications for Surgical Treatment

Background: This study aimed to clarify the impact of node involvement (affected to resected nodes) in optimally cytoreduced (residual tumour ≤1cm) stage IIIC/IV ovarian cancer. Methods: 108 consecutive patients with primary stage IIIC/IV ovarian cancer underwent stage-related surgery and got adjuvant platinum-based chemotherapy. Median follow-up: 53.5 months. All patients got systematic para-aortic and pelvic lymphadenectomy. Clinical parameters were retrospectively evaluated. Patients were stratified into 3 groups to evaluate node affection: 1) no (0%), 2) minor (>0%, ≤50%) >0 and 3) major (>50% of affected nodes). Kaplan-Meier survival curve was used to evaluate the prognostic value. Results: On average, 21.3 pelvic and para-aortic nodes were removed per patient (range 1-60 nodes). Minor nodal involvement (node ratio >0-≤0.5: (59%) was most often detected. Increasing node ratio leads to significant decreased overall survival (p<0.001). Significant best overall survival was associated with minor node involvement (node ratio >0 to ≤0.5). Complete cytoreduction correlated with node affection shows significant best prognostic impact in minor node affection compared to incomplete resection (R>0-≤1cm) independent to nodal status (OS p<0.001). Conclusion: Radical surgery is the main factor of improved overall and tumor free survival. Paraaortal and iliacal lymphadenectomy seems to play an important role for prognostic and therapeutic reasons: Prognostic in accurate staging and therapeutic in case of achieved optimal cytoreduction including lymph nodes with histology proven minor node involvement.

Impact of lymphadenectomy on survival after recurrence in patients with advanced ovarian cancer without suspected lymph node metastasis

OBJECTIVE

To investigate the impact of pelvic and para-aortic lymphadenectomy during primary debulking surgery (PDS) on recurrence pattern and survival after recurrence in patients with advanced epithelial ovarian cancer (EOC) without suspected lymph node (LN) metastasis in preoperative imaging studies and intraoperative findings.

METHODS

A retrospective review of patients with FIGO stage III and IV EOC without suspected lymph node metastasis was performed. Patients with stage III EOC due to LN metastasis without peritoneal disease were excluded from this study. Survival comparisons for progression-free survival (PFS), overall survival (OS), and survival after recurrence were performed between patients with or without lymphadenectomy.

RESULTS

Of the 261 EOC patients fulfilling inclusion criteria, 194 (74.3%) experienced relapse and a further 132 (50.6%) died within a median follow-up period of 48months (range, 6-139months). Patterns of recurrence and CA-125 level at recurrence were not different between patients with lymphadenectomy and without lymphadenectomy; however, patients with lymphadenectomy showed longer survival after recurrence than those without lymphadenectomy (43 vs. 32months, p=0.013). This difference was pronounced in the group with residual tumor <1cm (48 vs. 30months, p=0.010). The survival advantage of lymphadenectomy after recurrence remained significant in multivariate analysis (HR 0.57, 95% CI 0.38-0.84, p=0.005).

CONCLUSIONS

Lymphadenectomy during PDS was associated with longer survival, especially survival after recurrence. The underlying mechanism should be elucidated in future studies.

Prevalence and distribution pattern of nodal metastases in advanced ovarian cancer

The objective of this study was to examine the relevance of pelvic and para-aortic lymph node involvement and the tumour characteristics affecting nodal metastases and survival in primary advanced ovarian cancer. A total of 130 consecutive patients were retrospectively investigated. All the patients received stage-related surgery with pelvic and para-aortic lymphadenectomy. The median follow-up was 53.5 months. The clinicopathological parameters and distribution pattern of nodal metastases were evaluated. Lymph node metastases were detectable in 74.62% of the cases. Overall, both pelvic and para-aortic nodes were affected in 35.9% of the patients, whereas 13.3% had metastases only in the pelvic and 13.3% only in the para-aortic lymph nodes. Histological grade 1/2 and 3, serous and endometrioid histology were independent predictors of nodal metastasis. Serous and endometrioid cancers have shown a predilection for metastasis to the pelvic lymph nodes alone, both to the pelvic and the para-aortic nodes, or the para-aortic nodes alone. Overall survival was significantly positively affected by serous histology with positive nodes (P=0.043). It is crucial to investigate the risk factors and metastatic patterns of such patients in a multicenter analysis to evaluate individual subgroups. Prospective studies are required to investigate the prognostic effect of lymphadenectomy in advanced ovarian cancer and its association with histology and distribution pattern of nodal metastasis.

Clinical significance of systematic retroperitoneal lymphadenectomy during interval debulking surgery in advanced ovarian cancer patients

Objective

To investigate the clinical significance of systematic retroperitoneal lymphadenectomy during interval debulking surgery (IDS) in advanced epithelial ovarian cancer (EOC) patients.

Methods

We retrospectively reviewed the medical records of 124 advanced EOC patients and analyzed the details of neoadjuvant chemotherapy (NACT), IDS, postoperative treatment, and prognoses.

Results

Following IDS, 98 patients had no gross residual disease (NGRD), 15 had residual disease sized <1 cm (optimal), and 11 had residual disease sized ≥1 cm (suboptimal). Two-year overall survival (OS) and progression-free survival (PFS) rates were 88.8% and 39.8% in the NGRD group, 40.0% and 13.3% in the optimal group (p<0.001 vs. NGRD for both), and 36.3% and 0% in the suboptimal group, respectively. Five-year OS and 2-year PFS rates were 62% and 56.1% in the lymph node-negative (LN-) group and 26.2% and 24.5% in the lymph node-positive (LN+) group (p=0.0033 and p=0.0024 vs. LN-, respectively). Furthermore, survival in the LN+ group, despite surgical removal of positive nodes, was the same as that in the unknown LN status group, in which lymphadenectomy was not performed (p=0.616 and p=0.895, respectively). Multivariate analysis identified gross residual tumor during IDS (hazard ratio, 3.68; 95% confidence interval, 1.31 to 10.33 vs. NGRD) as the only independent predictor of poor OS.

Conclusion

NGRD after IDS improved prognosis in advanced EOC patients treated with NACT-IDS. However, while systematic retroperitoneal lymphadenectomy during IDS may predict outcome, it does not confer therapeutic benefits.

The prognostic relevance of node metastases in optimally cytoreduced advanced ovarian cancer

PURPOSE

To delineate the relevance of pelvic and para-aortic node involvement in optimally cytoreduced (residual tumour <1 cm) stage IIIC ovarian cancer patients.

METHODS

Ninety-five consecutive optimally cytoreduced (R ≤ 1 cm) patients with primary stage IIIc ovarian cancer underwent stage-related surgery and got adjuvant platinum-based chemotherapy. Median follow-up: 53.5 months. All patients got systematic lymphadenectomy. On average, 24.7 pelvic and para-aortic lymph nodes were removed per patient (range 1-60 nodes). Patients were stratified into three groups to evaluate node involvement (ratio: affected to resected nodes): (1) (=0); (2) (>0-≤ 0.5) >0 and ≤ 50 % of affected nodes; (3) (>0.5-≤ 1) >50 % of affected nodes. Clinical parameters were retrospectively evaluated. Kaplan-Meier survival curve was used to evaluate the prognostic value.

RESULTS

Most often serous histology, histologic grade 3 and a node ratio >0-≤ 0.5 (61.1 %) were detected. Complete cytoreduction (R = 0 mm) has significant best prognostic impact compared to R > 0 mm-1 cm (OS: p = 0.047, PFS: p = 0.00). Node involvement was associated with serous histology and grade 3. Increasing node ratio leads to significant decreased OS (p = 0.019) and significant best OS was associated with node ratio >0-≤0.5.

CONCLUSIONS

The goal is optimal cytoreduction in advanced ovarian cancer. More extensive lymphadenectomy seems to play an important role in providing an accurate staging, and the node ratio might give prognostic information. Current prospective studies like the LION study (AGO-Ovar) had to investigate if these data have therapeutic implications and may be considered in future staging.

The Prognostic Role of Optimal Cytoreduction in Advanced, Bowel Infiltrating Ovarian Cancer

AIM

In locally advanced ovarian cancer with bowel involvement appropriate surgical treatment is still controversial. Objective was to delineate factors to select those most likely to benefit from radical surgery in patients with locally advanced ovarian cancer.

METHODS

Therefore, we retrospectively evaluated 207 consecutive patients with primary stage IIB-IV ovarian cancer who underwent primary surgery between 2000 and 2007. Every patient received stage-related surgery and adjuvant platinum-based chemotherapy. Median follow-up was 53.5 months. Data collected included stage, histology, extent of cytoreduction and type of bowel resection. Univariate survival analyses were performed to investigate variables associated with outcome.

RESULTS

Optimal cytoreduction (OCR) (R ≤ 1 cm) was achieved in 76.8%. Most patients presented histologic grade 2/3 (96.6%), serous ovarian cancers (84.1%) and lymph node involvement (52.2%). Complete cytoreduction (R = 0 mm) has significant best prognostic impact in FIGO IIB-IV (p = .026). Regarding bowel involvement, bowel resection was performed in 82 patients (39.6%). In this subgroup of patients complete cytoreduction led to significant better overall survival than R > 0 mm-1 cm, even in FIGO IIIC-IV patients (p = .027); this fact is independent of bowel resection. Noticeably, for survival bowel resection achieving residual tumor mass below 1 cm was also one main prognostic factor and even recurrence rate was associated with residual tumor mass.

CONCLUSION

Our findings suggest that the major prognostic factor in patients with advanced ovarian cancer needing colorectal resection is completeness of cytoreduction. Therefore, in advanced ovarian cancer patients, multivisceral surgery is indicated to achieve OCR (R ≤ 1 cm) with or without bowel resection with best prognostic impact.

Nodal status--its impact on prognosis in advanced ovarian cancer

PURPOSE

Prognostic impact of nodal status or lymphadenectomy in advanced ovarian cancer is still unclear. Known best prognostic impact in advanced ovarian cancer has the residual tumor mass. The aim of this retrospective study is to examine the importance of nodal status in correlation with residual tumor mass.

METHODS

One hundred and fifty-seven consecutive patients with primary stage III ovarian cancer underwent surgery between 01/2000 and 06/2007 at the Department of gynecology and obstetrics, University Hospital, Tübingen, Germany. All patients got stage-related surgery and platin-based chemotherapy. Median follow-up time was 53.5 months, and all patients were included in the study.

RESULTS

Resection status and nodal status are significant prognostic factors in our study (P < 0.001). In FIGO III, patients without residual tumor (R0) had significant best OS and PFS independent to node status (N0/N+; P = 0.002) compared to patients with residual tumor. In contrast, node status had significant positive impact on PFS in patients without residual tumor and node negativity. With the increase in residual tumor, the influence of lymphnode metastases on prognosis is decreasing.

CONCLUSION

Main intention of primary surgery is R0 resection with best prognosis in advanced stages. A systematic lymphadenectomy in cases with R0 resection or residual tumor <1 cm seems to be reasonable with positive impact on prognosis. Node status has impact on prognosis in patients with negative node after R0 resection with best PFS in FIGO III. Further prospective studies had to show whether systematic lymphadenectomy in suboptimally tumor-reduced patients can improve prognosis.

Potential Role of Lymphadenectomy in Advanced Ovarian Cancer: A Combined Exploratory Analysis of Three Prospectively Randomized Phase III Multicenter Trials

Purpose

Primary surgery followed by platinum/taxane-based chemotherapy is the standard therapy in advanced ovarian cancer. The prognostic role of complete debulking has been well described; however, the impact of systematic pelvic and para-aortic lymphadenectomy and its interaction with biologic factors are still not fully defined.

Methods

This was an exploratory analysis of three prospective randomized trials (Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom trials 3, 5, and 7) investigating platinum/taxane-based chemotherapy regimens in advanced ovarian cancer conducted between 1995 and 2002.

Results

One thousand nine hundred twenty-four patients were analyzed. Lymphadenectomy was associated with superior survival in patients without gross residual disease. In patients with and without lymphadenectomy, the median survival time was 103 and 84 months, respectively, and 5-year survival rates were 67.% and 59.2%, respectively (P = .0166); multivariate analysis confirmed a significant impact of lymphadenectomy on overall survival (OS; hazard ratio [HR] = 0.74; 95% CI, 0.59 to 0.94; P = .0123). In patients with small residual tumors up to 1 cm, the effect of lymphadenectomy on OS barely reached significance (HR = 0.85; 95% CI, 0.72 to 1.00; P = .0497). For patients with small residual tumors and clinically suspect nodes, lymphadenectomy resulted in a 16% gain in 5-year OS (log-rank test, P = .0038).

Conclusion

Lymphadenectomy in advanced ovarian cancer might offer benefit mainly to patients with complete intraperitoneal debulking. However, this hypothesis should be confirmed in the context of a prospectively randomized trial.

Pattern and clinical predictors of lymph node metastases in epithelial ovarian cancer

Para-aortic lymphadenectomy is part of staging in early epithelial ovarian cancer (EOC) and could be part of therapy in advanced EOC. However, only a minority of patients receive therapy according to guidelines or have attendance to a specialized unit. We analyzed pattern of lymphatic spread of EOC and evaluated if clinical factors and intraoperative findings reliably could predict lymph node involvement, in order to evaluate if patients could be identified in whom lymphadenectomy could be omitted and who should not be referred to a center with capacity of performing extensive gynecological operations. Retrospective analysis was carried out of all patients with EOC who had systematic pelvic and para-aortic lymphadenectomy during primary cytoreductive surgery. One hundred ninety-five patients underwent systematic pelvic and para-aortic lymphadenectomy. Histologic lymph node metastases were found in 53%. The highest frequency was found in the upper left para-aortic region (32% of all patients) and between vena cava inferior and abdominal aorta (36%). Neither intraoperative clinical diagnosis nor frozen section of pelvic nodes could reliably predict para-aortic lymph node metastasis. The pathologic diagnosis of the pelvic nodes, if used as diagnostic tool for para-aortic lymph nodes, showed a sensitivity of only 50% in ovarian cancer confined to the pelvis and 73% in more advanced disease. We could not detect any intraoperative tool that could reliably predict pathologic status of para-aortic lymph nodes. Systematic pelvic and para-aortic lymphadenectomy remains part of staging in EOC. Patients with EOC should be offered the opportunity to receive state-of-the-art treatment including surgery

Secondary cytoreductive surgery for patients with recurrent epithelial ovarian carcinoma

OBJECTIVE

The aim of this prospective study was to evaluate the influence of secondary cytoreductive surgery on survival of patients with recurrent epithelial ovarian cancer.

METHODS

Between June 1993 and June 1999, 149 patients after primary treatment underwent secondary cytoreductive surgery: 69 (46.3%) had recurrence-free interval (RFI) 7-12 months, 59 (39.6%) RFI 13-24 months, and 21 (14.1%) RFI >24 months. Exclusion criteria included secondary cytoreduction during second-look laparotomy, interval cytoreduction, and palliative surgery in patients with intestinal obstruction or progressive disease.

RESULTS

The median follow-up was 27 months. According to multivariate analysis, RFI groups, prior chemotherapy combination, and residual tumor after secondary surgery were associated independently with overall survival. Residual tumor after secondary surgery was by far the most strongly predictive factor for patient's survival (hazard ratio (HR) 2.65; 95% confidence interval (CI) 1.43-4.92). The 2-year survival rates were 22.3, 62.9, and 22.7%, respectively, for patients with RFI 7-12, 13-24, and >24 months. The 5-year survival was 29% for patients with RFI 13-24 months. No patients with RFI 7-12 and >24 months outlived the 4-year estimate. Unexpectedly, RFI >24 months was not correlated significantly with overall survival. However, 17 patients (81%) with RFI >24 months were heavily treated with chemotherapy before secondary surgery.

CONCLUSIONS

Patients who have documented gross disease preoperatively should be selected for a secondary debulking operation; the entity of surgical effort would be modulated in relation to previous treatment.

Cytoreductive surgery for advanced stages of ovarian cancer

During the past two decades, maximum cytoreductive surgery (also called debulking surgery) has been the recommended surgical approach for advanced stages of ovarian carcinoma. The residual tumor volume after surgery is one of the strongest prognostic factors, and only patients who undergo complete or optimal surgery are likely to be long-term survivors (i.e., 50% after five years). A well-trained surgeon in the field of gynecologic oncology can achieve an optimal tumor reduction in up to 75% of patients with advanced stage ovarian cancer. During the procedure, bowel resection, especially rectosigmoid, must be undertaken in 30% to 40% of cases, and para-aortic and pelvic lymphadenectomy should be performed after adequate tumor reduction in the abdominal cavity. The experienced surgeon can perform these surgeries with an acceptable morbidity, allowing chemotherapy to be undertaken within the month following surgery. However, very advanced cancer with massive peritoneal carcinomatosis and/or Stage IV disease requires a very aggressive surgical procedure but yields a poor prognosis and a higher risk of unacceptable complications. For these worst cases, the concept of cytoreductive surgery is moving toward the alternative strategy of chemosurgical cytoreduction, in which interval cytoreductive surgery is undertaken after three cycles of front-line chemotherapy. The goal of this experimental strategy is to achieve a complete tumor response after front-line chemosurgical therapy, and a better quality of life.

Primary cytoreductive surgery with rectosigmoid colon resection for patients with advanced epithelial ovarian carcinoma

BACKGROUND

The impact of radical bowel resection with multiple organ resection on the survival if patients with advanced ovarian carcinoma has not been well defined. The authors investigated whether primary cytoreductive surgery including rectosigmoid colon resection would affect the recurrence free interval and survival of these patients.

METHODS

Between April 1990 and April 1997, 66 previously untreated Stage IIIC-IV ovarian carcinoma patients with macroscopic involvement of the rectosigmoid colon were enrolled. All patients underwent cytoreductive surgery with rectosigmoid colon resection to remove residual tumor less than 2 cm in greatest dimension and received 6 cycles of cisplatin-based postoperative chemotherapy.

RESULTS

The median follow-up was 26 months (range, 7-104 months). In multivariate analysis, residual disease and depth of tumor infiltration of the bowel wall were independently associated with overall survival and recurrence free interval. Disease stage was independently associated only with overall survival. Residual tumor was the most strongly predictive factor for recurrence or death. The 2-year estimated survival rates according to the amount of residual tumor were 100% for 24 patients with no macroscopic residual disease and 77.3% for 28 patients with residual disease less than 1 cm. None of the 14 patients with residual disease larger than 1 cm were alive 2-years after operation. Overall, 48 patients (72.7%) developed disease recurrence: 43 (65.1%) in the abdomen, 19 (29.8%) in the liver, and 3 (4.5%) in the pelvis.

CONCLUSIONS

The current findings suggest that cytoreductive surgery with rectosigmoid colon resection should be considered for ovarian carcinoma patients with bulky pelvic disease to help ensure that they are left with no residual disease after debulking surgery.

Pelvic and paraortic lymph nodal status in advanced ovarian cancer and survival

BACKGROUND

In order to analyze the prognostic role of node involvement in advanced ovarian cancer, we have analyzed data from a randomized clinical trial on advanced ovarian cancer.

METHODS

Cases were 456 women who entered a randomized multicentric clinical trial comparing two cisplatin-based schemes of treatment after cytoreductive surgery for advanced stage III-IV ovarian cancer. They underwent selective pelvic and/or paraortic lymphadenectomy.

RESULTS

A total of 161 (35.3%) cases had positive nodes. The frequency of positive nodes was statistically significantly higher in FIGO stage IV than in stage III. Also grade 3 tumors were more likely to have positive nodes than grade 1-2 tumors. No association was observed between nodal status and response to chemotherapy. The 3-year survival was 46.2 (standard error (SE) = 3.4 based on 147 deaths) and 44.6 (SE = 4.4, based on 84 deaths), respectively, in negative and positive node groups. The corresponding values, when the analysis was performed considering only subjects with residual tumor <1 cm or absent, after first-line cytoreductive surgery were 66.2 (SE = 5.7) and 62.4 (SE = 9.6).

CONCLUSIONS

We did not find any association between nodal status and survival. Particularly, nodal status was not a prognostic factor for survival in the subgroup of women with residual tumor <1 cm or absent after cytoreductive surgery.