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

Preoperative unveiling of mucinous ovarian cancer subtypes: Clinical and CT features

OBJECTIVES

To compare the frequency, clinical, imaging, and survival characteristics of mucinous ovarian carcinoma (MOC) growth pattern subtypes.

BACKGROUND

According to ESGO 2024 guidelines, fertility-sparing surgery can be considered for stages IA and IC1 expansile MOC due to their excellent prognoses and low recurrence risk. The ability to diagnose MOC subtypes preoperatively would aid treatment planning. However, variables for preoperatively distinguishing MOC subtypes have not been established.

METHODS

This IRB-approved, retrospective, single-center study included consecutive patients (≥18 years) with pre-treatment CT from 01/2000-12/2020 and pathological diagnosis of MOC. One experienced radiologist interpreted all CTs, reviewing challenging cases with a senior radiologist. Clinical (age, CA-125, FIGO stage), outcome (local recurrence, distant metastasis, death from cancer/unrelated cause), and CT (laterality, size, mass type, calcifications, adenopathy, peritoneal/serosal implants, ascites) were compared (p < 0.05).

RESULTS

Of 24 patients with MOC, 50 % (n = 12) had expansile disease. Compared to infiltrative MOC, expansile MOC appeared more often at stage I (92 % vs. 58 %), at younger ages (median, 45 vs. 68 years; p = 0.03), and with lower CA-125 (median, 18 vs. 78 ng/mL). At CT, 75 % of expansile vs. 58 % of infiltrative cases were multilocular masses with solid components and ill-defined borders; 25 % of infiltrative, but no expansile cases, were bilateral; 25 % of patients with infiltrative but none with expansile MOC experienced early recurrence, eventually dying of cancer. P-values were > 0.10 for all differences but age, potentially due to the small sample.

CONCLUSIONS

Although CT features of MOC subtypes were similar, expansile MOC presented in younger patients with lower CA-125 levels, was more often diagnosed at stage I, and was uniformly unilateral.

Prognosis of stage I ovarian mucinous tumors according to expansile and infiltrative types

OBJECTIVE

Mucinous ovarian carcinomas account for 3% of all epithelial ovarian carcinomas and are categorized into expansile or infiltrative subtypes. Nevertheless, the prognostic impact of these subtypes in stage I disease remains unclear.

METHODS

This retrospective study included patients with mucinous ovarian cancer who were referred to or treated at our institution between 1976 and 2022. Pathologic review was performed by 2 expert pathologists. Only patients with stage I disease were included in this study. Tumors were characterized as expansile or infiltrative, and oncologic features were analyzed.

RESULTS

A total of 80 cases met the inclusion criteria, with 36 and 44 patients having expansile and infiltrative subtypes, respectively. The disease stages were as follows: expansile subtype in 14 patients, stage IC in 22 patients, infiltrative subtype stage IA in 26 patients, and stage IC in 18 patients. The characteristics of the 2 groups of patients were comparable, except for the use of lymphadenectomy (more frequent in the infiltrative subtype: 28/44 [63%] vs 8/36 [22%] in expansile disease, p < .05). After a median follow-up of 79 months (range; 27.7-119.2), 10 (12.5%) recurrences occurred (3 expansile and 7 infiltrative). A total of 2 cases of expansile recurrence with pelvic recurrence were cured after secondary surgery and chemotherapy, and 1 patient died of the disease. A total of 5 patients with infiltrative recurrence had extra-pelvic spread and died of the disease, 1 patient was still alive with progressive disease, and the last was still alive and disease-free. A total of 2 cases of recurrence were observed after conservative surgery (1 of each subtype).

CONCLUSIONS

In this series, the overall and disease-free survival rates were not significantly different between patients with expansile and infiltrative stage I mucinous ovarian carcinoma. However, the prognosis of recurrent infiltrative cases is poorer than expansile cases.

The prognostic value of growth pattern-based grading for mucinous ovarian carcinoma (MOC): a systematic review and meta-analysis

Objective

To investigate the prognostic significance of expansile and infiltrative growth patterns in mucinous ovarian carcinoma (MOC).

Methods

A systematic search was conducted in the PubMed, Embase, and Web of Science databases for studies published between January 1, 2010, and September 6, 2024, examining the correlation between expansile and infiltrative tumor growth patterns and prognosis in MOC. Subgroup analyses were performed for mortality, recurrence, and FIGO stage I based on tumor subtype. The Chi-square test was used to evaluate the distribution of expansile and infiltrative tumors across FIGO stages I-IV.

Results

Twelve eligible studies, comprising a total of 1185 patients, were included in this systematic review and meta-analysis. The combined death rate in the expansile and infiltrative MOC was 10.5% (95%CI: 6.2-15.7) and 31.1% (95%CI: 14.1-50.9). The combined recurrence rate in the expansile and infiltrative MOC was 6.9% (95%CI: 3.1-11.9) and 24.5% (95%CI: 14.3-36.2). The combined International Federation of Gynecology and Obstetrics (FIGO) I rate in the expansile and infiltrative MOC was 89.8% (95%CI: 84.9-94.0) and 56.2% (95%CI: 41.5-70.4). A significant association was found between tumor type and FIGO stage (χ² (3) = 110.92, p < 0.00001).

Conclusion

Expansile MOC predicts better outcomes, while infiltrative MOC is linked to advanced stages and poorer prognosis. Complete surgical staging is crucial for infiltrative MOC but optional for early-stage expansile MOC. Early-stage patients should consider fertility-sparing surgery, timely conception, and close recurrence monitoring.

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.

Clinical implications of histologic subtypes on survival outcomes in primary mucinous ovarian carcinoma

OBJECTIVE

In 2014, the World Health Organization introduced a new histologic classification by dividing primary mucinous ovarian carcinoma (PMOC) into two: expansile (ES) or infiltrative subtypes (IS). This study investigated the clinical implications of these histological subtypes on survival outcomes.

METHODS

Data from 131 patients with PMOC who underwent primary surgery between 2003 and 2021 were analyzed. The patients baseline characteristics, surgical and pathological information were collected. Survival outcomes were calculated, while factors affecting them were also investigated.

RESULTS

During 55.9 months of median follow-up, 27 (20.6%) patients experienced recurrence and 20 (15.3%) died. Among 131 patients, 113 patients were classified into 87 (77%) ES and 26 (23%) IS after a slide review. Advanced stage, lymph node involvement, and residual tumors after surgery were more common in the IS, showing poorer prognosis. In multivariate analyses, advanced stage and residual tumors after surgery were associated with worse survival, while the IS showed no statistical significance. In subgroup analysis for stage I disease, survival did not vary between subtypes. Nevertheless, patients in the IS group who underwent fertility-sparing surgeries demonstrated a 5-year progression-free survival (PFS) rate of 83.3%, significantly lower than patients without fertility preservation, irrespective of histologic subtypes (5-year PFS rate: 97.9%; P = 0.002 for the ES, 5-year PFS rate: 100%; P = 0.001 for the IS).

CONCLUSIONS

The IS of PMOC had poorer survival outcomes and a higher proportion of advanced-stage tumors. Although its independent prognostic significance remains uncertain, adjuvant chemotherapy should be considered for patients with fertility preservation in the IS group.