Systematic Lymph Node Dissection May Be Abolished in Patients With Apparent Early-Stage Low-Grade Mucinous and Endometrioid Epithelial Ovarian Cancer

The impact of lymphadenectomy on the survival of patients with stage I ovarian clear cell carcinoma

Objective

To assess the impact of lymphadenectomy on the survival of patients with stage I ovarian clear cell carcinoma (OCCC).

Methods

The records of 93 patients with stage I OCCC treated between January 2012 and December 2019 were reviewed retrospectively. The relationships between survival outcomes and the number and region of removed lymph nodes (LNs) were assessed, and the independent prognostic factors were analyzed.

Results

The median number of LNs resected in 93 patients was 24. These patients were divided into two groups based on the median number; overall survival (OS) and recurrence-free survival (RFS) differed significantly between the two groups. Patients were also grouped by the region of the LNs: the pelvic lymph node dissection (PLND) and PLND and para-aortic. Moreover, no differences in OS or RFS were observed between the two groups. Cox regression analysis demonstrated that the number of removed LNs was a significant and independent prognostic factor for poor RFS.

Conclusion

This study exhibited that the number of removed LNs, as an important measure of adequate lymphadenectomy for stage I OCCC, contributed to improved RFS and OS. An independent prognostic factor for stage I OCCC was the number of dissected LNs.

Survival outcomes of lymph node dissection in early-stage epithelial ovarian cancer: identifying suitable candidates

OBJECTIVE

The study aimed to assess the effect of lymph node dissection on survival outcomes in patients presenting with early-stage epithelial ovarian cancer and to delineate patient characteristics that may indicate a greater benefit from pelvic lymph node dissection.

METHODS

A retrospective analysis was performed on individuals diagnosed with clinical stage I-II epithelial ovarian cancer who received primary cytoreductive surgery at the Cancer Hospital Affiliated with Harbin Medical University from January 1, 2010, to January 1, 2018. The investigation encompassed an examination of demographic data, clinicopathological profiles, perioperative complications, and survival outcomes.

RESULTS

A total of 315 patients diagnosed with ovarian cancer were incorporated into the study and were segregated into two distinct cohorts: 217 patients who underwent lymphadenectomy (Group A) and 98 patients who did not undergo the procedure (Group B). The disparities in progression-free survival and overall survival between the two cohorts did not attain statistical significance (p > 0.05). Upon conducting a subgroup analysis, it was discerned that patients characterized by clear cell carcinoma as the pathological subtype demonstrated a significantly extended progression-free survival post-lymphadenectomy (p = 0.02). Additionally, the operative duration for the patients in Group A was significantly protracted in comparison to Group B (146.15 ± 39.132 min vs. 133.49 ± 35.308 min, P = 0.043).

CONCLUSION

For patients with early-stage ovarian cancer, lymph node dissection does not significantly improve progression-free or overall survival rates. Our findings suggest that individuals with clear cell carcinoma pathology have a higher probability of benefiting in terms of survival following lymph node dissection.

Lymphadenectomy in clinically early epithelial ovarian cancer and survival analysis (LILAC): a Gynecologic Oncology Research Investigators Collaboration (GORILLA-3002) retrospective study

OBJECTIVE

This study aimed to evaluate the therapeutic role of lymphadenectomy in patients surgically treated for clinically early-stage epithelial ovarian cancer (EOC).

METHODS

This retrospective, multicenter study included patients with clinically early-stage EOC based on preoperative abdominal-pelvic computed tomography or magnetic resonance imaging findings between 2007 and 2021. Oncologic outcomes and perioperative complications were compared between the lymphadenectomy and non-lymphadenectomy groups. Independent prognostic factors were determined using Cox regression analysis. Disease-free survival (DFS) was the primary outcome. Overall survival (OS) and perioperative outcomes were the secondary outcomes.

RESULTS

In total, 586 patients (lymphadenectomy group, n=453 [77.3%]; non-lymphadenectomy groups, n=133 [22.7%]) were eligible. After surgical staging, upstaging was identified based on the presence of lymph node metastasis in 14 (3.1%) of 453 patients. No significant difference was found in the 5-year DFS (88.9% vs. 83.4%, p=0.203) and 5-year OS (97.2% vs. 97.7%, p=0.895) between the two groups. Using multivariable analysis, lymphadenectomy was not significantly associated with DFS or OS. However, using subgroup analysis, the lymphadenectomy group with serous histology had higher 5-year DFS rates than did the non-lymphadenectomy group (86.5% vs. 74.4%, p=0.048; adjusted hazard ratio=0.281; 95% confidence interval=0.107-0.735; p=0.010). The lymphadenectomy group had longer operating time (p<0.001), higher estimated blood loss (p<0.001), and higher perioperative complication rate (p=0.004) than did the non-lymphadenectomy group.

CONCLUSION

In patients with clinically early-stage EOC with serous histology, lymphadenectomy was associated with survival benefits. Considering its potential harm, lymphadenectomy should be performed according to histologic subtype and subsequent chemotherapy in patients with clinically early-stage EOC.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0007309.

The Role of Systematic Lymphadenectomy in Low-Grade Serous Ovarian Cancer: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the role of systematic lymphadenectomy in low-grade serous ovarian cancer (LGSOC) and determine its impact on clinical outcomes in overall survival (OS) and disease-free survival (DFS) terms.

METHODS

A comprehensive, systematic computer literature search on PubMed was performed using the following Medical Subject Headings (MeSH) terms: "low grade serous ovarian cancer" AND/OR "lymphadenectomy" AND/OR "staging" AND/OR "ovarian cancer" AND/OR "cytoreduction". Separate searches were performed with MeSH terms on MEDLINE and EMBASE to extract all the relevant literature available. We included only patients with histologically confirmed LGSOC.

RESULTS

Three studies were considered in the quantitative analysis. Systematic lymphadenectomy in LGSOC failed to provide a significant OS or PFS benefit in LGSOC when compared to no lymphadenectomy in the entire (all the stages) population (for OS: HR = 1.15, 95% CI [0.42, 3.18] I2 = 84% and for PFS: HR = 1.46, 95% CI [0.63, 3.41], I2 = 71%), nor did it in the subtype analysis regarding FIGO stages. For FIGO early-stage I-II LGSOC, the DFS data were pooled (HR = 1.48, 95% CI [0.58, 3.78], I2 = 75%). In patients with advanced-stage (FIGO II-IV), we also failed to prove survival benefit for lymphadenectomy in OS (HR = 1.74, 95% CI [0.87, 3.48], I2 = 11%) or DFS (HR = 1.48, 95% CI [0.58, 3.78], I2 = 75%) compared to no lymphadenectomy.

CONCLUSION

More extensive prospective research is mandatory to understand the real impact of lymphadenectomy on survival in LGSOC. The existing literature does not provide strong evidence.

Patterns of spread and genetic alterations of primary endometrioid carcinomas of the ovary

OBJECTIVE

The primary objective was to characterize the rate of lymph node involvement in a cohort of patients with primary ovarian endometrioid adenocarcinoma. Additionally, we sought to quantify the recurrence rate, genetic alterations, and impact of lymphadenectomy on survival in this group of patients.

METHODS

Patients diagnosed with primary endometrioid adenocarcinoma of the ovary without synchronous carcinomas of the female genital tract between 2012 and 2021 were identified. Demographic and disease-related data were collected from pathology reports and clinical records. Kaplan-Meier survival analysis using log rank test and Cox regression was performed.

RESULTS

Sixty-three patients met inclusion criteria. Median age was 60 (range 22-90) years. Histologic grade was 1 in 20 (32%), 2 in 27 (43%), and 3 in 16 (25%) tumors. International Federation of Gynecology and Obstetrics (FIGO) stage after surgery included IA/B (n=20, 32%), IC (n=23, 37%), II (n=16, 25%), and III (n=4, 6%). Forty-one (65%) patients had pelvic and 33 (52%) had both pelvic and para-aortic lymphadenectomy. All assessed lymph nodes were negative for metastatic carcinoma. No patients with clinically pelvis-confined disease had tumors upstaged by either lymphadenectomy or omentectomy. Twenty-eight patients (44%) had germline mutational status documented; two had a germline BRCA mutation, confirmed to be pathogenic by molecular studies. Complete staging did not significantly impact progression free or overall survival, after adjusting for age and histologic grade in a Cox proportional hazards model. The recurrence rate was 15% for patients with grade 1 endometrioid carcinoma, 7% for grade 2, and 31% for grade 3, respectively.

CONCLUSION

There were no lymph node metastases in patients with comprehensively staged primary endometrioid ovarian carcinoma. Staging did not impact survival and may be omitted, regardless of grade. Germline BRCA mutations are rare in ovarian endometrioid carcinoma compared with reported rates in high-grade serous carcinomas.

Prognostic significance and risk factors for pelvic and para-aortic lymph node metastasis in type I and type II ovarian cancer: a large population-based database analysis

BACKGROUND

To compare the prognosis of lymphatic metastasis in type I and type II epithelial ovarian cancer (OC) and to identify the risk factors for pelvic lymph node metastases (PLNs) and para-aortic lymph node metastases (PALNs).

METHODS

Patients diagnosed with epithelial OC were collected from the Surveillance, Epidemiology, and End Results (SEER) database. Overall survival (OS) and cancer-specific survival (CSS) were estimated. The Cox proportional hazards regression model was used to identify independent predictors of survival.

RESULTS

A total of 11,275 patients with OC were enrolled, including 31.2% with type I and 68.8% with type II. Type II and high tumour stage were risk factors for lymph node involvement (p < 0.05). The overall rate of lymph node metastasis in type I was 11.8%, and that in type II was 36.7%. In the type I group, the lymph node metastasis rates in stages T1, T2, T3 and T_XM₁ were 3.2%, 14.5%, 40.4% and 50.0%, respectively. In the type II group, these rates were 6.4%, 20.4%, 54.1% and 61.1%, respectively. Age and tumour size had little effect on lymph node metastasis, and grade 3 was not always a risk factor. For the type I group, the 10-year CSS rates of LN(-), PLN( +), PALN( +), and PLN + PALN( +) were 80.6%, 46.6%, 36.3%, and 32.3%, respectively. The prognosis of PLN ( +) was better than that of PALN ( +) in the type I group (p > 0.05). For the type II group, the 10-year CSS rates of LN(-), PLN( +), PALN( +), and PLN + PALN( +) were 55.6%, 18.5%, 25.7%, and 18.2%, respectively. PALN ( +) had a significantly better prognosis than PLN ( +) in the type II group (p < 0.05).

CONCLUSIONS

The clinical characteristics and prognoses of patients with type I and type II OC differed greatly. Patients with type II and higher tumour stages had poorer prognoses. Type I with PALN metastasis and type II with PLN metastasis indicated a worse prognosis. Patients with stage TI did not require lymph node dissection, especially in the type I group.

Progression Free Survival, Overall Survival, and Relapse Rate in Endometrioid Ovarian Cancer and Synchronous Endometrial-Ovarian Endometrioid Cancer (SEO-EC): Results from a Large Retrospective Analysis

Background and Objectives: We aimed to evaluate Progression Free Survival (PFS), Overall Survival (OS), and relapse rate in women affected by endometrioid ovarian cancer and synchronous endometrial-ovarian endometrioid cancer (SEO-EC). As secondary outcome, we assessed whether systematic pelvic and para-aortic lymphadenectomy could be considered a determinant of relapse rate in this population. Materials and Methods: We performed a retrospective analysis of women with diagnosis of endometrioid ovarian cancer or SEO-EC between January 2010 to September 2020, and calculated PFS, OS and relapse rate. Results: In almost all the patients (97.6%) who underwent systematic pelvic and para-aortic lymphadenectomy, there were no lymph node metastases confirmed by histology. We did not find a significant difference (p = 0.6570) for the rate of relapse in the group of women who underwent systematic pelvic and para-aortic lymphadenectomy (4/42; 9.5%) compared with the group of women who did not undergo the same procedure (1/21; 4.8%). During a median follow-up was 23 months, both PFS and OS were excellent. Conclusions: Women affected by early-stage low-grade endometrioid cancer and SEO-EC without apparent lymph node involvement at pre-operative imaging showed a very low rate of lymph node metastasis and similar relapse rate with or without lymphadenectomy.

Incidence of lymph node metastasis in early-stage low-grade serous ovarian cancer: a systematic review

OBJECTIVE

The objective of this systematic review was to assess the incidence of lymph node metastasis in patients with clinically presumed early-stage low-grade serous ovarian cancer that underwent primary surgical treatment.

METHODS

This study was registered in PROSPERO (CRD42022308923). A systematic literature review was conducted following the Meta-analyses Of Observational Studies in Epidemiology (MOOSE) checklist. PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Ovid, and Scopus databases were searched since inception and up to March 2022. The inclusion criteria were: pathological confirmation of low-grade serous ovarian cancer (clinically presumed FIGO 2014 stages I-IIA at time of surgery) that underwent primary surgical treatment, including pelvic and/or para-aortic lymph node dissection.

RESULTS

The search identified 3763 articles; 59 were considered potentially eligible after removing duplicates, and eight studies finally met the selection criteria. In total, 35 of 277 (12.6%) patients had lymph node metastasis, and only four studies reported upstaging due to lymph node metastasis in 16 of 153 (10.5%) patients. None of the eight studies included reported the rate of complications or complications specifically for the subgroup of patients with early-stage low-grade tumors.

CONCLUSION

In patients with early-stage low-grade serous ovarian cancer, lymph node assessment should be discussed when counseling for primary surgical staging.

Surgical staging of apparent early-stage ovarian mucinous carcinoma

Objectives

The aim of the study was to explore the rate of upstaging after complete surgical staging among patients with apparent FIGO stage I ovarian mucinous carcinoma.

Methods

Ovarian mucinous carcinoma patients with surgical treatment at the Peking Union Medical College Hospital between October 2020 and January 1994 were retrospectively reviewed.

Results

In total, 163 patients were included in this study. Surgical restaging was performed in 89 patients after initial incomplete surgical staging, and one-step complete surgical staging was performed in 74 patients. Among these initially incompletely staged patients, residual tumors were found in 16 patients (16/89, 17.9%). Among the 19 patients with apparent FIGO stage IA, no patient was found to have residual tumors after incomplete staging surgery, according to the final pathology result of restaging surgery. Ovarian cystectomy (OR=4.932, 95% CI= 1.347–18.058, P=0.016) was an independent risk factor for residual tumors after incomplete staging surgery. Among all 163 patients, upstaging occurred in 15 patients (15/163, 9.2%). Among 44 apparent FIGO stage IA patients, no patient was upstaged to FIGO II–IVB. Moreover, both a history of ovarian mucinous tumor (OR=4.745, 95% CI= 1.132–19.886, P=0.033) and bilateral ovary involvement (OR=9.739, 95% CI= 2.016–47.056, P=0.005) were independent risk factors for upstaging to FIGO stage II–IVB.

Conclusions

For patients with apparent FIGO stage IA disease, the possibility of residual tumors and upstaging is relatively low. For patients with cystectomy, bilateral mucinous carcinomas, or a history of ovarian mucinous tumors, complete staging surgery maintains greater significance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02758-0.

A Nomogram Based on SEER Database for Predicting Prognosis in Patients with Mucinous Ovarian Cancer: A Real-World Study

Purpose

Mucinous ovarian cancer (MOC) is a rare histological type of EOC. In order to guide the clinical diagnosis and management of MOC patients, we constructed and verified a nomogram for the estimation of overall survival in patients with MOC.

Patients and Methods

We collected 494 patients with MOC diagnosed from 2010 to 2015 in SEER database, and the following main inclusion criteria were used: (1) patients whose MOC was confirmed by pathology; (2) patients without a history of primary other cancer. Subsequently, we performed randomized grouping (6:4) and Cox hazard regression analysis in the training group. Subsequently, the nomogram was established. A variety of indicators were used to validate the prognosis value of nomogram, including the C-index, area under the receiver operating characteristic curve, calibration curve, and decision curve analysis (DCA). Moreover, Kaplan–Meier analysis was used to compare the survival results among different risk subgroups.

Results

Cox hazard regression analysis revealed that age, grade, FIGO stage and log odds of positive lymph nodes stage were independent risk factors for patients with MOC. In the training group, the C-index of the nomogram was 0.827 (95% CI: 0.791–0.863) and the areas under the curve (AUC) predicting the 1-, 3- and 5-year survival rate were 0.853 (95% CI: 0.791–0.915), 0.886 (95% CI: 0.852–0.920) and 0.815 (95% CI: 0.766–0.864), respectively. The calibration curve revealed that the nomogram of the 1-, 3- and 5-year survival rate was consistent with the actual fact. Patients with high risk had a poorer prognosis than those with low risk (P < 0.001). DCA revealed that the nomogram had the best clinical value than other classical prognostic markers. Similarly, nomogram had excellent prognostic ability in the testing group.

Conclusion

The nomogram was constructed to predict overall survival in patients with MOC, which had the significance for clinical evaluation.