Prognostic significance of lymph node metastasis and clear cell histology in ovarian carcinoma limited to the pelvis (pT1M0 and pT2M0)

Comorbid thrombosis as an adverse prognostic factor in patients with ovarian clear cell carcinoma regardless of staging

OBJECTIVE

Patients with ovarian clear cell carcinoma (OCCC) often present with thrombosis. While cancer patients with concomitant thrombosis were generally reported to have worse prognoses than those without, the association between thrombosis and prognosis has not been elucidated in OCCC. This study aimed to determine how the co-occurrence of thrombosis affects OCCC prognoses.

METHODS

We retrospectively examined 115 patients with OCCC who were diagnosed and treated at the University of Tokyo Hospital between 2009 and 2019.

RESULTS

Of 115 patients with OCCC, thrombosis was present in 12.5% of 80 patients and in 42.8% of 35 patients who had OCCC stage I/II and stage III/IV, respectively. In stage I/II, the 5-year progression-free survival was 20.6% and 91.8% among patients with thrombosis and among those without, respectively, while the corresponding 5-year overall survival rates were 50.0% and 94.1%. Therefore, the outcomes were significantly poorer among patients with thrombosis (p < 0.0001 and p < 0.0001, respectively). In stage III/IV, the 5-year progression-free survival was 26.7% and 52.8% among patients with thrombosis and among those without, respectively, while the corresponding 5-year overall survival rates were 32.0% and 62.2%. Similarly, the outcomes were significantly poorer among patients with thrombosis (p = 0.0139 and p = 0.369, respectively).

CONCLUSION

We determined that thrombosis is more likely to develop in advanced OCCC stages than in early stages, and its co-occurrence is associated with a poor prognosis, regardless of disease stage.

The impact of lymphadenectomy on the survival outcomes of ovarian clear cell carcinoma: A retrospective study of the SEER database and Chinese registry

BACKGROUND

Ovarian clear cell carcinoma (OCCC) is a rare pathological type of ovarian cancer with a poor prognosis, and lymphadenectomy is controversial in patients with OCCC. The objective of this study was to evaluate the impact of lymphadenectomy on the prognosis of patients with OCCC.

METHODS

In this retrospective study, we collected data from the Surveillance, Epidemiology and End Results (SEER) database and institutional registries in China. The SEER cohort included 1777 women diagnosed with OCCC between 2010 and 2019, while the Chinese cohort included 199 women diagnosed between April 2004 and April 2021. Recurrence-free survival (RFS) and overall survival (OS) were studied using Kaplan-Meier curve and Cox regression analysis. We also employed propensity score matching (PSM) to adjust for baseline imbalances between the lymphadenectomy group and the no-lymphadenectomy group.

RESULTS

Multivariate cox regression analysis showed that lymphadenectomy was not associated with better overall survival (OS) in either early (hazard ratio [HR] 0.84[0.50-1.43], p = 0.528) or advanced (HR 0.78[0.50-1.21], p = 0.270) patients in the SEER cohort after PSM. Additionally, in the Kaplan-Meier curve analysis, lymphadenectomy did not significantly improve OS in both early (p = 0.28) and advanced (p = 0.49) patients in the SEER cohort after PSM. Similarly, in the Chinese cohort, lymphadenectomy had no significant effect on OS (early p = 0.22; advanced p = 0.61) or RFS (early p = 0.18; advanced p = 0.83) in both early and advanced patients.

CONCLUSION

In completely homogeneous groups, lymphadenectomy in women diagnosed with OCCC had no effect on either recurrence-free survival or overall survival compared to patients without lymphadenectomy.

Sentinel lymph node technique in early-stage ovarian cancer (SENTOV): a phase II clinical trial

Objective

Early-stage ovarian cancer might represent an ideal disease scenario for sentinel lymph node application. Nevertheless, the published experience seems to be limited. Our objective was to assess the feasibility and safety concerns of sentinel lymph node biopsy in patients with clinical stage I–II ovarian cancer.

Methods

We conducted a prospective cohort study of 20 patients with histologically confirmed ovarian cancer. ^99mTc and indocyanine green were injected into both the utero-ovarian and infundibulopelvic ligament stump, if they were present, during surgical staging. An intraoperative gamma probe and near-infrared fluorescence imaging were used to detect the sentinel lymph nodes. Inclusion criteria included: >18 years of age, suspicious adnexal mass (unilateral or bilateral) at ultrasound and CT imaging or confirmed ovarian tumor after previous surgery (unilateral or bilateral salpingo-oophorectomy with or without hysterectomy). Adverse events were recorded through postoperative day 30. The primary trial end point was to report adverse events related to the technique, including the use of ^99mTc and ICG intraperitoneally, as well as the feasibility of the technique.

Results

A total of 20 patients were included in the analysis. Sentinel lymph nodes were detected in 14/15 (93%) pelvic and all 20 (100%) para-aortic regions. Five patients did not have utero-ovarian injection because of prior hysterectomy. The mean time from injection to sentinel lymph node resection was 53±15 min (range; 30–80). The mean number of harvested sentinel lymph nodes was 2.2±1.5 (range; 0–5) lymph nodes in the pelvis and 3.3±1.8 (range; 1–7) lymph nodes in the para-aortic region. There were no adverse intraoperative events, nor any within the 30 days of follow-up related with the technique.

Conclusion

Sentinel lymph node mapping in early-stage ovarian cancer is feasible without major intraoperative or < 30 days safety concerns. (NCT03452982).

Trial registration number

ClinicalTrials.gov, NCT03452982.

Clinical application of the sentinel lymph node technique in early ovarian cancer: a pilot study

Introduction

There is limited evidence favoring the use of the sentinel lymph node technique in ovarian cancer, and no standardized approach has been studied. The objective of the present pilot study is to determine the feasibility of the sentinel lymph node technique by applying a clinical algorithm.

Methods

Patients with confirmed ovarian cancer were included. 99mTc and indocyanine green were injected into the ovarian and infundubulo-pelvic ligament stump. A gamma probe and near-infrared fluorescence imaging were used for sentinel lymph node detection.

Results

The sentinel lymph node technique was performed in ten patients with a detection rate in the pelvic and/or para-aortic region of 100%. The tracer distribution rates of sentinel lymph nodes in the pelvic and para-aortic regions were 87.5% and 70%, respectively.

Conclusion

The detection of sentinel lymph nodes in early-stage ovarian cancer appears to be achievable. Based on these results, a clinical trial entitled SENTOV (SENtinel lymph node Technique in OVarian cancer) will be performed.

Retrospective analysis of sites of recurrence in stage I epithelial ovarian cancer

OBJECTIVE

The aim of the study is to investigate recurrence of stage I epithelial ovarian cancer.

METHODS

Six hundred two patients diagnosed with stage I epithelial ovarian cancer at 4 hospitals between 2000 and 2013 were retrospectively analyzed. Age, surgical procedure, substage, histologic type, adjuvant chemotherapy, recurrence, initial recurrence site (peritoneal dissemination [P], hematogenous recurrence [H], lymphogenous recurrence [L], and others [O]), and frequency of recurrence at each site were investigated retrospectively.

RESULTS

Median age was 54 years and median follow-up was 60 months. The stage was IA in 180 cases (30%), IB in 8 (1%), IC1 in 247 (41%), IC2 in 63 (10%), and IC3 in 104 (17%). Systematic lymph node dissection including both pelvic and para-aortic lymph nodes was performed in 224 patients (37%), and 412 patients (68%) received adjuvant chemotherapy. Recurrence occurred in 70 patients (11.6%). The median time to recurrence was 18 months, and the stage was IA in 13 (19%), IB in 1 (1%), IC1 in 24 (34%), IC2 in 9 (13%), and IC3 in 23 (33%) cases. The numbers of recurrence at the P, H, L, and O sites, including overlapping cases, were 49 (70%), 18 (26%), 9 (13%), and 6 (9%), respectively, and recurrence by peritoneal dissemination in the pelvis occurred in 43 cases (61%).

CONCLUSION

Recurrence of stage I epithelial ovarian cancer by peritoneal dissemination was frequent, especially in the pelvis. There is a need to elucidate the pathogenesis of peritoneal recurrence and to prepare a treatment strategy to prevent pelvic peritoneal recurrence.

Update on rare epithelial ovarian cancers: based on the Rare Ovarian Tumors Young Investigator Conference

There has been significant progress in the understanding of the pathology and molecular biology of rare ovarian cancers, which has helped both diagnosis and treatment. This paper provides an update on recent advances in the knowledge and treatment of rare ovarian cancers and identifies gaps that need to be addressed by further clinical research. The topics covered include: low-grade serous, mucinous, and clear cell carcinomas of the ovary. Given the molecular heterogeneity and the histopathological rarity of these ovarian cancers, the importance of designing adequately powered trials or finding statistically innovative ways to approach the treatment of these rare tumors has been emphasized. This paper is based on the Rare Ovarian Tumors Conference for Young Investigators which was presented in Tokyo 2015 prior to the 5th Ovarian Cancer Consensus Conference of the Gynecologic Cancer InterGroup (GCIG).

Surgical lymph node assessment in mucinous ovarian carcinoma staging: a systematic review and meta-analysis

BACKGROUND

The proportion of women with mucinous ovarian carcinoma in whom nodal metastases are identified during staging remains unclear.

OBJECTIVES

To review the literature on surgical lymph node assessment during staging of women diagnosed with mucinous ovarian carcinoma.

SEARCH STRATEGY

A systematic search using synonyms of 'mucinous ovarian carcinoma' and 'lymph node assessment' was conducted in PubMed, Scopus, Embase and the Cochrane Library.

SELECTION CRITERIA

When they covered ten or more mucinous ovarian carcinoma cases, staging surgery and minimally one of the following outcomes: prevalence of metastases, stage shift or survival data.

DATA COLLECTION AND ANALYSIS

Studies were quality evaluated with the Cochrane risk-of-bias assessment tool for non-randomised studies of interventions. Outcomes were pooled using an inverse variance weighted random effects model.

MAIN RESULTS

Sixteen studies were included. In 278 women with mucinous ovarian cancer suspected to be stage I-II, a pooled proportion of 0.8% (95% CI <0.1-2.9%) had lymph node metastases and were upstaged. In those suspected of stage I (n = 184), this proportion was 0.7% (95% CI <0.1-3.8%). No difference (P = 0.287) was found in metastases between sampling at 0.0% (95% CI 0.0-3.3%) and complete pelvic and/or para-aortic lymph node dissection at 1.2% (95% CI <0.1-4.2%). One study directly compared the survival of patients staged with and without lymph node dissection and reported no significant difference.

CONCLUSIONS

Surgical lymph node assessment in women suspected of stage I-II mucinous ovarian carcinoma rarely identifies nodal metastases and consequently has no significant impact on staging.

TWEETABLE ABSTRACT

Surgical lymph node assessment in women with stage I-II mucinous ovarian cancer rarely has staging consequences.

Incidence of Lymph Node Metastases in Apparent Early-Stage Low-Grade Epithelial Ovarian Cancer: A Comprehensive Review

Objectives

This study aimed to determine the incidence of lymph node (LN) metastases in presumed stage I-II low-grade epithelial ovarian cancer (EOC).

Methods

Eligible studies were identified from MEDLINE and EMBASE (time frame, 2015–1975), that analyzed patients with clinical or radiologic presumed early-stage EOC who underwent a complete pelvic and para-aortic lymphadenectomy as part of their surgical staging. The number and site of dissected and involved LNs and the correlation with overall outcome are analyzed. The termlow gradeand also the older termwell differentiatedwere used.

Results

Thirteen of 978 identified studies were selected, and 13 of 75 studies were identified as eligible. A total of 1403 patients were analyzed in these 13 retrospective studies. The final International Federation of Gynecology and Obstetrics staging after completed surgical staging was I to II in 912 patients (65%). A total of 338 patients (24%) had grade 1 tumors whereas 473 patients (34%) had grade 2, and 502 patients (36%) had grade 3 tumors. Systematic lymphadenectomy was performed in 1159 patients (83%), whereof 1142 (82%) were pelvic and para-aortic LN dissections.

In 185 patients (13%), an upstaging from an apparent clinical stage I-II to IIIC occurred because of LN involvement: 64 (35%) of the patients had only pelvic LNs metastases, 69 (37%) had only para-aortic LNs metastasis, and 51 (28%) had both a pelvic and para-aortic LN involvement. When analyzing only the patients with low-grade (grade 1 as the old classification) presumed early-stage disease (n = 273), only 8 patients (2.9%; range, 0–6.2) were identified with LNs metastases present.

Conclusions

The incidence of occult LN metastases in apparent early-stage low-grade EOC is 2.9% in a metaanalysis of retrospective studies. Future larger-scale prospectively assessed studies with established surgical quality of the LN dissection are warranted to establish the true incidence of LN metastasis in presumed early low-grade disease.

Understanding Lymphatic Drainage Pathways of the Ovaries to Predict Sites for Sentinel Nodes in Ovarian Cancer

Supplemental digital content is available in the text.

Objective

In ovarian cancer, detection of sentinel nodes is an upcoming procedure. Perioperative determination of the patient’s sentinel node(s) might prevent a radical lymphadenectomy and associated morbidity. It is essential to understand the lymphatic drainage pathways of the ovaries, which are surprisingly up till now poorly investigated, to predict the anatomical regions where sentinel nodes can be found. We aimed to describe the lymphatic drainage pathways of the human ovaries including their compartmental fascia borders.

Methods

A series of 3 human female fetuses and tissues samples from 1 human cadaveric specimen were studied. Immunohistochemical analysis was performed on paraffin-embedded transverse sections (8 or 10 μm) using antibodies against Lyve-1, S100, and α-smooth muscle actin to identify the lymphatic endothelium, Schwann, and smooth muscle cells, respectively. Three-dimensional reconstructions were created.

Results

Two major and 1 minor lymphatic drainage pathways from the ovaries were detected. One pathway drained via the proper ligament of the ovaries (ovarian ligament) toward the lymph nodes in the obturator fossa and the internal iliac artery. Another pathway drained the ovaries via the suspensory ligament (infundibulopelvic ligament) toward the para-aortic and paracaval lymph nodes. A third minor pathway drained the ovaries via the round ligament to the inguinal lymph nodes. Lymph vessels draining the fallopian tube all followed the lymphatic drainage pathways of the ovaries.

Conclusions

The lymphatic drainage pathways of the ovaries invariably run via the suspensory ligament (infundibulopelvic ligament) and the proper ligament of the ovaries (ovarian ligament), as well as through the round ligament of the uterus. Because ovarian cancer might spread lymphogenously via these routes, the sentinel node can be detected in the para-aortic and paracaval regions, obturator fossa and surrounding internal iliac arteries, and inguinal regions. These findings support the strategy of injecting tracers in both ovarian ligaments to identify sentinel nodes.

Role of lymphadenectomy for ovarian cancer

Japan Society of Gynecologic Oncology (JSGO) recently revised its Ovarian Cancer Treatment Guidelines and the 4th edition will be released next year. This Guidelines state that lymphadenectomy is essential to allow accurate assessment of the clinical stage in early ovarian cancer, but there is no randomized controlled trial that shows any therapeutic efficacy of lymphadenectomy. In patients with advanced stage tumors, lymphadenectomy should be considered if optimal debulking has been performed. I fully agree with this recommendation of the JSGO and I would like to discuss the role of lymphadenectomy in the management of ovarian cancer.

Sentinel node in ovarian cancer: study protocol for a phase 1 study

Background

The concept of sentinel lymph node surgery is to determine whether the cancer has spread to the very first lymph node or sentinel node. If the sentinel node does not contain cancer, then there is a high likelihood that the cancer has not spread to other lymph nodes. The sentinel node technique has been proven to be effective in different types of cancer. In this study we want to determine whether a sentinel node procedure in patients with ovarian cancer is feasible when the tracers are injected into the ovarian ligaments.

Methods/Design

Patients with a high likelihood of having an ovarian malignancy in whom a median laparotomy and a frozen section analysis is planned and patients with endometrial cancer in whom a staging laparotomy is planned will be included.

Before starting the surgical staging procedure, blue dye and radioactive colloid will be injected into the ligamentum ovarii proprium and the ligamentum infundibulo-pelvicum. In the analysis we calculate the percentage of patients in whom it is feasible to identify sentinel nodes. Other study parameters are the anatomical localization of the sentinel node(s) and the incidence of false negative lymph nodes.

Trial registration

Approval number: NL40323.068.12

Name: Medical Ethical Committee Maastricht University Hospital, University of Maastricht

Affiliation: Maastricht University Hospital

Board Chair Name: Medisch Ethische Commissie azM/UM

Analysis of para-aortic lymphadenectomy up to the level of the renal vessels in apparent early-stage ovarian cancer

Objective

The aim of this study was to evaluate the impact of para-aortic lymphadenectomy up to the renal vessels on the accurate staging in ovarian cancer patients presumed preoperatively to be confined to the ovary.

Methods

We retrospectively analyzed data on 124 patients with primary epithelial ovarian cancer who were preoperatively thought to have tumor confined to the ovary and underwent primary staging surgery. The distribution of lymph node metastasis and various risk factors for nodal involvement were investigated.

Results

Surgical staging yielded: 87 (70.2%) patients had International Federation of Gynecology and Obstetrics (FIGO) stage I disease and 37 (29.8%) patients had stage II-III disease: 4 IIA, 6 IIB, 9 IIC, 1 IIIA, and 17 IIIC. Eighty-six patients had pelvic lymphadenectomy only and 69 had pelvic and para-aortic lymphadenectomy. Lymph node metastases were found in 17 (24.6%) of 69 patients; 5 (7.2%) patients had lymph node metastasis in the pelvic lymph nodes only, 8 (11.6%) in the para-aortic lymph nodes only, and 4 (5.8%) in both pelvic and para-aortic lymph nodes. Six (8.7%) patients had lymph node metastasis in the para-aortic lymph node above the level of the inferior mesenteric artery. On multivariate analysis, grade 3 tumor (p=0.01) and positive cytology (p=0.03) were independent predictors for lymph node metastasis.

Conclusion

A substantial number of patients with apparently early ovarian cancer had upstaged disease. Of patients who underwent lymphadenectomy, some patients had lymph node metastasis above the level of the inferior mesenteric artery. Para-aortic lymphadenectomy up to the renal vessels may detect occult metastasis and be of help in tailoring appropriate adjuvant treatment as well as giving useful information about the prognosis.

Clear cell carcinoma of the ovary: is there a role of histology-specific treatment?

Several clinical trials to establish standard treatment modality for ovarian cancers included a high abundance of patients with serous histologic tumors, which were quite sensitive to platinum-based chemotherapy. On the other hand, ovarian tumor with rare histologic subtypes such as clear cell or mucinous tumors have been recognized to show chemo-resistant phenotype, leading to poorer prognosis. Especially, clear cell carcinoma of the ovary (CCC) is a distinctive tumor, deriving from endometriosis or clear cell adenofibroma, and response rate to platinum-based therapy is extremely low. It was implied that complete surgical staging enabled us to distinguish a high risk group of recurrence in CCC patients whose disease was confined to the ovary (pT1M0); however, complete surgical staging procedures could not lead to improved survival. Moreover, the status of peritoneal cytology was recognized as an independent prognostic factor in early-staged CCC patients, even after complete surgical staging. In advanced cases with CCC, the patients with no residual tumor had significantly better survival than those with the tumor less than 1 cm or those with tumor diameter more than 1 cm. Therefore, the importance of achieving no macroscopic residual disease at primary surgery is so important compared with other histologic subtypes. On the other hand, many studies have shown that conventional platinum-based chemotherapy regimens yielded a poorer prognosis in patients with CCC than in patients with serous subtypes. The response rate by paclitaxel plus carboplatin (TC) was slightly higher, ranging from 22% to 56%, which was not satisfactory enough. Another regimen for CCC tumors is now being explored: irinotecan plus cisplatin, and molecular targeting agents. In this review article, we discuss the surgical issues for early-staged and advanced CCC including possibility of fertility-sparing surgery, and the chemotherapy for CCC disease.

URG4 upregulation is associated with tumor growth and poor survival in epithelial ovarian cancer

PURPOSE

Up-regulated gene 4 (URG4) has been demonstrated to be involved in progression of various human cancers. This study investigated the clinicopathological significance of URG4 in epithelial ovarian cancer (EOC).

METHODS

Immunohistochemistry was applied to investigate the expression of URG4 in ovarian tissues of 116 patients. The correlation of URG4 with proliferating cell nuclear antigen index (PCNA) was analyzed and the prognostic value of URG4 in patients was also investigated. Pearson Chi-square test, Spearman correlation coefficient, univariate analysis, multivariate analysis, and Kaplan-Meier method were adopted.

RESULTS

The positive rate of URG4 in EOC was higher than that in borderline and benign tumors (P = 0.001). URG4 was positively correlated with PCNA (r = 0.86, P = 0.006). In addition, univariate analysis showed URG4 expression level, clinical stage, pathologic grade, lymphatic metastasis, chemotherapy, and ascites influenced survival time (all P < 0.05). In Cox multivariate analysis, all the aforementioned factors were found to be independent prognostic factors except pathologic grade and ascites (all P < 0.05).

CONCLUSIONS

Our results suggest for the first time that the URG4 might be involved in the progression of EOC. URG4 was a new target to assess the prognosis of EOC.

Clinical and prognostic value of the presence of irregular giant nuclear cells in pT1 ovarian clear cell carcinoma

In the early stages of epithelial ovarian cancer, histopathological grading is important. However, the grading of ovarian clear cell carcinoma (OCCC) remains controversial. We aimed to identify irregular giant nuclear cells (IGNCs) by a simple method in clinical practice, and to evaluate the prognostic value of IGNCs in pT1 OCCC. Eighty-seven pT1 OCCC patients who underwent initial surgery at Jikei University Kashiwa Hospital, Chiba, Japan, were retrospectively assessed. Paraffin-embedded tissue sections (PTSs) stained with hematoxylin and eosin were reviewed. Giant nuclear cells (GNCs) were defined as cells with a nuclear length of more than twice the median nuclear length. GNCs with irregular nuclear circumferences were defined as IGNCs. Cases where one or more GNCs existed and where IGNCs accounted for >10% of the GNCs were classified as IGNC-positive. We also attempted to identify IGNCs on touch imprint cytology smears (TICSs). Among the 87 cases, 68 were IGNC-negative and 19 were IGNC-positive. The 5-year disease-free and overall survival rates were 88.9% and 90.3% in the total patients, 98.3% and 100% in the IGNC-negative group, and 59.7% and 62.0% in the IGNC-positive group, respectively. These survival rates were significantly lower in the IGNC-positive group than in the IGNC-negative group (adjusted hazard ratio = 14, 95% confidence interval = 2.7-124 and adjusted hazard ratio = 25, 95% confidence interval =  2.9-768, respectively). Prognostic differences were not identified for other factors. IGNC identification on 28 available TICSs predicted IGNC identification on PTSs (sensitivity = 50.0%, specificity = 100%, P = 0.007). The presence of IGNCs has clinical and prognostic value for pT1 OCCC.

The relevance and role of vascular endothelial growth factor C, matrix metalloproteinase-2 and E-cadherin in epithelial ovarian cancer

We investigated the correlation of vascular endothelial growth factor C, matrix metalloproteinase-2, E-cadherin to explore mechanisms of vascular endothelial growth factor C in the metastasis of ovarian cancer and the relationship of prognosis. We applied immunohistochemistry to investigate the expression of vascular endothelial growth factor C, matrix metalloproteinase-2 and E-cadherin in ovarian tissues of 227 patients. We adopted Pearson chi-square test, Spearman correlation coefficient, univariate analysis, multivariate analysis, and Kaplan-Meier method. The positive rate of vascular endothelial growth factor C, matrix metalloproteinase-2 and E-cadherin in ovarian cancer was higher than that in borderline and benign tumor (P < 0.01). Vascular endothelial growth factor C was positively correlated with matrix metalloproteinase-2 (r = 0.665, P < 0.01) while negatively with E-cadherin(r = -0.185, P < 0.05). Univariate analysis showed clinical stage, pathologic grade, lymphatic metastasis, residual disease, chemotherapy, ascites, vascular endothelial growth factor C, and matrix metalloproteinase-2-influenced survival time (P < 0.05). In Cox multivariate analysis, all the aforementioned factors were found to be independent prognostic factors except pathologic grade. Vascular endothelial growth factor C was a new target to assess the prognosis of ovarian cancer. The expression of vascular endothelial growth factor C in ovarian cancer was related to matrix metalloproteinase-2 and E-cadherin.

Lymph node metastasis in grossly apparent clinical stage Ia epithelial ovarian cancer: Hacettepe experience and review of literature

Background

Lymphadenectomy is an integral part of the staging system of epithelial ovarian cancer. However, the extent of lymphadenectomy in the early stages of ovarian cancer is controversial. The objective of this study was to identify the lymph node involvement in unilateral epithelial ovarian cancer apparently confined to the one ovary (clinical stage Ia).

Methods

A prospective study of clinical stage I ovarian cancer patients is presented. Patient's characteristics and tumor histopathology were the variables evaluated.

Results

Thirty three ovarian cancer patients with intact ovarian capsule were evaluated. Intraoperatively, neither of the patients had surface involvement, adhesions, ascites or palpable lymph nodes (supposed to be clinical stage Ia). The mean age of the study group was 55.3 ± 11.8. All patients were surgically staged and have undergone a systematic pelvic and paraaortic lymphadenectomy. Final surgicopathologic reports revealed capsular involvement in seven patients (21.2%), contralateral ovarian involvement in two (6%) and omental metastasis in one (3%) patient. There were two patients (6%) with lymph node involvement. One of the two lymph node metastasis was solely in paraaortic node and the other metastasis was in ipsilateral pelvic lymph node. Ovarian capsule was intact in all of the patients with lymph node involvement and the tumor was grade 3.

Conclusion

In clinical stage Ia ovarian cancer patients, there may be a risk of paraaortic and pelvic lymph node metastasis. Further studies with larger sample size are needed for an exact conclusion.

The impact of complete surgical staging upon survival in early-stage ovarian clear cell carcinoma: a multi-institutional retrospective study

Pure-type clear cell carcinoma (CCC) has been recognized as a distinct subtype of ovarian cancer, showing resistance to conventional platinum-based chemotherapy and resulting in poor prognosis. The aim of the study was to evaluate the effects of complete surgical staging procedures for early-stage CCC patients in a retrospective multi-institutional analysis. During the period 1992 to 2002, a total of 199 patients with pT1 M0 CCC were identified. Survival analysis was estimated by Kaplan-Meier methods, and prognostic factors were evaluated using a Cox regression model. Among pT1 M0 tumors, retroperitoneal lymph node status was negative in 125 cases (pN0, 63%), positive in 10 cases (pN1, 5%), and unknown in 64 cases (pNx, 32%). Progression-free survival of pN1 was significantly worse than that of pN0 (P < 0.05), whereas there was no significant difference between pN1 and pNx. There was no significant difference of overall survival (OS) among the 3 groups. Multivariate analysis revealed that peritoneal cytology status was the only independent prognostic factor for progression-free survival (P = 0.04), but completion of surgical staging procedures was not a prognostic factor. There was no significant prognostic factor for OS. Our study implied that complete surgical staging enabled us to distinguish a high-risk group of recurrence in pT1 M0 CCC; however, the procedure could not improve OS. Although the study was a limited retrospective study, the impact of peritoneal cytology status was more important than complete surgical staging procedure in CCC patients. More effective treatment modality was warranted, especially for CCC cases positive for malignant peritoneal cytology.

Expression of Organic Cation Transporter SLC22A16 in Human Epithelial Ovarian Cancer

The SLC22A16 is one of the newly isolated organic cation transporters, which is responsible for uptake and transport of adriamycin into cells. Adriamycin is considered to be an active agent for ovarian cancer. Recently, the benefit of adding adriamycin to the current standard regimen, paclitaxel and platinum, is evaluated to improve the outcome of patients with ovarian cancer. Therefore, we examined the expression of SLC22A16 in ovarian cancers. Twelve ovarian carcinoma cell lines were used for immunoblotting and reverse transcription-polymerase chain reaction to confirm the expression of SLC22A16 mRNA and protein. Five normal ovaries, 12 ovarian adenomas, and 94 ovarian cancer cases were obtained from patients after surgical therapy. The specimens were used for immunohistochemistry. The median value of relative SLC22A16 gene expression in cell lines derived from clear-cell adenocarcinoma was significantly higher than that in cell lines from other histologies (P < 0.001). Expression of SLC22A16 protein was also detected in cell lines derived from clear-cell adenocarcinoma. The SLC22A16 immunoreactivity was detected in 15 (16%) of 94 epithelial ovarian cancer, 1 (8.3%) of 12 benign adenomas, but 0 (0%) of 5 normal ovary cases. In ovarian cancer tissues, SLC22A16 immunoreactivity was detected in 2 (5%) of 38 serous adenocarcinoma, 1 (6.7%) of 15 endometrioid adenocarcinoma, 0 (0%) of 14 mucinous adenocarcinoma, and 12 (46.2%) of 26 clear-cell adenocarcinoma (P < 0.0001, clear-cell vs other histologies). In conclusion, SLC22A16 was abundantly expressed in clear-cell adenocarcinoma. Our results suggest that adriamycin-related chemicals that are taken up via SLC22A16 may have the potential to be effective against clear-cell adenocarcinoma.

Management of retroperitoneal lymph nodes in the treatment of ovarian cancer

The mechanisms and clinical significance of lymph node involvement in ovarian cancer have been revealed since the International Federation of Gynaecology and Obstetrics (FIGO) introduced a new clinical staging including retroperitoneal lymph node status. The multiple directions of the lymph drainage pathway in ovarian cancer have been recognized. The incidence and pattern of lymph node involvement depends on the extent of disease progression and the histological type. Thus, it is difficult to specify a single node as the sentinel node. As a surgical approach, systemic lymphadenectomy is necessary to obtain accurate clinical stage, and it has obvious diagnostic value. Nevertheless, a recent large randomized trial in patients with advanced ovarian cancer revealed that systemic lymphadenectomy had no impact on survival compared with removing only macroscopic lymph nodes. Other factors, such as chemosensitivity, histological grade, and the size of residuals have also influenced survival in ovarian cancer. From the viewpoint of adverse effects and survival benefit, the efficacy of lymphadenectomy remains controversial. Therefore, further accumulation of clinical data is needed to establish the indications for lymph node dissection; when this procedure is done, it should be performed by experienced gynecologic oncologists at selected institutions.

Occult metastasis in early ovarian cancers: risk factors and associated prognosis

OBJECTIVE

The purpose of this study was to define risk factors associated with the occult metastasis in early stage epithelial ovarian carcinoma (EOC), and to compare the survivals in respect to occult metastasis.

STUDY DESIGN

A retrospective review of 169 patients with clinically early stage EOC was performed.

RESULTS

Overall, 53 patients (53/169, 31.4%) were upstaged. The most common occult metastasis was the lymphatic involvement (22/53; 41.5%). Overall, 64.1% (34/53) of these upstaged patients had unrecognized disease in the upper abdomen or retroperitoneal space. Multivariable analysis revealed 3 factors to be associated with occult metastasis: Ca-125 levels > or = 500 U/mL (P = .04), positive peritoneal cytology (P = .001), and grade III disease (P = .04). Five-year survival rates were 61.83% and 88.25%, respectively, in patients with or without occult metastasis. Among the upstaged patients, omental or peritoneal metastasis revealed the worst prognosis.

CONCLUSION

Proper surgical staging is an important issue in early stage ovarian cancers, particularly in patients with high Ca-125 levels, positive cytology, and high grade tumor.

Laparoscopic staging of early ovarian carcinoma

PURPOSE OF REVIEW

A European randomized trial on early stage ovarian cancer confirmed the importance of accurate staging to select candidates for adjuvant chemotherapy. Since early-stage disease is often discovered incidentally, staging is not always carried out or inadequately performed at the time of primary surgery. Laparoscopy was reported more than 10 years ago as a method of performing the staging procedure while avoiding the morbidity from a classical midline incision.

RECENT FINDINGS

Several teams have recently published their results on laparoscopic staging. Updated results of an earlier series in addition to other recent studies are discussed. All highlight the advantages and limits of the method.

SUMMARY

Complete laparoscopic management seems feasible in selected cases of apparently early stage ovarian cancer. Re-staging procedures remain an ideal indication for laparoscopy in early adnexal carcinomas. Due to the critical nature of the information obtained, this approach should only be reserved for teams trained in advanced laparoscopy.

Clear cell carcinoma of the ovary: a retrospective multicentre experience of 254 patients with complete surgical staging

A retrospective analysis was performed to evaluate the clinical characteristics and prognostic factors in the patients with clear cell carcinoma (CCC) of the ovary. After central pathological review and scanning of the medical records of nine Japanese institutions between 1992 and 2003, a total of 254 patients with CCC of the ovary were enrolled in the present study. Mean age was 52.4 years (range 23–73 years). Tumours were 13% (33/254) stage Ia, 36% (92/254) stage Ic, 13% (33/254) stage II, 30% (80/254) stage III, and 6% (16/254) stage IV. Five-year progression-free survival and overall survival was 84 and 88% in stage I, 57 and 70% in stage II, 25 and 33% in stage III and 0 and 0% in stage IV, respectively. Retroperitoneal lymph node metastasis was observed in 9% in pT1a tumours, 7% in pT1c tumours, 13% in pT2 tumours, and 58% in pT3 tumours, respectively. There was no survival benefit according to chemotherapeutic differences in the patients who received complete surgical staging procedures and conventional chemotherapy. Peritoneal cytological status was an independent prognostic factor in stage Ic patients (P=0.03) and only residual tumour diameter was an independent prognostic factor in stage III, IV patients (P=0.02). Our results suggest that cytoreductive surgery resulting in no residual tumour only could improve the prognosis of advanced CCC patients.

Proliferative activity of early ovarian clear cell adenocarcinoma depends on association with endometriosis

OBJECTIVE

To investigate differences in the biological characteristics of ovarian clear cell adenocarcinoma based on the presence/absence of endometriosis and tumor proliferative activity.

METHODS

Stage I ovarian clear cell adenocarcinoma patients were divided into groups with and without endometriosis, and immunohistochemical expression of proliferating cell nuclear antigen was determined in surgical specimens. Then xenograft models of human ovarian clear cell adenocarcinoma with or without human ectopic endometrium were created in severe combined immunodeficiency mice, and tumor growth was assessed from the wet weight and the bromodeoxyuridine uptake. Furthermore, a xenograft model of human endometriosis was made with or without ovarian clear cell adenocarcinoma and cytokine production was investigated.

RESULTS

The proliferating cell nuclear antigen labeling index was significantly lower in the tumors of patients with endometriosis compared to the tumors of patients without endometriosis. In tumor-bearing mice, the tumor weight and bromodeoxyuridine uptake were both significantly lower when ovarian clear cell adenocarcinoma was associated with endometriosis than in its absence. Release of transforming growth factor-beta1 and interleukin-6 from the ectopic human endometrium was greater in the presence of clear cell adenocarcinoma than without it, and transforming growth factor-beta1 levels showed a significant difference.

CONCLUSION

The proliferative activity of early ovarian clear cell adenocarcinoma seems to depend on the association of this cancer with endometriosis. When endometriosis is associated with ovarian clear cell adenocarcinoma, there is a change of its cytokine production that may inhibit tumor growth.

Prise en charge chirurgicale des tumeurs épithéliales malignes de l’ovaire

The notoriously poor prognosis of ovarian cancer requires optimal management by a multidisciplinary gynecologic and oncologic surgical team. Ovarian cancers which appear to be of early stage must be accurately staged to be sure that no potential metastatic sites are missed. Such an omission may have grave consequences for disease progression and may reduce the chances of cure in young patients. With advanced-stage ovarian carcinoma, the challenge is to perform a detailed pre-operative staging of the extent of disease to enable neo-adjuvant chemotherapy when the disease is judged to be inoperable and/or the the general condition of the patient is unsuitable for surgery. Only patients who have had complete cytoreductive surgery to all affected areas in the abdomen can hope to have an acceptable 5 year survival rate of 50%.

Lymphatic mapping and sentinel node identification as related to the primary sites of lymph node metastasis in early stage ovarian cancer

OBJECTIVE

We evaluated the primary sites of lymph node (LN) metastasis in patients during the early stage of ovarian cancer.

METHODS

Study 1: patients with clinical stage I and II common epithelial ovarian carcinoma (n = 150) underwent systematic retroperitoneal LN dissection of the pelvic and paraaortic areas. The relationship between the incidence and location of LN metastasis and clinical and histological characteristics was examined. Study 2: we studied 11 women with endometrial or fallopian tube tumors. At laparotomy, activated charcoal solution was injected into the unilateral cortex of the ovary. Ten minutes later, the retroperitoneal spaces were opened and charcoal uptake within the pelvic lymph node (PLN) and paraaortic node (PAN) as far as the level of renal vein was examined.

RESULTS

Study 1: The incidence of LN metastasis by stage was 6.5% (8/123) in stage I and 40.7% (11/27) in stage II. Among 19 patients with LN metastasis, 14 had only PAN, 2 had only pelvic LN, and 3 had both PAN and PLN metastases. Metastasis was limited to the ipsilateral side in 12 (63%) patients, but was bilateral in 5 (26%) and contralateral to the neoplastic ovary in 2 (11%). Positive peritoneal cytology was significantly (P < 0.05) correlated with lymph node metastasis. Study 2: Lymphatic channels along the ovarian vessels were identified in all injected ovaries. Charcoal was deposited in the LN of all patients. The locations of these nodes included PAN in all patients, common iliac node in three, and external iliac node in one.

CONCLUSION

PAN is the primary site of LN metastasis in ovarian cancer. Bilateral PAN dissections are necessary to determine the extent of tumors even in stage I ovarian carcinoma.

Multivariate analysis for prognostic significance of histologic subtype, GST-pi, MDR-1, and p53 in stages II-IV ovarian cancer

It has been suggested that histologic subtype of ovarian cancer is a factor that determines the chemoresponsiveness of tumor. In this study, we wanted to clarify the prognostic significance of histologic subtype and its correlation to expression of chemoresistance-related proteins (CRPs) in ovarian cancer. A total of 93 stage II-IV ovarian cancers, where the proportion of serous, endometrioid, mucinous, and clear cell subtype was 61.3%, 14.0%, 7.5%, and 17.2%, respectively, were investigated for glutathione S-transferase-pi (GST-pi), MDR (multidrug resistance)-1, and p53 expression using immunohistochemistry. GST-pi expression was detected in 62.4% of the tumors and was not related to histologic subtype of tumor. MDR-1 expression was observed in 12.9% of the tumors tested and was more frequently detected in clear cell adenocarcinomas than other histologic subtypes of tumor (10/ 16 vs. 2 / 77, P < 0.001). P53 expression was found in 49.1% of serous, 53.8% of endometrioid, and 50% of mucinous adenocarcinomas. In contrast, none of 16 clear cell adenocarcinomas showed positive p53 staining. In univariate analysis, no direct correlations were found between CRPs and overall survival. Histology of mucinous/clear cell tumors (P = 0.0063), as well as FIGO stage III/IV (P = 0.0091) and residual tumor >or= 2 cm (P = 0.0045), was found to have independent prognostic value in multivariate analysis. In conclusion, histologic subtype proved to be the significant independent prognostic factor in addition to FIGO stage and residual tumor in stage II-IV ovarian cancer. GST-pi, MDR-1, and p53 expression pattern is closely related to histologic subtype of ovarian cancer, although they are not significant predictors of survival.

Model for paraaortic lymph node metastasis produced by orthotopic implantation of ovarian carcinoma cells in athymic nude mice

Lymph node metastasis through the lymphatic vessels is a critical step in determining the outcome of ovarian cancer patients, and prognosis should be improved by preventing lymph node metastasis. However, experimental models for lymph node metastasis of ovarian carcinoma are not available. We developed an orthotopic transplantation model to study this process in nude mice using the human ovarian carcinoma cell lines, KF and MH. Highly metastatic sublines (KF-LN3 and MH-LN3) were selected in vivo in nude mice by repeated orthotopic transplantation, lymph node metastasis formation and culturing the tumour cells in vitro. Because this model seems to correspond to the advanced clinical stage of ovarian carcinomas, it should be useful in understanding the molecular biology of ovarian carcinomas and in the development of therapeutic modalities against lymph node metastasis.

Lymph node involvement in epithelial ovarian cancer: analysis of 276 pelvic and paraaortic lymphadenectomies and surgical implications

BACKGROUND

The purpose was to determine the factors influencing nodal involvement and topography of pelvic and paraaortic node involvement in ovarian carcinoma.

STUDY DESIGN

Between 1985 and 2001, 276 women with epithelial ovarian carcinoma underwent systematic bilateral pelvic and paraaortic lymphadenectomy.

RESULTS

The overall frequency of lymph node involvement was 44% (122 of 276). The frequency of pelvic and paraaortic metastases were 30% (82 of 276) and 40% (122 of 276), respectively. The frequency of lymph node metastases according to the stage of the disease (stages I, II, and III + IV) were: 20% (17 of 85), 40% (6 of 15), and 55% (99 of 176), respectively. In patients with stage IA, IB, and IC disease, the rates of nodal involvement were 13% (8 of 60), 33% (4 of 12), and 38% (5 of 13), respectively. None of 15 patients with stage IA grade 1 disease had nodal involvement. None of the 20 patients with mucinous tumors confined to the ovary(ies) (stage I disease) had nodal involvement. When paraaortic nodes were involved, the left paraaortic chain above the level of the inferior mesenteric artery was the most frequently involved site (70 patients, 63%). One of nine patients (11%) with a macroscopic stage I unilateral tumor and paraaortic involvement had contralateral metastases.

CONCLUSIONS

Lymphadenectomy should be performed even in patients with stage IA disease. This procedure could be omitted in patients with mucinous apparent stage I disease and stage I grade 1 tumor. Lymphadenectomy should involve the whole pelvic and paraaortic chain up to the level of the left renal vein. A bilateral dissection should be performed even in cases of patients with a unilateral tumor.

Biological markers in pT1 and pT2 ovarian cancer with lymph node metastases

OBJECTIVE

A relatively high incidence of pelvic and paraaortic lymph node metastases is found in patients with pT1 and pT2 ovarian cancer. This paper investigates the clinicomorphological parameters and the expression of various biological markers in these tumors in order to define possible risk factors for lymphatic dissemination.

METHODS

In a retrospective study we identified 51 patients with pT1 and pT2 ovarian cancer. All patients underwent total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and systemic pelvic +/- paraaortal lymphadenectomy. The incidence of lymph node metastases in these patients and the clinicomorphological parameters of their tumors were examined. Immunohistochemistry was used to determine the expression levels of the cell proliferation marker Ki-67, the cell adhesion molecules CD44s and CD44v6, and the oncoprotein HER2/neu of the tumors and their respective lymph node metastases.

RESULTS

Lymph node involvement was found in 5 of 26 patients with pT1 ovarian cancer and in 6 of 25 patients with pT2 ovarian cancer. Serous adenocarcinoma was associated with a significantly higher incidence of lymph node metastases than other histological types (chi(2) = 4.7, P = 0.03). No correlation was found between tumor grade and the lymph node status. High Ki-67 expression was significantly correlated with spread to the lymph nodes (chi(2) = 4.2, P = 0.04), whereas expression of CD44s, CD44v6, and HER2/neu was not related to the lymph node status. Survival analyses showed no difference in disease-free and overall survival in patients with lymph node metastases compared to those without lymph node metastases. No association was seen among histological type, tumor grade, and immunohistochemically detected Ki-67, CD44s, CD44v6, and HER2/neu expression on the one hand and disease-free and overall survival on the other hand.

CONCLUSIONS

Our data suggest that in early stage ovarian cancer the serous histological type and tumors showing a high Ki-67 expression carry a high risk of lymph node metastases. With respect to prognosis our data showed a minor role for Ki-67, CD44s, CD44v6, and HER2/neu expression and the occurrence of lymph node metastases in pT1 and pT2 ovarian cancer.

The effect of platinum-based combination chemotherapy on the lymph nodes in advanced-stage epithelial ovarian cancer: does it decrease the incidence of lymph node involvement?

This paper aims to determine the impact of platinum-based combination chemotherapy on the lymph nodes in advanced-stage epithelial ovarian carcinoma. From 1997 to 2000, the patients in whom we performed lymphadenectomy before (group A) or after chemotherapy (group B) in the Department of Obstetrics and Gynecology, Akdeniz University School of Medicine were enrolled in this study. A total of 47 cases were included in the study. Twenty five cases had lymphadenectomy during the initial laparatomy and 22 cases during second-look procedures. Lymph node metastasis was detected in 14 (56%) patients in group A and in 10 (45.4%) cases in group B (P > 0.05). Platinum-based combination chemotherapy does not decrease significantly the incidence of involved lymph nodes in advanced-stage epithelial ovarian carcinoma.

The prognostic importance of p53, bcl-2, and bax in early stage epithelial ovarian carcinoma treated with adjuvant chemotherapy

Epithelial ovarian cancer is one of the major causes of death among women. The increasing knowledge about molecular events involved in the early stages of ovarian tumorigenesis may provide the basis for management in the future. In a series of 109 patients with epithelial carcinomas in FIGO stages IA-IIC, a number of clinicopathologic prognostic factors (age, FIGO stage, histopathologic type, and tumor grade) were studied in relation to the biologic factors p53, bcl-2, and bax, which are important regulators of apoptosis. Immunohistochemical techniques were used. All the patients received adjuvant chemotherapy after the primary surgery. Univariate analysis showed that expression of p53 was significantly associated with tumor grade (P = 0.014), probability of persistent disease (P = 0.016), and cancer-specific survival rate (P = 0.007). Positive bcl-2 staining was associated with endometrioid tumor subtype (P = 0.029) and a favorable tumor grade distribution (P = 0.034), but not with the survival status. The combined p53-bcl-2 expression was related to histopathologic subtype (P = 0.032), tumor grade (P = 0.011), persistent disease (P = 0.014), and risk of dying due to the disease (P = 0.039). The bax status was not a prognostic factor, but the combined p53-bax expression showed an association with FIGO stage (P = 0.014), tumor grade (P = 0.034), persistent disease (P = 0.006), and risk of dying due to the disease (P = 0.039). The combined bcl-2-bax expression was related to histopathologic subtype (P = 0.045) and tumor grade (P = 0.022). In a multivariate Cox analysis, tumor grade (P = 0.014), and p53 status (P = 0.020) were independent and significant prognostic factors with regard to the cancer-specific survival rate.