Lymph node metastasis in patients with epithelial ovarian cancer macroscopically confined to the ovary: review of a single-institution experience

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.

Nomogram for predicting lymph node metastasis in patients with ovarian cancer using ultrasonography: a multicenter retrospective study

BACKGROUND

Ovarian cancer is a common cancer among women globally, and the assessment of lymph node metastasis plays a crucial role in the treatment of this malignancy. The primary objective of our study was to identify the risk factors associated with lymph node metastasis in patients with ovarian cancer and develop a predictive model to aid in the selection of the appropriate surgical procedure and treatment strategy.

METHODS

We conducted a retrospective analysis of data from patients with ovarian cancer across three different medical centers between April 2014 and August 2022. Logistic regression analysis was employed to establish a prediction model for lymph node metastasis in patients with ovarian cancer. We evaluated the performance of the model using receiver operating characteristic (ROC) curves, calibration plots, and decision analysis curves.

RESULTS

Our analysis revealed that among the 368 patients in the training set, 101 patients (27.4%) had undergone lymph node metastasis. Maximum tumor diameter, multifocal tumor, and Ki67 level were identified as independent risk factors for lymph node metastasis. The area under the curve (AUC) of the ROC curve in the training set was 0.837 (95% confidence interval [CI]: 0.792-0.881); in the validation set this value was 0.814 (95% CI: 0.744-0.884). Calibration plots and decision analysis curves revealed good calibration and clinical application value.

CONCLUSIONS

We successfully developed a model for predicting lymph node metastasis in patients with ovarian cancer, based on ultrasound examination results and clinical data. Our model accurately identified patients at high risk of lymph node metastasis and may guide the selection of appropriate treatment strategies. This model has the potential to significantly enhance the precision and efficacy of clinical management in patients with ovarian cancer.

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.

CUP-syndrome: Inguinal high grade serous ovarian carcinoma lymph node metastases with unknown primary origin – a case report and literature review

Objective

High-grade serous ovarian carcinoma (HGSC) often presents lymph node involvement. According to the paths of lymphatic drainage, the most common site of nodal metastasis is in the aortic area. However, pelvic lymph nodes are also involved and inguinal metastases are less frequent.

Methods

Our report concerns the case of a 78-year-old woman with an inguinal lymph node relapse of HGSC, with the prior positivity of a right inguinal lymph node, after the primary surgery. Ovaries and tubes were negative on histological examination. A comprehensive search of the literature published from January 2000 to October 2021 was conducted on PubMed and Scopus. The papers were selected following the PRISMA guidelines. Nine retrospective studies were evaluated.

Results

Overall, 67 studies were included in the initial search. Applying the screening criteria, 36 articles were considered eligible for full-text reading of which, after applying the exclusion criteria, 9 studies were selected for the final analysis and included in the systematic review. No studies were included for a quantitative analysis. We divided the results according to the relapse location: loco-regional, abdominal, and extra-abdominal recurrence.

Conclusions

Inguinal node metastasis is a rare but not unusual occurrence in HGSC. A reasonable level of suspicion should be maintained in patients with inguinal adenopathy and high CA125 values, especially in women with a history of gynecologic surgery, even in the absence of negative imaging for an ovarian origin.

Fertility-sparing treatment for early-stage epithelial ovarian cancer: Contemporary oncologic, reproductive and endocrinologic perspectives

AIM

Epithelial ovarian cancer (EOC) can be a devastating diagnosis in women of reproductive age who desire future fertility. However, in early-stage disease, fertility-sparing surgery (FSS) can be considered in appropriately selected patients.

METHODS

This is a narrative descriptive review of the recent literature on FSS for EOC from oncologic, reproductive and endocrinologic perspectives.

RESULTS

The recurrence rate following FSS performed for stage I EOC in published retrospective studies collectively is 13% but ranges from 5 to 29%, while mortality ranges from 0 to 18%. Five-year disease-free survival following FSS is over 90% but decreases with higher stage and grade. Recurrences following FSS are more likely to be localized with a more favorable prognosis compared to recurrences following radical surgery. Adjuvant chemotherapy is recommended in women with high-risk disease, and strategies to minimize gonadotoxicity during chemotherapy such as gonadotropin-releasing hormone (GnRH) agonists may be considered. Oocyte, embryo and/or ovarian cryopreservation can also be offered to patients desiring future biologic children. Reproductive outcomes following FSS, including pregnancy and miscarriage rates, resemble those of the general population, with a chance of successful pregnancy of nearly 80%.

CONCLUSION

In retrospective data, FSS appears to be oncologically safe in stage IA and IC grade 1-2 non-clear cell EOC. In patients with grade 3 tumors or clear cell histology, treatment can be individualized, weighing a slightly higher risk of recurrence with fertility goals. A multidisciplinary approach with oncology and reproductive endocrinology may be of utility to help these patients achieve their fertility goals.

Survival effect of different lymph node staging methods on ovarian cancer: An analysis of 10 878 patients

Background

To compare the survival impact of several lymph node staging methods and therapeutic role of lymphadenectomy in patients with epithelial ovarian cancer who had undergone lymphadenectomy.

Methods

Data were retrospectively collected from the Surveillance, Epidemiology, and End Results program between 1988 and 2013.

Results

An increasing number of resected lymph nodes (RLNs) was associated with a significant improvement in survival of FIGO stage II and III disease. However, for FIGO stage IV patients, better survival was not significantly associated with a more extensive lymphadenectomy. A higher lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) were associated with poorer survival regardless of stage. Nevertheless, four‐category classification of LODDS was more suitable for stage IV patients when three‐category classification was compatible with stage I‐III disease. Multivariate analysis demonstrated that LODDS and LNR were significant independent prognostic factors, but not RLN classification.

Conclusion

Sixteen to thirty RLNs are recommended for stage I disease. For stages II and III patients, the more lymph node excision, the better the prognosis. However, lymphadenectomy was nonessential for stage IV patients. Considering staging methods, for stages II and III patients, three‐category classification of LODDS was recommended to evaluate the prognosis. For stage I and IV, three‐category classification of positive LNR was idoneous.

Normal Size Ovary Carcinoma Syndrome with Inguinal Ovarian Cancer Lymph Node Metastases - A Case Report and Literature Review

Inguinal lymph node mass as the first sign in patients with ovarian cancer represents a rare situation, with only few cases being reported so far. We present the case of a 46-year-old patient who presented for the apparition of bilateral inguinal tumoral masses in the absence of any other pathological signs. The biopsy revealed the presence of an adenocarcinoma with probable genital origin; however, neither the gynaecological examination nor the computed tomography demonstrated the presence of any suspect lesion. The patient was submitted to a positron emission computed tomography which revealed a high capitation in both adnexal areas as well as at the level of the inguinal lymph nodes. The patient was submitted to surgery, the frozen section of the adnexas confirming the ovarian origin of the tumor. Complete cytoreduction to no residual disease was successfully performed. At one-year follow-up the patient is free of any recurrent disease.

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 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.

Staging Lymphadenectomy in Patients With Clear Cell Carcinoma of the Ovary

OBJECTIVE

The purpose of this study was to assess the rate of lymph node (LN) metastasis in comprehensively staged ovarian clear cell carcinoma (OCCC) clinically confined to the ovary and determine factors associated with LN metastasis.

METHODS

We identified all cases of OCCC treated at 4 institutions from January 1994 through December 2011. We included cases with disease grossly confined to the ovary that had surgical staging performed, including at least 10 LNs sampled. Clinical and pathologic data were abstracted from electronic medical records, and a deidentified data set was compiled and processed at a single institution. Factors potentially associated with LN metastasis were tested. Appropriate statistical tests were performed.

RESULTS

We identified 145 eligible cases that met the criteria for this analysis. Median age was 52.9 years (range, 30-81 years), and median total LN count was 19 (range, 10-74). Seven (4.8%) of 145 comprehensively staged cases had LN metastasis; 6 of these cases (4.1%) were isolated metastasis. Cytologic washings, peritoneal, omental, and fallopian tube involvement were not associated with nodal metastasis. Cases with ovarian surface involvement and positive cytology had a 37.5% incidence of LN positivity, which was statistically meaningful when compared with all other cases (P = 0.003).

CONCLUSIONS

Women who underwent comprehensive staging for clinical stage I OCCC had an LN metastasis rate of 4.8%. The subgroup of cases with both ovarian surface involvement and positive cytology had the highest incidence of LN metastasis. This may influence clinical decision making on whether to perform lymphadenectomy in patients with incidental OCCC found after salpingo-oophorectomy.

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.

MicroRNA-17-5p induces drug resistance and invasion of ovarian carcinoma cells by targeting PTEN signaling

Background

The miR-17-5p was overexpressed in ovarian cancer cells, and those cells were treated with paclitaxel. The proliferation of ovarian cancer cells was assessed by MTT assay. The Caspase-Glo3/7 and TUNEL assay were used to examine the effect of miR-17-5p on paclitaxel-induced apoptosis in ovarian cancer cells. The migration and invasion of ovarian cancer cells were analyzed by BD matrigel assays. Western blot was performed to evaluate the expression of apoptotic proteins and epithelial-mesenchymal transition markers in ovarian cancer cells.

Results

The survival rate of ovarian cancer cells was increased after overexpression of miR-17-5p. The apoptosis decreased in miR-17-5p overexpressed ovarian cancer cells. Altered miR-17-5p expression affected migration and invasion of ovarian cancer cells. The overexpression of miR-17-5p altered the expression of EMT markers. miR-17-5p activates AKT by downregulation of PTEN in ovarian cancer cells.

Conclusion

Our results indicate that miR-17-5p might serve as potential molecular therapeutic target.

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.