The impact of lymph node dissection and adjuvant chemotherapy on survival: A nationwide cohort study of patients with clinical early-stage ovarian cancer

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.

Sentinel-node biopsy in apparent early stage ovarian cancer: final results of a prospective multicentre study (SELLY)

AIM

To evaluate the sensitivity and specificity of sentinel-lymph-node mapping compared with the gold standard of systematic lymphadenectomy in detecting lymph node metastasis in apparent early stage ovarian cancer.

METHODS

Multicenter, prospective, phase II trial, conducted in seven centers from March 2018 to July 2022. Patients with presumed stage I-II epithelial ovarian cancer planned for surgical staging were eligible. Patients received injection of indocyanine green in the infundibulo-pelvic and, when feasible, utero-ovarian ligaments and sentinel lymph node biopsy followed by pelvic and para-aortic lymphadenectomy was performed. Histopathological examination of all nodes was performed including ultra-staging protocol for the sentinel lymph node.

RESULTS

174 patients were enrolled and 169 (97.1 %) received study interventions. 99 (58.6 %) patients had successful mapping of at least one sentinel lymph node and 15 (15.1 %) of them had positive nodes. Of these, 11 of 15 (73.3 %) had a correct identification of the disease in the sentinel lymph node; 7 of 11 (63.6 %) required ultra-staging protocol to detect nodal metastasis. Four (26.7 %) patients with node-positive disease had a negative sentinel-lymph-node (sensitivity 73.3 % and specificity 100.0 %).

CONCLUSIONS

In a multicenter setting, identifying sentinel-lymph nodes in apparent early stage epithelial ovarian cancer did not reach the expected sensitivity: 1 of 4 patients might have metastatic lymphatic disease unrecognized by sentinel-lymph-node biopsy. Nevertheless, 35.0 % of node positive patients was identified only thanks to ultra-staging protocol on sentinel-lymph-nodes.

Speculation on optimal numbers of examined lymph node for early-stage epithelial ovarian cancer from the perspective of stage migration

Introduction

In early-stage epithelial ovarian cancer (EOC), how to perform lymphadenectomy to avoid stage migration and achieve reliable targeted excision has not been explored in depth. This study comprehensively considered the stage migration and survival to determine appropriate numbers of examined lymph node (ELN) for early-stage EOC and high-grade serous ovarian cancer (HGSOC).

Methods

From the Surveillance, Epidemiology, and End Results database, we obtained 10372 EOC cases with stage T1M0 and ELN ≥ 2, including 2849 HGSOC cases. Generalized linear models with multivariable adjustment were used to analyze associations between ELN numbers and lymph node stage migration, survival and positive lymph node (PLN). LOESS regression characterized dynamic trends of above associations followed by Chow test to determine structural breakpoints of ELN numbers. Survival curves were plotted using Kaplan-Meier method.

Results

More ELNs were associated with more node-positive diseases, more PLNs and better prognosis. ELN structural breakpoints were different in subgroups of early-stage EOC, which for node stage migration or PLN were more than those for improving outcomes. The meaning of ELN structural breakpoint varied with its location and the morphology of LOESS curve. To avoid stage migration, the optimal ELN for early-stage EOC was 29 and the minimal ELN for HGSOC was 24. For better survival, appropriate ELN number were 13 and 8 respectively. More ELNs explained better prognosis only at a certain range.

Discussion

Neither too many nor too few numbers of ELN were ideal for early-stage EOC and HGSOC. Excision with appropriate numbers of lymph node draining the affected ovary may be more reasonable than traditional sentinel lymph node resection and systematic lymphadenectomy.

Influence of lymphadenectomy on survival and recurrence in patients with early-stage epithelial ovarian cancer: a meta-analysis

BACKGROUND

This meta-analysis aimed to evaluate the effectiveness of lymphadenectomy on survival and recurrence in patients with early-stage epithelial ovarian cancer (eEOC).

METHODS

Relevant studies were searched from four online databases. Hazard ratios (HRs) with 95% confidence intervals (CIs) or risk ratios (RRs) with 95% CIs were used to evaluate the effects of lymphadenectomy on overall survival (OS), progression-free survival (PFS), and recurrence rates. A subgroup analysis was performed to explore the sources of heterogeneity, followed by sensitivity and publication bias assessments.

RESULTS

Fourteen articles involving 22,178 subjects were included. Meta-analysis revealed that lymphadenectomy was significantly associated with improved OS (HR = 0.72; 95% CI:0.61, 0.84; P < 0.001), improved PFS (HR = 0.74; 95% CI: 0.67, 0.80; P < 0.001), and reduced recurrence rates (RR = 0.72; 95% CI: 0.60, 0.85; P < 0.001). Subgroup analysis showed that factors including area, histology, and source of the control group were significantly related to improved OS and PFS in patients with eEOC. Sensitivity analysis showed that the combined results were stable and reliable, and no significant publication bias was observed.

CONCLUSIONS

Patients with eEOC can benefit from lymphadenectomy, with improved survival outcomes (OS and PFS) and a lower recurrence rate.

Impact of complete surgical staging on survival of patients with early-stage (FIGO I or II) ovarian cancer: Data from the Cote d'Or Registry of Gynecological Cancers from 1998 to 2015

INTRODUCTION

Early-stage ovarian cancer represents 20 to 33% of all ovarian cancers and is thus quite rare in France, with around 1200 new cases per year. No study to date has convincingly demonstrated the utility of lymphadenectomy in early-stage ovarian cancer. We sought to evaluate the impact on overall survival of complete surgical staging in patients management for FIGO stage I and II ovarian cancer.

METHODS

We performed a retrospective observational study using data from the Cote d'Or Registry of Gynecological Cancers. We included patients with invasive early stage epithelial ovarian cancer (FIGO stages I and II), diagnosed between 1 January 1998 and 31 December 2015.

RESULTS

A total of 179 patients were included in the study. Patients who had lymphadenectomy were younger on average (P<0.001) and had fewer comorbidities (P=0.03). Lymphadenectomy was performed during the first surgery in 59.2% of cases (58 patients) and during a second, re-staging surgery in 40.8% (n=40). When complete surgical staging was performed, the rate of up-staging (to at least FIGO stage III) was 11.2% (11/98). The median follow-up was 8.4 years. At the study, 31.6% patients with complete surgical staging had died and 48.4% patients also died in the group without lymphadenectomy, HR 0.59 CI [0.36-0.97] P<0.04.

CONCLUSION

In patients with early-stage ovarian cancer, complete surgical staging appears to yield a benefit in terms of overall survival. In 10 to 15% of cases, it leads to upstaging, with the resultant indication for maintenance therapy, which has also shown a survival benefit.

Toosendanin reduces cisplatin resistance in ovarian cancer through modulating the miR-195/ERK/β-catenin pathway

BACKGROUND

Cisplatin (DDP) resistance is prevalent in ovarian cancer (OC) patients and contributes to the poor prognosis. Therefore, it is of great significance to develop new agent to intervene and even reverse DDP resistance in OC. Toosendanin (TSN), a triterpenoid extracted from the bark or fruits of Melia toosendan Sieb et Zucc, has been proved to possess significant antitumor activities. However, the efficacy of TSN on DDP resistance in OC has not been reported yet.

PURPOSE

The aim of this study is to investigate the effects of TSN on DDP resistance in OC and explore the molecular mechanism in vitro and in vivo.

METHODS

Human OC cell line (SKOV3) and DDP-resistant cell line (SKOV3/DDP) were used. Cell proliferation was measured by CCK-8 and colony formation assay. Annexin V/PI double staining and hoechst 33342 nuclear staining were employed to detect cell apoptosis. Transwell and wound-healing assay were used to determine the invasion and migration potential of cells respectively. Quantitative real-time PCR (qPCR) and western blotting were performed to detect the expression of molecules related to miR-195/ERK/β-catenin pathway. The effects and mechanism of TSN on DDP resistance of OC in vivo was investigated using xenograft model, TUNEL staining assay and immunohistochemistry.

RESULTS

TSN improved the DDP sensitivity of SKOV3/DDP cells in vitro and in vivo, reflected in promoting inhibition of proliferation, invasion, migration and epithelial mesenchymal transformation (EMT) as well as induction of apoptosis by DDP. TSN could modulate the miR-195/ERK/β-catenin axis by upregulating the miR-195-5p expression and then suppressing ERK/GSK3β/β-catenin pathway which were activated in SKOV3/DDP cells. Moreover, co-treatment of β-catenin pathway activator LiCl or miR-195-5p silencing partially recovered the DDP resistance which was previously repressed by TSN.

CONCLUSION

Both in vitro and in vivo data demonstrated that TSN could reduce DDP resistance in OC through regulating the miR-195/ERK/β-catenin pathway, highlighting the potential of TSN as an effective agent for favoring overcoming clinical DDP resistance in OC.

miR-219-5p attenuates cisplatin resistance of ovarian cancer by inactivating Wnt/β-catenin signaling and autophagy via targeting HMGA2

Our previous study confirmed that miR-219-5p inhibits the progression of ovarian cancer (OC) by targeting high mobility group AT-hook 2 (HMGA2), while the role of miR-219-5p on the chemoresistance of OC is unclear. HMGA2 and miR-219-5p expression in OC tumors and various types of OC cells were determined by reverse transcription-quantitative PCR (RT-qPCR) and western blotting. The miRNA profiles in A2780 and cisplatin-resistant A2780 cells were investigated via bulk miRNA sequencing, and the interactions of miR-219-5p and HMGA2 were determined by luciferase reporter activity assay. Cell function was verified through Cell Counting Kit-8, invasion assay, wound-healing, and TUNEL assays. HMGA2 level is highly expressed in cisplatin-resistant OC cell lines compared to normal OC cells, while the expression trend of miR-219-5p is the opposite. In addition, we found that miR-219-5p is one of the miRNAs that have the most significant reduction in levels in the cisplatin-resistant A2780/DDP cell line compared to A2780 cells. Then, we reveal that miR-219-5p directly targets HMGA2 in cisplatin-resistant OC cells, and upregulation of miR-219-5p significantly reduces the resistance of OC cells to cisplatin both in vitro and in vivo. Finally, our results suggest that Wnt/β-catenin signaling and autophagy pathway is involved in the role of miR-219-5p/HMGA2 on resistance of OC cells to cisplatin via gain-of-function experiments. Collectively, the present study shows that miR-219-5p decreases the resistance of OC cells to cisplatin via Wnt/β-catenin signaling and autophagy by regulating HMGA2, which provides a feasible solution for the resistance of OC to chemotherapy.

Guideline adherence in ovarian cancer for surgical staging in the Netherlands

OBJECTIVE

Previous studies have shown low adherence to surgical staging guidelines in patients with clinical early-stage ovarian carcinoma. The aim of this study was to identify guideline adherence for surgical staging and to show the distribution of each surgical item within the study population. In addition, we examined whether regional variation in the Netherlands exists for complete surgical staging.

METHODS

Patients with ovarian cancer and surgical staging registered in the Dutch Gynecological Oncology Audit between January 1, 2015 and December 31, 2019 in the Netherlands were included. Complete surgical staging was defined according to the Dutch evidence-based guideline. Surgical items were ranked and illustrated. Variation in complete surgical staging for eight regional cancer networks was shown in funnel plots. Manual validation of registered data was performed in three gynecological oncology centers.

RESULTS

604 patients underwent surgical staging, 365 (60%) underwent an incomplete staging procedure, 295 (81%) were registered with early-stage disease (International Federation of Gynecology and Obstetrics I-IIA) and, of these patients, 115 (39%) received adjuvant chemotherapy. Patients with incomplete surgical staging were operated more often with minimal invasive techniques (laparoscopy or robot) compared with patients in the complete staging group (p<0.001). Sampling of cytology/ascites was the most frequently lacking factor (29%). Manual validation of data in three gynecological oncology centers identified reasons for incomplete staging, the most common being 'perioperative findings' such as dense adhesions between tumor and peritoneum, consistent with advanced stage disease (≥IIA). Regional variation for complete surgical staging showed two regions performing outside the confidence intervals (12.5% and 25.5%, mean 40%).

CONCLUSION

Guideline adherence for staging was lower than expected and validation of data gave additional insights into the reasons that were contributing to incomplete surgical staging. Moreover, this analysis showed that regional variation for surgical staging exists, which forms a starting point to improve and harmonize staging procedures for these patients nationwide.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

Incomplete surgical staging in clinical early-stage ovarian cancer: guidelines versus daily practice

Background

Incomplete surgical staging of patients with early-stage epithelial ovarian cancer (EOC) has been reported in up to 98% of cases, when based on the International Federation of Obstetrics and Gynecology (FIGO) staging procedure. The aim of the present retrospective study was to clarify the reasons for incomplete staging.

Methods

The PRISMA (Prevention Recovery Information System for Monitoring and Analysis) technique was used to evaluate cases with FIGO I-IIa EOC based on incomplete staging from five gynecologic oncologic center hospitals in the Netherlands in the period 2010-2014.

Results

Fifty cases with an incomplete surgical staging of EOC according to national guidelines were included. The most common reasons for incomplete staging were insufficient random biopsies of the peritoneum (n = 34, 68%), and less than ten lymph nodes being resected and/or found at pathology (n = 16, 32%). The most mentioned reason for not performing biopsies was, besides forgetting to do so, believing that after careful inspection and palpation, taking biopsies is irrelevant and/or already are being taken while performing a hysterectomy (peritoneum of cul-de-sac, bladder). The value of contralateral pelvic lymph node dissection in case of a unilateral ovarian malignancy was also doubted, influencing the number of lymph nodes resected.

Conclusions

The most important reasons for incomplete staging in EOC are, besides omitting elements by accident, questioning the importance of obligatory elements of the staging procedure. A structured list of staging steps during surgery and more evidence-based consensus concerning these obligatory elements might increase the number of complete staging procedures in EOC.

Oncologic outcomes after splenectomy during initial cytoreductive surgery in advanced epithelial ovarian cancer: a nationwide population-based cohort study

INTRODUCTION

Epithelial ovarian cancer (EOC) patients undergoing splenectomy during cytoreductive surgery represent a small subgroup of patients. Splenic metastases or technical reasons due to extensive upper abdominal disease may require a splenectomy. It has been hypothesized that as the spleen's antitumor immunologic functions may inhibit cancer growth, splenectomy may promote the growth of residual disease as observed in other cancer types of murine studies. The few studies assessing the impact of splenectomy on the oncologic outcomes of advanced stage EOC patients have reported inconsistent results. It remains unclear whether splenectomy during cytoreductive surgery is justified to achieve complete cytoreduction. The aim of this study was to assess the impact of a splenectomy on perioperative outcomes and survival of advanced stage EOC patients.

MATERIAL AND METHODS

In this nationwide population-based study, all consecutive patients diagnosed with FIGO stage IIIC and IV EOC between 1 January 2008 and 31 December 2015 were identified from the Netherlands Cancer Registry. Patients who underwent cytoreductive surgery combined with platinum-based chemotherapy as primary treatment were selected. Differences in clinicopathologic characteristics between splenectomy and non-splenectomy patients were assessed. Progression-free survival (PFS) and overall survival (OS) were analyzed using Kaplan-Meier survival curves and log-rank tests. Cox proportional hazards models were used to adjust for covariates that influence survival.

RESULTS

A total of 3911 patients were identified: 99 splenectomy and 3812 non-splenectomy patients. Splenectomy patients were more likely to undergo extensive surgery or surgical reintervention, to receive intraperitoneal chemotherapy, intraoperative and postoperative blood transfusion, to experience postoperative infections, and to be admitted to an intensive care unit (all p < 0.002). No significant differences in PFS or OS were observed between splenectomy versus non-splenectomy patients after adjusting for covariates.

CONCLUSIONS

Although advanced stage EOC patients who undergo splenectomy during cytoreductive surgery have less favorable perioperative outcomes, no adverse impact of splenectomy on the survival of advanced stage EOC patients was observed. Splenectomy during cytoreductive surgery seems to be justified to achieve complete cytoreduction in advanced stage EOC patients.

Borderline ovarian tumor frozen section diagnoses with features suspicious of invasive cancer: a retrospective study

Background

A frozen section diagnosis of a borderline ovarian tumor with suspicious features of invasive carcinoma (“at least borderline” or synonymous descriptions) presents us with the dilemma of whether or not to perform a full ovarian cancer staging procedure. Quantification of this dilemma may help us with the issue of this clinical decision. The present study assessed and compared both the prevalence of straightforward borderline and “at least borderline” frozen section diagnoses and the proportion of these women with a final histopathological diagnosis of invasive carcinoma, with a special interest in histologic subtypes.

Methods

A retrospective cohort study was performed in three hospitals in The Netherlands. All women that underwent ovarian surgery with perioperative frozen section evaluation in one of these hospitals between January 2007 and July 2018 were identified and included in case of a borderline or “at least borderline” frozen section diagnosis and a borderline ovarian tumor or invasive carcinoma as a final diagnosis.

Results

A total of 223 women were included, of which 41 women (18.4%) were diagnosed with “at least borderline” at frozen section. Thirteen of forty-one women (31.7%) following “at least borderline” frozen section diagnosis and 14 of 182 women (7.7%) following a straightforward borderline frozen section diagnosis were diagnosed with invasive carcinoma at paraffin section evaluation (p < 0.001). When compared to straightforward borderline frozen section diagnoses, the proportion of women diagnosed with invasive carcinoma increased from 3.1 to 35.7% for serous tumors (p = 0.001), 10.0 to 21.7% for mucinous tumors (p = 0.129) and 50.0 to 75.0% (p = 0.452) in case of other histologic subtypes following an “at least borderline” frozen section diagnosis.

Conclusions

Overall, when compared to women with a decisive borderline frozen section diagnosis, women diagnosed with “at least borderline” frozen section diagnoses were found to have a higher chance of carcinoma upon final diagnosis (7.7% vs 31.7%). Especially in the serous subtype, full staging during initial surgery might be considered after preoperative consent to prevent a second surgical procedure or chemotherapy in unstaged women. Further studies are needed to evaluate whether additional sampling in case of an “at least borderline” diagnosis may decrease the risk of surgical over-treatment.

Survival impact of number of removed para-aortic lymph nodes in stage I epithelial ovarian cancer

PURPOSE

The survival effect of presence or absence of lymphadenectomy in early-stage epithelial ovarian cancer (EOC) was priorly shown but the effect of number of removed lymph nodes kept in background. We aimed to evaluate the survival impact of number of removed lymph nodes and their localizations in stage I EOC.

METHODS

This study included 182 patients. The best cut-off levels for number of pelvic and para-aortic lymph nodes (PaLN) were 24 and 10, respectively. Univariate and multivariate survival analyses were performed for these cut-offs and other prognostic factors.

RESULTS

The median age of the patients was 49. The median number of removed pelvic and paraartic lymph nodes were 29 and 9, respectively. The median overall (OS) and progression-free survival (PFS) were 67 and 50 months, respectively. The 5-year OS rate was 89.6%. Recurrence occured in 24 (19.5%) patients. In univariate analyses tumor grade (p: 0.005), pelvic LN number (p: 0.041) and PaLN number (p: 0.004) were the factors that were significantly associated with PFS. Tumor grade and PaLN number were independently and significantly associated with PFS in multivariate analyses (p: 0.015 and p: 0.017, respectively). In OS analyses, age, tumor grade, presence of LVI, number of pelvic and PaLNs were the significantly associated factors (p < 0.05 for all). In multivariate analyses, age and PaLN number were independently and significantly associated with OS (p: 0.011 and p: 0.021, respectively).

CONCLUSIONS

The number and localizations of removed lymph nodes may have a survival affect in stage I EOC. We also think that this study may constitute a kernel point for larger prospective series on lymph node number and lymphatic regions.

Does complete-staging lymphadenectomy improve survival outcomes in stage I endometrioid epithelial ovarian carcinoma? A multi-institutional retrospective study with propensity score-weighted analysis

BACKGROUND

We investigated the prognostic impact of complete-staging lymphadenectomy on patients with clinically apparent Stage I endometrioid epithelial ovarian carcinoma.

METHODS

We conducted a regional multi-institutional retrospective study between 1986 and 2018. Amongst 4897 patients with malignant ovarian tumours diagnosed under central pathological review, 259 women with Stage I endometrioid epithelial ovarian carcinoma were eligible. We evaluated differences in survival of patients with both pelvic and para-aortic lymphadenectomy (Group A) and those with only pelvic lymphadenectomy and/or clinical lymph node evaluation (Group B). To analyse the therapeutic effects, the baseline imbalance between patients with both pelvic and para-aortic lymphadenectomy and others was adjusted with an inverse probability of treatment weighting using propensity score involving independent clinical variables.

RESULTS

In total, 145 patients (56.0%) received both pelvic and para-aortic lymphadenectomy. With propensity score-based adjustment, estimated survival was better in Group A compared with that in Group B but not significant. Pelvic and para-aortic lymphadenectomy also led to no significant improvement of overall survival in most of the subgroups. However, point estimations of the hazard ratio for lymphadenectomy in patients with an age of 45 or younger (hazard ratio, 0.304; 95% confidence interval, 0.094-0.982), a Grade 1-2 (hazard ratio, 0.441; 95% confidence interval, 0.204-0.954) and T1c2-3 tumour (hazard ratio, 0.449; 95% confidence interval, 0.164-1.231) were better compared with those with the opposite characteristics.

CONCLUSIONS

Complete-staging lymphadenectomy was not a significant prognostic factor in patients with Stage I endometrioid epithelial ovarian carcinoma, where we still need to explore appropriate candidate for the procedure.

Frozen section diagnosis of borderline ovarian tumors with suspicious features of invasive cancer is a devil's dilemma for the surgeon: A systematic review and meta-analysis

Introduction

Frozen section diagnoses of borderline ovarian tumors are not always straightforward and a borderline frozen section diagnosis with suspicious features of invasive carcinoma (reported as “at least borderline” or synonymous descriptions) presents us with the dilemma of whether or not to perform a full surgical staging procedure. By performing a systematic review and meta‐analysis, the prevalence of straightforward borderline and “at least borderline” frozen section diagnoses, as well as proportion of patients with a final diagnosis of invasive carcinoma in these cases, were assessed and compared, as quantification of this dilemma may help us with the issue of this clinical decision.

Material and methods

PubMed, EMBASE and Cochrane library databases were searched and studies discussing “at least borderline” frozen section diagnoses were included in the review. Numbers of specific frozen section diagnoses and subsequent final histological diagnoses were extracted and pooled analysis was performed to compare the proportion of patients diagnosed with invasive carcinoma following borderline and “at least borderline” frozen section diagnoses, presented as risk ratio and risk difference with 95% confidence intervals (95% CI).

Results

Of 4940 screened records, eight studies were considered eligible for quantitative analysis. A total of 921 women was identified and 230 (25.0%) of these women were diagnosed with “at least borderline” ovarian tumor at the time of frozen section. Final histological diagnoses were reported in five studies, including 61 women with an “at least borderline” diagnosis and 290 women with a straightforward borderline frozen section diagnosis. Twenty‐five of 61 women (41.0%) of the “at least borderline” group had invasive cancer at final diagnosis, compared with 28 of 290 women (9.7%) of the straightforward borderline frozen section group (risk difference −0.34, 95% CI −0.53 to −0.15; relative risk 0.25, 95% CI 0.13–0.50).

Conclusions

Women diagnosed with “at least borderline” frozen section diagnoses were found to have a higher chance of carcinoma upon final diagnosis when compared with women with a straightforward borderline frozen section diagnosis (41.0% vs 9.7%). Especially in the serous subtype, and after preoperative consent, full staging during initial surgery might be considered in these cases to prevent a second surgical procedure.

Assessment of Lymph Node Involvement with PET-CT in Advanced Epithelial Ovarian Cancer. A FRANCOGYN Group Study

The objective of our study is to evaluate the diagnostic performance of positron emission tomography/computed tomography (PET-CT) for the assessment of lymph node involvement in advanced epithelial ovarian, fallopian tubal or peritoneal cancer (EOC). This was a retrospective, bicentric study. We included all patients over 18 years of age with a histological diagnosis of advanced EOC who had undergone PET-CT at the time of diagnosis or prior to cytoreduction surgery with pelvic or para-aortic lymphadenectomy. We included 145 patients with primary advanced EOC. The performance of PET-CT was calculated from the data of 63 patients. The sensitivity of PET-CT for preoperative lymph node evaluation was 26.7%, specificity was 90.9%, PPV was 72.7%, and NPV was 57.7%. The accuracy rate was 60.3%, and the false-negative rate was 34.9%. In the case of primary cytoreduction (n = 16), the sensitivity of PET-CT was 50%, specificity was 87.5%, PPV was 80%, and NPV was 63.6%. The accuracy rate was 68.8%, and the false negative rate was 25%. After neoadjuvant chemotherapy (n = 47), the sensitivity of PET-CT was 18.2%, specificity was 92%, PPV was 66.7%, and NPV was 56.1%. The accuracy rate was 57.5%, and the false negative rate was 38.3%. Due to its high specificity, the performance of a preoperative PET-CT scan could contribute to the de-escalation and reduction of lymphadenectomy in the surgical management of advanced EOC in a significant number of patients free of lymph node metastases.

The impact of lymph node dissection on apparent Stage I epithelial ovarian carcinoma: A population-based study

OBJECTIVE

To explore the impact of lymphadenectomy on the prognosis of women of reproductive age with clinically apparent Stage I epithelial ovarian cancer (EOC).

METHODS

Data of women of reproductive age with Stage I EOC, diagnosed between 2010 and 2016, were extracted from the Surveillance, Epidemiology, and End Results database. Five-year cancer-specific survival (CSS) was evaluated using the Kaplan-Meier method. Multivariate Cox analysis was performed to evaluate the effect of lymph node dissection on survival. Propensity score (PS) matching was conducted to balance various clinicopathologic factors.

RESULTS

Of 2222 patients included, 1609 (72.4%) received lymph node dissection. The rate of histopathologically confirmed lymph node metastasis was highest in serous subtype (10.2%) and lowest in mucinous subtype (2.2%). No significant difference between the lymphadenectomy and non-lymphadenectomy groups in 5-year CSS was observed in the original cohort (P = 0.364) or in the PS matching cohort (P = 0.248). Nevertheless, there was a significant difference between the lymphadenectomy and non-lymphadenectomy groups for patients with Stage IC EOC (92.4% vs. 88.1%, P = 0.027). According to the multivariate analysis, performance of the lymphadenectomy was not significantly associated with CSS in the original cohort (P = 0.163) or the PS matching cohort (P = 0.101).

CONCLUSION

Dissection of lymph nodes was not significantly associated with improved prognosis for most Stage I EOC, but, lymphadenectomy may be necessary for women of reproductive age with Stage IC subtype.

Transferability of the early-stage ovarian malignancy (EOM) score: an external validation study that includes advanced-stage and metastatic ovarian cancer

PURPOSE

To validate the diagnostic performance of the Early-stage Ovarian Malignancy (EOM) score in an external dataset that includes advanced-stage and metastatic ovarian cancer.

METHODS

The data from two cross-sectional cohorts were used in the statistical analysis. The development dataset of the EOM score was collected in Phrapokklao Hospital between September 2013 and December 2017. The validation dataset was collected in Maharaj Nakorn Chiang Mai Hospital between April 2010 and March 2018. The internal and external performance of the EOM score was evaluated in terms of discrimination via area under the receiver-operating characteristic curve (AuROC) and calibration.

RESULTS

There were 270 and 479 patients included in the development and validation datasets, respectively. The prevalence of ovarian malignancy was 20.0% (54/270) in the development set and 30.3% (145/479) in the validation set. The EOM score had excellent discriminative ability in both the development and validation sets (AuROC 88.0 (95% CI 82.6, 93.9) and 88.0 (95% CI 84.3, 91.4), respectively). The EOM score also showed good calibration in both datasets.

CONCLUSIONS

The EOM score had consistent diagnostic performance in the external validation data. It is recommended for use as a triage tool in patient referrals instead of the RMI in settings where experienced sonographers are not available.

Early-Stage Ovarian Malignancy Score versus Risk of Malignancy Indices: Accuracy and Clinical Utility for Preoperative Diagnosis of Women with Adnexal Masses

Background and objectives: To compare the diagnostic accuracy and clinical utility of the Early-stage Ovarian Malignancy (EOM) score with the Risk of Malignancy Index (RMI) in the presurgical assessment of women presenting with adnexal masses. Materials and Methods: A secondary analysis was carried out in a retrospective cohort of women who presented with an adnexal mass and were scheduled for surgery at Phrapokklao Hospital between September 2013 and December 2017. The clinical characteristics, ultrasonographic features of the masses, and preoperative CA-125 levels were recorded. The EOM and the RMI score were calculated and compared in terms of accuracy and clinical utility. Decision curve analysis (DCA), which examined the net benefit (NB) of applying the EOM and the RMI in practice at a range of threshold probabilities, was presented. Results: In this study, data from 270 patients were analyzed. Fifty-four (20.0%) women in the sample had early-stage ovarian cancer. All four RMI versions demonstrated a lower sensitivity for the detection of patients with early-stage ovarian cancer compared to an EOM score ≥ 15. An EOM ≥ 15 resulted in a higher proportion of net true positive or NB than all versions of the RMIs from a threshold probability of 5% to 30%. Conclusions: It also showed a higher capability to reduce the number of inappropriate referrals than the RMIs at a threshold probability between 5% and 30%. The EOM score showed higher diagnostic sensitivity and has the potential to be clinically more useful than the RMIs to triage women who present with adnexal masses for referral to oncologic gynecologists. Further external validation is required to support our findings.

Is there any therapeutic role of pelvic and para-aortic lymphadenectomy in apparent early stage epithelial ovarian cancer?

OBJECTIVE

The therapeutic role of pelvic and para-aortic lymphadenectomy in surgical staging of apparent early-stage epithelial ovarian cancer (eEOC) is still under debate. The aim of this study was to evaluate the potential therapeutic role of systematic lymphadenectomy in patients with eEOC.

METHODS

Multi-center retrospective cohort study, comparing women with apparent eEOC who underwent comprehensive bilateral pelvic and para-aortic lymphadenectomy (defined as ≥20 lymph nodes) versus patients receiving no lymphadenectomy or lymph node sampling, from 05/1985 to 12/2016. Patients with bulky nodes at CT-scan and those without complete intra-peritoneal surgical staging were excluded. Only patients who received at least 3 cycles of platinum-based adjuvant chemotherapy were included.

RESULTS

Out of 2559 patients with FIGO stage IA-IIIA1 ovarian cancer, 639 (25.0%) met inclusion criteria. 360 (56.3%) underwent comprehensive lymphadenectomy, 150 (23.5%) lymph node sampling and 129 (20.2%) no lymphadenectomy. Patients who underwent comprehensive lymphadenectomy were younger (p < 0.001), experienced a higher number of severe post-operative complications (p = 0.008) and had a longer time to start chemotherapy (p = 0.034). There was no difference in intra-operative complications. Median follow-up was 63 months (range, 5-342). The 5-year disease-free survival (DFS) was 79.7% vs. 76.5% vs. 68.3% (p = 0.006), and 5-year overall survival (OS) was 92.3% vs. 94.5% vs. 89.8% (p = 0.165) in women who received comprehensive lymphadenectomy vs. lymph node sampling vs. no lymphadenectomy, respectively. Lymphadenectomy represented an independent factor for DFS improvement, HR 0.52 (95%CI 0.37-0.73) (p < 0.001).

CONCLUSION

Pelvic and para-aortic lymphadenectomy in surgical staging of eEOC improves DFS for the price of increasing post-operative complications and time to chemotherapy but does not affect OS. Better understanding of tumor biology may help to identify those patients in whom lymphadenectomy should still play a role.

The Prognostic Relevance of the Proliferation Markers Ki-67 and Plk1 in Early-Stage Ovarian Cancer Patients With Serous, Low-Grade Carcinoma Based on mRNA and Protein Expression

Since type and duration of an appropriate adjuvant chemotherapy in early-stage ovarian cancer (OC) are still being debated, novel markers for a better stratification of these patients are of utmost importance for the design of an improved chemotherapeutical strategy. In contrast to numerous cancer studies on cellular proliferation based on the immunohistochemistry-driven evaluation of protein expression, we compared mRNA and protein expression of two independent markers of cellular proliferation, Ki-67 and Plk1, in a large cohort of 243 early-stage OC and their relationship with clinicopathological features and survival. Based on marker expression we demonstrate that early-stage OC patients (stages I/II, low-grade, serous) with high expression (Ki-67, Plk1) had a significantly shorter progression-free survival (PFS) and overall survival (OS) compared to patients with low expression (Ki-67, Plk1). Remarkably, based on mRNA expression this significant difference got lost in advanced stages (III/IV): At least for PFS, high levels of Ki-67 and Plk1 correlate with moderately better survival compared to patients with low expressing tumors. Our data suggest that in addition to Ki-67, Plk1 is a novel marker for the stratification of early-stage OC patients to maximize therapeutic efforts. Both, Ki-67 and Plk1, seem to be better suited in early-stages (I/II) as therapeutical targets compared to advanced-stages (III/IV) OC.

CT Scan in the Prediction of Lymph Node Involvement in Ovarian Cancer - a Retrospective Analysis of a Tertiary Gyneco-Oncological Unit

Background The prognostic value of lymph node removal in ovarian cancer varies depending on the tumor stage. While in the advanced stage the removal of clinically normal lymph nodes does not improve the prognosis, this is still unclear in the early stages. Evaluation of the lymph nodes based on preoperative imaging influences the surgical procedure.

Methods This retrospective analysis was performed by analyzing data from 114 patients with ovarian cancer, treated in our university hospital in the years 2000 – 2012. Diagnostic performance of imaging by computer tomography with respect to the correct prediction of lymph node status was analyzed in terms of sensitivity, specificity, positive predictive value and negative predictive value.

Results Imaging by computer tomography showed a rather limited diagnostic performance with regard to the detection of lymph node metastases in ovarian cancer, with a sensitivity of 40.7%, a specificity of 89.1%, a positive predictive value of 80.0%, and a negative predictive value of 58.3%. A separate analysis for pelvic and paraaortic lymph node involvement showed a better diagnostic performance of computer tomography for the detection of positive paraaortic lymph nodes (41.2, 93.1, 84.0, and 64.3% for sensitivity, specificity, positive predictive value and negative predictive value, respectively) as compared to the detection of positive pelvic lymph nodes (25.6, 91.8, 62.5, and 69.8%).

Conclusion The preoperative prediction of lymph node status by computer tomography is limited. A decision for or against lymphadenectomy should not be made solely on the basis of this approach.

Sentinel-node biopsy in early-stage ovarian cancer: preliminary results of a prospective multicentre study (SELLY)

BACKGROUND

Systematic paraaortic and bilateral pelvic lymphadenectomy is the standard of a comprehensive surgical staging in presumed early epithelial ovarian cancer, but no prospective randomized evidence suggests a possible therapeutic value. Moreover, this procedure is associated with potential severe morbidity. The Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial is a prospective study designed to test whether sentinel node detection can accurately predict nodal status in a cohort of women with early epithelial ovarian cancer.

OBJECTIVES

We here present the results of the first part of the Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial, regarding the feasibility of the sentinel lymph node technique and the preliminary findings regarding its safety and accuracy.

STUDY DESIGN

The Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial is a prospective, phase II, single-arm study included patients with presumed stages I-II epithelial ovarian cancer planned for immediate or delayed minimally invasive comprehensive staging. The ovarian pedicle is injected with 2 mL of a 1.25 mg/mL indocyanine green solution. The pelvic and lumboaortic retroperitoneum is then accessed and inspected to identify and remove sentinel nodes. After sentinel node procedure, staging is completed including systematic pelvic and paraaortic lymphadenectomy. Assuming a sensitivity of 98.5% in predicting positive sentinel lymph nodes at histology, a pathological lymph node prevalence of 14.2%, a precision of estimate (ie, the maximum marginal error) d = 5%, a type I error α = 0.05, a sample size of 160 patients is needed to test the general hypothesis. Here we present the preliminary results on the first 31 patients enrolled.

RESULTS

Thirty-one patients were included. Sentinel node was identified in 21 patients (detection rate, 67.7%). The detection rate was significantly higher in women undergoing immediate vs delayed staging (88.9% vs 41.7%, P = .003). Four patients had positive nodes. In all the patients with lymphatic dissemination, a positive sentinel node was identified (sensitivity, 100%; false-negative rate, 0%; negative predictive value, 100%). One (3.2%) intra- and 2 (6.5%) postoperative grade I complications occurred.

CONCLUSION

Our data show that the detection of sentinel node in early epithelial ovarian cancer is low when patients are submitted to delayed-staging surgery. However, sentinel node procedure is feasible and has the potential to provide reliable and useful information on nodal status and may allow the avoidance of systematic lymphadenectomy in the majority of patients.

Feasibility of sentinel lymph node mapping of the ovary: a systematic review

Pelvic and para-aortic lymphadenectomy is routinely performed in early ovarian cancer to define the stage of the disease. However, it may be associated with increased blood loss, operative time, and length of hospitalization. The sentinel lymph node technique has been shown to be safe and feasible in vulvar, uterine, and cervical cancer. Data detailing feasibility and outcomes of sentinel lymph node mapping in ovarian cancer are scarce.

To summarize the studies evaluating the feasibility of sentinel lymph node detection from the ovary, examining the technique and detection rate.

A systematic search of the literature was performed using PubMed and Embase from June 1991 to February 2019. Studies describing the sentinel lymph node technique and lymphatic drainage of the ovaries were incorporated in this review. Ten articles were selected, comprising a total of 145 patients. A variety of agents were used, but the primary markers were technetium-99m radiocolloid (Tc-99m), patent blue, or indocyanine green, and the most common injection site was the ovarian ligaments.

The overall sentinel lymph node detection rate was 90.3%.

We propose a standardized technique sentinel lymph node mapping in ovarian cancer, using indocyanine green, or Tc-99m and blue dye as alternative tracers, injected in both the suspensory and the infundibulopelvic ligament of the ovary.

Prognostic value of lymph nodes ratio in patients with stage III ovarian clear cell carcinoma: A retrospective study of patients in Southwest China

Background: Ovarian clear cell carcinoma (OCCC) has a worse prognosis compared to other histological subtypes. Although the survival effect of lymph nodes ratio (LNR) on ovarian carcinoma have been elucidated in several studies, the prognostic effect of LNR in OCCC has not been separately studied. This study aimed to investigate the prognostic significance of LNR in FIGO stage III OCCC.

Methods: Patients with FIGO stage III OCCC who underwent primary cytoreductive surgery and systematic lymphadenectomy from January 2008 to June 2014 in two independent hospitals were retrospectively reviewed. Two independent patients cohorts were used to investigate the survival impact of LNR by using Kaplan-Meier and Cox regression proportional hazard method.

Results: In training cohort, the 5-year progression-free survival (PFS) rates was 32.4% for patients with LNR ≤ 25%, and 19.8% for patients with LNR > 25%, respectively (p = 0.017). The 5-year overall survival (OS) rates was 41.3% for patients with LNR ≤ 25%, and 25.8% for patients with LNR > 25%, respectively (p = 0.003). In multivariate analysis, increased LNR was correlated with a poorer DFS (HR = 2.12 ,95% CI 1.32-3.41, p = 0.002) and OS (HR = 2.29, 95% CI 1.37-5.12, p = 0.001). These results were verified in a validation cohort.

Conclusions: LNR is an independent survival predictor in patients with FIGO stage III OCCC.

Impact of retroperitoneal lymph node dissection in ovarian cancer - time for paradigm shift?

Ovarian cancer is the second most common malignant neoplasm of the genital tract. Staging procedures for ovarian cancer include longitudinal laparotomy, hysterectomy, bilateral salpingo-oophorectomy and infragastric omentectomy as well as systematic pelvic and para-aortic lymphadenectomy. In general, the goal of this primary procedure is to achieve the maximum cytoreduction of all abdominal diseases; a residual disease <1 cm defines optimal cytoreduction, however, a maximal effort should be made to remove all gross disease as this offers superior survival outcomes. The role of lymphadenectomy in ovarian cancer has been the focus of gynecological oncologists during recent years. The core issue of the controversy is whether the removal of lymph nodes should be performed only to stage the disease or if the removal itself improves survival. To further comprehend the issue, one must take into account that several studies have shown that systematic lymphadenectomy is associated with a risk of vascular injury, lymph cyst formation, pulmonary embolism and increased post-operative mortality even when performed by surgeons with extensive experience. We present an extensive review of the available literature on the matter, hoping to provide some insight into the true need for such a procedure.

Internal hernia beneath the left external iliac artery after robotic-assisted laparoscopic prostatectomy with extended pelvic lymph node dissection: a case report

BACKGROUND

Formation of an internal hernia beneath a skeletonized pelvic vessel after pelvic lymph node dissection is extremely rare. We report a case of an internal hernia formation beneath the left external iliac artery after a robotic-assisted laparoscopic prostatectomy with extended pelvic lymph node dissection.

CASE PRESENTATION

A 72-year-old man visited our hospital complaining of severe lower abdominal pain. On physical examinations, his abdomen was distended and tympanitic with rebound tenderness and muscular defense. Abdominal non-enhanced computed tomography showed a small bowel obstruction with marked ascites. A coronal non-enhanced computed tomography image revealed thickened loops of small bowel with surrounding mesenteric edema in the left lower quadrant. Enhanced computed tomography was not performed because we decided to perform urgent surgery with a diagnosis of strangulated small bowel obstruction based on physical examination and the computed tomography findings. The patient underwent urgent laparotomy at which time bloody ascites was seen in the peritoneal cavity. The ileum, which was approximately 60 cm proximal to the ileocecal junction, formed a closed loop beneath the left external iliac artery. The incarcerated ileum, 120 cm in length, appeared non-viable with a color change of the ileum to black. We therefore resected the strangulated ileum for a length of 120 cm and performed a functional end-to-end anastomosis. The orifice beneath the left external iliac artery was about 4 cm in diameter. We did not close the orifice because of the risk of injuring the left iliac artery. The postoperative course was uneventful, and the patient was discharged from our hospital 10 days after surgery. Presently, the patient is doing well 5 months after surgery without recurrent disease.

CONCLUSION

We report an extremely rare case of internal hernia formation beneath the left external iliac artery after a robotic-assisted laparoscopic prostatectomy with extended pelvic lymphadenectomy. Awareness of such complication and early surgical treatment are important when treating patients with this rare occurrence.

[Surgery in early-stage ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

Early stage ovarian epithelial cancer (stage I according to the FIGO classification, i.e. limited to ovaries) affects 20% to 33% of patients with ovarian cancer. This chapter only describes data on these presumed early stages. The rate of occult epiploic metastases varies from 2% to 4%, and leads to over-staging in stage III A of 3% to 11% of patients. Performing an omentectomy does not result in a change in survival in this situation (NP4). The rate of appendix metastasis ranges from 0% to 26.7% (NP4). In the mucinous subtype, this rate can reach 53% if the appendix is macroscopically abnormal (NP2). The rate of positive peritoneal cytology ranges from 20.9% to 27%. Positive peritoneal cytology is responsible for over-staging of patients in 4.3% to 52% of cases and appears as a poor prognostic factor on survival (NP4). The rate of occult peritoneal metastases varies from 1.1% to 16%. Performing these peritoneal biopsies results in over-staging of 4% to 7.1% (NP4). In the management of ovarian cancers at a presumed early stage, it is recommended to perform: omentectomy, peritoneal biopsies, cytology, appendectomy (grade C). In case of incomplete or incomplete initial staging, restaging including omentectomy, peritoneal biopsies and appendectomy (if not explored) is recommended; especially in the absence of a reported indication of chemotherapy. The lymph node invasion rate ranges from 6.3% to 22%. It is 4.5% to 18% for stages I and 17.5% to 31% in stages II. Between 8.5% and 13% of patients with suspected early stage ovarian cancer are reclassified to stage IIIA1 following the completion of lymphadenectomy (NP3). Pelvic and lumbo-aortic lymphadenectomy improves the survival of patients with ovarian cancer at a presumptive early stage (NP2). Pelvic and lumbo-aortic lymphadenectomy is recommended for presumed early ovarian stages (grade B). In case of initial treatment of early-stage ovarian cancer without lymph node staging, restadification including lymphadenectomy is recommended; especially in the absence of a stated indication of chemotherapy (grade B). No studies have shown any laparoscopic disadvantage compared to laparotomy for feasibility, safety, or postoperative rehabilitation (NP3) in surgical staging of patients with early-stage ovarian cancer. For the initial surgical management of these patients, the choice between laparoscopy or laparotomy depends on local conditions (tumor size) and surgical expertise. If complete surgery without risk of tumor rupture is possible, the laparoscopic approach is preferred (grade C). In the opposite case, median laparotomy is recommended. As part of surgical restadification, the laparoscopic approach is recommended (grade C). Intraoperative tumor rupture leads to a decrease in disease free survival (hazard ratio=2.28) and overall survival (hazard ratio=3.79) (NP2). It is recommended that all precautions be taken to avoid perioperative ovarian tumor rupture, including the intraoperative decision of laparoconversion (grade C). There is no specific study to answer the question of the feasibility of a one-time or two-time surgery during an extemporane diagnosis of an early stage ovarian cancer. The high sensitivity and specificity of this extemporane examination in this situation makes it possible to consider a surgical management of staging during the same operating time.

Borderline tumours of the ovary: Common practice in the Netherlands

Objectives

Discordance between frozen section diagnosis and the definite histopathological diagnosis and the fact that the frozen section result is not always unambiguous, may contribute to differences in clinical practice regarding perioperative treatment and follow-up of borderline ovarian tumours (BOTs) patients amongst gynaecologic oncologists, which may lead to over- and undertreatment. The aim of the study was to map the Dutch gynaecologists' preferred treatment and follow-up strategy in case of BOTs.

Methods

A questionnaire was sent to all Dutch gynaecologists involved in ovarian surgery with perioperative frozen section analysis, and the outcomes were assessed using descriptive statistics.

Results

Nearly half of the respondents (41.0%) would not perform a staging procedure in case of a BOT. In case of an ambiguous frozen section diagnosis, tending towards invasive carcinoma, a considerable number (sBOT 56.4%; mBOT 30.8%) would perform a lymph node sampling as part of the staging procedure. A relaparotomy/relaparoscopy, to perform a lymph node sampling in case of a serous or mucinous carcinoma after a BOT frozen section diagnosis, would be performed by 97.4% and 48.7% of the respondents, respectively.

Conclusions

A considerable number of gynaecologists would perform a staging procedure that is recommended for ovarian cancer in case of an ambiguous BOT frozen section diagnosis, especially for serous tumours. In addition, nearly all gynaecologists would perform a second procedure including a lymph node sampling in case of a serous invasive carcinoma after a BOT frozen section diagnosis, which applies to half of the gynaecologists in case of a mucinous carcinoma.

•

In case of an unambiguous frozen section BOT diagnosis, a staging procedure is omitted by nearly half of the gynaecologists.

•

When the frozen section BOT diagnosis is ambiguous, a full ovarian cancer staging procedure is frequently performed.

•

Most gynaecologists perform a second procedure to complete staging when definitive diagnosis shows invasive ovarian cancer.

•

Full staging is performed more frequently in case of serous histopathology, when compared to mucinous tumours.

Impact of the new FIGO 2013 classification on prognosis of stage I epithelial ovarian cancers

Purpose

The stage of disease is one of the strongest prognostic factors in epithelial ovarian cancer. The International Federation of Gynecology and Obstetrics (FIGO) classification was revised in 2013; stage IC was subdivided into IC1 (intraoperative surgical spill), IC2 (capsule rupture before surgery or tumor on surface), and IC3 (positive peritoneal washing or ascites). Our aim was to compare the outcome of patients in the new FIGO stage I subgroups, as this might influence adjuvant therapy decisions.

Patients and methods

Patient databases of three gynecological oncology centers were retrospectively analyzed. Patients with FIGO stage I ovarian cancers were restaged according to the revised classification, based on operative and pathological reports, and determined patient outcomes.

Results

We analyzed 128 patients with ovarian cancers. In FIGO IA, we found 11.3% recurrences and 4.2% deaths. In FIGO IC, 21.8% of the patients recurred and 7.3% died. There was a trend toward a shorter time to recurrence when comparing IA to IC (P=0.076). Within all new subgroups of FIGO IC, there was no difference in time to recurrence (P=0.59). There was also no significant difference in survival when FIGO IA was compared to FIGO IC in comparison with the new individual classifications (IA to IC, IA to IC1, 2, or 3; P=0.60, P=0.15, P=0.61, P=0.66, respectively) or within the different subgroups (P=0.56). Platinum-based chemotherapy was given to the majority (82.6%, n=38/46) of the FIGO IC patients compared to 30.9% in FIGO IA (n=17/55). There was no significant difference within the new subgroups of FIGO IC (P=0.88).

Conclusion

In our retrospective analysis, the new FIGO staging of IC ovarian cancers did not predict prognosis, but the use of adjuvant chemotherapy in 82.6% of the stage IC patients may have biased the outcome.

Down-regulation of OGT promotes cisplatin resistance by inducing autophagy in ovarian cancer

Cisplatin resistance significantly affects the survival rate of patients with ovarian cancer. However, the main mechanism underlying cisplatin resistance in ovarian cancer remains unclear.

Methods: Immunohistochemistry was used to determine the expression of OGT, OGA and O-GlcNAc in chemoresistant and chemosensitive ovarian cancer tissues. Functional analyses (in vitro and in vivo) were performed to confirm the role of OGT in cisplatin resistance. Autophagy-related proteins were tested by western blot. Transmission electron microscopy and mRFP-GFP-LC3 adenovirus reporter were used for autophagy flux analysis. Immunoprecipitation assay was utilized to detect protein-protein interactions.

Results: We found that O-GlcNAc and O-GlcNAc transferase (OGT) levels were significantly lower in chemoresistant ovarian cancer tissues than in chemosensitive tissues, whereas O-GlcNAcase (OGA) levels did not differ. The down-regulation of OGT increased cisplatin resistance in ovarian cancer cells but had no effect on the efficacy of paclitaxel. The down-regulation of OGT improved tumor resistance to cisplatin in a mouse xenograft tumor model. OGT knockdown enhanced cisplatin-induced autophagy, which reduced apoptotic cell death induced by cisplatin, and promoted autolysosome formation. A reduction in O-GlcNAcylated SNAP-29 levels caused by the down-regulation of OGT promoted the formation of the SNARE complex and autophagic flux.

Conclusion: Our findings suggest that down-regulation of OGT enhances cisplatin-induced autophagy via SNAP-29, resulting in cisplatin-resistant ovarian cancer. OGT may represent a novel target for overcoming cisplatin resistance in ovarian cancer.

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.

Adequate pelvic lymphadenectomy and survival of women with early-stage epithelial ovarian cancer

OBJECTIVE

To examine the trends and survival for women with early-stage epithelial ovarian cancer who underwent adequate lymphadenectomy during surgical treatment.

METHODS

This is a retrospective observational study examining the Surveillance, Epidemiology, End Results program between 1988 and 2013. We evaluated 21,537 cases of stage I-II epithelial ovarian cancer including serous (n=7,466), clear cell (n=6,903), mucinous (n=4,066), and endometrioid (n=3,102) histology. A time-trend analysis of the proportion of patients who underwent adequate pelvic lymphadenectomy (≥8 per Gynecologic Oncology Group [GOG] criteria, ≥12 per Collaborative Group Report [CGR] criteria for bladder cancer, and >22 per Mayo criteria for endometrial cancer) and a survival analysis associated with adequate pelvic lymphadenectomy were performed.

RESULTS

There were significant increases in the proportion of women who underwent adequate lymphadenectomy: GOG criteria 3.6% to 28.6% (1988-2010); CGR criteria 2.4% to 22.4% (1988-2013); and Mayo criteria 0.7% to 9.5% (1988-2013) (all, p<0.05). On multivariable analysis, adequate lymphadenectomy was independently associated with improved cause-specific survival compared to inadequate lymphadenectomy: GOG criteria, adjusted-hazard ratio (HR)=0.75, CGR criteria, adjusted-HR=0.77, and Mayo criteria, adjusted-HR=0.85 (all, p<0.05). Compared to inadequate lymphadenectomy, adequate lymphadenectomy was significantly associated with improved cause-specific survival for serous (HR range=0.67-0.73), endometrioid (HR range=0.59-0.61), and clear cell types (HR range=0.66-0.73) (all, p<0.05) but not in mucinous type (HR range=0.80-0.91; p>0.05).

CONCLUSION

Quality of lymphadenectomy during the surgical treatment for early-stage epithelial ovarian cancer has significantly improved. Adequate lymphadenectomy is associated with a 15%-25% reduction in ovarian cancer mortality compared to inadequate lymphadenectomy.

Contribution of lymph node staging method and prognostic factors in malignant ovarian sex cord-stromal tumors: A world wide database analysis

OBJECTIVE

To investigate the clinicopathologic prognostic factors in patients with malignant sex cord-stromal tumors (SCSTs) with lymph node dissection, and at the same time, to evaluate the influence of the log odds of positive lymph nodes (LODDS) on their survival.

METHODS

Patients diagnosed with malignant SCSTs who underwent lymph node dissection were extracted from the 1988-2013 Surveillance, Epidemiology, and End Results (SEER) database. Overall survival (OS) and cancer-specific survival (CSS) were estimated by Kaplan-Meier curves. The Cox proportional hazards regression model was used to identify independent predictors of survival.

RESULTS

576 patients with malignant SCSTs and with lymphadenectomy were identified, including 468 (81.3%) patients with granulosa cell tumors (GCTs) and 80 (13.9%) patients with Sertoli-Leydig cell tumors (SLCTs). 399 (69.3%) patients and 118 (20.5%) patients were in the LODDS < -1 group and -1 ≤ LODDS < -0.5 group, respectively. The 10-year OS rate was 80.9% and CSS was 87.2% in the LODDS < -0.5 group, whereas the survival rates for other groups were 68.5% and 73.3%. On multivariate analysis, age 50 years or less (p < 0.001), tumor size of 10 cm or less (p < 0.001), early-stage disease (p < 0.001), and GCT histology (p ≤ 0.001) were the significant prognostic factors for improved survival. LODDS < -0.5 was associated with a favorable prognosis (OS: p = 0.051; CSS:P = 0.055).

CONCLUSIONS

Younger age, smaller tumor size, early stage, and GCT histologic type are independent prognostic factors for improved survival in patients with malignant SCST with lymphadenectomy. Stratified LODDS could be regarded as an effective value to assess the lymph node status, and to predict the survival status of patients.

No improvement in long-term survival for epithelial ovarian cancer patients: A population-based study between 1989 and 2014 in the Netherlands

AIM

This study investigates changes in therapy and long-term survival for patients with epithelial ovarian cancer (EOC) in the Netherlands.

METHODS

All patients with EOC, including peritoneal and fallopian tube carcinoma, diagnosed in the Netherlands between 1989 and 2014 were selected from the Netherlands Cancer Registry. Changes in therapy were studied and related to overall survival (OS) using multivariable Cox regression models.

RESULTS

A total of 32,540 patients were diagnosed with EOC of whom 22,047 (68%) had advanced stage disease. In early stage, lymph node dissection as part of surgical staging procedures increased over time from 4% in 1989-1993 to 62% in 2009-2014 (P < 0.001). In advanced stage, the number of patients receiving optimal treatment with surgery and chemotherapy increased from 55% in 1989-1993 to 67% in 2009-2014 (P < 0.001). Five-year survival rates improved in both early stage (74% versus 79%) and advanced stage (16% versus 24%) as well as in all patients combined (31% versus 34%). Ten-year survival rates, however, slightly improved in early stage (62% versus 67%) and advanced stage (10% versus 13%) but remained essentially unchanged at 24% for all patients combined.

CONCLUSION

Despite intensified treatment and staging procedures, long-term survival for women with EOC has not improved in the last 25 years. The observed improvements in 5-year OS reflect a more prolonged disease control rather than better chances for cure. Furthermore, the apparent better long-term outcome, when early and advanced stage patients are analysed separately, is largely due to improved staging procedures and the ensuing stage migration. These effects disappear in a combined analysis of all patients.

The impact of examined lymph node count on survival in squamous cell carcinoma and adenocarcinoma of the uterine cervix

Introduction

The prognostic impact of the number of examined lymph nodes (ELNs) in different histological subtypes of cervical cancer remains unclear. We aimed to assess the impact of the number of ELNs in stage IA2–IIA cervical cancer with different histological subtypes.

Methods

Data of patients with stage IA2–IIA squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the uterine cervix between 1988 and 2013 were retrieved from the Surveillance, Epidemiology, and End Results program. Univariate and multivariate Cox regression analyses were performed to analyze the effect of number of ELNs on cause-specific survival (CSS) and overall survival (OS).

Results

The final data set identified 11,830 patients including 7,920 (66.9%) women with SCC and 3,910 (33.1%) with AC. The median number of ELNs was 19. The multivariate analysis indicated that the number of ELNs was an independent prognostic factor influencing CSS and OS, both as a continuous or a categorical variable. Patients with a higher number of ELNs had better survival outcomes. In SCC subtype, the number of ELNs was also the independent prognostic factor of CSS and OS in node-positive patients, but not in patients with node-negative disease. In AC patients, ELN count was not an independent predictor of CSS and OS regardless of lymph node status.

Conclusion

The number of ELNs is an independent prognostic factor in patients with stage IA2–IIB cervical cancer. A higher number of ELNs is associated with better survival outcomes, especially in the node-positive SCC subtype.

Surgical treatment of early-stage ovarian cancer

The treatment of early-stage (stages I-IIA) ovarian carcinoma is predominantly surgical, and the surgical staging is the most relevant step in the treatment of this disease. The significance of surgical staging is twofold. First, proper staging distinguishes between 'real' early-stage ovarian carcinoma and 'perhaps' early-stage disease. The latter carries an appreciable likelihood of unappreciated residual disease in 16-42% of cases. Second, there is solid proof that proper surgical staging is an independent prognostic factor for improved disease-free and overall survival in early-stage ovarian carcinoma. In this chapter, the relevance of various staging steps is discussed and surgical guidelines are given. The indication for adjuvant chemotherapy after surgery is closely related to the adequacy of surgical staging. Adjuvant chemotherapy only works in patients in whom surgical staging was inadequate and who, thus, remain with a certain risk of unnoticed residual intraperitoneal or retroperitoneal tumour spread. Moreover, there is no indication that adjuvant chemotherapy is of any value after an adequate, comprehensive staging procedure. Controversies and misunderstandings on this important issue are discussed.