Risk factors for lymph node metastasis in ovarian cancer: Implications for systematic lymphadenectomy

Development and validation of an ultrasound‑based radiomics nomogram to predict lymph node status in patients with high-grade serous ovarian cancer: a retrospective analysis

BACKGROUND

Despite advances in medical imaging technology, the accurate preoperative prediction of lymph node status remains challenging in ovarian cancer. This retrospective study aimed to investigate the feasibility of using ultrasound-based radiomics combined with preoperative clinical characteristics to predict lymph node metastasis (LNM) in patients with high-grade serous ovarian cancer (HGSOC).

RESULTS

Patients with 401 HGSOC lesions from two institutions were enrolled: institution 1 for the training cohort (n = 322) and institution 2 for the external test cohort (n = 79). Radiomics features were extracted from the three preoperative ultrasound images of each lesion. During feature selection, primary screening was first performed using the sample variance F-value, followed by recursive feature elimination (RFE) to filter out the 12 most significant features for predicting LNM. The radscore derived from these 12 radiomic features and three clinical characteristics were used to construct a combined model and nomogram to predict LNM, and subsequent 10-fold cross-validation was performed. In the test phase, the three models were tested with external test cohort. The radiomics model had an area under the curve (AUC) of 0.899 (95% confidence interval [CI]: 0.864-0.933) in the training cohort and 0.855 (95%CI: 0.774-0.935) in the test cohort. The combined model showed good calibration and discrimination in the training cohort (AUC = 0.930) and test cohort (AUC = 0.881), which were superior to those of the radiomic and clinical models alone.

CONCLUSIONS

The nomogram consisting of the radscore and preoperative clinical characteristics showed good diagnostic performance in predicting LNM in patients with HGSOC. It may be used as a noninvasive method for assessing the lymph node status in these patients.

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.

Nomogram incorporating log odds of positive lymph nodes improves prognostic prediction for ovarian serous carcinoma: a real-world retrospective cohort study

OBJECTIVES

Ovarian serous carcinoma (OSC) is a major cause of gynaecological cancer death, yet there is a lack of reliable prognostic models. To address this, we developed and validated a nomogram based on conventional clinical characteristics and log odds of positive lymph nodes (LODDS) to predict the prognosis of OSC patients.

SETTING

A Real-World Retrospective Cohort Study from the Surveillance, Epidemiology and End Results programme.

PARTICIPANTS

We obtained data on 4192 patients diagnosed with OSC between 2010 and 2015. Eligibility criteria included specific diagnostic codes, OSC being the primary malignant tumour and age at diagnosis over 18 years. Exclusion criteria were missing information on various factors and unknown cause of death or survival time.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome were overall survival (OS) and ovarian cancer-specific survival (OCSS).

RESULTS

For OS and OCSS outcomes, we selected 7 and 5 variables, respectively, to establish the nomogram. In the training and validation cohorts, the C index for OS or OCSS was 0.716 or 0.718 and 0.731 or 0.733, respectively, with a 3-year time-dependent area under the curve (AUC) of 0.745 or 0.751 and a 5-year time-dependent AUC of 0.742 or 0.751. Calibration curves demonstrated excellent consistency between predicted and observed outcomes. The Net Reclassification Index, integrated discrimination improvement and decision curve analysis curves indicated that our nomogram performed better than the International Federation of Gynaecology and Obstetrics (FIGO) staging system in predicting OS and OCSS for OSC patients in both the training and validation cohorts.

CONCLUSION

Our nomogram, which includes LODDS, offers higher accuracy and reliability than the FIGO staging system and can predict overall and OCSS in OSC patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Nomogram for Preoperative Prediction of the Risk of Lymph Node Metastasis in Patients with Epithelial Ovarian Cancer

Objective: To develop a nomogram for predicting lymph node metastasis (LNM) in patients with epithelial ovarian cancer (EOC). Methods: Between December 2012 and August 2022, patients with EOC who received computed tomography (CT) and serological examinations and were treated with upfront staging or debulking surgery were included. Systematic pelvic and para-aortic lymphadenectomy was performed in all patients. Univariate and multivariate analysis was used to identify significant risk factors associated with LNM. A nomogram was then constructed to assess the risk of LNM, which was evaluated with respect to its area under the receiver operating characteristic curve (AUC), calibration, and clinical usefulness. Results: Of 212 patients enrolled in this study, 78 (36.8%) had positive LNs. The nomogram integrating CT-reported LN status, child-bearing status, tumour laterality, and stage showed good calibration and discrimination with an AUC of 0.775, significantly improving performance over the CT results (0.699, p = 0.0002) with a net reclassification improvement of 0.593 (p < 0.001) and integrated discrimination improvement of 0.054 (p < 0.001). The decision curve analysis showed the nomogram was of clinical use. Conclusions: A nomogram was constructed and internally validated, which may act as a decision aid in patients with EOC being considered for systemic lymphadenectomy.

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.

Tumor-Derived Exosomes Modulate Primary Site Tumor Metastasis

Tumor-derived exosomes (TDEs) are actively produced and released by tumor cells and carry messages from tumor cells to healthy cells or abnormal cells, and they participate in tumor metastasis. In this review, we explore the underlying mechanism of action of TDEs in tumor metastasis. TDEs transport tumor-derived proteins and non-coding RNA to tumor cells and promote migration. Transport to normal cells, such as vascular endothelial cells and immune cells, promotes angiogenesis, inhibits immune cell activation, and improves chances of tumor implantation. Thus, TDEs contribute to tumor metastasis. We summarize the function of TDEs and their components in tumor metastasis and illuminate shortcomings for advancing research on TDEs in tumor metastasis.

Factors associated with the involvement of lymph nodes in low-grade serous ovarian cancer

BACKGROUND AND OBJECTIVES

Evaluating nodal metastases in low-grade serous ovarian cancer (LGSOC) patients.

METHODS

Women with LGSOC who had undergone primary cytoreductive surgery comprising systematic pelvic-paraaortic lymphadenectomy were included. Data were obtained retrospectively from 12 oncology centers.

RESULTS

One hundred and forty-eight women with LGSOC who had undergone comprehensive surgical staging were included. Seventy-one (48.0%) patients had metastatic lymph nodes. Preoperative serum CA-125 levels of ≥170 U/ml (odds ratio [OR]: 3.84; 95% confidence interval [CI]: 1.22-12.07; p = 0.021) and presence of lymphovascular space invasion (LVSI) (OR: 13.72; 95% CI: 3.36-55.93; p < 0.001) were independent predictors of nodal metastasis in LGSOC. Sixty (40.5%) patients were classified to have apparently limited disease to the ovary/ovaries. Twenty (33.3%) of them were upstaged after surgical staging. Twelve (20.0%) had metastatic lymph nodes. Presence of LVSI (OR: 12.96; 95% CI: 1.14-146.43; p = 0.038) and preoperative serum CA-125 of ≥180 U/ml (OR: 7.19; 95% CI: 1.35-38.12; p = 0.02) were independent predictors of lymph node metastases in apparent Stage Ⅰ disease.

CONCLUSIONS

Clinicians may consider to perform a reoperation comprising systematic lymphadenectomy in patients who had apparently limited disease to the ovary/ovaries and had not undergone lymphadenectomy initially. Reoperation may be considered particularly in patients whose preoperative serum CA-125 is ≥180 U/ml and/or whose pathological assessment reported the presence of LVSI.

The Development and Validation of a CT-Based Radiomics Nomogram to Preoperatively Predict Lymph Node Metastasis in High-Grade Serous Ovarian Cancer

Purpose

To develop and validate a radiomics model for predicting preoperative lymph node (LN) metastasis in high-grade serous ovarian cancer (HGSOC).

Materials and Methods

From May 2008 to January 2018, a total of 256 eligible HGSOC patients who underwent tumor resection and LN dissection were divided into a training cohort (n=179) and a test cohort (n=77) in a 7:3 ratio. A Radiomics Model was developed based on a training cohort of 179 patients. A radiomics signature (defined as the Radscore) was selected by using the random forest method. Logistics regression was used as the classifier for modeling. An Integrated Model that incorporated the Radscore and CT_reported LN status (CT_LN_report) was developed and presented as a radiomics nomogram. Its performance was determined by the area under the curve (AUC), calibration, and decision curve. The radiomics nomogram was internally tested in an independent test cohort (n=77) and a CT-LN-report negative subgroup (n=179) using the formula derived from the training cohort.

Results

The AUC value of the CT_LN_report was 0.688 (95% CI: 0.626, 0.759) in the training cohort and 0.717 (95% CI: 0.630, 0.804) in the test cohort. The Radiomics Model yielded an AUC of 0.767 (95% CI: 0.696, 0.837) in the training cohort and 0.753 (95% CI: 0.640, 0.866) in the test. The radiomics nomogram demonstrated favorable calibration and discrimination in the training cohort (AUC=0.821), test cohort (AUC=0.843), and CT-LN-report negative subgroup (AUC=0.82), outperforming the Radiomics Model and CT_LN_report alone.

Conclusions

The radiomics nomogram derived from portal phase CT images performed well in predicting LN metastasis in HGSOC and could be recommended as a new, convenient, and non-invasive method to aid in clinical decision-making.

Preoperative Prediction of Metastasis for Ovarian Cancer Based on Computed Tomography Radiomics Features and Clinical Factors

Background

There is urgent need for an accurate preoperative prediction of metastatic status to optimize treatment for patients with ovarian cancer (OC). The feasibility of predicting the metastatic status based on radiomics features from preoperative computed tomography (CT) images alone or combined with clinical factors were investigated.

Methods

A total of 101 OC patients who underwent primary debulking surgery were enrolled. Radiomics features were extracted from the tumor volumes contoured on CT images with LIFEx package. Mann-Whitney U tests, least absolute shrinkage selection operator (LASSO), and Ridge Regression were applied to select features and to build prediction models. Univariate and regression analysis were applied to select clinical factors for metastatic prediction. The performance of models generated with radiomics features alone, clinical factors, and combined factors were evaluated and compared.

Results

Nine radiomics features were screened out from 184 extracted features to classify patients with and without metastasis. Age and cancer antigen 125 (CA125) were the two clinical factors that were associated with metastasis. The area under curves (AUCs) for the radiomics signature, clinical factors model, and combined model were 0.82 (95% CI, 0.66-0.98; sensitivity = 0.90, specificity = 0.70), 0.83 (95% CI, 0.67-0.95; sensitivity = 0.71, specificity = 0.8), and 0.86 (95% CI, 0.72-0.99, sensitivity = 0.81, specificity = 0.8), respectively.

Conclusions

Radiomics features alone or radiomics features combined with clinical factors are feasible and accurate enough to predict the metastatic status for OC patients.

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.

The association between lymph node metastases and long-term survival in patients with epithelial ovarian cancer

Introduction

A key survival prognosis factor for patients treated for ovarian cancer is complete cytoreductive surgery where all macroscopic neoplastic implants, including enlarged metastatic lymph nodes, are removed. We presume that investigating the involvement of the lymphatic system can result in a more individualized approach to the treatment of ovarian cancer patients. The main aim of our study was to analyze the relationship between the presence, number and types of lymph node metastases and ovarian cancer patient prognosis.

Material and methods

We carried out a retrospective analysis of patients who underwent cytoreduction due to primary ovarian cancer, between 2010 and 2015. We analyzed the number of metastatic lymph nodes, the lymph node ratio defined as the ratio of the number of metastatic lymph nodes to the total number of lymph nodes removed, extracapsular involvement, and the histopathological pattern of metastases.

Results

The study group included 651 patients. Of these, 377 had lymphadenectomy, 144 presented with lymph node metastases, and 233 had no lymph node metastases. We also included a group of 274 patients who did not have lymphadenectomy. Patients with more than 4 metastatic lymph nodes and a lymph node ratio of ≥ 0.1 had significantly poorer overall survival. Extracapsular involvement had no relation to patient overall survival. Multivariant survival analysis indicated that a lymph node ratio of ≥ 0.1 was an independent predictor of poor survival.

Conclusions

The analysis of lymph node metastases in ovarian cancer patients can have predictive value for patient overall survival.

Isolated lymph node recurrence in epithelial ovarian cancer: Recurrence with better prognosis?

INTRODUCTION

The aim of this study was to compare overall survival (OS) between women with isolated lymph node recurrence (ILNR) and those with isolated peritoneal localization of recurrence (ICR), in patients managed for epithelial ovarian cancer.

METHODS

Data from 1508 patients with ovarian cancer were collected retrospectively from1 January 2000 to 31 December 2016, from the FRANCOGYN database, pooling data from 11 centres specialized in ovary treatment. Median overall survival was determined using the Kaplan-Meier method. Univariate and multivariate analyses were performed to define prognostic factors of overall survival. Patients included had a first recurrence defined as ILNR or ICR during their follow up.

RESULTS

79 patients (5.2 %) presented with ILNR, and 247 (16.4 %) patients had isolated carcinomatosis recurrence. Complete lymphadenectomy was performed more frequently in the ILNR group vs. the ICR group (67.1 % vs. 53.4 %, p = 0.004) and the number of pelvic lymph nodes involved was higher (2.4 vs. 1.1, p = 0.008). The number of involved pelvic LN was an independent predictor of ILNR (OR = 1.231, 95 % CI [1.074-1.412], p = 0.0024). The 3-year and 5-year OS rates in the ILNR group were 85.2 % and 53.7 % respectively, compared to 68.1 % and 46.8 % in patients with ICR. There was no significant difference in terms of OS after initial diagnosis (p = 0.18). 3- year and 5-year OS rates after diagnosis of recurrence were 62.6 % and 15.6 % in the ILNR group, and 44 % and 15.7 % in patients with ICR (p = 0.21).

CONCLUSION

ILNR does not seem to be associated with a better prognosis in terms of OS.

The Risk of Para-Aortic Lymph Node Metastases in Apparent Early Stage Ovarian Cancer

Background and objectives: To identify the risk factors for para-aortic lymph node metastases in cases with presumed early stage ovarian cancer. Materials and methods: Between 2014 and 2019, 48 patients with apparent early stage ovarian cancer were submitted to surgery. In all cases, pelvic and para-aortic lymph node dissection was performed for staging purposes. Results: Among the 48 cases we identified nine cases with positive pelvic lymph nodes and 11 cases with positive para-aortic lymph nodes. The positivity of the retrieved lymph nodes was significantly correlated with the histopathological subtype represented by serous histology (p = 0.02), as well as with the degree of differentiation (p = 0.004). Conclusions: Patients with serous ovarian carcinomas in association with a poorer degree of differentiation are at risk of associated lymph node metastases even in presumed early stages of the disease. Therefore, lymph node dissection should be performed in such cases in order to provide adequate staging and tailoring of further treatment.

Correlation Between Pelvic Peritoneal Disease and Nodal Metastasis in Advanced Ovarian Cancer: Can Intraoperative Findings Define the Need for Systematic Nodal Dissection?

To explore the relationship of peritoneal, and rectal involvement with lymph nodal metastases to identify clinical parameters to guide systematic nodal dissection in advanced ovarian cancer (stage 3c). It is a retrospective study of stage III C epithelial ovarian cancers undergoing cytoreductive surgery with systematic nodal dissection, from January 2011 to December 2016. LS3 score is a cumulative score given for the presence of size 3 lesion (peritoneal disease measuring more than 5 cm) in regions 5, 6, and 7. The depth of rectal involvement was assigned progressive numerical values from 1 (for serosa) to maximum 4 (for mucosa) to generate rectal involvement score. There were 91 patients. 48.35% patients had LS3 lesions in regions 5, 6, 7. Of these, 36% (27/44) had positive nodes. Of the 41 node-positive cases, 43.9% had single and 34.14% had two station involvements. Rectum was involved in 47 patients (51.64%), serosal involvement being the most common type (50.57%). Twenty patients had positive mesorectal nodes (42.55%). The presence of rectal involvement was influenced by the Peritoneal Carcinomatosis Index (PCI) score, the presence of LS3 in lower quadrants (p = 0.008), and LSE score of lower quadrants (p = 0.003). With the increasing depth of rectal infiltration, mesorectal positivity increased significantly (p = 0.000). In multivariate analysis, lower quadrant (regions 5, 6, 7) PCI, LS3 in lower quadrants, LS3 score, rectal involvement score, and the total number of lines of chemotherapy significantly affected different nodal disease parameters. In advanced ovarian cancer, LS3 disease in regions 5, 6, and 7 and rectal involvement directly impact the nodal metastasis and hence mandates a systematic nodal dissection. Mesorectal nodal involvement significantly increases with the increasing depth of rectal involvement necessitating systematic mesorectal nodal clearance for all rectal resections.