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Kostov S, Selçuk I, Watrowski R, Dineva S, Kornovski Y, Slavchev S, Ivanova Y, Yordanov A. Neglected Anatomical Areas in Ovarian Cancer: Significance for Optimal Debulking Surgery. Cancers (Basel) 2024; 16:285. [PMID: 38254777 PMCID: PMC10813817 DOI: 10.3390/cancers16020285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/31/2023] [Accepted: 01/06/2024] [Indexed: 01/24/2024] Open
Abstract
Ovarian cancer (OC), the most lethal gynecological malignancy, usually presents in advanced stages. Characterized by peritoneal and lymphatic dissemination, OC necessitates a complex surgical approach usually involving the upper abdomen with the aim of achieving optimal cytoreduction without visible macroscopic disease (R0). Failures in optimal cytoreduction, essential for prognosis, often stem from overlooking anatomical neglected sites that harbor residual tumor. Concealed OC metastases may be found in anatomical locations such as the omental bursa; Morison's pouch; the base of the round ligament and hepatic bridge; the splenic hilum; and suprarenal, retrocrural, cardiophrenic and inguinal lymph nodes. Hence, mastery of anatomy is crucial, given the necessity for maneuvers like liver mobilization, diaphragmatic peritonectomy and splenectomy, as well as dissection of suprarenal, celiac, and cardiophrenic lymph nodes in most cases. This article provides a meticulous anatomical description of neglected anatomical areas during OC surgery and describes surgical steps essential for the dissection of these "neglected" areas. This knowledge should equip clinicians with the tools needed for safe and complete cytoreduction in OC patients.
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Affiliation(s)
- Stoyan Kostov
- Research Institute, Medical University Pleven, 5800 Pleven, Bulgaria;
- Department of Gynecology, Hospital “Saint Anna”, Medical University—“Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (S.S.)
| | - Ilker Selçuk
- Department of Gynecologic Oncology, Ankara Bilkent City Hospital, Maternity Hospital, 06800 Ankara, Turkey;
| | - Rafał Watrowski
- Department of Obstetrics and Gynecology, Helios Hospital Müllheim, 79379 Müllheim, Germany;
- Faculty Associate, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Svetla Dineva
- Diagnostic Imaging Department, Medical University of Sofia, 1431 Sofia, Bulgaria;
- National Cardiology Hospital, 1309 Sofia, Bulgaria
| | - Yavor Kornovski
- Department of Gynecology, Hospital “Saint Anna”, Medical University—“Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (S.S.)
| | - Stanislav Slavchev
- Department of Gynecology, Hospital “Saint Anna”, Medical University—“Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (S.S.)
| | - Yonka Ivanova
- Department of Gynecology, Hospital “Saint Anna”, Medical University—“Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (S.S.)
| | - Angel Yordanov
- Department of Gynecologic Oncology, Medical University Pleven, 5800 Pleven, Bulgaria
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2
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Taskiran C, Knapp P, Fotopoulou C. Perioperative ovarian cancer guidelines: prevention and management of upper abdominal complications. Int J Gynecol Cancer 2022; 32:ijgc-2022-003812. [PMID: 36191957 DOI: 10.1136/ijgc-2022-003812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Cagatay Taskiran
- Department of Obstetrics and Gynecology, Chair, Koc University School of Medicine and VKV American Hospital, Istanbul, Turkey
| | - Pawel Knapp
- University Oncology Center University Hospital of Bialystok, University of Bialystok Institute of History and Political Sciences, Bialystok, Podlaskie, Poland
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3
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Loverro M, Ergasti R, Conte C, Gallitelli V, Nachira D, Scaglione G, Fagotti A, Scambia G, Gallotta V. Minimally Invasive Secondary Cytoreductive Surgery for Superficial Celiac and Cardio-Phrenic Isolated Nodal Recurrence of Ovarian Cancer. Ann Surg Oncol 2022; 29:2603-2604. [DOI: 10.1245/s10434-021-11267-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/12/2021] [Indexed: 11/18/2022]
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4
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Benoit L, Koual M, Le Frère-Belda MA, Zerbib J, Fournier L, Nguyen-Xuan HT, Delanoy N, Bentivegna E, Bats AS, Azaïs H. Risks and benefits of systematic lymphadenectomy during interval debulking surgery for advanced high grade serous ovarian cancer. Eur J Surg Oncol 2021; 48:275-282. [PMID: 34753619 DOI: 10.1016/j.ejso.2021.10.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/18/2021] [Accepted: 10/28/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Lymphadenectomy is debated in patients with ovarian cancer. The aim of our study was to evaluate the impact of lymphadenectomy in patients with high-grade serous ovarian cancer receiving neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). METHODS A retrospective, unicentric study including all patients undergoing NACT and IDS was carried out from 2005 to 2018. Patients with and without lymphadenectomy were compared in terms of recurrence free survival (RFS), overall survival (OS), and complication rates. RESULTS We included 203 patients. Of these, 133 had a lymphadenectomy (65.5%) and 77 had involved nodes (57.9%). Patients without a lymphadenectomy were older, had a more extensive disease and less complete CRS. No differences were noted between the lymphadenectomy and no lymphadenectomy group concerning 2-year RFS (47.4% and 48.6%, p = 0.87, respectively) and 5-year OS (63.2% versus 58.6%, p = 0.41, respectively). Post-operative complications tended to be more frequent in the lymphadenectomy group (18.57% versus 31.58%, p = 0.09). In patients with a lymphadenectomy, survival was significantly altered if the nodes were involved (positive nodes: 2-year RFS 42.5% and 5-year OS 49.4%, negative nodes: 2-year RFS 60.7% and 5-year OS 82.2%, p = 0.03 and p < 0.001, respectively). CONCLUSION Lymphadenectomy during IDS does not improve survival and increases post-operative complications.
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Affiliation(s)
- Louise Benoit
- Gynecologic and Breast Oncologic Surgery Department, Georges Pompidou European Hospital, APHP. Centre, Paris, France; Paris University, Faculty of Medicine, Paris, France; INSERM UMR-S 1124, Université de Paris, Centre Universitaire des Saint-Père, Paris, France.
| | - Meriem Koual
- Gynecologic and Breast Oncologic Surgery Department, Georges Pompidou European Hospital, APHP. Centre, Paris, France; Paris University, Faculty of Medicine, Paris, France; INSERM UMR-S 1124, Université de Paris, Centre Universitaire des Saint-Père, Paris, France
| | | | - Jonathan Zerbib
- Radiology Department, Georges Pompidou European Hospital, APHP. Centre, Paris, France
| | - Laure Fournier
- Radiology Department, Georges Pompidou European Hospital, APHP. Centre, Paris, France
| | - Huyen-Thu Nguyen-Xuan
- Gynecologic and Breast Oncologic Surgery Department, Georges Pompidou European Hospital, APHP. Centre, Paris, France; Paris University, Faculty of Medicine, Paris, France
| | - Nicolas Delanoy
- Oncology Department, Georges Pompidou European Hospital, APHP. Centre, Paris, France
| | - Enrica Bentivegna
- Gynecologic and Breast Oncologic Surgery Department, Georges Pompidou European Hospital, APHP. Centre, Paris, France; Paris University, Faculty of Medicine, Paris, France
| | - Anne-Sophie Bats
- Gynecologic and Breast Oncologic Surgery Department, Georges Pompidou European Hospital, APHP. Centre, Paris, France; Paris University, Faculty of Medicine, Paris, France; INSERM UMR-S 1147, Université de Paris, Centre de Recherche des Cordeliers, Paris, France
| | - Henri Azaïs
- Gynecologic and Breast Oncologic Surgery Department, Georges Pompidou European Hospital, APHP. Centre, Paris, France; Paris University, Faculty of Medicine, Paris, France; INSERM UMR-S 1147, Université de Paris, Centre de Recherche des Cordeliers, Paris, France
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5
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Huang H, Wei R, Long Y, Mo Y, Xie Y, Yao D. Hepatic Hilar Lymph Node Resection in Cytoreductive Surgery for Advanced Ovarian Cancer: A Necessity or Not? Cancer Manag Res 2021; 13:7981-7988. [PMID: 34707404 PMCID: PMC8542736 DOI: 10.2147/cmar.s334658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/12/2021] [Indexed: 11/23/2022] Open
Abstract
Objective This review aims to clarify the necessity of hepatic hilar lymph node resection on advanced ovarian cancer patients. Background PARP inhibitors and surgery have significantly improved the survival of patients with ovarian cancer. However, for patients with advanced ovarian cancer, there are often extensive epigastric disseminated metastatic lesions, especially the lymph nodes in the hepatic hilar area. Because of the complicated anatomical relationship and lack of experience in this area, this is easily ignored by gynecological oncologists. Methods Through the retrieval and analysis of the current database, namely PubMed, Medline, Web of Science, EMBASE, Cochrane Library, and Wangfang, etc., the literature regarding this topic published before March 2021 were thoroughly investigated. Conclusion For the hepatic hilar regional lymph node surgery, through careful preoperative evaluation, surgical-indication clarification, appropriate case selection, standardized surgical operations and multidisciplinary cooperation with general surgeons, the prognosis of patients is significantly improved. Postoperative complications are also safe and controllable and convincing. To conclude, the application of hilar region lymph node cytoreductive surgery for patients with advanced ovarian cancer is a feasible and preferred choice.
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Affiliation(s)
- Honglian Huang
- Hechi People's Hospital, Hechi City, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Renjie Wei
- Hechi People's Hospital, Hechi City, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Ying Long
- Gynecologic Oncology Department, Guangxi Medical University Affiliated Cancer Hospital, Nanning City, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Yu Mo
- Hechi People's Hospital, Hechi City, Guangxi Zhuang Autonomous Region, People's Republic of China
| | - Yu Xie
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, People's Republic of China
| | - Desheng Yao
- Gynecologic Oncology Department, Guangxi Medical University Affiliated Cancer Hospital, Nanning City, Guangxi Zhuang Autonomous Region, People's Republic of China
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6
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Son JH, Chang SJ. Cholecystectomy, porta hepatis stripping, and omental bursectomy. Gland Surg 2021; 10:1230-1234. [PMID: 33842269 DOI: 10.21037/gs-2019-ursoc-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
As ovarian cancer commonly involves the visceral organs without boundary, more aggressive procedures are adopted during cytoreductive surgery. One of the most difficult aspect of the operation involves the procedure for the gall bladder, porta hepatis, and omental bursa. As the upper abdominal surgical field is not familiar to the gynecologic surgeon, and the vital organs or vessels are densely positioned, these procedures can be challenging for achieving the optimal cytoreductive surgery. The surgical approaches for advanced ovarian cancer that are required in the upper abdomen have evolved with the progress in surgical techniques. This article will discuss the surgical approach by focusing on cholecystectomy, porta hepatis debulking, and omental bursectomy, as well as the regional anatomy in patients with advanced ovarian cancer.
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Affiliation(s)
- Joo-Hyuk Son
- Division of Gynecologic Oncology, Ajou University School of Medicine, Suwon, Korea.,Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Suk-Joon Chang
- Division of Gynecologic Oncology, Ajou University School of Medicine, Suwon, Korea.,Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
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7
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Di Donato V, Giannini A, D'Oria O, Schiavi MC, Di Pinto A, Fischetti M, Lecce F, Perniola G, Battaglia F, Berloco P, Muzii L, Benedetti Panici P. Hepatobiliary Disease Resection in Patients with Advanced Epithelial Ovarian Cancer: Prognostic Role and Optimal Cytoreduction. Ann Surg Oncol 2020; 28:222-230. [PMID: 32779050 PMCID: PMC7752869 DOI: 10.1245/s10434-020-08989-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 05/31/2020] [Indexed: 12/26/2022]
Abstract
Objective The purpose of this study was to evaluate the feasibility and safety in terms of prognostic significance and perioperative morbidity and mortality of cytoreduction in patients affected by advance ovarian cancer and hepato-biliary metastasis. Methods Patients with a least one hepatobiliary metastasis who have undergone surgical treatment with curative intent of were considered for the study. Perioperative complications were evaluated and graded with Accordion severity Classification. Five-year PFS and OS were estimated using the Kaplan–Meier curve. Results Sixty-seven (20.9%) patients had at least one metastasis to the liver, biliary tract, or porta hepatis. Forty-four (65.7%) and 23 (34.3%) patients underwent respectively high and intermediate complexity surgery according. Complete cytoreduction was achieved in 48 (71.6%) patients with hepato-biliary disease. In two patients (2.9%) severe complications related to hepatobiliary surgery were reported. The median PFS for the patients with hepato-biliary involvement (RT = 0 vs. RT > 0) was 19 months [95% confidence interval (CI) 16.2–21.8] and 8 months (95% CI 6.1–9.9). The median OS for the patients with hepato-biliary involvement (RT = 0 vs. RT > 0) 45 months (95% CI 21.2–68.8 months) and 23 months (95% CI 13.9–32.03). Conclusions Hepatobiliary involvement is often associated with high tumor load and could require high complex multivisceral surgery. In selected patients complete cytoreduction could offer survival benefits. Morbidity related to hepatobiliary procedures is acceptable. Careful evaluation of patients and multidisciplinary approach in referral centers is mandatory. Electronic supplementary material The online version of this article (10.1245/s10434-020-08989-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Violante Di Donato
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy.
| | - Andrea Giannini
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Ottavia D'Oria
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Michele Carlo Schiavi
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Anna Di Pinto
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Margherita Fischetti
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Francesca Lecce
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Giorgia Perniola
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Francesco Battaglia
- Department Obstetrics and Gynecological Hospital Santa Maria Goretti of Latina, "Sapienza" University of Rome, Rome, Italy
| | - Pasquale Berloco
- Department of General Surgery and Organ Transplantation, "Sapienza" University of Rome, Rome, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
| | - Pierluigi Benedetti Panici
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Umberto I Hospital, Rome, Italy
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8
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Bacalbasa N, Balescu I, Diaconu C, Iliescu L, Filipescu A, Pop C, Dima S, Vilcu M, Brezean I. Right Upper Abdominal Resections in Advanced Stage Ovarian Cancer. In Vivo 2020; 34:1487-1492. [PMID: 32354951 DOI: 10.21873/invivo.11934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM The right upper abdominal involvement is frequently encountered in patients with advanced stage ovarian cancer. The aim of this paper is to study the safety and efficacy of extended resections at this level as well as to determine the sites of residual disease. PATIENTS AND METHODS Between January 2016 and December 2019, 26 patients submitted to right upper abdominal resections were identified. RESULTS Peritoneal stripping and full thickness resections were the most commonly performed resections (in 57% and 19% of cases, respectively), followed by capsular liver resection and atypical liver resection (in 30% and 23% of cases, respectively) while the most common sites where resection was incomplete were the liver pedicle and porta hepatis. Exceptionally, one case necessitated performing a pancreatoduodenectomy as part of debulking surgery. Postoperatively, two cases developed serious complications and required reintervention; however, the overall mortality was null. CONCLUSION Right upper abdominal resections seem to be feasible and effective in order to maximize the debulking effort with acceptable risks arising from perioperative complications.
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Affiliation(s)
- Nicolae Bacalbasa
- Department of Obstetrics and Gynecology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Obstetrics and Gynecology, "I. Cantacuzino" Clinical Hospital, Bucharest, Romania.,Department of Visceral Surgery, Center of Excellence in Translational Medicine "Fundeni" Clinical Institute, Bucharest, Romania
| | - Irina Balescu
- Department of Surgery, "Ponderas" Academic Hospital, Bucharest, Romania .,Department of Surgery, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Camelia Diaconu
- Department of Obstetrics and Gynecology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Internal Medicine, Clinical Emergency Hospital, Bucharest, Romania
| | - Laura Iliescu
- Department of Obstetrics and Gynecology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Internal Medicine, "Fundeni" Clinical Institute, Bucharest, Romania
| | - Alexandru Filipescu
- Department of Obstetrics and Gynecology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Internal Medicine, "Fundeni" Clinical Institute, Bucharest, Romania
| | - Cora Pop
- Department of Internal Medicine, University Emergency Hospital Bucharest, Bucharest, Romania
| | - Simona Dima
- Department of Visceral Surgery, Center of Excellence in Translational Medicine "Fundeni" Clinical Institute, Bucharest, Romania
| | - Mihaela Vilcu
- Department of Obstetrics and Gynecology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Visceral Surgery, "I. Cantacuzino" Clinical Hospital, Bucharest, Romania
| | - Iulian Brezean
- Department of Obstetrics and Gynecology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Visceral Surgery, "I. Cantacuzino" Clinical Hospital, Bucharest, Romania
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9
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[Are there still indications of lymph node dissection in epithelial ovarian cancers after the LION trial?]. Bull Cancer 2019; 107:707-714. [PMID: 31587803 DOI: 10.1016/j.bulcan.2019.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 06/16/2019] [Indexed: 11/22/2022]
Abstract
In March 2019, Harter et al. published the results of the LION study (Lymphadenectomy in patients with advanced ovarian neoplasms) which raises the question of pelvic and para-aortic lymphadenectomy for patients with advanced-stage epithelial ovarian cancer (EOC). These results influenced the new French recommendations published in December 2018 by the French National Cancer Institute (INCa). Thus, it no longer seems consistent to perform a systematic lymphadenectomy for patients for whom there is no argument for nodal involvement, when a macroscopic complete peritoneal cytoreductive surgery has been performed. The question of preoperative lymph node assessment is therefore essential, whereas more than half of the patients in the LION study had metastatic lymph node involvement that was histologically proven. For the assessment of lymph node status by imaging, superior sensitivity for Positron Emission Tomography is demonstrated in comparison with CT-scan or Magnetic Resonance Imaging. Nevertheless, thoraco-abdomino-pelvic CT-scan with contrast injection remains the gold standard for this indication. In the absence of suspected involvement, supra-renal, mesenteric, coelio-hepatic, and cardio-phrenic lymphadenectomy are not recommended. Lymphadenectomies should always be performed in the other situations of EOC management apart from the rare case of stage 1 expansile subtype mucinous carcinoma. The aim of this review is to discuss lymphadenectomy indications for the surgical management of EOC by taking into account new data from the scientific literature.
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10
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Wang M, Zhou J, Zhang L, Zhao Y, Zhang N, Wang L, Zhu W, He X, Zhu H, Xu W, Pan Q, Mao A, Li Q, Wang L. Surgical treatment of ovarian cancer liver metastasis. Hepatobiliary Surg Nutr 2019; 8:129-137. [PMID: 31098360 DOI: 10.21037/hbsn.2018.12.06] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In addition to hepatocellular carcinoma, metastatic liver cancer (MLC) is another focus of hepatic surgeon. Good outcome of patients with liver metastasis (LM) from colorectal cancer or neuroendocrine tumor have been achieved. Ovarian cancer liver metastasis (OCLM) has its unique oncological characteristics and a variety of metastasis patterns, which brings a challenge to hepatic surgeon. Hepatic surgeons hold different views and techniques from gynecologists, which makes differences in the evaluation and treatment of the disease. We reviewed recent studies and, in combination with our own clinical experience, attempted to introduce the progress of surgical treatment of liver metastases from OC. In our experience, both preoperative imaging and surgical procedures are based on the assurance of R0 resection. R0 cytoreductive surgery (CRS) is the most favorable determinant for the prognosis of OC patients, and R0 liver resection (LR) is a component of R0 CRS. Gynecologists and hepatic surgeons should do their own preoperative and intraoperative evaluation for the extrahepatic and intrahepatic metastasis respectively. During the operation, regardless of the miliary nodules dissemination between the right hemidiaphragm and liver capsule, liver parenchymal infiltration (LPI) or liver parenchymal metastasis (LPM), 1-2 cm resection margin should be emphasized. For patients with liver portal lymph node metastasis (LPLNM), hepatic portal skeletonization should be performed, rather than portal lymph node dissection. The operation should be as radical as possible to ensure the patients to achieve good prognosis.
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Affiliation(s)
- Miao Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Jiamin Zhou
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Lyu Zhang
- Research Center for Translational Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Yiming Zhao
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Ning Zhang
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Longrong Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Weiping Zhu
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xigan He
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Hongxu Zhu
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Weiqi Xu
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qi Pan
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Anrong Mao
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qinchuan Li
- Department of Cardiothoracic Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Lu Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai 200032, China
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11
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Ferron G, Narducci F, Pouget N, Touboul C. [Surgery for advanced 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]. ACTA ACUST UNITED AC 2019; 47:197-213. [PMID: 30792175 DOI: 10.1016/j.gofs.2019.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Indexed: 01/10/2023]
Abstract
Debulking surgery is the key step of advanced stage ovarian cancer treatment with chemotherapy. The quality of surgical resection is the main prognosis factor, thus a complete resection must be achieved (grade A) in an expert center (grade B). Surgery for stage IV is possible and has a benefit in case of complete peritoneal resection (LoE3). Pelvic and aortic lymphadenectomies are recommended in case of clinical or radiological suspicious lymph nodes (grade B). In absence of clinical or radiological suspicious lymph nodes and in case of complete peritoneal resection during initial debulking surgery, lymphadenectomy can be omitted because it won't change nor medical treatment nor overall survival (grade B). Neoadjuvant chemotherapy can be proposed in case of: impossibility to perform initial complete surgical resection (grade B) ; alteration of general state or co-morbidities or elderly patient (in order to decrease morbidity and increase quality of life) (grade B); stage IV with multiple intra-hepatic or pulmonary metastasis or important ascites with miliary (grade B). In case of stage III or IV ovarian cancer diagnosed on a biopsy during prior laparotomy, a neoadjuvant chemotherapy and interval debulking surgery should be preferred (gradeC). In case of palliative surgery or peroperative impossibility to perform a complete resection, no data regarding the type of surgery to perform influencing survival or quality of life is available. Peritoneal carcinosis description before resection and residual disease at the end of the surgery should be reported (size, location and reason of non-extirpability) (grade B). A score of peritoneal carcinosis such as Peritoneal Carcinosis Index (PCI) should be used in order to objectively evaluate the tumoral burden (gradeC). A standardized operative report is recommended (gradeC).
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Affiliation(s)
- G Ferron
- Inserm CRCT 19, département de chirurgie oncologique, institut Claudius Regaud, institut universitaire du cancer, 31000 Toulouse, France
| | - F Narducci
- Inserm U1192, département de chirurgie oncologique, centre Oscar Lambret, 59000 Lille, France
| | - N Pouget
- Département de chirurgie oncologique, chirurgie gynécologique et mammaire, institut Curie, site Saint-Cloud, 75005 Paris, France
| | - C Touboul
- IMRB, U955 Inserm, service de gynécologie obstétrique et médecine de la reproduction, centre hospitalier intercommunal de Créteil, institut Mondor de recherche biomédicale, 94000 Créteil, France.
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12
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Angeles MA, Ferron G, Cabarrou B, Balague G, Martínez-Gómez C, Gladieff L, Pomel C, Martinez A. Prognostic impact of celiac lymph node involvement in patients after frontline treatment for advanced ovarian cancer. Eur J Surg Oncol 2019; 45:1410-1416. [PMID: 30857876 DOI: 10.1016/j.ejso.2019.02.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/09/2019] [Accepted: 02/14/2019] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Completeness of cytoreduction is the most important prognostic factor in patients with advanced ovarian cancer (OC). Extensive upper abdominal surgery has allowed to increase the rate complete cytoreduction and the feasibility of resection of celiac lymph nodes (CLN) and porta hepatis disease in these patients has been demonstrated. The aim of our study was to assess the prognostic impact of CLN involvement in patients with primary advanced OC undergoing a complete cytoreductive surgery (CRS). MATERIAL AND METHODS We designed a retrospective unicentric study. We reviewed data from patients who underwent CLN resection with or without porta hepatis disease resection, within upfront or interval complete CRS in the frontline treatment of advanced epithelial OC between January 2008 and December 2015. Patients were classified in two groups according to CLN status. Univariate and multivariate analyses were conducted. Survival rates were estimated using Kaplan-Meier method. RESULTS Forty-three patients were included and positive CLN were found in 39.5% of them. The median disease-free survival in the group of patients with positive and negative CLN were 11.3 months and 25.8 months, respectively. In multivariable analysis, both CLN involvement and high peritoneal cancer index were independently associated with decreased disease-free survival. Computed tomography re-reading by an expert radiologist has good sensitivity for detection of positive CLN. CONCLUSION CLN involvement and high preoperative tumor burden are independently associated with decreased survival after complete cytoreduction for OC. CLN involvement is a marker of diffuse disease and an independent risk factor for early recurrent disease.
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Affiliation(s)
- Martina Aida Angeles
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT), Oncopole, Toulouse, France
| | - Gwénaël Ferron
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT), Oncopole, Toulouse, France; INSERM CRCT 19, Toulouse, France
| | - Bastien Cabarrou
- Biostatistics Unit, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT), Oncopole, Toulouse, France
| | - Gisèle Balague
- Department of Radiology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT), Oncopole, Toulouse, France
| | - Carlos Martínez-Gómez
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT), Oncopole, Toulouse, France; INSERM CRCT 1, Toulouse, France
| | - Laurence Gladieff
- Department of Medical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT), Oncopole, Toulouse, France
| | - Christophe Pomel
- Department of Surgical Oncology, CRLCC Jean Perrin, Clermont-Ferrand, France
| | - Alejandra Martinez
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT), Oncopole, Toulouse, France; INSERM CRCT 1, Toulouse, France.
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Angeles MA, Martínez-Gómez C, Migliorelli F, Voglimacci M, Figurelli J, Motton S, Tanguy Le Gac Y, Ferron G, Martinez A. Novel Surgical Strategies in the Treatment of Gynecological Malignancies. Curr Treat Options Oncol 2018; 19:73. [DOI: 10.1007/s11864-018-0582-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
OBJECTIVES In advanced epithelial ovarian cancer (AOC), lesser sac (LS) metastasis particularly to the supragastric LS (SGLS) may be overlooked, resulting in unrecognized residual disease. We aimed to identify the frequency, distribution, and predictors of LS metastasis using laparoscopic evaluation at laparotomy and perioperative surgical complications associated with evaluation and resection/ablation. METHODS Prospective observational study in consecutive patients with AOC undergoing laparotomy for primary or interval cytoreductive surgery in 2 centers between November 2013 and December 2016. RESULTS Of 182 AOC patients undergoing laparotomy, 150 were eligible for metastasis distribution analysis; 96/150 (64%) had LS metastasis with 90/150 (60%) involving the SGLS, including lesser omentum (47.3%), floor (42%), upper recess (24.6%), and caudate lobe (22.6%), with 62/90 (68.8%) being less than 1 cm in dimension. Of 144 undergoing cytoreductive surgery, 92 (64%) had LS metastasis, which was completely resected/ablated in 77/92 (83.6%).The strongest multivariate predictors of LS metastasis were involvement of Morison pouch (P < 0.001) and peritoneal cancer index of 17 or greater (P < 0.001). The LS metastasis was significantly associated with diaphragmatic surgery (84% vs 54%), cholecystectomy (33% vs 2%), splenectomy (50% vs 14%), retroperitoneal nodal metastasis (75% vs 49%), and surgical complexity score of 8 or higher (75% vs 35%). Morbidity related to treatment of LS metastasis was minimal. CONCLUSIONS Lesser sac metastasis and SGLS metastasis are present in almost two thirds of cases of AOC and often small in size. Systematic exploration is necessary to detect and treat metastases to LS to prevent unrecognized incomplete cytoreduction.
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Gallotta V, Ferrandina G, Vizzielli G, Conte C, Lucidi A, Costantini B, De Rose AM, Di Giorgio A, Zannoni GF, Fagotti A, Scambia G, Chiantera V. Hepatoceliac Lymph Node Involvement in Advanced Ovarian Cancer Patients: Prognostic Role and Clinical Considerations. Ann Surg Oncol 2017; 24:3413-3421. [PMID: 28718034 DOI: 10.1245/s10434-017-6005-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND The study aimed too investigate the rate of hepatoceliac lymph node (HCLN) involvement, as well as its association with clinicopathologic features, together with morbidity of HCLN resection and the prognostic impact of metastatic HCLN status on patients with advanced ovarian cancer (OC) undergoing cytoreductive surgery. METHODS All consecutive patients with stages 3c to 4 epithelial OC who underwent HCLN surgery from January 2010 to September 2016 were analyzed for surgical procedures, pathology, and oncologic outcomes. RESULTS During the study period, 85 patients underwent HCLN resection. Absence of visible tumor at the end of surgery was documented for 73 of the patients (85.9%). The median number of HCLNs removed was 6 (range 1-18). Histopathologic evaluation was able to identify HCLN metastasis in 45 (52.9%) of the 85 cases. No difference in the rate of surgical morbidity according to pathologic status of HCLN was observed. As of December 2016, the median follow-up period was 36 months (range 6-54 months). Recurrence of disease was observed in 35 (41.2%) of the 85 cases. Relapse of disease most frequently occurred for the patients with metastatic HCLN involvement (65.7%) compared with the patients who had no HCLN involvement (34.3%) (p = 0.048). The median progression-free survival values were 16 months (95% confidence interval [CI], 12-19 months) for the patients with metastatic HCLNs and 22 months (95% CI, 12-19 months) for the patients with no HCLN involvement (p = 0.035). CONCLUSIONS The study confirmed that HCLN surgery is feasible with acceptable morbidities for patients with advanced OC. Metastatic HCLNs are a marker of disease severity associated with worst oncologic outcome.
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Affiliation(s)
- Valerio Gallotta
- Department of Women's and Children's Health, "Agostino Gemelli" Foundation University Hospital, Rome, Italy.
| | - Gabriella Ferrandina
- Department of Women's and Children's Health, Catholic University of the Sacred Heart, Rome, Italy.,Department of Health Sciences and Medicine, University of Molise, Campobasso, Italy
| | - Giuseppe Vizzielli
- Department of Women's and Children's Health, "Agostino Gemelli" Foundation University Hospital, Rome, Italy
| | - Carmine Conte
- Department of Women's and Children's Health, "Agostino Gemelli" Foundation University Hospital, Rome, Italy
| | - Alessandro Lucidi
- Division of Gynecologic Oncology, University of Palermo, Palermo, Italy
| | - Barbara Costantini
- Department of Women's and Children's Health, "Agostino Gemelli" Foundation University Hospital, Rome, Italy
| | - Agostino Maria De Rose
- Hepatobiliary Surgery Unit, A. Gemelli Hospital "Agostino Gemelli" Foundation University Hospital, Rome, Italy
| | - Andrea Di Giorgio
- Division of Surgery, "Agostino Gemelli" Foundation University Hospital, Rome, Italy
| | - Gian Franco Zannoni
- Department of Pathology, Catholic University of the Sacred Heart, Rome, Italy
| | - Anna Fagotti
- Department of Women's and Children's Health, Catholic University of the Sacred Heart, Rome, Italy
| | - Giovanni Scambia
- Department of Women's and Children's Health, Catholic University of the Sacred Heart, Rome, Italy
| | - Vito Chiantera
- Division of Gynecologic Oncology, University of Palermo, Palermo, Italy
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Tozzi R, Traill Z, Garruto Campanile R, Ferrari F, Soleymani Majd H, Nieuwstad J, Hardern K, Gubbala K. Porta hepatis peritonectomy and hepato-celiac lymphadenectomy in patients with stage IIIC-IV ovarian cancer: Diagnostic pathway, surgical technique and outcomes. Gynecol Oncol 2016; 143:35-39. [PMID: 27519966 DOI: 10.1016/j.ygyno.2016.08.232] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 07/31/2016] [Accepted: 08/04/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To report the surgical technique of ovarian cancer resection at the porta hepatis (PH) and hepato-celiac lymph nodes (HCL). To assess surgical and survival outcomes. Define the accuracy of an integrated diagnostic pathway. METHODS Patients with FIGO stage IIIC-IV ovarian cancer that underwent Visceral-Peritoneal Debulking (VPD). Data of patients with disease at the PH/HCL during VPD were extracted from our database. The CT scan findings were compared with the exploratory laparoscopy. Accuracy of CT scan, intra- and post-operative morbidity, rate of complete resection (CR), disease free and overall survival are reported. RESULTS Thirty one patients out of 216 (14.3%) had tumor at the PH and/or HCL. In 8 patients out of 31 (25.8%) it was only found with the aid of the exploratory laparoscopy. CR was achieved in 28 patients out of 31 (90.3%). Pathology confirmed disease in the PH/HCL specimens of all but one patient. Overall morbidity relating to the VPD was 29.2%. No complication was specifically related to the PH/HCL. Median disease free survival was 19months and median overall survival was 42months. CONCLUSION PH/HCL surgery was required in 15% of patients with FIGO stage IIIC-IV. The surgery was feasible, safe and significantly contributed to CR. CT scan failed to identify the disease in 31% of the patients. CT and laparoscopy correctly identified all patients.
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Affiliation(s)
- Roberto Tozzi
- Department of Gynaecologic Oncology, Oxford University Hospital, Oxford, UK.
| | - Zoe Traill
- Department of Radiology, Oxford University Hospital, Oxford, UK
| | | | - Federico Ferrari
- Department of Gynaecologic Oncology, Oxford University Hospital, Oxford, UK
| | | | - Joost Nieuwstad
- Department of Gynaecologic Oncology, Oxford University Hospital, Oxford, UK
| | - Kieran Hardern
- Department of Gynaecologic Oncology, Oxford University Hospital, Oxford, UK
| | - Kumar Gubbala
- Department of Gynaecologic Oncology, Oxford University Hospital, Oxford, UK
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Abstract
While there is an ongoing debate regarding the timing of the maximal surgical effort in epithelial ovarian cancer, it is well established that patients with suboptimal tumor debulking derive no benefit from the surgical procedure. The amount of residual disease after cytoreductive surgery has been repeatedly identified as a strong predictor of survival, and accordingly, the surgical effort to achieve the goal of complete gross tumor resection has been constantly evolving. Centers that have adopted the concept of radical surgery in patients with advanced ovarian cancer have reported improvements in their patients' survival. In addition to the expected improvements in the pharmacologic treatment of this disease, some of the next challenges in the surgical management of ovarian cancer include the preoperative prediction of suboptimal debulking, improving the drug delivery to the tumor, and increasing access to centers of excellence in ovarian cancer regardless of geographical, financial, or other social barriers. This review will discuss an update on the role of surgery in the treatment of primary epithelial ovarian cancer as it has evolved since the emergence of the concept of surgical cytoreduction.
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International Federation of Gynecology and Obstetrics Staging Classification for Cancer of the Ovary, Fallopian Tube, and Peritoneum: Estimation of Survival in Patients With Node-Positive Epithelial Ovarian Cancer. Int J Gynecol Cancer 2015; 25:49-54. [DOI: 10.1097/igc.0000000000000316] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
ObjectiveThe objective of this study was to determine the survival of patients with node-positive epithelial ovarian cancer according to the 2014 International Federation of Gynecology and Obstetrics (FIGO) staging system.Materials and MethodsWe performed a retrospective chart review. Data from all consecutive patients with node-positive epithelial ovarian cancer (stages IIIC and IV) who underwent cytoreductive surgery at the Mayo Clinic from 1996 to 2000 were reassessed to evaluate the prognostic significance of the new FIGO stages. Multivariate Cox regression was performed, and Kaplan-Meier survival curves constructed.ResultsThe distribution of the restaged patients was as follows: IIIA1, 23 patients (IIIA1i, 9 patients; and IIIA1ii, 14 patients); IIIA2, 3 patients; IIIB, 4; IIIC, 67 patients; IVA, 4 patients; and IVB, 15 patients. In the univariate analysis, the relative risk for positive nodes greater than 10 mm on the longer axis was 2.57 and 3.00 for patients with microscopic peritoneal disease, compared with patients with microscopic positive nodes. However, the difference was not statistically significant. Moreover, the univariate analyses revealed statistically significant differences for 2014 FIGO stages (IIIA, IIIB, IIIC, and IVA-B), anatomical sites of peritoneal metastases, and disease staged at IIIC because of the presence of omental metastases. Multivariate analysis showed that survival was higher in patients restaged to IIIA-B than in those restaged to IIIC and IV (hazard ratios, 2.75 and 3.16, respectively; P = 0.002). The hazard ratio for patients with abdominal peritoneal metastases was 2.76 compared with patients with pelvic peritoneal metastases (P = 0.001).ConclusionsThe current 2014 FIGO staging system for ovarian cancer successfully correlates survival, anatomical location of peritoneal metastases, and extra-abdominal lymph node metastases.
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Abstract
OBJECTIVE The aim of the study was to report on the oncologic outcome of the disease spread to celiac lymph nodes (CLNs) in advanced-stage ovarian cancer patients. METHODS All patients who had CLN resection as part of their cytoreductive surgery for epithelial ovarian, fallopian, or primary peritoneal cancer were identified. Patient demographic data with particular emphasis on operative records to detail the extent and distribution of the disease spread, lymphadenectomy procedures, pathologic data, and follow-up data were included. RESULTS The median follow-up was 26.3 months. The median overall survival values in the group with positive CLNs and in the group with negative CLNs were 26.9 months and 40.04 months, respectively. The median progression-free survival values in the group with metastatic CLNs and in the group with negative CLNs were 8.8 months and 20.24 months, respectively (P = 0.053). Positive CLNs were associated with progression during or within 6 months after the completion of chemotherapy (P = 0.0044). Tumor burden and extensive disease distribution were significantly associated with poor progression-free survival, short-term progression, and overall survival. In multivariate analysis, only the CLN status was independently associated with short-term progression. CONCLUSIONS Disease in the CLN is a marker of disease severity, which is associated to a high-risk group of patients with presumed adverse tumor biology, increased risk of lymph node progression, and worst oncologic outcome.
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Horvath S, George E, Herzog TJ. Unintended consequences: surgical complications in gynecologic cancer. ACTA ACUST UNITED AC 2014; 9:595-604. [PMID: 24161311 DOI: 10.2217/whe.13.60] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
More than 91,000 women in the USA will be diagnosed with a gynecologic malignancy in 2013. Most will undergo surgery for staging, treatment or both. No therapeutic intervention is without consequence, therefore, it is imperative to understand the possible complications associated with the perioperative period before undertaking surgery. Complication rates are affected by a patient population that is increasingly older, more obese and more medically complicated. Surgical modalities consist of abdominal, vaginal, laparoscopic and robotic-assisted approaches, and also affect rates of complications. An understanding of the various approaches, patient characteristics and surgeon experience allow for individualized decision-making to minimize the complications after surgery for gynecologic cancer.
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Affiliation(s)
- Sarah Horvath
- Columbia University, New York Presbyterian Hospital, NY, USA
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21
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[The place of para-aortic lymphadenectomy in gynaecological malignancies. An old debate]. Bull Cancer 2014; 101:345-8. [PMID: 24793624 DOI: 10.1684/bdc.2014.1927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is a lack of prospective randomized trial and scientific evidence for the use of para-aortic lymphadenectomy in gynaecological malignancies. This results in variations between countries for its utility. Based on the recommandations of the French Institute of Cancer (INCa), we open the debate of the place of para-aortic lymphadenectomy.
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Pölcher M, Zivanovic O, Chi DS. Cytoreductive Surgery for Advanced Ovarian Cancer. WOMENS HEALTH 2014; 10:179-90. [DOI: 10.2217/whe.14.4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The amount of the largest diameter of visible residual tumor after cytoreductive surgery remains one of the strongest prognostic factors In advanced ovarian cancer. The Implementation of a more aggressive surgical approach to Increase the proportion of patients without visible residual tumor Is, therefore, a rational concept. Thus, the surgical management of advanced ovarian, primary peritoneal and fallopian tube cancers now Incorporates more comprehensive surgical procedures. However, these more extensive surgical procedures are associated with an Increased risk of morbidity, which may have a negative Impact on the oncologic outcome. In addition, It Is unclear whether all patients benefit from a comprehensive surgical Intervention In the same way or If there are patients whose disease course will not be Influenced by this approach. The methodologic analysis of surgical effectiveness Is complex and controversial owing to a lack of prospective surgical trials. This review acknowledges controversies and alms to discuss novel developments In the field of cytoreductive surgery for patients with ovarian, primary peritoneal and fallopian tube cancers. The focus of the review Is to discuss the role of surgery at Initial diagnosis. The role of secondary and tertiary surgery In the recurrent setting Is beyond the scope of this review.
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Affiliation(s)
- Martin Pölcher
- Red Cross Women's Hospital Munich, Department of Gynecologic Oncology & Minimally-Invasive Surgery, Munich, Germany
| | - Oliver Zivanovic
- Department of Surgery, Gynecology Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Dennis S Chi
- Department of Surgery, Gynecology Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Gallotta V, Fanfani F, Fagotti A, Chiantera V, Legge F, Alletti SG, Nero C, Margariti AP, Papa V, Alfieri S, Ciccarone F, Scambia G, Ferrandina G. Mesenteric Lymph Node Involvement in Advanced Ovarian Cancer Patients Undergoing Rectosigmoid Resection: Prognostic Role and Clinical Considerations. Ann Surg Oncol 2014; 21:2369-75. [DOI: 10.1245/s10434-014-3558-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Indexed: 11/18/2022]
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Lacorre A, Gauthier T, Gardet E, Berger J, Loum O, Monteil J, Tubiana N, Aubard Y. [Resection of iliac vessels and adnexial cancer: report of 2 cases]. ACTA ACUST UNITED AC 2014; 42:265-8. [PMID: 24411338 DOI: 10.1016/j.gyobfe.2013.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Indexed: 11/20/2022]
Abstract
Aim of no residual macroscopic disease has to be the objective of the gynecologist oncologist surgeon. It can require extensive surgical procedures in all the abdomen area. We report 2 rare cases of cytoreductive surgery with iliac vessels resection and use of vascular prosthesis. We discuss the opportunity of this surgery with high morbidity.
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Affiliation(s)
- A Lacorre
- Service de gynécologie-obstétrique, hôpital Mère-Enfant, CHU Dupuytren, avenue Larrey, 87000 Limoges, France
| | - T Gauthier
- Service de gynécologie-obstétrique, hôpital Mère-Enfant, CHU Dupuytren, avenue Larrey, 87000 Limoges, France.
| | - E Gardet
- Service de chirurgie vasculaire, CHU Dupuytren, avenue Luther-King, 87000 Limoges, France
| | - J Berger
- Service d'urologie, CHU Dupuytren, avenue Luther-King, 87000 Limoges, France
| | - O Loum
- Service de gynécologie-obstétrique, hôpital Mère-Enfant, CHU Dupuytren, avenue Larrey, 87000 Limoges, France
| | - J Monteil
- Service de médecine nucléaire, CHU Dupuytren, avenue Luther-King, 87000 Limoges, France
| | - N Tubiana
- Service d'oncologie médicale, CHU Dupuytren, avenue Luther-King, 87000 Limoges, France
| | - Y Aubard
- Service de gynécologie-obstétrique, hôpital Mère-Enfant, CHU Dupuytren, avenue Larrey, 87000 Limoges, France
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Ansaloni L, Coccolini F, Catena F, Frigerio L, Bristow RE. Cytoreductive surgery in primary advanced epithelial ovarian cancer. World J Obstet Gynecol 2013; 2:116-123. [DOI: 10.5317/wjog.v2.i4.116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 02/02/2013] [Accepted: 03/07/2013] [Indexed: 02/05/2023] Open
Abstract
Epithelial ovarian cancer is one of the most common malignancy and one of the principal causes of death among gynaecological neoplasm. The majority of patients (about 70%) present with an advanced International Federation of Gynaecology and Obstetrics stage disease. The current standard treatment for these patients consists of complete cytoreduction and combined systemic chemotherapy (CT). An increasing proportion of patients undergoing complete cytoreduction to no gross residual disease (RD) is associated with progressively longer overall survival. As a counterpart, some authors hypothesized the improving in survival could be due more to a less diffused initial disease than to an increase in surgical cytoreduction rate. Moreover the biology of the tumor plays an important role in survival benefit of surgery. It’s still undefined how the intrinsic features of the tumor make intra-abdominal implants easier to remove. Adjuvant and hyperthermic intraperitoneal CT could play a decisive role in the coming years as the completeness of macroscopic disease removal increases with advances in surgical techniques and technology. The introduction of neo-adjuvant CT moreover will play a decisive role in the next years Anyway cytoreduction with no macroscopic residual of disease should always be attempted. However the definition of RD is not universal. A unique and definitive definition is needed.
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The impact of pelvic retroperitoneal invasion and distant nodal metastases in epithelial ovarian cancer. Surg Oncol 2013; 23:40-4. [PMID: 24183480 DOI: 10.1016/j.suronc.2013.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 10/10/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND The absence of disease after debulking surgery is the most important prognostic factor in the treatment of advanced epithelial ovarian cancer (EOC). Occasionally, the presence of extra-abdominal disease complicates the ability to obtain a complete surgery, considering some locations of the metastatic disease as unresectable. The objective of the study was to estimate the survival impact of pelvic retroperitoneal invasion and extrapelvic and aortic distant nodal metastases in EOC patients. The anatomical landmarks of primary cytoreductive surgery will be discussed. MATERIAL AND METHODS We reviewed data from 116 consecutive Mayo Clinic patients with epithelial ovarian cancer (EOC) stage IIIC and IV, undergoing primary cytoreduction surgery between 1996 and 2000. Univariate and multivariate analysis for patients with positive distant nodes and pelvic retroperitoneal invasion was performed, including 57 patients with no residual disease after surgery. Kaplan-Meier curves were used to estimate the probability of survival. RESULTS The median patient's age was 65 years (range 24-87 years). The 5 years overall survival was 44.8% (range 30.1-57.9 months) and the median length of survival was 39.9 months (range 0.13-60 months, 95% confidence interval: 30.1-57.9). Pelvic retroperitoneal invasion was present in 22 EOC patients (18.9%) and distant positive nodes were noted in 11 (9.5%): suprarenal/celiac (5.2%), inguinal (4.3%) and supraclavicular (0.9%). Univariate and multivariate Cox regression analysis, identified distant positive lymph nodes and pelvic retroperitoneal invasion as factors statistically associated with overall survival (p = 0.002 and p = 0.025, respectively). CONCLUSIONS Metastatic distant nodes and pelvic retroperitoneal invasion are independent prognostic factors for survival in patients with advanced EOC.
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Chiva LM, Lapuente F, Alonso S. Approaching suspicious lymph nodes on the upper abdomen in gynecologic oncology. Gynecol Oncol 2013; 131:213. [PMID: 23880153 DOI: 10.1016/j.ygyno.2013.07.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 07/05/2013] [Accepted: 07/15/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Luis M Chiva
- Department of Gynecologic Oncology, MD Anderson Cancer Center, Madrid, Spain; University of Texas, TX, USA.
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Maximal cytoreduction in patients with FIGO stage IIIC to stage IV ovarian, fallopian, and peritoneal cancer in day-to-day practice: a Retrospective French Multicentric Study. Int J Gynecol Cancer 2013; 22:1337-43. [PMID: 22964527 DOI: 10.1097/igc.0b013e31826a3559] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To evaluate the outcome of maximal cytoreductive surgery in patients with stage IIIC to stage IV ovarian, tubal, and peritoneal cancer regarding overall survival (OS) and disease-free survival (DFS). MATERIALS AND METHODS Five hundred twenty-seven patients with stage IIIC (peritoneal) and stage IV (pleural) ovarian, fallopian tube, and peritoneal carcinoma underwent surgery between January 2003 and December 2007 in 7 gynecologic oncology centers in France. Patients undergoing primary and interval debulking surgery were included, whichever the number of chemotherapy cycles. The extent of disease, type of surgical procedure, and amount of residual disease were recorded. A multivariate analysis of the outcome was performed, taking into account the stage, grade, and timing of surgery. RESULTS Median DFS was 17.9 months, but median OS was not reached at the time of analysis. Complete cytoreductive surgery, without evident residual tumor at the end of the procedure, was obtained in 71% of all patients (primary surgery, 33%). After neoadjuvant therapy, the rate of complete debulking surgery was higher (74%) compared to primary cytoreductive surgery (65%). Twenty-three percent of patients needed "ultra radical surgery" to achieve this goal. The most significant predictive factor for DFS and OS was complete cytoreductive surgery compared to any amount, even minimal (1-10 mm), of residual disease. In the group of patients with complete cytoreductive surgery, the patients undergoing surgery before chemotherapy showed better DFS than those having first chemotherapy. CONCLUSION The findings confirm that complete cytoreduction is the criterion standard of surgery in the management of advanced ovarian, peritoneal, and fallopian tube cancer, whatever the timing of surgery. With experienced teams, surgery was completed, without evident residual tumor in 71% of the cases.
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Pathiraja P, Tozzi R. Advances in gynaecological oncology surgery. Best Pract Res Clin Obstet Gynaecol 2013; 27:415-20. [PMID: 23482071 DOI: 10.1016/j.bpobgyn.2013.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 01/09/2013] [Indexed: 12/26/2022]
Abstract
Latest surgical advances in the field of gynaecological oncology, a sub-specialty of gynaecology, are reviewed in this chapter. The surgery is mainly practised in cancer centres by board-certified gynaecologists, and requires a 2-3 year period of additional training in gynaecological oncology. Surgical treatment of gynaecological malignancies has progressed in two directions: reduction of the invasiveness of the surgery and expansion of the number and type of procedures performed. Gynaecological oncology focuses on the pelvis to the upper abdomen and the thorax to target (all visible disease) the last cancer cell in women with advanced ovarian cancer. Minimal-access surgery has evolved to include any operation by laparoscopy. It uses fewer ports (single-port surgery), and robotic assistance improves the comfort of the surgeon. The concept of fertility-sparing surgery for women with cervical cancer is now supported by mature data. The indication and the aggressiveness of the exenterative surgery are also broader than originally recommended. The ideal timing of surgery is under investigation in several areas, mainly in women with ovarian and cervical cancer. The aim is to reduce morbidity and mortality of surgical procedures while maintaining the survival outcome.
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Affiliation(s)
- Pubudu Pathiraja
- Department of Gynaecologic Oncology, Oxford Cancer Centre, Oxford University Hospital - Churchill Hospital, Old Road OX3 7LJ, Oxford, UK
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Raspagliesi F, Ditto A, Martinelli F, Haeusler E, Lorusso D. Advanced ovarian cancer: omental bursa, lesser omentum, celiac, portal and triad nodes spread as cause of inaccurate evaluation of residual tumor. Gynecol Oncol 2013; 129:92-6. [PMID: 23385151 DOI: 10.1016/j.ygyno.2013.01.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 01/12/2013] [Accepted: 01/27/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We evaluated the role of omental bursa (OB), surface of the pancreas, lesser omentum, caudate lobe, celiac nodes (CNs), portal nodes and triad nodes spread in advanced ovarian cancer (AOC). We investigated if the exploration and cleaning up of these areas can lead to a more complete cytoreduction and to a more realistic assessment of residual tumor in AOC. METHODS We prospectively recruited patients diagnosed with AOC, who underwent a complete cytoreduction. Demographics, surgical procedures, morbidities, pathologic findings and correlations with OB spread were assessed. RESULTS A total of 37 patients had an optimal debulking including OB evaluation and peritonectomy. The OB area procedure required in mean 65 min with an estimated blood loss of 250 ml. OB involvement was found in 67% (25/37) of cases. Peritoneal disease was found in 22 cases including 18 supragastric lesser sac and 4 porta hepatis peritoneum. CNs metastases were found in 5 cases, of which 3 cases are with bulky nodes, all presented also bulky nodes in the para-aortic area. Only in the case of a macroscopic involvement of the diaphragm OB was positive for disease. When adhesions occluding the Winslow foramen were present, no OB peritoneum involvement was found. OB resection related complications were low (2 out 25). CONCLUSIONS The data of this prospective study demonstrate the high rate of OB, surface of the pancreas, lesser omentum, caudate lobe, CNs, portal and triad nodes involvement and the value of investigating the dissemination and cytoreduction in these sites to obtain a real optimal debulking.
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Abstract
Ovarian cancer affects approximately 21,880 women and accounts for over 13,000 deaths annually in the United States. Although survival rates have improved over the past several decades, directly as a result of advances in chemotherapy and surgery, ovarian cancer continues to have high mortality rates. Understanding the multiple roles of surgery throughout the disease course is the focus of this review.
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Chang SJ, Bristow RE. Evolution of surgical treatment paradigms for advanced-stage ovarian cancer: redefining 'optimal' residual disease. Gynecol Oncol 2012; 125:483-92. [PMID: 22366151 DOI: 10.1016/j.ygyno.2012.02.024] [Citation(s) in RCA: 133] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 02/10/2012] [Accepted: 02/16/2012] [Indexed: 12/14/2022]
Abstract
Over the past 40 years, the survival of patients with advanced ovarian cancer has greatly improved due to the introduction of combination chemotherapy with platinum and paclitaxel as standard front-line treatment and the progressive incorporation of increasing degrees of maximal cytoreductive surgery. The designation of "optimal" surgical cytoreduction has evolved from residual disease ≤ 1 cm to no gross residual disease. There is a growing body of evidence that patients with no gross residual disease have better survival than those with optimal but visible residual disease. In order to achieve this, more radical cytoreductive procedures such as radical pelvic resection and extensive upper abdominal procedures are increasingly performed. However, some investigators still suggest that tumor biology is a major determinant in survival and that optimal surgery cannot fully compensate for tumor biology. The aim of this review is to outline the theoretical rationale and historical evolution of primary cytoreductive surgery, to re-evaluate the preferred surgical objective and procedures commonly required to achieve optimal cytoreduction in the platinum/taxane era based on contemporary evidence, and to redefine the concept of "optimal" residual disease within the context of future surgical developments and analysis of treatment outcomes.
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Affiliation(s)
- Suk-Joon Chang
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Republic of Korea
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