FIGO stage IV epithelial ovarian, fallopian tube and peritoneal cancer revisited.Gynecol Oncol. 2016;142:597-607. [PMID: 27335253 DOI: 10.1016/j.ygyno.2016.06.013]

Overcoming cisplatin resistance in ovarian cancer: A novel approach via mitochondrial targeting peptide Pal-pHK-pKV

Cisplatin (DDP) resistance in advanced stages of ovarian cancer significantly reduces survival rates. Mitochondria may serve as a potential therapeutic target for ovarian cancer. Pal-pHK-pKV is a mitochondrial targeting peptide synthesized by supramolecular assembly. Our study aims to investigate whether Pal-pHK-pKV serves as a useful strategy to reverse DDP resistance in ovarian cancer. Subcutaneous tumor implantation of the DDP-resistant ovarian cancer cell line A2780CP was conducted in nude mice, and drugs were administered intraperitoneally to compare the inhibitory effects of Pal-pHK-pKV and DDP on A2780CP cells in vivo. Combination index values were calculated for various concentrations of DDP and Pal-pHK-pKV to determine the optimal combination concentration. Mitochondrial membrane potential, cytochrome C distribution and immunofluorescence were also measured. Our studies demonstrated that Pal-pHK-pKV treatment reduced the proliferation, invasion and metastasis of ovarian cancer cells and impaired mitochondrial function. Furthermore, the combination of Pal-pHK-pKV and DDP exhibited a synergistic effect. Mechanistically, Pal-pHK-pKV can impair mitochondrial function, reduce mitochondrial membrane potential and release ROS. On the other hand, Pal-pHK-pKV can affect ERK pathway activation and inhibit tumor development. In conclusion, the mitochondria-specific amphiphilic peptide Pal-pHK-pKV provides a novel approach for treating ovarian cancer and may potentially overcome DDP drug resistance.

Fallopian tube cancer with inguinal lymph node metastasis as the first symptom: A case study and review of the literature

INTRODUCTION AND IMPORTANCE

Fallopian tube cancer that is characterized only by inguinal lymph node metastasis without intra-abdominal widespread is rare. Here we report a patient with primary Fallopian tube cancer with bilateral inguinal metastases as the first symptom.

CASE PRESENTATION

A 68-year-old patient with primary Fallopian tube cancer, with painless bilateral inguinal enlargement (7 × 6 cm on the right side, 3 × 2 cm on the left side) as the only manifestation, was confirmed by preoperative biopsy as metastatic high-grade serous denocarcinoma, consider the adnexal or peritoneal source. Pelvic MRI, abdominal CT and PET-CT showed irregular signal foci can be seen in the right adnexal area, with a maximum cross-section of about 7.5 × 7.0 × 4.0 cm, considering malignancy, ovarian cancer may be possible; bilateral pelvic wall, bilateral inguinal, right iliac vessels with hypermetabolic lymph nodes. Serum CA125 level was markedly elevated at 922.40 U/ml and HE4 at 394.50 pmol/L. No abnormality was found in gastrointestinal endoscopy. At exploratory laparotomy, the tumor was confined to the right rear of the uterus, and a solid tumor with a size of about 10 × 6 × 6 cm was seen. The surface was smooth and closely related to the uterus. There was almost no tumor spread in the pelvic abdominal cavity, but there was 50 ml of pale blood-colored peritoneal fluid. The right ovarian capsule was intact. Cytoreductive surgery was performed, postoperative pathology confirmed adenocarcinoma of the right fallopian tube, and the patient received six cycles of paclitaxel plus cisplatin combination chemotherapy were administered, with three 3-weeks intervals between cycles. And subsequent the patient participated in a clinical trial. The work has been reported in line with the SCARE criteria.

CLINICAL DISCUSSION

Literature review indicates that inguinal lymph node as the first manifestation of fallopian tube cancer is not usual, and with no widespread lymphadenopathies and abdominopelvic cavity are even rarer. This case shows that rare cases with only inguinal lymph node metastasis may occur through the underlying lymphatic and/or hematogenous routes.

CONCLUSION

The diagnosis of tubal cancer is sometimes complicated and delayed. For elderly women without nonspecific symptoms, especially those with obvious masses, detailed examinations, and imaging studies should be carried out in time. The treatment of tubal cancer is multi-modal. Due to the high risk of recurrence of fallopian tube cancer, the possibility of metastasis after the initial diagnosis is large, so it is very important to receive close and regular follow-up for patients with fallopian tube cancer after treatment. We suggest that more tumor centers study the possible mechanisms, metastasis patterns, biological characteristics, etc. of such patients, and at the same time efforts should be made to early differential diagnosis, and ultimately prolong the survival time of such patients.

Cardiophrenic lymph node metastasis as the sole presentation of high grade serous ovarian carcinoma

Key Clinical Message

Cardiophrenic metastasis is typically a late stage manifestation of ovarian high grade serous carcinoma. Here we present a case where this was the sole presentation of this disease. This case challenges our current understanding of the natural course of ovarian high grade serous carcinoma.

Abstract

Ovarian cancer is typically described to spread from its primary site within the fallopian tubes or ovaries into the peritoneal cavity and beyond with cardiophrenic lymph node involvement being considered a late stage disease process. Here we present the case of a lady in her 60s where increased metabolic activity of the cardiophrenic lymph node was picked up in the investigation of an adenocarcinoma of the lung. Post-thoracoscopic resection histopathological analysis of this lymph node showing an epithelial structure with positive immunohistochemical markers PAX8, WT1, ER, and p16 with a p53 wild type-pattern were the sole presenting features of a high grade serous ovarian carcinoma, that was otherwise undetectable by radiological or hematological screening. Only histopathological analysis after modified radical hysterectomy in gynae-oncological fashion were able to identify a 4 mm lesion within the left fallopian tube. This case questions our current understanding of the natural history of ovarian carcinomas.

Survival outcomes of primary vs interval cytoreductive surgery for International Federation of Gynecology and Obstetrics stage IV ovarian cancer: a nationwide population-based target trial emulation

BACKGROUND

The effect of primary cytoreductive surgery vs interval cytoreductive surgery on International Federation of Gynecology and Obstetrics stage IV ovarian cancer outcomes remains uncertain and may vary depending on the stage and the location of extraperitoneal metastasis. Emulating target trials through causal assessment, combined with propensity score adjustment, has become a leading method for evaluating interventions using observational data.

OBJECTIVE

This study aimed to assess the effect of primary vs interval cytoreductive surgery on progression-free and overall survival in patients with International Federation of Gynecology and Obstetrics stage IV ovarian cancer using target trial emulation.

STUDY DESIGN

Using the comprehensive French national health insurance database, we emulated a target trial to explore the causal impacts of primary vs interval cytoreductive surgery on stage IV ovarian cancer prognosis (Surgery for Ovarian cancer FIGO 4: SOFI-4). The clone method with inverse probability of censoring weighting was used to adjust for informative censoring and to balance baseline characteristics between the groups. Subgroup analyses were conducted based on the stages and extraperitoneal metastasis locations. The study included patients younger than 75 years of age, in good health condition, who were diagnosed with stage IV ovarian cancer between January 1, 2014, and December 31, 2022. The primary and secondary outcomes were respectively 5-year progression-free survival and 7-year overall survival.

RESULTS

Among the 2772 patients included in the study, 948 (34.2%) were classified as having stage IVA ovarian cancer and 1824 (65.8%) were classified as having stage IVB ovarian cancer at inclusion. Primary cytoreductive surgery was performed for 1182 patients (42.6%), whereas interval cytoreductive surgery was conducted for 1590 patients (57.4%). The median progression-free survival for primary cytoreductive surgery was 19.7 months (interquartile range, 19.3-20.1) as opposed to 15.7 months (interquartile range, 15.7-16.1) for those who underwent interval cytoreductive surgery. The median overall survival was 63.1 months (interquartile range, 61.7-65.4) for primary cytoreductive surgery in comparison with 55.6 months (interquartile range, 53.8-56.3) for interval cytoreductive surgery. The findings of our study indicate that primary cytoreductive surgery is associated with a 5.0-month increase in the 5-year progression-free survival (95% confidence interval, 3.8-6.2) and a 3.9-month increase in 7-year overall survival (95% confidence interval, 1.9-6.2). These survival benefits of primary over interval cytoreductive surgery were observed in both the International Federation of Gynecology and Obstetrics stage IVA and IVB subgroups. Primary cytoreductive surgery demonstrated improved progression-free survival and overall survival in patients with pleural, supradiaphragmatic, or extra-abdominal lymph node metastasis.

CONCLUSION

This study advocates for the benefits of primary cytoreductive surgery over interval cytoreductive surgery for patients with stage IV ovarian cancer and suggests that extraperitoneal metastases like supradiaphragmatic or extra-abdominal lymph nodes should not automatically preclude primary cytoreductive surgery consideration in suitable patients.

High-throughput viable circulating tumor cell isolation using tapered-slit membrane filter-based chipsets in the differential diagnosis of ovarian tumors

OBJECTIVE

To evaluate the diagnostic performance of circulating tumor cells (CTCs) using tapered-slit membrane filter (TSF)-based chipsets for the differential diagnosis of adnexal tumors.

METHODS

A total of 230 women with indeterminate adnexal tumors were prospectively enrolled. The sensitivity, specificity, and accuracy of the CTC-detecting chipsets were analyzed according to postoperative pathological results and compared with those of cancer antigen (CA)-125 and imaging tests.

RESULTS

Eighty-one (40.3%) benign tumors, 31 (15.4%) borderline tumors, and 89 (44.3%) ovarian cancers were pathologically confirmed. The sensitivity, specificity, and accuracy of CTC-detecting chipsets (75.3%, 58.0%, and 67.1%) for differentiating ovarian cancer from benign tumors were similar to CA-125 (78.7%, 53.1%, and 66.5%), but lower than CT/MRI (94.2%, 77.9%, and 86.5%). "CTC or CA125" showed increased sensitivity (91.0%) and "CTC and CA-125" revealed increased specificity (77.8%), comparable to CT/MRI. CTC detection rates in stage I/II and stage III/IV ovarian cancers were 69.6% and 81.4%, respectively. The sensitivity to detect high-grade serous (HGS) cancer from benign tumors (84.6%) was higher than that to detect non-HGS cancers (68.0%).

CONCLUSION

Although the diagnostic performance of the TSF platform to differentiate between ovarian cancer and benign tumors did not yield significant results, the combination of CTC and CA-125 showed promising potential in the diagnostic accuracy of ovarian cancer.

Prognostic factors and the role of primary debulking in operable stage IVB ovarian cancer with supraclavicular lymph node metastasis: a retrospective study in Chinese patients

BACKGROUND

Recent studies showed heterogeneity in stage IVB patients. However, few studies focused on the prognosis of supraclavicular metastatic ovarian cancer. This study aimed to explore the prognostic factors and the role of primary debulking in IVB ovarian cancer patients with supraclavicular lymph node metastasis.

METHODS

We retrospectively analyzed patients newly diagnosed as primary epithelial ovarian cancer with supraclavicular lymph node metastasis from January 2015 to July 2020. Supraclavicular lymph node metastasis was defined as either the pathological diagnosis by supraclavicular lymph node biopsy, or the radiological diagnosis by positron emission tomography-computed tomography (PET-CT).

RESULTS

In 51 patients, 37 was diagnosed with metastatic supraclavicular lymph nodes by histology, 46 by PET-CT, and 32 by both methods. Forty-four (86.3%) with simultaneous metastatic paraaortic lymph nodes (PALNs) by imaging before surgery or neoadjuvant chemotherapy were defined as "continuous-metastasis type", while the other 7 (13.7%) defined as "skip-metastasis type". Nineteen patients were confirmed with metastatic PALNs by histology. Thirty-four patients were investigated for BRCA mutation, 17 had germline or somatic BRCA1/2 mutations (g/sBRCAm). With a median follow-up of 30.0 months (6.3-63.4 m), 16 patients (31.4%) died. The median PFS and OS of the cohort were 17.3 and 48.9 months. Survival analysis showed that "continuous-metastasis type" had longer OS and PFS than "skip-metastasis type" (OS: 50.0/26.6 months, PFS: 18.5/7.2months, p=0.005/0.002). BRCA mutation carriers also had longer OS and PFS than noncarriers (OS: 57.4 /38.5 m, p=0.031; PFS: 23.6/15.2m, p=0.005). Multivariate analysis revealed only metastatic PALNs was independent prognostic factor for OS (p=0.040). Among "continuous-metastasis type" patients, 22 (50.0%) achieved R0 abdominopelvic debulking, who had significantly longer OS (55.3/42.3 months, p =0.034) than those with residual abdominopelvic tumors.

CONCLUSIONS

In stage IVB ovarian cancer patients with supraclavicular lymph nodes metastasis, those defined as "continuous-metastasis type" with positive PALNs had better prognosis. For them, optimal abdominopelvic debulking had prognostic benefit, although metastatic supraclavicular lymph nodes were not resected. Higher BRCA mutation rate than the general population of ovarian cancer patients was observed in patients with IVB supraclavicular lymph node metastasis, leading to better survival as expected.

Do PET-positive supradiaphragmatic lymph nodes predict overall survival or the success of primary surgery in patients with advanced ovarian cancer?

OBJECTIVES

Compared to conventional computed tomography (CT), fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) detects higher rates of lymph node and distant metastases in patients with ovarian cancer. However, FDG-PET/CT is not routinely performed during preoperative work-up. Therefore, we investigated the prognostic value of preoperative FDG-PET/CT in advanced epithelial ovarian cancer (EOC) and its predictive value for surgical resection in patients with no residual disease. The potential significance of PET-positive supradiaphragmatic lymph nodes (SDLNs) for these parameters was evaluated.

METHODS

All patients with FIGO IIA-IVB EOC diagnosed between March 2014 and January 2021 at our certified gynaecological cancer centre, who underwent FDG PET/CT before primary surgery were retrospectively included.

RESULTS

Fifty-three consecutive patients were included in the study. Eighteen (34 %) patients had PET-positive SDLNs. We could not demonstrate a significant correlation between PET-positive SDLNs and median overall survival (OS; SDLN-positive: 58.76 months, SDLN-negative: 60.76 months; p = 0.137) or intra- or perioperative outcomes.

CONCLUSIONS

FDG PET/CT has a higher detection rate for SDLNs in patients with ovarian cancer than CT has, as described in the literature. Moreover, PET-positive SDLNs failed to predict intraoperative outcomes or overall survival.

Ovarian serous carcinoma with stomach metastasis: a rare case report and literature review

Ovarian cancer is a common tumor among women. It is often asymptomatic in the early stages, with most cases already at stage III to IVE at the time of diagnosis. Direct spread and lymphatic metastasis are the primary modes of metastasis, whereas hematogenous spread is rare. An initial diagnosis of ovarian cancer that has metastasized to the stomach is also uncommon. Therefore, clear treatment methods and prognostic data for such metastasis are lacking. In our hospital, we encountered a patient with an initial imaging diagnosis of a gastric tumor and a history of an ovarian tumor with endoscopic abdominal metastasis. Based on the characteristics of the case, the two tumors were considered to be the same. After chemotherapy, a partial response was observed in the stomach and pelvic lesions, suggesting the effectiveness of the treatment. Through three treatments of recurrence, gastroscopy confirmed the stomach to be a metastatic site. Therefore, determining the primary source of advanced tumors is crucial in guiding treatment decisions. Clinicians must approach this comprehensively, relying on thorough evaluation and personal experience.

Risk factors for the failure of first-line PARP inhibitor maintenance therapy in patients with advanced ovarian cancer: Gynecologic Oncology Research Investigators Collaboration Study (GORILLA-3004)

OBJECTIVE

To identify the risk factors for failure of first-line poly (ADP-ribose) polymerase inhibitor (PARPi) maintenance therapy in patients with advanced ovarian cancer.

METHOD

Patients with stage III-IV epithelial ovarian cancer who received first-line PARPi maintenance therapy were retrospectively reviewed. Clinicopathologic factors were compared between two groups-recur/progression of disease (PD) and non-recur/PD.

RESULTS

In total, 191 patients were included. Median follow-up was 9.9 months, and recurrence rate was 20.9%. BRCA mutations were found in 63.4% patients. Postoperative residual tumor (60.5% vs. 37.8%), non-high grade serous carcinoma (HGSC) (15.0% vs. 6.0%), neoadjuvant chemotherapy (NAC) (55.0% vs. 35.8%), and pre-PARPi serum CA-125 levels ≥23.5 U/mL (35.9% vs. 15.2%) were more frequently observed in the recur/PD group. Multivariate Cox-regression analysis revealed pre-PARPi serum CA-125 levels ≥23.5 U/mL (HR, 2.17; 95%CI, 1.03-4.57; p = 0.042), non-HGSC (3.28; 1.20-8.97; p = 0.021), NAC (2.11; 1.04-4.26; p = 0.037), and no BRCA mutation (2.23; 1.12-4.44; p = 0.023) as independent risk factors associated with poor progression-free survival (PFS). A subgroup analysis according to BRCA mutation status showed that pre-PARPi serum CA-125 levels ≥26.4 U/mL were the only independent risk factor for poor PFS in women with BRCA mutations (2.75; 1.03-7.39; p = 0.044). Non-HGSC (5.05; 1.80-14.18; p = 0.002) and NAC (3.36; 1.25-9.04; p = 0.016) were independent risk factors in women without BRCA mutations.

CONCLUSION

High pre-PARPi serum CA-125 levels, non-HGSC histology, NAC, and no BRCA mutation might be risk factors for early failure of first-line PARPi maintenance therapy. In women with BRCA mutations, high pre-PARPi serum CA-125 levels, which represent a large tumor burden before PARPi, were the only independent risk factor for poor PFS.

A retrospective analysis for investigating the relationship between FIGO stage IVA/IVB and cytoreductive surgery with prognosis in epithelial ovarian cancer

Objective

To investigate the effect of primary debulking surgery (PDS), NACT followed by interval debulking surgery (NACT-IDS), and chemotherapy alone on the prognosis of FIGO stage IV epithelial ovarian cancer (EOC) with different metastatic patterns.

Methods

We retrospectively analyzed 133 cases of FIGO stage IV EOC with pleural effusion (stage IVA), parenchymal metastases (stage IVB), or extra-abdominal lymph node metastases (stage IVB) at our Hospital between January 2014 and July 2021.

Results

Among 133 cases with stage IV disease, 16.5% (n=22) presented with pleural effusion, 46.6% (n=62) with parenchymal metastases, and 36.9% (n=49) with extra-abdominal lymph node metastases. Regardless of the metastatic patterns, the 90.2% (n=120) of cases who underwent PDS/NACT-IDS exhibited a significantly superior overall survival (OS) compared to the 9.8% cases (n=13) who received chemotherapy alone (32 vs 17 months, p=0.000). The cohort was further stratified into 58 cases (48.3%) with R0, 41 cases (34.2%) with R1, and 21 cases (17.5%) with R2. The median OS of cases with R0 was significantly better than that of cases with R1/R2 (74 vs 27 months, p=0.000). There was no significant difference in median OS between PDS and NACT-IDS (43 vs 31 months, p=0.676), as well as between FIGO IVA and IVB (35 vs 31 months, p=0.582). Additionally, the metastatic patterns and the number of neoadjuvant chemotherapy cycles (≤4 or >4) did not demonstrate any prognostic significance for median OS (p=0.820 and 33 vs 26 months, p=0.280, respectively).

Conclusion

Regardless of FIGO IVA and IVB stages or metastatic patterns, patients diagnosed with stage IV EOC may benefit from cytoreductive surgery with abdominal R0, compared with chemotherapy alone.

Survival Outcomes of Patients with International Federation of Gynecology and Obstetrics Stage IV Ovarian Cancer: Cytoreduction Still Matters

PURPOSE

There is still no consensus on the therapeutic strategies for patients with International Federation of Gynecology and Obstetrics (FIGO) stage IV ovarian cancer (OC). We aim to outline the clinical characteristics and optimal therapeutic strategies of patients with FIGO stage IV OC.

METHODS

This single center retrospective study analyzed the clinical features and survival of patients with FIGO stage IV OC that underwent cytoreduction or received at least one course of chemotherapy between January 2014 and December 2020.

RESULTS

One hundred and twenty patients were included. Surgery, especially optimal cytoreduction without residual mass improved the overall survival of patients in surgery group (P = .047, HR .432, 95% CI .181-.987). Secondly, the completion of chemotherapy improved median overall survival of patients either with (53.0 months vs 25.0 months, P < .001, HR 7.015, 95% CI 1.372-35.881) or without cytoreduction (43.0 months vs 6.0 months, P = .006, HR 5.969, 95% CI 1.115-31.952). In patients with FIGO stage IVB, those with only extra-abdominal lymph node metastases had better survival.

CONCLUSIONS

In patients with FIGO stage IV, complete resection of intra-abdominal tumor foci and completion of chemotherapy provided considerable survival benefits to patients with FIGO stage IV OC. Among patients with FIGO stage IVB, those with only extra-abdominal lymph node metastases had a better prognosis.

Neoadjuvant chemotherapy in advanced epithelial ovarian cancer by histology: A SEER based survival analysis

To evaluate the prognostic effect of neoadjuvant chemotherapy (NACT) in advanced epithelial ovarian cancer (EOC) patients with different histological subtype. Stage III/IV EOC patients diagnosed between 2010 and 2018 were identified from the surveillance, epidemiology, and end results database (SEER) database and stratified by histological subtype. Kaplan-Meier analysis was used for the assessment of overall survival (OS) cause-specific survival (CSS) before and after matching for baseline characteristics between NACT and primary debulking surgery (PDS) groups. Cox proportional risk model was conducted to identify independent prognostic factors. A total of 13,582 patients were included in the analysis. Of them, 9505 (74.50%) received PDS and 3253 (25.50%) received NACT. Overall, an inferior OS and CSS was observed among patients with high-grade serous carcinoma (HGSC) receiving NACT, while NACT served as a protective factor in clear cell carcinoma and carcinosarcoma in both original cohorts and adjusted cohorts. For other histo-subtypes, PDS showed survival benefit over NACT in certain cohorts of models. Prognostic effect of NACT in advanced EOC differed from pathological subtypes. Although it served as a risk factor for HGSC, patients with less common subtypes may benefit from NACT.

Feasibility of extended cycles of neoadjuvant chemotherapy in patients with advanced ovarian cancer in terms of prognosis and surgical outcomes

OBJECTIVE

We aimed to identify the effect of an extended number of neoadjuvant chemotherapy (NAC) cycles on prognosis and surgical morbidity after interval debulking surgery (IDS) in patients with newly diagnosed advanced ovarian cancer.

METHODS

Medical records of patients with advanced ovarian cancer treated with NAC and having undergone IDS were retrospectively reviewed. Clinicopathological factors were compared between two groups: conventional (≤4 cycles) and extended (≥5 cycles) NAC groups. Kaplan-Meier analysis was performed to evaluate progression-free survival (PFS) and overall survival (OS).

RESULTS

A total of 156 patients were included, 112 patients in the conventional group and 44 patients in the extended NAC group. The extended NAC group had a significantly higher frequency of cancer antigen (CA)-125 normalization after NAC (59.1% vs. 33.9%, P = 0.004), a lower rate of bowel surgery (18.2% vs. 34.8%, P = 0.042), and a lower rate of transfusion during or after IDS (36.4% vs. 59.8%, P = 0.008) as compared to the conventional group. The complete cytoreduction rate after IDS was similar between the groups. In multivariate Cox regression analysis for PFS, radiologically stable and progressive disease after NAC (Hazard ratio [HR], 1.983; 95% Confidence interval [CI], 1.141-3.446; P = 0.015) and gross residual tumor after IDS (HR, 2.054; 95% CI, 1.414-2.983; P < 0.001) were independent risk factors for poor PFS. However, extended NAC cycles were not significantly associated with poor PFS. The median PFS was 19.5 and 16.9 months (P = 0.830), and the 5-year OS was 71.4 and 63.2% (P = 0.677) in the conventional and extended NAC groups, respectively.

CONCLUSION

Our study showed that extended NAC cycles were not inferior to conventional NAC cycles in terms of survival in patients with advanced ovarian cancer and reduced surgical morbidity such as bowel surgery and transfusion during or after IDS.

Response to treatment and prognostic significance of supradiaphragmatic disease in patients with high-grade serous ovarian cancer

OBJECTIVES

This study was designed to investigate the response to chemotherapy of supradiaphragmatic disease diagnosed by preoperative imaging. As secondary objectives, oncologic outcomes of patients affected by supradiaphragmatic disease and their pattern of recurrence were also evaluated.

METHODS

Data of consecutive patients with newly diagnosed FIGO stage IV (for supradiaphragmatic disease) epithelial ovarian cancer undergoing either primary debulking surgery or neoadjuvant chemotherapy plus interval debulking surgery between 2004 and 2021, were retrospectively collected. All patients were preoperatively evaluated by chest/abdominal CT scan or ¹⁸F-FDG PET/CT preoperatively and at follow-up to evaluate response to chemotherapy. At follow-up visits, site of recurrence diagnosed by imaging techniques was systematically recorded as it occurred. Progression-free and overall survival were measured by using Kaplan-Meier and Cox models.

RESULTS

A total of 130 patients was included in this study with a median (range) follow-up of 32.9 (12.8-176.7) months. Complete or partial response was achieved in most of the patients after 3 cycles (77.7%) and 6 cycles (85.4%) of chemotherapy. At follow-up, recurrence occurred in 96 (73.8%) patients and the main site of recurrence was abdomen only in 64 (66.7%) patients. At multivariate analysis, residual disease after surgery was the only variable influencing survival outcomes.

CONCLUSIONS

Supradiaphragmatic disease respond to chemotherapy in most patients affected by advanced EOC and recurrence mainly occurs in the abdomen. Results from this study confirms that abdominal optimal cytoreduction is the main surgical goal in the treatment of women affected by FIGO stage IV EOC.

What are the implications of radiologically abnormal cardiophrenic lymph nodes in advanced ovarian cancer? An analysis of tumour burden, surgical complexity, same-site recurrence and overall survival

INTRODUCTION

Our paper evaluates the relationship between radiologically abnormal cardiophrenic lymph nodes (CPLN) in advanced ovarian cancer and pattern of disease distribution, tumour burden, surgical complexity, rates of cytoreduction and same-site recurrence. Impact of suspicious CPLN and CPLN dissection on overall survival also determined.

MATERIALS AND METHODS

Retrospective review of index CT imaging for 151 consecutive patients treated for stage III/IV ovarian malignancy in a large UK cancer centre to identify radiologically abnormal CPLN. Corresponding surgical, histo-pathological and survival data analysed.

RESULTS

42.6% of patients had radiologically 'positive' CPLN on index CT. Radiological identification of CPLN involvement demonstrated a sensitivity of 82% within our centre. Patients with cardiophrenic lymphadenopathy on pre-operative CT had significantly more co-existing ascites (p = 0.003), omental (p = 0.01) and diaphragmatic disease (p < 0.0001). At primary debulking (PDS), suspicious CPLN were associated with significantly higher surgical complexity scores, without feasibility of complete cytoreduction being impacted. Cardiophrenic involvement at initial diagnosis was associated with same-site relapse at recurrence (p = 0.001). No significant difference in overall survival was demonstrated according to CPLN status following either PDS or delayed debulking (DDS). CPLN dissection did not improve patient outcomes.

CONCLUSION

Radiological identification of abnormal CPLN is reliable. Suspicious CPLN appear to represent a surrogate marker of tumour volume - in particular, heralding upper abdominal disease - and should prompt anticipation of high complexity surgery and referral to an appropriate centre. Patients with prior CPLN involvement are more likely to develop same-site recurrence at relapse. Our survival data suggests cardiophrenic LN disease does not worsen patient prognosis and that the therapeutic benefit of CPLN dissection remains unclear.

Construction and validation of a histone acetylation-related lncRNA prognosis signature for ovarian cancer

Ovarian cancer (OC) leads to the most deaths among gynecological malignancies. The various epigenetic regulatory mechanisms of histone acetylation in cancer have attracted increasing attention from scientists. Long non-coding RNA (lncRNA) also plays an important role in multiple biology processes linked to OC. This study aimed to identify the histone acetylation-related lncRNAs (HARlncRNAs) with respect to the prognosis in OC. We obtained the transcriptome data from Genotype-Tissue Expression (GTEx) project and The Cancer Genome Atlas (TCGA); HARlncRNAs were first identified by co-expression and differential expression analyses, and then univariate Cox regression and the least absolute shrinkage and selection operator (LASSO) were used to construct the HARlncRNAs risk signature. Kaplan–Meier analysis, time-dependent receiver operating characteristics (ROC), univariate Cox regression, multivariate Cox regression, nomogram, and calibration were conducted to verify and evaluate the risk signature. Gene set enrichment analysis (GSEA) in risk groups were conducted to explore the tightly correlated pathways with the risk group. A risk signature with 14 HARlncRNAs in OC was finally established and further validated in the International Cancer Genome Consortium (ICGC) cohort; the 1-, 3-, and 5-year ROC value, nomogram, and calibration results confirmed the good prediction power of this model. The patients were grouped into high- and low-risk subgroups according to the risk score by the median value. The low-risk group patients exhibited a higher homologous recombination deficiency (HRD) score, LOH_frac_altered, and mutLoad_nonsilent. Furthermore, consensus clustering analysis was employed to divide OC patients into three clusters based on the expression of the 14 HARlncRNAs, which presented different survival probabilities. Principal component analysis (PCA) and t-distributed stochastic neighbor embedding (t-SNE) were also performed to evaluate the three clusters. In conclusion, the risk signature composed of 14 HARlncRNAs might function as biomarkers and prognostic indicators with respect to predicting the response to the anti-cancer drugs in OC.

Survival in Advanced-Stage Epithelial Ovarian Cancer Patients with Cardiophrenic Lymphadenopathy Who Underwent Cytoreductive Surgery: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the clinical outcomes of enlarged cardiophrenic lymph node (CPLN) in advanced-stage epithelial ovarian cancer (AEOC) patients who underwent cytoreductive surgery.

METHODS

The Embase, Medline, Web of Science, Cochrane Library, and Google Scholar databases were searched for articles from the database inception to June 2021. Meta-analysis was conducted to determine the prognostic impact of surgical outcome, postoperative complication, and survival using random-effects models.

RESULTS

A total of 15 studies involving 727 patients with CPLN adenopathy and 981 patients without CPLN adenopathy were included. The mean size of preoperative CPLN was 9.1± 3.75 mm. Overall, 82 percent of the resected CPLN were histologically confirmed pathologic nodes. Surgical outcomes and perioperative complications did not differ between both groups. The median OS time was 42.7 months (95% CI 10.8-74.6) vs. 47.3 months (95% CI 23.2-71.2), in patients with and without CPLN adenopathy, respectively. At 5 years, patients with CPLN adenopathy had a significantly increased risk of disease recurrence (HR 2.14, 95% CI 1.82-2.52, p < 0.001) and dying from the disease (HR 1.74, 95% CI 1.06-2.86, p = 0.029), compared with those without CPLN adenopathy. CPLN adenopathy was significantly associated with ascites (OR 3.30, 95% CI 1.90-5.72, p < 0.001), pleural metastasis (OR 2.58, 95% CI 1.37-4.82, p = 0.003), abdominal adenopathy (OR 2.30, 95% CI 1.53-3.46, p < 0.001) and extra-abdominal metastasis (OR 2.30, 95% CI 1.61-6.67, p = 0.001).

CONCLUSIONS

Enlarged CPLN in preoperative imaging is highly associated with metastatic involvement. Patients with CPLN adenopathy had a lower survival rate, compared with patients without CPLN adenopathy. Further randomized controlled trials should be conducted to definitively demonstrate whether CPLN resection at the time of cytoreductive surgery is beneficial.

Addressing hepatic metastases in ovarian cancer: Recent advances in treatment algorithms and the need for a multidisciplinary approach

The lifetime risk for ovarian cancer incidence is 1.39% and the lifetime risk of death is 1.04%. Most ovarian cancer patients are diagnosed at advanced stages (III, IV) because there were no specific symptoms or existing screening tests. Liver metastases have been found in up to 50% of patients dying of advanced ovarian cancer. Recent studies indicate the need for a multidisciplinary approach from initial diagnosis to oncologic surgery and chemotherapy treatment, mandating the involvement of gynecologic oncologists, surgical oncologist, medical oncologists, hepatobiliary surgeons, and interventional radiologists.

Preoperative LMR and Serum CA125 Level as Risk Factors for Advanced Stage of Ovarian Cancer

Objectives: This study was to analyze the relationships between lymphocyte-to-monocyte ratio (LMR) alone or combined with serum CA125 (COLC) and advanced stage of ovarian cancer (OC).

Methods: The receiver-operating characteristic (ROC) curves of LMR, CA125, and COLC staging OC were constructed by a retrospective study. Furthermore, a binary logistic regression model was used to assay the independent risk factors for OC staging.

Results: Two hundred and twenty-five patients with OC were identified in this cohort. Eighty-five OC patients were diagnosed at an early stage, and 140 OC patients were diagnosed at an advanced stage. The median of LMR in the early stage was higher than that in advanced stage (4.4 vs. 2.8), and the median of serum CA125 was lower than that in advanced stage (80 U/mL vs. 251.3 U/mL). Multivariate logistic regression LMR≤3.7 (OR=0.299, 95% CI: 0.093-0.962, P=0.043) and CA125>95.7 U/mL (OR=4.317, 95% CI: 1.436-12.977, P=0.009) were risk factors for stage of advanced OC whether presence or absence of malignant ascites. Furthermore, the area under the curve of COLC was higher than that of LMR (0.782 vs. 0.732) or serum CA125 (0.782 vs. 0.708) in staging OC. The specificity of COLC was higher than that of LMR (87.1% vs. 70.6%) or serum CA125 (87.1% vs. 61.2%) in staging OC.

Conclusion: LMR alone or in combination with serum CA125 might be associated with OC staging. Besides, as a predictive factor, COLC may have a high specificity in staging OC.

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.

Role of surgery and hyperthermic intraperitoneal chemotherapy in ovarian cancer

Ovarian cancer is one of the deadliest gynaecological malignancies and tends to be diagnosed at an advanced stage. Similar to many malignancies, surgery plays a critical role in many aspects of ovarian cancer management. Hyperthermic intraperitoneal chemotherapy (HIPEC) involves the induction of hyperthermia and delivery of intraperitoneal chemotherapy directly into the peritoneal cavity. Combined with cytoreductive surgery, HIPEC is an emerging treatment modality for ovarian cancer. Ovarian cancer survival outcomes can be improved by treatment with surgery and HIPEC in selected patients. Thus, this study aimed to review the current role of surgery and HIPEC in epithelial ovarian cancer. Evidence from the monumental and recent literature will be introduced.

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Surgery plays a critical role in many aspects of ovarian cancer management.

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Combined with cytoreductive surgery, HIPEC is an emerging modality for ovarian cancer.

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Improvement of survival outcomes is expected by applying individualised surgery and HIPEC for each ovarian cancer patient.

To compare the optimal cytoreduction rate in advanced epithelial ovarian cancer stage III/IV after 3 versus 6 cycles of neoadjuvant chemotherapy

This study aimed to compare the impact of 3 versus 6 cycles of neoadjuvant chemotherapy (NACT) on the optimal cytoreduction in patients of advanced ovarian malignancy during interval debulking surgery (IDS). Thirty patients with advanced-stage IIIc/IV epithelial ovarian cancer, fallopian tube cancer, and primary peritoneal cancer were randomly allocated to receive 6 cycles in the late IDS group versus 3 cycles in early IDS before undergoing interval debulking surgery. A higher percentage of patients achieved optimal cytoreduction in the late IDS group compared to the early IDS group (60 versus 23%) which was statistically significant (p = .010). Giving 6 cycles of NACT before surgery increased the odd of optimal cytoreduction by 10 than giving 3 cycles of NACT which was statistically significant (p = 0.046) Thus, we conclude that administering 6 cycles of neoadjuvant chemotherapy before debulking surgery helps in achieving optimal cytoreduction in a higher number of patients with lesser surgical morbidity.IMPACT STATEMENTWhat is already known on the subject? Currently, there are no established criteria that would help to determine the number of chemotherapy cycles before debulking surgery in patients with advanced ovarian malignancy.What do the results of this study add? Administering 6 cycles of neoadjuvant chemotherapy before debulking surgery helps in achieving optimal cytoreduction in a higher number of patients with lesser surgical morbidity in cases of advanced epithelial ovarian cancer.What are the implications of these findings for clinical practice and/or further research? We conclude that late interval debulking may be used as a treatment option in the advanced stage IIIc/stage IV. However, the findings need to be studied in a larger study group with a longer follow up period.

Extra-abdominal ovarian cancer presenting with breast metastases at diagnosis: Case report and literature review

OBJECTIVE

Malignant ovarian tumours are diagnosed at an advanced stage in the majority of cases. However, only a small percentage present as extra-abdominal, non-lymph-node solid metastases, as in the breast, and they are usually cases of relapse. The discovery of mono- or bilateral breast lesions with peritoneal carcinosis and/or abdomino-pelvic lesions can be cumbersome in the differential diagnosis of primary tumours. This article aims to summarize current evidence on the detection of breast metastases at diagnosis of ovarian cancer.

STUDY DESIGN

A systematic review of the literature in Scopus, PubMed/MEDLINE, ScienceDirect and the Cochrane Library, including case reports and case series, was undertaken. Data regarding study features; population characteristics; clinical, radiological and histological assessment of the disease; treatment and follow-up were collected. In addition, a case report of a patient managed at the authors' centre is provided.

RESULTS

According to the search strategy, 16 articles (18 patients) were included in this review. Serous ovarian, fallopian tube or primary peritoneal cancer was detected in 61% of cases, while another type or a non-specified type of epithelial ovarian cancer was detected in 27.7% of cases; there was one case with granulosa cell tumour of the ovary and one case with mucinous ovarian tumour of low malignant potential. Breast metastases were mainly monolateral (66.6%), with other extra-abdominal sites of disease in the majority of the cases. A minority of patients (16.6%) received treatment for primary breast cancer with a subsequent diagnosis of ovarian cancer. Concomitant breast and abdominal surgery can be an option. PAX8, WT1 and CA125 immunohistochemical staining can aid in differential diagnosis.

CONCLUSION

Breast metastases of malignant ovarian tumours must be promptly recognized to ensure proper treatment. Specific immunohistochemical analysis can be a decisive assessment in uncertain cases.

A descriptive study of the clinico-pathological and surgical characteristics of patients with primary epithelial ovarian cancer. A cross sectional study

Objective

To study the clinical, pathological and surgical features of primary epithelial ovarian cancer treated at our institution.

Methods

fifty-nine patients with primary epithelial ovarian cancer were included. Clinical data collected included patient's age, presenting symptoms, laboratory and tumor markers results as well as preoperative imaging reports. Pathological and surgical findings included were: spread of the disease, histologic type, stage of the disease, type of surgical procedure and amount of residual disease.

Results

Mean age of the patients was 54.5 years. Lower abdominal pain was the most common presenting symptom, followed by abdominal distension. The commonest histopathological type was high grade serous carcinoma (72.9%). In our study, majority of patients were diagnosed with stage III disease, accounting for 69.5% of the total number of patients. Complete cytoreduction with no gross residual disease was achieved in 77.3% of patients with stage 3–4 disease.

Conclusion

clinical and pathological features of primary epithelial ovarian carcinoma in our populations are similar to what is reported worldwide. We have also documented that our surgical approach to the management of ovarian cancer is comparable to the international consensus.

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The commonest histopathological type of ovarian cancer in our institute is high grade serous carcinoma (72.9%).

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In our study, majority of patients were diagnosed with stage III disease, accounting for 69.5% of the total number of patients.

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Complete cytoreduction with no gross residual disease was achieved in 77.3% of patients with stage 3–4 disease.

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We have reported a high complete cytoreduction rate (77.3%).

Prognostic significance of preoperative circulating FAR and FCI scores in patients with ovarian cancer

BACKGROUND

Ovarian malignancy is among the most common lethal cancers in gynaecology. It has been considered that nutrition status and inflammation are two essential factors associated with the poor survival rates of patients suffering from multiple tumours.

METHODS

This research included 174 subjects who suffered from FIGO stage I-IV OC and underwent surgeries between May 2008 and March 2013.

RESULTS

The results showed that FAR, T3-T4 depth, high CA125, stage III-IV and metastasis were highly associated with low overall survival rates. Moreover, higher FCI was markedly correlated with decreased survival in patients with OC.

CONCLUSIONS

The combination of FAR and CA125 could be a new non-invasive marker in blood and probably assist physicians in evaluating the prognosis of patients.

The Prevalence and associated Factors for Liver Metastases, Development and Prognosis in newly diagnosed Epithelial Ovarian Cancer: A large Population-Based Study from the SEER Database

Background: Primary Epithelial Ovarian Cancer (EOC), a malignant gynecologic disease, is considered one of the leading causes of mortality in women. The development of Liver Metastases (LM) in women with primary ovarian cancer commonly results in a poorer prognosis. This retrospective population-based study aims to measure the prevalence, prognostic factors, and associated risk factors for epithelial ovarian cancer patients with liver metastases (EOCLM). Materials and Methods: The current study cohort of patients based on the Surveillance, Epidemiology, and End Results (SEER) database identified with primary ovarian cancer between the years 2010 and 2016. A chi-square test was employed to compare Metastatic differences among demographic and clinical factors. Univariable and multivariable logistic regression analysis models were used to predict related prognostic factors for LM development. 7-year Kaplan-Meier curves were applied to compare the survival patterns of patients with and without LM. The Multivariable Cox regression model was used to estimate potential risk factors associated with LM related deaths. Results: 33895 eligible primary EOC patients were identified. Among them 2635 (7.77%) patients were initially diagnosed with de novo LM, and 31260 (92.23%) without metastases disease to any site. Non-serous histology type; Malignant Brenner Carcinoma, NOS (OR 1.94; CI: 1.39-2.71; P<0.001), T3/T1 stage (OR 5.65; CI: 3.87-8.24; P<0.001), N1/N0 stage (OR 1.67; CI: 1.43-4.95; P<0.001), grade; G3/G1 (OR 2.16; CI: 1.29-3.59, P<0.001), and cancer antigen-125; Elevated/Normal (OR 1.79; CI: 1.19-2.69, P<0.001) were significantly associated with LM occurrence. The median survival of EOC patients with LM was 12.0 (95% CI: 11.0-14.0; P<0.001) months. Multivariable cox regression showed being unmarried (HR 1.16; CI: 1.04-1.30; P=0.001), non-serous histology types, Mucinous (HR 2.38; CI: 1.82-3.12; P<0.001), Clear cell (HR 1.83; CI: 1.32-2.55; P<0.001), Malignant Brenner Carcinoma, NOS (HR 1.44; CI:1.23-1.66; P<0.001), Carcinosarcoma NOS, (HR 1.44; CI: 1.11-1.88; P<0.001) and radiotherapy (HR 1.52; CI: 1.12-2.06; P<0.001), were positively related to death. Chemotherapy (HR 0.30; CI: 1.12-2.06; P<0.001) and surgery (HR 0.34; CI: 0.29-0.39; P<0.001) were related with reduced rate of death. Conclusion: The retrospective cohort study showed that women with primary EOC had some high-risk factors associated with LM. LM can intensely decrease the survival of EOC patients. The findings of our research provided estimates for LM occurrence prediction and potential prognostic factors of EOC with de novo LM development. These findings can be useful for follow-up strategies, guidelines for screening, and treatment of EOCLM.

Metastatic patterns do not provide additional prognostic information for patients with FIGO stage IV high-grade serous ovarian cancer

BACKGROUND

The aim of our study was to investigate whether metastatic patterns were associated with the prognosis of patients with FIGO stage IV high-grade serous ovarian cancer (HGSC).

METHODS

We retrospectively investigated 83 consecutive patients with FIGO stage IV HGSC who underwent primary surgery between April 2005 and June 2013 at our institution. Metastatic patterns were defined as pleural effusion (stage IVA), parenchymal metastases (stage IVB), and extra-abdominal lymph node metastases (stage IVB). Correlations of clinical characteristics and prognosis with metastatic patterns were analyzed.

RESULTS

Forty-two (50.6%) patients were stage IVA with pleural effusion. Among the remaining stage IVB patients, 19 (22.9%) patients had parenchymal metastases and 22 (26.5%) had extra-abdominal lymph node metastases. FIGO IVA and IVB subclassification did not have a prognostic impact on progression-free survival (PFS) (P = .361). In addition, no differences in PFS were observed among patients presenting the three metastatic patterns (P = .506). The 5-year overall survival (OS) rates of patients with stage IVA and IVB diseases were 35.2% and 34.3%, respectively, (P = .856). In addition, metastatic patterns did not provide additional prognostic information for OS (P = .292).

CONCLUSION

Neither the subclassification into FIGO IVA and IVB stages nor metastatic patterns of FIGO stage IV provided additional prognostic information.

Perception of side effects associated with anticancer treatment in women with breast or ovarian cancer (KEM-GO-1): a prospective trial

PURPOSE

Due to advances in anticancer treatment and supportive care, patients increasingly complained about nonphysical side effects of chemotherapy and targeted therapy in recent years. Therefore, continuous assessment of side effects and patients' perceptions is important. The aim of this study was to evaluate the identification and severity of side effects perceived by ovarian cancer (OC) and breast cancer (BC) patients undergoing contemporary anticancer therapy.

METHODS

Between 2015 and 2017, consecutive chemo-naïve OC and BC patients were enrolled in this prospective cohort study. Interviews were performed 12 ± 3 weeks after start of anticancer therapy, and patients were asked to select and rank, according to severity, 72 physical or nonphysical symptoms potentially related to their treatment. Data were analyzed with descriptive statistics.

RESULTS

Forty-five OC patients and 98 BC patients completed the interview. Sleeping difficulties were ranked as the most troublesome symptom, followed by concerns about family or partner, and loss of hair. Alopecia was the most predominant side effect for BC patients, whereas OC patients were highly afflicted by numbness in limbs. Chemotherapy alone or in combination with targeted therapy caused pronounced sleep disturbances. Prolonged taxane treatment led to shortness of breath and numbness in limbs. Vomiting was ranked by one and nausea by eight women among the five most bothersome symptoms.

CONCLUSIONS

Sleep disturbances have lately emerged as the most severe problem in women with OC or BC receiving anticancer therapy. Concerns about family and partner were ranked second in the current study and first in previous investigations.

The Feasibility of Cardiophrenic Lymphnode Assessment and Removal in Patients Requiring Diaphragmatic Resection During Interval Debulking Surgery for Ovarian Cancer

BACKGROUND

Several studies have demonstrated the feasibility and role of bulky cardiophrenic lymph nodes (CPLNs) resection during primary debulking surgery (PDS) for stage IV ovarian cancer (OC). However, no studies, to date, investigated the accuracy and feasibility of CPLNs assessment and removal during interval debulking surgery (IDS) after neoadjuvant chemotherapy (NACT).

MATERIAL AND METHODS

A retrospective analysis of consecutive stage IV OC patients who underwent NACT followed by IDS with CPLNs assessment and/or resection from July 2017 to June 2018. Bulky CPLNs were considered for excision when a full-thickness diaphragmatic resection was required in order to achieve complete tumour resection.

RESULTS

A total of 21 ovarian cancer stage IV patients treated with NACT followed by IDS were identified. Seven (33.3%) patients underwent CPLNs resection due to bulky appearance of the CPLNs at the intraoperative palpation. The final histological examination of the CPLNs reported metastatic disease in four (57%) of seven patients. Complete cytoreduction without residual disease was achieved in five cases (71.4%) while in two case (28.6%) optimal cytoreduction was performed. Intra-operative surgical complications occurred in one patient. One patient had a major postoperative complication (Clavien-Dindo 3). Two cases of postoperative cardiac arrhythmia were observed.

CONCLUSIONS

CPLNs intraoperative assessment is less accurate during IDS compared to previous PDS studies. CPLNs removal during IDS after NACT for stage IV OC could be safely performed to achieve a complete resection.

Malignant Pleural Effusion and Its Current Management: A Review

Malignant pleural effusion (MPE) is an exudative effusion with malignant cells. MPE is a common symptom and accompanying manifestation of metastatic disease. It affects up to 15% of all patients with cancer and is the most common in lung, breast cancer, lymphoma, gynecological malignancies and malignant mesothelioma. In the last year, many studies were performed focusing on the pathophysiological mechanisms of MPE. With the advancement in molecular techniques, the importance of tumor-host cell interactions is becoming more apparent. Additionally, the process of pathogenesis is greatly affected by activating mutations of EGFR, KRAS, PIK3CA, BRAF, MET, EML4/ALK and RET, which correlate with an increased incidence of MPE. Considering all these changes, the authors aim to present a literature review of the newest findings, review of the guidelines and pathophysiological novelties in this field. Review of the just recently, after seven years published, practice guidelines, as well as analysis of more than 70 articles from the Pubmed, Medline databases that were almost exclusively published in indexed journals in the last few years, have relevance and contribute to the better understanding of the presented topic. MPE still presents a severe medical condition in patients with advanced malignancy. Recent findings in the field of pathophysiological mechanisms of MPE emphasize the role of molecular factors and mutations in the dynamics of the disease and its prognosis. Treatment guidelines offer a patient-centric approach with the use of new scoring systems, an out of hospital approach and ultrasound. The current guidelines address multiple areas of interest bring novelties in the form of validated prediction tools and can, based on evidence, improve patient outcomes. However, the role of biomarkers in a clinical setting, possible new treatment modalities and certain specific situations still present a challenge for new research.

Combined score of pretreatment platelet count and CA125 level (PLT-CA125) stratified prognosis in patients with FIGO stage IV epithelial ovarian cancer

Background

The majority of death-related ovarian cancer is epithelial ovarian cancer (EOC). Regarding the Federation of Gynecology and Obstetrics (FIGO) stage IV EOC, the 5-year overall survival (OS) has not changed in last decades. Platelet (PLT) count and CA125 level are both prognostic markers that related to inflammation and immune evasion in EOC. This study intended to assess the prognostic value of pretreatment PLT count and CA125 level in FIGO stage IV EOC.

Methods

The study included 108 patients diagnosed with FIGO stage IV EOC and treated with surgery and/or chemotherapy between January 1995 and December 2016. The PLT counts and CA125 levels of the patients before any treatment were analysed with clinical and pathological parameters, OS and progression-free survival (PFS). The survival of different groups was analyzed using the Kaplan-Meier method. The PLT-CA125 scores (0, 1, and 2) were defined basing on the presence of thrombocytosis (PLT count > 400,000/μL), an elevated CA125 level (CA125 > 1200 U/mL), or both. The prognostic value of PLT-CA125 was assessed with a Cox regression model.

Results

Median OS, but not median PFS, was significantly decreased in patients with thrombocytosis or elevated CA125 levels when compared with the others (p = 0.011 & p = 0.004). The median OS was significantly decreased in patients with a PLT-CA125 score of 2 [37.8 months; 95% confidence interval (CI) 20.6–54.9] compared with patients with a PLT-CA125 score of 0 (70.0 moths, 95% CI 38.0–101.9, p < 0.001). The median PFS was also significantly decreased in patients with a PLT-CA125 score of 2 (19.6 months; 95% CI 13.0–26.3) compared with patients with a PLT-CA125 score of 0 (32.0 months; 95% CI 23.3–40.7, p = 0.011). Furthermore, multivariate analysis identified both PLT-CA125 scores of 2 and 1 as independent poor prognostic factors for OS (p = 0.004 & p < 0.001) and PFS (p = 0.033 & p = 0.017) compared with a PLT-CA125 score of 0.

Conclusions

The pretreatment PLT-CA125 score can be a reliable marker with high accessibility for stratifying prognosis in patients with FIGO stage IV EOC.

Berberine in combination with cisplatin induces necroptosis and apoptosis in ovarian cancer cells

Background

Berberine (BBR), a compound extracted from a variety of medicinal herbs, has been shown multiple pharmacological effects against cancer cells of different origins. Cisplatin (DDP) is known as an effective chemotherapeutic agent against cancer by inducing DNA damage and cell apoptosis. However, the effect of the combined used of BBR and DDP on cell necroptosis in ovarian cancer has not been reported.

Methods

OVCAR3 and three patient-derived primary ovarian cancer cell lines (POCCLs) were chosen as the experimental objects. To determine the potential anti-cancer activity of BBR and DDP in combination, we firstly treated OVCAR3 and POCCLs cells with BBR and/or DDP. The cell viability of OVCAR3 and POCCLs with treatment of BBR or DDP for different hours was measured by CCK-8 assay. Flow cytometry was used to analyze cell cycle distribution and changes in apoptotic cells after treatment with BBR and/or DDP. The morphological changes of OVCAR3 cells were observed by using Transmission electron microscopy (TEM) analysis. Proliferation, apoptosis and necroptosis related markers of OVCAR3 and POCCLs with treatment of BBR or DDP were measured by RT-qPCR, western blotting and immunofluorescence assay.

Results

Our results demonstrated that BBR significantly inhibited the proliferation of OVCAR3 and primary ovarian cancer cells in a dose- and time-dependent manner. The combination treatment of BBR and DDP had a prominent inhibitory effect on cancer cell growth and induced G0/G1 cell cycle arrest. TEM revealed that the majority of cells after BBR or DDP treatment had an increasing tendency of typical apoptotic and necrotic cell death morphology. Besides, BBR and DDP inhibited the expression of PCNA and Ki67 and enhanced the expression and activation of Caspase-3, Caspase-8, RIPK3 and MLKL.

Conclusion

This study proposed that the combination therapy of BBR and DDP markedly enhanced more ovarian cancer cell death by inducing apoptosis and necroptosis, which may improve the anticancer effect of chemotherapy drugs. The apoptosis involved the caspase-dependent pathway, while the necroptosis involved the activation of the RIPK3–MLKL pathway. We hope our findings might provide a new insight for the potential of BBR as a therapeutic agent in the treatment of ovarian cancer.

Incidental Thoracic Findings on Routine Computed Tomography in Epithelial Ovarian Cancer

INTRODUCTION

Multidetector computed tomography (MDCT) is routinely used in the surveillance of epithelial ovarian cancer. The aim of this study was to determine the incidence of thoracic findings on routine MDCT surveillance imaging in patients with ovarian carcinoma.

MATERIALS AND METHODS

Retrospective evaluation of 100 MDCT studies of patients with a diagnosis of epithelial ovarian cancer was performed at a university teaching hospital. The cross-sectional studies were reviewed by a consultant radiologist with subspeciality training in cross-sectional imaging.

RESULTS

Intrathoracic findings were identified in 35% of patients. Pleural effusions were identified in 40%, pulmonary nodules in 37%, mediastinal adenopathy in 17%, and thyroid nodules in 6% of patients. Thirty-five (35%) patients were found to have thoracic findings on computed tomography. Pleural effusions developed in 14 (40%) of these patients. Small lung nodules (<1 cm) were present in 13 (37%) patients. Mediastinal lymphadenopathy was seen in 6 (17%) patients. Two patients (6%) had thyroid nodules of unknown significance. Pleural effusions and small lung nodules were present at a similar level to that of the general population.

CONCLUSIONS

This retrospective study supports the imaging recommendations of the European Society of Urogenital Radiology that MDCT protocols for the initial staging and evaluation of recurrent disease in epithelial ovarian carcinoma require only inclusion of the lung bases to the inguinal region reducing exposure to ionizing radiation, alleviating patient anxiety, and offering a cost-benefit to hospitals.

Peptide-mediated delivery of therapeutic mRNA in ovarian cancer

Ovarian cancer is the most lethal gynecological malignancy in the developed world. In spite of intensive research, the mortality has hardly decreased over the past twenty years. This necessitates the exploration of novel therapeutic modalities. Transient protein expression through delivery of mRNA is emerging as a highly promising option. In contrast to gene therapy there is no risk of integration into the genome. Here, we explore the expression of mRNA in models of ovarian cancer of increasing complexity. The cell-penetrating peptide (CPP) PepFect 14 (PF14) was used to formulate CPP-mRNA nanoparticles. Efficient expression of a reporter protein was achieved in two-dimensional tissue cultures and in three-dimensional cancer cell spheroids. PF14 nanoparticles greatly outperformed a lipid-based transfection agent in vivo, leading to expression in various cell types of tumor associated tissue. Protein expression was restricted to the peritoneal cavity. Messenger RNA expression across different cell types was confirmed in primary ovarian cancer explants. As ovarian cancer is confined to the peritoneal cavity in most cases, the results create the basis for applications in which the tumor microenvironment is transiently modified through protein expression.

Cellular Senescence in the Treatment of Ovarian Cancer

Objective

This review aimed to update the research and development of cellular senescence in the treatment of ovarian cancer. We discussed the current mechanisms of senescence and the major biomarkers of senescence, especially the methods of cellular senescence in the treatment of ovarian cancer.

Materials and Methods

We collected all relevant studies in PubMed from 1995 to 2017. The search terms included senescence and cancer, senescence and ovarian cancer, senescence-associated secretory phenotype, ovarian cancer and chemotherapy, radiotherapy, or biotherapy. PubMed search with the key words senescence and ovarian cancer lists approximately 85 publications. After excluding the duplicated articles, we selected 68 articles most relevant to senescence and ovarian cancer in this review.

Results

Cellular senescence plays a key role in various biological processes of ovarian cancer, which is closely related with the occurrence, development, and treatment of ovarian cancer. Cellular senescence on the one hand can reduce the dose of chemotherapy in ovarian cancer; on the other hand, it also can solve the problem of tumor resistance to apoptosis. Therefore, cellular senescence has been shown to be the third intracellular mechanism of ovarian cancer prevention followed by cellular DNA repair and apoptosis.

Conclusions

In the near future, cellular senescence therapy could be a powerful tool for ovarian cancer treatment.

Isolated distant lymph node metastases in ovarian cancer. Should a new substage be created?

Objective

To evaluate the prognostic significance of isolated distant lymph node metastases in comparison to other metastatic sites and stage IIIC disease.

Methods

The National Cancer Data Base was accessed and patients diagnosed between 2004 and 2014 with stage IV or IIIC epithelial ovarian cancer who met criteria for pathological staging were identified. Overall survival (OS) was calculated with Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for confounders.

Results

A total of 33,561 patients met the inclusion criteria; 582 (1.7%) had stage IV only due to distant lymph node metastases (stage IV-LN), 8130 (24.2%) had stage IV with other sites of distant metastases (stage IV-other) and 24,849 (75.4%) had stage IIIC disease. The median OS for patients with stage IV-LN was 42.41 months (95% CI: 37.59, 47.23) compared to 30.23 months (95% CI: 29.30, 31.16) for those with stage IV-other (p < .001) and 45.57 (95% CI: 44.86, 46.28) for those with stage IIIC disease (p = .54). On multivariate analysis, patients with stage IV-other had a worse survival (HR: 1.41, 95% CI: 1.27, 1.57) compared to those with stage IV-LN. There was no statistically significant difference in survival between patients with stage IV-LN and stage IIIC disease (HR: 1.00, CI: 0.90, 1.11, p = .99).

Conclusions

Isolated distant LN metastases is associated with better survival compared to stage IV disease due to other metastatic sites and comparable to patients with stage IIIC disease.

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Stage IV due to isolated distant lymph node metastasis is rare.

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These patients had better survival compared to those with stage IV disease due to other metastases.

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Their survival was comparable to patients with stage IIIC disease.

The FIGO Stage IVA Versus IVB of Ovarian Cancer: Prognostic Value and Predictive Value for Neoadjuvant Chemotherapy

OBJECTIVE

The revised version of the International Federation of Gynaecology and Obstetrics (FIGO) staging system (2014) for epithelial ovarian cancer includes a number of changes. One of these is the division of stage IV into 2 subgroups. Data on the prognostic and predictive significance of this classification are scarce. The effect of neoadjuvant chemotherapy (NACT) versus primary debulking surgery (PDS) in relation to the subclassification of FIGO stage IV is also unknown.

METHODS

We used data of the EORTC 55971 trial, in which 670 patients with previous stage IIIC or IV epithelial ovarian cancer were randomly assigned to PDS or NACT; 160 patients had previous stage IV. Information on previous FIGO staging and presence of pleural effusion with positive cytology were used to classify tumors as either stage IVA or IVB. We tested the association between stage IVA/IVB and survival to evaluate the prognostic value and interactions between stage, treatment, and survival to evaluate the predictive performance.

RESULTS

Among the 160 participants with previous stage IV disease, 103 (64%) were categorized as stage IVA and 57 (36%) as stage IVB tumors. Median overall survival was 24 months in FIGO stage IVA and 31 months in stage IVB patients (P = 0.044). Stage IVB patients treated with NACT had 9 months longer median overall survival compared with IVB patients undergoing PDS (P = 0.025), whereas in IVA patients, no significant difference was observed (24 vs 26 months, P = 0.48).

CONCLUSIONS

The reclassification of FIGO stage IV into stage IVA or IVB was not prognostic as expected. Compared with stage IVA patients, stage IVB patients have a better overall survival and may benefit more from NACT.

Lymphatic Invasion in the Fallopian Tube is a Late Event in the Progression of Pelvic Serous Carcinoma and Correlates With Distant Metastasis

The majority of extrauterine high-grade serous carcinomas are believed to arise in the fallopian tube as serous tubal intraepithelial carcinomas. The primary mode of metastasis is intraperitoneal, and patients usually present with peritoneal carcinomatosis. Although the tubes have a rich lymphatic network, tubal lymphatic invasion is observed in only a minority of cases. Fallopian tube sections from 222 patients with advanced stage high-grade extrauterine serous carcinoma were reviewed and lymphatic invasion within the lamina propria and myosalpinx were assessed. Seventeen patients were FIGO stage II, 162 stage III, and 43 stage IV. Tubal lymphatic invasion was identified in 44 cases (19.7%). Among the cases with lymphatic invasion, nonfimbrial lamina propria, fimbrial lamina propria, and myosalpingeal lymphatic invasion were present in 23 (52%), 21 (48%), and 21 (48%), respectively. Among cases with lymphatic invasion, 16 (36%) were FIGO stage IV, while among cases without lymphatic invasion, 27 (15%) were stage IV (P=0.0014, χ). In summary, in women with advanced stage high-grade extrauterine serous carcinoma, lymphatic invasion in the fallopian tube is uncommon, and is more than twice as likely to be associated with distant metastases as compared with those without tubal lymphatic invasion.

Localization of distant metastases defines prognosis and treatment efficacy in patients with FIGO stage IV ovarian cancer

BACKGROUND

Patients with ovarian cancer who are diagnosed with Federation of Gynecology and Obstetrics (FIGO) stage IV disease are a highly heterogeneous group with possible survival differences. The FIGO staging system was therefore updated in 2014.

OBJECTIVE

To evaluate the 2014 changes to FIGO stage IV ovarian cancer on overall survival.

METHODS

We identified all patients diagnosed with FIGO stage IV disease between January 2008 and December 2015 from the Netherlands Cancer Registry. We analyzed the prognostic effect of FIGO IVa versus IVb. In addition, patients with extra-abdominal lymph node involvement as the only site of distant disease were analyzed separately. Overall survival was analyzed by Kaplan-Meier curves and multivariable Cox regression models.

RESULTS

We identified 2436 FIGO IV patients, of whom 35% were diagnosed with FIGO IVa disease. Five-year overall survival of FIGO IVa and IVb patients (including those with no or limited therapy) was 8.9% and 13.0%, respectively (p=0.51). Patients with only extra-abdominal lymph node involvement had a significant better overall survival than all other FIGO IV patients (5-year overall survival 25.9%, hazard ratio 0.77 [95% CI 0.62 to 0.95]).

CONCLUSION

Our study shows that the FIGO IV sub-classification into FIGO IVa and IVB does not provide additional prognostic information. Patients with extra-abdominal lymph node metastases as the only site of FIGO IV disease, however, have a better prognosis than all other FIGO IV patients. These results warrant a critical appraisal of the current FIGO IV sub-classification.

Olaparib induced senescence under P16 or P53 dependent manner in ovarian cancer

Objective

Poly (ADP-ribose) polymerase (PARP) is an important molecule in the early stress response of DNA damage, which is involved in DNA damage repair and cellular senescence. Olaparib, as PARP inhibitor, has an anti-tumor effect on high grade serous ovarian cancer, but its effects on cellular senescence have not been reported. This study intends to explore the role of olaparib in the regulation of senescence in ovarian cancer cells.

Methods

The effects of olaparib on the senescence of ovarian cancer cells were detected by using the senescence-associated β-galactosidase (SA-β-Gal) and senescence-associated heterochromatin aggregation (SAHF). Quantitative real-time polymerase chain reaction was used to analyze the senescence-associated secretory phenotype (SASP). Cell cycle and apoptosis were detected by flow cytometry. The effect of olaparib on tumor growth was analyzed in a nude mouse xenograft transplantation model.

Results

Long-term (6 days) treatment with olaparib (5 μM) significantly inhibited the growth of ovarian cancer cells, leading to arrest the cell cycle at G0/G1 phase, significant increase the number of positive SA-β-Gal stained cells and positive SAHF cells. The expression of P16 and retinoblastoma protein (p-RB) were significantly enhanced in SKOV3 cells under olaparib treated, meanwhile, the expression of P53 and p-RB were upregulated in A2780 cells. In OVCAR-3 cells, the expression of P53 was downregulated and p-RB was upregulated. Mice with SKOV3 xenograft transplantation was given olaparib (10 mg/kg/day) via abdominal cavity administration, the tumor volume was reduced (p<0.01).

Conclusion

Continuous low dosage administration of olaparib induced senescence under P16 or P53 dependent manner in ovarian cancer.

Primary debulking surgery versus primary neoadjuvant chemotherapy for high grade advanced stage ovarian cancer: comparison of survivals

Background The aim of the study was to analyze the overall survival (OS) and progression free survival (PFS) of patients with high grade and advanced stage epithelial ovarian cancer (EOC) with at least 60 months of follow-up treated in a single gynecologic oncology institute. We compared primary debulking surgery (PDS) versus neoadjuvant chemotherapy plus interval debulking surgery (NACT + IDS) stratifying data based on residual disease with the intent to identify the rationale for therapeutic option decision and the role of laparoscopic evaluation of resectability for that intention. Patients and methods This is observational retrospective study on consecutive patients with diagnosis of high grade and International Federation of Gynecology and Obstetrics (FIGO) stage III/IV EOC referred to our center between January 2008 and May 2012. We selected only patients with a follow-up of at least 60 months. Primary endpoint was to compare PDS versus NACT + IDS in term of progression free survival (PFS) and overall survival (OS). Secondary endpoints were PFS and OS stratifying data according to residual disease after surgery in patients receiving PDS versus NACT + IDS. Finally, through Cox hazards models, we tested the prognostic value of different variables (patient age at diagnosis, residual disease after debulking, American Society of Anesthesiologists (ASA) stage, number of adjuvant-chemotherapy cycles) for predicting OS. Results A total number of 157 patients were included in data analysis. Comparing PDS arm (108 patients) and NACT + IDS arm (49 patients) we found no significant differences in term of OS (41.3 versus 34.5 months, respectively) and PFS (17.3 versus 18.3 months, respectively). According to residual disease we found no significant differences in term of OS between NACT + IDS patients with residual disease = 0 and PDS patients with residual disease = 0 or residual disease = 1, as well as no significant differences in PFS were found comparing NACT + IDS patients with residual disease = 0 and PDS patients with residual disease = 0; contrarily, median PFS resulted significantly lower in PDS patients receiving optimal debulking (residual disease = 1) in comparison to NACT + IDS patients receiving complete debulking (residual disease = 0). PDS arm was affected by a significant higher rate of severe post-operative complications (grade 3 and 4). Diagnostic laparoscopy before surgery was significantly associated with complete debulking. Conclusions We confirm previous findings concerning the non-superiority of NACT + IDS compared to PDS for the treatment of EOC, even if NACT + IDS treatment was associated with significant lower rate of post-operative complications. On the other hand, selecting patients for NACT + IDS, based on laparoscopic evaluation of resectabilty prolongs the PFS and does not worse the OS compared to the patients not completely debulked with PDS.