Impact of lymphadenectomy on survival after recurrence in patients with advanced ovarian cancer without suspected lymph node metastasis

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

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

Prognostic value of systematic lymphadenectomy in patients with ovarian cancer: A systematic review and meta-analysis

OBJECTIVE

To appraise clinical outcomes of systematic lymphadenectomy in women with ovarian cancer based on stage, control group and type of chemotherapy.

STUDY DESIGN

A literature search was conducted on SCOPUS, PUBMED, COCHRANE, MEDLINE, and WEB OF SCIENCE databases. All comparative studies that assess outcomes of systematic lymphadenectomy in patients with ovarian cancer were eligible. Overall survival was analyzed by pooling log hazard ratio (HR) and standard error of multivariable Cox regression models. MOGGE Meta-analysis Matrix is a novel illustration tool that was used to demonstrate multiple subgroup analyses of included studies.

RESULTS

Twenty-two studies were eligible. Systematic lymphadenectomy was associated with better overall survival, that was close to significance, compared to control group (HR 0.93, 95 %CI 0.86-1.00). Among women treated with adjuvant chemotherapy, overall survival improved in women with stage IIB-IV who underwent systematic lymphadenectomy (HR 0.91, 95 %CI 0.84-0.99) and was most significant among patients with stage III to IV (HR 0.85, 95 %CI 0.73-0.99). Systematic lymphadenectomy did not improve survival in women who received neoadjuvant chemotherapy (HR 0.97, 95 %CI 0.73-1.29). Systematic lymphadenectomy was associated with improved progress-free survival compared to control group (HR 0.88, 95 %CI 0.79-0.99).

CONCLUSION

Although data from clinical trials do not support role of systematic lymphadenectomy in advanced ovarian cancer, overall data conveys stage-specific survival benefit. Further clinical trials may be warranted to assess substage survival outcomes in women with advanced stages.

Systematic Lymph Node Dissection May Be Abolished in Patients With Apparent Early-Stage Low-Grade Mucinous and Endometrioid Epithelial Ovarian Cancer

OBJECTIVE

To investigate whether systematic lymph node dissection can confer clinical benefits in patients with apparent early-stage low-grade epithelial ovarian cancer.

METHODS

Patients with apparent early-stage low-grade epithelial ovarian cancer seen at Peking Union Medical College Hospital from January 1, 2005, to December 31, 2015, were retrospectively enrolled. Patients with other histological types and those who did not receive necessary adjuvant chemotherapy were excluded. Data collection and long-term follow-up were performed. According to the removed lymph node number, three groups based on surgical methods were used: abnormal lymph node resection, pelvic lymphadenectomy, and systematic lymph node dissection to control surgical quality. Their effects on prognosis were analyzed in pathological subgroups.

RESULTS

A total of 196 patients were enrolled; 30.1% of patients had serous, 42.3% of patients had mucinous, and 27.6% of patients had endometrioid carcinoma, of which 51 (26.0%), 96 (49.0), and 49 (25.0%) patients were treated with the above surgical methods, respectively. The occult lymph node metastasis rate was 14 (7.1%), and only five (2.6%) of apparent early-stage patients were upstaged due to lymph node metastasis alone. Systematic lymph node dissection did not benefit progression-free survival or disease-specific overall survival of apparent early-stage low-grade mucinous and endometrioid epithelial ovarian cancer but prolonged progression-free survival of apparent early-stage low-grade serous patients (OR, 0.231, 95% CI, 0.080, 0.668, p = 0.007).

CONCLUSIONS

Systematic lymph node dissection may be abolished in patients with apparent early-stage low-grade mucinous and endometrioid epithelial ovarian cancer but may be considered for apparent early-stage low-grade serous patients.

Lymphadenectomy for primary ovarian cancer: a systematic review and meta-analysis

Objective

To assess the effectiveness of lymphadenectomy at primary debulking surgery (PDS) on the survival of patients with epithelial ovarian cancer (EOC).

Methods

We searched PubMed, Ichushi, and the Cochrane Library. Randomized controlled trials (RCTs) and retrospective cohort studies comparing survival of women with EOC undergoing lymphadenectomy at PDS with that of women without lymphadenectomy were included. We performed a meta-analysis of overall survival (OS), progression-free survival (PFS), and adverse events.

Results

For advanced-stage EOC, 2 RCTs including 1,074 women and 7 cohort studies comprising 3,161 women were evaluated. Meta-analysis revealed that lymphadenectomy was associated with improved OS (hazard ratio [HR]=0.80; 95% confidence interval [CI]=0.70–0.90). However, meta-analysis of 2 RCTs revealed no significant difference in OS between the lymphadenectomy and no-lymphadenectomy groups (OS: HR=1.02; 95% CI=0.85–1.22). For early-stage EOC, 1 RCT comprising 268 women and 4 cohort studies comprising 14,228 women were evaluated. Meta-analysis showed that lymphadenectomy was associated with improved OS (HR=0.75; 95% CI=0.68–0.82). A RCT of early-stage EOC reported that lymphadenectomy was not associated with improved OS (HR=0.85; 95% CI=0.49–1.47). Surgery-related deaths were similar in both groups (risk ratio [RR]=1.00; 95% CI=0.99–1.01); however, blood transfusion was required less frequently in the no-lymphadenectomy group (RR=0.74; 95% CI=0.63–0.86).

Conclusions

Meta-analysis of RCTs and observational studies suggest that lymphadenectomy was associated with improved OS in advanced- and early-stage EOC. However, results from RCTs demonstrate that lymphadenectomy was not associated with improved OS in advanced- and early-stage EOC.

Effect of Waiting Time from Pathological Diagnosis to Definitive Concurrent Chemoradiation (CCRT) for Cervical Cancer on Overall Survival

Purpose

This study aimed to evaluate the effect of waiting time, from diagnosis to initiation of definitive concurrent chemoradiation (CCRT), on overall survival in cervical cancer patients.

Materials and Methods

Patients with cervical cancer who were treated with definitive CCRT between 2000 and 2017 were retrospectively reviewed. Time from initial pathological diagnosis to definitive CCRT was analyzed both as a continuous variable (per day) and as a categorical variable in two groups (group 1 ≤ median, group 2 > median). Patients with a waiting time of more than 60 days were excluded.

Results

The median waiting time was 14 days (0–60). There were differences between group 1 and group 2 in age and chemotherapy regimens. However, no significant difference was found in the International Federation of Gynecology and Obstetrics stage, cell type, or the number of cycles of chemotherapy received during CCRT. A longer waiting time was associated with poorer overall survival on the Kaplan-Meier curve (group 1 vs. group 2, p=0.042). On multivariate analysis, intervals as either a continuous variable (hazard ratio [HR], 1.023; 95% confidence interval [CI], 1.006 to 1.040; p=0.007) or a categorical variable (HR, 1.513; 95% CI, 1.073 to 2.134; p=0.018), FIGO stage, cell type, and the number of cycles of chemotherapy received during CCRT were significant independent prognostic factors for overall survival.

Conclusion

A shorter waiting time from pathological diagnosis to definitive CCRT showed benefit on overall survival. Our findings suggest that an effort to minimize waiting times should be recommended in cervical cancer patients who are candidates for CCRT.

The value of systematic lymphadenectomy during debulking surgery in the treatment of ovarian cancer: a meta-analysis of randomized controlled trials

Background

The therapeutic value of systematic lymphadenectomy during debulking surgery for ovarian cancer remains controversial. We conduct this meta-analysis to evaluate the significance of systematic lymphadenectomy in patients treated with optimal cytoreduction for ovarian cancer.

Method

The PubMed, Medline, Embase, Cochrane Library and Web of Science databases were searched up to October 2019. Only English-language publications of randomized controlled trials (RCTs) that investigated the role of systematic lymphadenectomy in patients with ovarian cancer were selected for this analysis. For overall survival (OS) and progression-free survival (PFS), pooled hazard ratios (HR) with 95% confidence intervals (CIs) were calculated; for complications rate, we calculated pooled risk ratio (RR) with 95% confidence interval (CI). Statistical heterogeneity was assessed using both the I² and chi-square tests. In cases of I² being larger than 50%, a random-effect model was used, otherwise a fixed-effect model was used.

Results

Four RCTs involving 1607 patients were included in the present analysis. There was no difference in OS between systematic lymphadenectomy and unsystematic lymphadenectomy (HR = 1.00; 95% CI = 0.94, 1.07; p = 0.90). Similarly, no significant difference was observed in PFS between these two groups (HR = 0.97; 95% CI = 0.87, 1.08; p = 0.62). And postoperative complications occurred more frequently in the systematic lymphadenectomy group (RR = 1.50; 95% CI = 1.34, 1.68; p < 0.00001).

Conclusion

Systematic lymphadenectomy in patients with optimally cytoreduced ovarian cancer was not associated with longer overall or progression-free survival than unsystematic lymphadenectomy and was associated with a higher incidence of postoperative complications.

Survival Analysis of Lymph Node Resection in Ovarian Cancer: A Population-Based Study

Objective: This study aimed at comprehensively investigating the survival impact of lymphadenectomy during primary surgery in ovarian cancer. Methods: Based on the surveillance, epidemiology, and end results registry (SEER) database, we included ovarian cancer patients with detailed information between 2010 and 2016. Cox regression was performed to select prognostic factors. We conducted propensity score-weighted survival analysis to balance baseline variables, and series of stratified analyses to control main confounding factors. Results: A total of 8,652 patients were ultimately identified. Among 4,360 patients with advanced disease, lymphadenectomy did not show significant survival benefit in general (median overall survival 44 months in non-lymphadenectomy vs. 49 months in lymphadenectomy group, P = 0.055). In subgroup analysis on patients received optimal debulking, lymphadenectomy did not significantly benefit the survival outcome (median overall survival 51, 47, 60, and 58 months in the non-lymphadenectomy, 1-9 lymph nodes, 10-19 lymph nodes, ≥20 lymph nodes groups, respectively, P = 0.287). Consistent results were observed in further stratification analyses. In optimal debulking subgroup, lymph node metastasis indicated worse survival. However, when limited the number of removed lymph nodes to more than 15, there was a marginal statistical difference in overall survival (P = 0.0498) while no significant difference presented in cause-specific survival (P = 0.129) between non-lymphadenectomy, pathological negative lymph node group and positive lymph node group. And the regions of lymph metastasis were also not significantly associate with survival (P = 0.123). Among 3,266 (75%) patients with apparent early-stage disease received lymphadenectomy, 7.75% of whom were reported isolated lymph nodes metastasis and have a poorer survival (P < 0.05). Conclusions: In primary debulking for patients with advanced ovarian cancer, lymphadenectomy was not associated with more favorable outcomes when compared to no lymphadenectomy. The value of lymphadenectomy lies more in staging for apparent early disease rather than therapeutic benefit.

Prognostic Significance of Systematic Lymphadenectomy in Patients With Optimally Debulked Advanced Ovarian Cancer: A Meta-Analysis

Background: The effect of systematic lymphadenectomy (SL) on survival in patients with optimally debulked advanced ovarian cancer remains unclear. We evaluated the therapeutic value of SL in advanced ovarian cancer patients who underwent primary optimal debulking surgery.

Methods: A meta-analysis was carried out using articles retrieved from the PubMed, Embase, and Cochrane databases. Overall survival (OS) and progression-free survival (PFS) were compared between patients who underwent SL and those who underwent unsystematic lymphadenectomy (USL).

Results: Seven studies that included 2,425 patients with advanced ovarian cancer were included in the meta-analysis. The overall analyses indicated significantly improved OS [hazard ratio (HR) = 0.64, 95% confidence interval (CI): 0.49–0.84, P < 0.01] but not PFS (HR = 0.89, 95% CI: 0.69–1.15, P = 0.38) in patients who underwent SL compared to those who underwent USL. Subgroup analyses based on study type, study quality, total numbers of patients, and International Federation of Gynecology and Obstetrics (FIGO) stage provided similar results. However, subgroup analysis of patients with no residual tumor revealed that SL was not associated with improved OS (HR = 0.81, 95% CI: 0.66–1.00, P = 0.05) or PFS (HR = 1.09, 95% CI: 0.91–1.30, P = 0.33).

Conclusions: In patients with optimally debulked advanced ovarian cancer, SL may improve OS but not PFS. However, SL does not provide a survival advantage when macroscopically complete resection of all visible tumors is achieved.

Upregulation of long non‑coding RNA CCEPR is associated with poor prognosis and contributes to the progression of ovarian cancer through regulating the Wnt/β‑catenin signaling pathway

Accumulating evidence has demonstrated that the expression of long non‑coding RNAs (lncRNAs) is altered in various types of cancer, which may prove beneficial for their use as biomarkers. Cervical carcinoma expressed PCNA regulatory lncRNA (CCEPR) is a recently identified lncRNA, which has an important role in regulating cell proliferation and apoptosis in cervical and bladder cancer; however, whether CCEPR is involved in the progression of ovarian cancer (OC) remains largely unclear. The aim of the present study was to determine the clinical significance of CCEPR in OC and to investigate its biological roles. Cell Counting Kit‑8 assay was used to analyze cell proliferation, Transwell assay was used to assess invasion, flow cytometric analysis was used to analyze apoptosis, and western blotting was used to perform mechanistic studies. CCEPR expression levels were significantly elevated in OC tissues compared with adjacent non‑cancer tissues. Similarly, significant increases in CCEPR expression were observed in OC cell lines (SK‑OV‑3 and OVCAR‑3) compared with the ovarian surface epithelial cell line, HOSEpiC. The increased expression levels of CCEPR were associated with increased invasion, higher International Federation of Gynecology and Obstetrics stage and a poorer overall survival rate. In vitro, the genetic silencing of CCEPR decreased the cell proliferation rate and invasive ability of OC cells, and promoted apoptosis. CCEPR‑silenced OC cells also demonstrated decreased expression levels of four proteins involved in the Wnt/β‑catenin signaling pathway: Cyclin D1, β‑catenin, Myc and matrix metallopeptidase‑7. In conclusion, the present study demonstrated that increased expression levels of CCEPR may predict poor prognosis in patients with OC and contribute to the progression of OC through regulating the Wnt/β‑catenin signaling pathway.