Lymphadenectomy in surgical stage I epithelial ovarian cancer

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

Introduction

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

Methods

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

Results

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

Discussion

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Predictive value of PET metabolic parameters for occult lymph node metastases in PET/CT defined node-negative patients with advanced epithelial ovarian cancer

Accurate lymph node metastasis (LNM) prediction is crucial for patients with advanced epithelial ovarian cancer (AEOC) since it guides the decisions about lymphadenectomy. Previous studies have shown that occult lymph node metastasis (OLNM) is common in AEOC. The objective of our study is to quantitatively assess the probability of occult lymph node metastasis defined by 18F-Fluorodeoxyglucose PET/CT in AEOC and explore relationship between OLNM and PET metabolic parameters. The patients with pathologically confirmed AEOC who underwent PET/CT for preoperative staging at our institute were reviewed. Univariate and multivariate analysis were performed to evaluate the predictive value of PET/CT-related metabolic parameters for OLNM. The result of our study showed metastatic TLG index had a better diagnostic performance than other PET/CT-related metabolic parameters. Two variables were independently and significantly associated with OLNM in multivariate analysis: metastatic TLG index and primary tumor location. The logistic model combining metastatic TLG index, primary tumor location, and CA125 might be a promising tool to effectively predict the individualized possibility of OLNM for AEOC patients.

The impact of omentectomy on cause-specific survival of Stage I-IIIA epithelial ovarian cancer: A PSM-IPTW analysis based on the SEER database

Objective

Routine omentectomy is generally performed during surgery for patients with epithelial ovarian cancer (EOC). The current study aims to evaluate the impact of omentectomy on cause-specific survival of Stage I-IIIA EOC patients.

Methods

Patients who presented with clinical Stage I-IIIA serous, clear cell, endometrioid, and mucinous ovarian cancers were selected from the SEER Database for the period between 2004 and 2018. We extracted clinicopathological data and surgical information with the focus on the performance of omentectomy and lymphadenectomy. Binary logistic regression and recursive partitioning analyses were conducted to identify the significant factors for the performance of omentectomy during surgery. Propensity score matching (PSM) and inverse probability treatment weighting (IPTW) techniques were utilized to balance confounding factors. Multivariate, exploratory subgroup analyses and sensitivity analyses were conducted to evaluate the impact of omentectomy on cause-specific survival (CSS).

Results

A total of 13,302 patients with EOC were enrolled in the study. The cohort comprised 3,569 endometrioid, 4,915 serous, 2,407 clear cell, and 2,411 mucinous subtypes. A total of 48.62% (6,467/13,302) of patients underwent the procedure of omentectomy during primary surgery, and only 3% absolute improvement in CSS at the individual level was observed, without statistical significance based on multivariate analysis. According to the regression-tree model with recursive partitioning analysis, the procedure of lymphadenectomy was found to be the strongest factor to distinguish the performance of omentectomy, followed by the tumor stage. Patients who underwent omentectomy were more likely to be managed in Stage I than those who underwent lymphadenectomy. After PSM-IPTW adjustment, the inclusion of omentectomy in the initial surgical procedure did not demonstrate a beneficial impact on CSS compared with those who did not undergo the procedure. Exploratory subgroup analysis indicated that the performance of omentectomy improved 5-year CSS in Stage II-IIIA patients. In the sensitive analyses for various tumor stages, omentectomy appeared to benefit only Stage II patients. However, patients across various stages seemed to benefit from the performance of lymphadenectomy, irrespective of the performance of omentectomy on them.

Conclusion

Routine omentectomy may not be associated with survival benefit for patients with a grossly normal-appearing omentum, especially for those with clinical Stage I epithelial ovarian cancers.

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.

Impact of Lymphadenectomy on Outcomes of Early-Stage Ovarian Cancer: A Systematic Review and Meta-Analysis

Objective: The study aimed to assess if additional lymphadenectomy with primary staging surgery improves overall survival (OS) and disease-free survival (DFS) of early-stage ovarian cancer (ESOC).

Methods: PubMed and Embase databases were searched for any type of study comparing OS or DFS between lymphadenectomy and control groups for any type of ESOC. Adjusted hazard ratios (HR) were pooled in a random-effects model.

Results: Twelve studies were included. Meta-analysis indicated that lymphadenectomy is associated with significantly improved OS only for epithelial tumors (HR 0.75 95% CI 0.68, 0.82 I² = 0% p < 0.00001) but not for malignant germ cell tumors (HR 1.31 95% CI 0.88, 1.94 I² = 0% p = 0.18). Single studies indicated a tendency of improved OS with lymphadenectomy which was significant for ovarian carcinosarcoma but not for sex cord-stromal tumors. On meta-regression of all histological types, the percentage of patients with lymph node metastasis in the lymphadenectomy group was not found to influence the effect size. Meta-analysis also indicated that lymphadenectomy is associated with significantly improved DFS for epithelial tumors (HR 0.59 95% CI 0.45, 0.77 I² = 0% p < 0.0001). Single studies on malignant germ cell and sex cord-stromal tumors failed to demonstrate any significant beneficial effect of lymphadenectomy on DFS.

Conclusions: Within the limitations of the review, lymphadenectomy may improve OS and DFS for epithelial ESOC. Scarce data suggest that lymphadenectomy is not associated with improved outcomes for malignant germ cell and sex cord-stromal tumors but may benefit ovarian carcinosarcoma. Large-scale RCTs and robust observational studies shall improve current evidence.

Ovarian Cancer, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States and is the country's fifth most common cause of cancer mortality in women. A major challenge in treating ovarian cancer is that most patients have advanced disease at initial diagnosis. These NCCN Guidelines discuss cancers originating in the ovary, fallopian tube, or peritoneum, as these are all managed in a similar manner. Most of the recommendations are based on data from patients with the most common subtypes─high-grade serous and grade 2/3 endometrioid. The NCCN Guidelines also include recommendations specifically for patients with less common ovarian cancers, which in the guidelines include the following: carcinosarcoma, clear cell carcinoma, mucinous carcinoma, low-grade serous, grade 1 endometrioid, borderline epithelial, malignant sex cord-stromal, and malignant germ cell tumors. This manuscript focuses on certain aspects of primary treatment, including primary surgery, adjuvant therapy, and maintenance therapy options (including PARP inhibitors) after completion of first-line chemotherapy.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Survival effect of different lymph node staging methods on ovarian cancer: An analysis of 10 878 patients

Background

To compare the survival impact of several lymph node staging methods and therapeutic role of lymphadenectomy in patients with epithelial ovarian cancer who had undergone lymphadenectomy.

Methods

Data were retrospectively collected from the Surveillance, Epidemiology, and End Results program between 1988 and 2013.

Results

An increasing number of resected lymph nodes (RLNs) was associated with a significant improvement in survival of FIGO stage II and III disease. However, for FIGO stage IV patients, better survival was not significantly associated with a more extensive lymphadenectomy. A higher lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) were associated with poorer survival regardless of stage. Nevertheless, four‐category classification of LODDS was more suitable for stage IV patients when three‐category classification was compatible with stage I‐III disease. Multivariate analysis demonstrated that LODDS and LNR were significant independent prognostic factors, but not RLN classification.

Conclusion

Sixteen to thirty RLNs are recommended for stage I disease. For stages II and III patients, the more lymph node excision, the better the prognosis. However, lymphadenectomy was nonessential for stage IV patients. Considering staging methods, for stages II and III patients, three‐category classification of LODDS was recommended to evaluate the prognosis. For stage I and IV, three‐category classification of positive LNR was idoneous.

Danish Gynecological Cancer Database

Aim of database

The Danish Gynecological Cancer Database (DGCD) is a nationwide clinical cancer database and its aim is to monitor the treatment quality of Danish gynecological cancer patients, and to generate data for scientific purposes. DGCD also records detailed data on the diagnostic measures for gynecological cancer.

Study population

DGCD was initiated January 1, 2005, and includes all patients treated at Danish hospitals for cancer of the ovaries, peritoneum, fallopian tubes, cervix, vulva, vagina, and uterus, including rare histological types.

Main variables

DGCD data are organized within separate data forms as follows: clinical data, surgery, pathology, pre- and postoperative care, complications, follow-up visits, and final quality check. DGCD is linked with additional data from the Danish “Pathology Registry”, the “National Patient Registry”, and the “Cause of Death Registry” using the unique Danish personal identification number (CPR number).

Descriptive data

Data from DGCD and registers are available online in the Statistical Analysis Software portal. The DGCD forms cover almost all possible clinical variables used to describe gynecological cancer courses. The only limitation is the registration of oncological treatment data, which is incomplete for a large number of patients.

Conclusion

The very complete collection of available data from more registries form one of the unique strengths of DGCD compared to many other clinical databases, and provides unique possibilities for validation and completeness of data. The success of the DGCD is illustrated through annual reports, high coverage, and several peer-reviewed DGCD-based publications.

Survival of ovarian cancer patients in Denmark: Results from the Danish gynaecological cancer group (DGCG) database, 1995-2012

BACKGROUND

Ovarian cancer has a high mortality rate, especially in Denmark where mortality rates have been reported higher than in adjacent countries with similar demographics. This study therefore examined recent survival and mortality among Danish ovarian cancer patients over an 18-year study period.

METHODS

This nationwide registry-based observational study used data from the Danish Gynecology Cancer Database, Danish Pathology Registry, and Danish National Patient Registry. All patients with ovarian cancer diagnosed between 1995 and 2012 were included in the study. The data sources were linked via the patients' personal identification number and the analyses included data on cancer stage, age, survival, surgery status and comorbidity. The computed outcome measures were age-adjusted mortality rates and age-adjusted overall and relative survival rates for one and five years.

RESULTS

We identified 9972 patients diagnosed with ovarian cancer in the period 1995-2012. The absolute one-year mortality rate decreased from 42.8 (CI 40.3-45.6) in 1995-1999 to 28.3 (CI 25.9-30.9) in 2010-2012, and the five-year mortality rate decreased from 28.2 (CI 27.0-29.5) in 1995-1999 to 23.9 (CI 22.9-25.0) in 2005-2009. After stratification by age, comorbidity and cancer stage, the decrease in one-year mortality was most substantial in the 65-74 year old age group 41.1 (CI 38.8-43.5) to 26.5 (CI 24.4-28.7) and for stage III 39.1 (CI 35.1-43.6) to 22.9 (CI 19.9-26.5) and stage IV 91.3 (CI 80.8-103.2) to 41.9 (CI 35.5-49.5). For overall survival, we showed an increase in one-year survival from 68% (CI 66-69%) in 1995-1999 to 76% (CI 74-78%) in 2010-2012 and an increase in five-year survival from 33% (CI 32-35%) in 1995-1999 to 36% (CI 34-38%) in 2005-2009. Relative survival showed similar increases through the period.

CONCLUSIONS

Ovarian cancer survival in Denmark has improved substantially from 1995 to 2012, bringing Denmark closer to the standards set by adjacent countries.