The impact of systematic para-aortic and pelvic lymphadenectomy on survival in patients with optimally debulked ovarian cancer

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.

The role of systematic pelvic and para-aortic lymphadenectomy in the management of patients with advanced epithelial ovarian, tubal, and peritoneal cancer: A systematic review and meta-analysis

OBJECTIVE

To investigate whether systematic pelvic and para-aortic lymphadenectomy offers superior survival rates in patients with advanced epithelial ovarian cancer (EOC), tubal, or peritoneal cancer.

METHODS

We searched the electronic databases PubMed (from 1996), Cochrane Central Register of Controlled trials (from 1996), and Scopus (from 2004) to September 2021. We considered randomised controlled trials (RCTs) comparing systematic pelvic and para-aortic lymphadenectomy with no lymphadenectomy in patients with advanced EOC. Primary outcomes were overall survival and progression-free survival. Secondary outcomes were peri-operative morbidity and operative mortality. The revised Cochrane tool for randomised trials (RoB 2 tool) was utilised for the risk of bias assessment in the included studies. We performed time-to-event and standard pairwise meta-analyses, as appropriate.

RESULTS

Two RCTs with a total of 1074 patients were included in our review. Meta-analysis demonstrated similar overall survival (HR = 1.03, 95% CI [0.85-1.24]; low certainty) and progression-free survival (HR = 0.92, 95% CI [0.63-1.35]; very low certainty). Regarding peri-operative morbidity, systematic lymphadenectomy was associated with higher rates of lymphoedema and lymphocysts formation (RR = 7.31, 95% CI [1.89-28.20]; moderate certainty) and need for blood transfusion (RR = 1.17, 95% CI [1.06-1.29]; moderate certainty). No statistically significant differences were observed in regard to other peri-operative adverse events between the two arms.

CONCLUSIONS

Systematic pelvic and para-aortic lymphadenectomy is likely associated with similar overall survival and progression-free survival compared to no lymphadenectomy in optimally debulked patients with advanced EOC. Systematic lymphadenectomy is also associated with an increased risk for certain peri-operative adverse events. Further research needs to be conducted on whether we should abandon systematic lymphadenectomy in completely debulked patients during primary debulking surgery.

A prospective randomized multicenter trial for lymphadenectomy in early-stage ovarian cancer: LOVE study

BACKGROUND

The Lymphadenectomy in Ovarian Neoplasms (LION) study revealed that systemic lymphadenectomy did not bring survival benefit for advanced ovarian cancer patients with clinically normal lymph nodes and was associated with a higher incidence of operative complications. However, there is no consensus on whether lymphadenectomy has survival benefit or not in early epithelial ovarian cancer (EOC).

METHODS

We designed the LOVE study, a multicenter, randomized controlled, phase III trial to compare the efficacy and safety of comprehensive staging surgery with or without lymphadenectomy in stages IA-IIB EOC and fallopian tube carcinomas (FTC). The hypothesis is that the oncological outcomes provided by comprehensive staging surgery without lymphadenectomy are non-inferior to those of conventional completion staging surgery in early-stage EOC and FTC patients who have indications for post-operative adjuvant chemotherapy. Patients assigned to experimental group will undergo comprehensive staging surgery, but lymphadenectomy. Patients assigned to comparative group will undergo completion staging surgery including systematic pelvic and para-aortic lymphadenectomy. All subjects will receive 3-6 cycles of standard adjuvant chemotherapy. Major inclusion criteria are pathologic confirmed stage IA-IIB EOC or FTC, and patients have indications for adjuvant chemotherapy either confirmed by intraoperative fast frozen section or previous pathology after an incomplete staging surgery. Major exclusion criteria are non-epithelial tumors and low-grade serous carcinoma. Patients with severe rectum involvement which lead to partial rectum resection will be excluded. The sample size is 656 subjects. Primary endpoint is disease-free survival.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04710797.

Ovarian clear cell carcinoma with or without endometriosis origin in a single institution cohort

BACKGROUND

As ovarian clear cell carcinoma (OCCC) has distinct clinical features, biology, genetic characteristics and mechanisms of pathogenesis, and whether the origin of endometriosis or not affects the prognosis of OCCC remains controversial.

METHODS

We retrospectively collected medical records and follow-up data of patients with OCCC treated at the Obstetrics and Gynecology Hospital of Fudan University from January 2009 to December 2019. Further, we divided patients into 2 groups. Group 1: non-endometriosis origin; Group 2: endometriosis origin. Clinicopathological characteristics and survival outcomes were compared between the 2 groups.

RESULTS

A total of one hundred and twenty-five patients with ovarian clear cell carcinoma were identified and included. In the overall patients' population, the 5 year overall survival was 84.8%, the mean overall survival was 85.9 months. The results of the stratified analysis showed that early stage (FIGO stage I/II) OCCC had a good prognosis. The results of univariate analyses indicated that a statistically significant relationship between overall survival (OS) and FIGO stage, lymph node metastasis, peritoneum metastasis, chemotherapy administration methods, Chinese herbal treatment, molecular target therapy. As for progression-free survival (PFS), a significant relationship between PFS and child-bearing history, largest residual tumor size, FIGO stage, tumor maximum diameter, lymph node metastasis was found, respectively. FIGO stage and lymph node metastasis are common poor prognostic factors affecting OS and PFS. The multivariate regression analysis revealed that FIGO stage (p = 0.028; HR, 1.944; 95% CI 1.073-3.52) and treatment by Chinese herbs (p = 0.018; HR, 0.141; 95% CI 0.028-0.716) were identified as influencing factors with regard to survival. The presence or absence of lymphadenectomy did not affect OS of 125 OCCC patients (p = 0.851; HR, 0.825; 95% CI 0.111-6.153). There was a trend towards a better prognosis for patients with OCCC of endometriosis origin than those with OCCC of non-endometriosis origin (p = 0.062; HR, 0.432; 95% CI 0.179-1.045). The two groups differed with respect to several clinicopathological factors. And the proportion of patients with disease relapse was higher in Group 1 (46.9%) than in Group 2 (25.0%), with a statistically significant difference (p = 0.048).

CONCLUSIONS

Surgical staging and treatment by Chinese herbs postoperatively are two independent prognostic factors affecting the OS of OCCC, early detection and Chinese herbal medicine combined with chemotherapy postoperatively may be a good choice. Tumor with endometriosis-origin was found less likely to relapse. While the non-necessity of lymphadenectomy in advanced ovarian cancer has been proven, the need for lymphadenectomy in the early stage ovarian cancer, including early stage OCCC, still deserved to be explored.

Impact of complete surgical staging on survival of patients with early-stage (FIGO I or II) ovarian cancer: Data from the Cote d'Or Registry of Gynecological Cancers from 1998 to 2015

INTRODUCTION

Early-stage ovarian cancer represents 20 to 33% of all ovarian cancers and is thus quite rare in France, with around 1200 new cases per year. No study to date has convincingly demonstrated the utility of lymphadenectomy in early-stage ovarian cancer. We sought to evaluate the impact on overall survival of complete surgical staging in patients management for FIGO stage I and II ovarian cancer.

METHODS

We performed a retrospective observational study using data from the Cote d'Or Registry of Gynecological Cancers. We included patients with invasive early stage epithelial ovarian cancer (FIGO stages I and II), diagnosed between 1 January 1998 and 31 December 2015.

RESULTS

A total of 179 patients were included in the study. Patients who had lymphadenectomy were younger on average (P<0.001) and had fewer comorbidities (P=0.03). Lymphadenectomy was performed during the first surgery in 59.2% of cases (58 patients) and during a second, re-staging surgery in 40.8% (n=40). When complete surgical staging was performed, the rate of up-staging (to at least FIGO stage III) was 11.2% (11/98). The median follow-up was 8.4 years. At the study, 31.6% patients with complete surgical staging had died and 48.4% patients also died in the group without lymphadenectomy, HR 0.59 CI [0.36-0.97] P<0.04.

CONCLUSION

In patients with early-stage ovarian cancer, complete surgical staging appears to yield a benefit in terms of overall survival. In 10 to 15% of cases, it leads to upstaging, with the resultant indication for maintenance therapy, which has also shown a survival benefit.

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.

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.

Assessment of Lymph Node Involvement with PET-CT in Advanced Epithelial Ovarian Cancer. A FRANCOGYN Group Study

The objective of our study is to evaluate the diagnostic performance of positron emission tomography/computed tomography (PET-CT) for the assessment of lymph node involvement in advanced epithelial ovarian, fallopian tubal or peritoneal cancer (EOC). This was a retrospective, bicentric study. We included all patients over 18 years of age with a histological diagnosis of advanced EOC who had undergone PET-CT at the time of diagnosis or prior to cytoreduction surgery with pelvic or para-aortic lymphadenectomy. We included 145 patients with primary advanced EOC. The performance of PET-CT was calculated from the data of 63 patients. The sensitivity of PET-CT for preoperative lymph node evaluation was 26.7%, specificity was 90.9%, PPV was 72.7%, and NPV was 57.7%. The accuracy rate was 60.3%, and the false-negative rate was 34.9%. In the case of primary cytoreduction (n = 16), the sensitivity of PET-CT was 50%, specificity was 87.5%, PPV was 80%, and NPV was 63.6%. The accuracy rate was 68.8%, and the false negative rate was 25%. After neoadjuvant chemotherapy (n = 47), the sensitivity of PET-CT was 18.2%, specificity was 92%, PPV was 66.7%, and NPV was 56.1%. The accuracy rate was 57.5%, and the false negative rate was 38.3%. Due to its high specificity, the performance of a preoperative PET-CT scan could contribute to the de-escalation and reduction of lymphadenectomy in the surgical management of advanced EOC in a significant number of patients free of lymph node metastases.

The impact of lymph node dissection on survival in patients with clinical early-stage ovarian cancer

Objective

To estimate the impact of lymph node dissection on survival in patients with apparent early-stage epithelial ovarian cancer (EOC).

Methods

We conducted a retrospective review of patients with clinical stage I–II EOC. All patients underwent primary surgery at Sun Yat-sen University Cancer Center between January 2003 and December 2015. Demographic features and clinicopathological information as well as perioperative adverse events were investigated, and survival analyses were performed.

Results

A total of 400 ovarian cancer patients were enrolled, and patients were divided into 2 groups: 81 patients did not undergo lymph node resection (group A), and 319 patients underwent lymph node dissection (group B). In group B, the median number of removed nodes per patient was 25 (21 pelvic and 4 para-aortic nodes). In groups A and B, respectively, the 5-year progression-free survival (PFS) rates were 83.3% and 82.1% (p=0.305), and the 5-year overall survival (OS) rates were 93.1% and 90.9% (p=0.645). The recurrence rate in the retroperitoneal lymph nodes was not associated with lymph node dissection (p=0.121). The median operating time was markedly longer in group B than in group A (220 minutes vs. 155 minutes, p<0.001), and group B had a significantly higher incidence of lymph cysts at discharge (32.9% vs. 0.0%, p<0.001).

Conclusion

In patients with early-stage ovarian cancer, lymph node dissection was not associated with a gain in OS or PFS and was associated with an increased incidence of perioperative adverse events.

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.

[Surgery in early-stage ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

Early stage ovarian epithelial cancer (stage I according to the FIGO classification, i.e. limited to ovaries) affects 20% to 33% of patients with ovarian cancer. This chapter only describes data on these presumed early stages. The rate of occult epiploic metastases varies from 2% to 4%, and leads to over-staging in stage III A of 3% to 11% of patients. Performing an omentectomy does not result in a change in survival in this situation (NP4). The rate of appendix metastasis ranges from 0% to 26.7% (NP4). In the mucinous subtype, this rate can reach 53% if the appendix is macroscopically abnormal (NP2). The rate of positive peritoneal cytology ranges from 20.9% to 27%. Positive peritoneal cytology is responsible for over-staging of patients in 4.3% to 52% of cases and appears as a poor prognostic factor on survival (NP4). The rate of occult peritoneal metastases varies from 1.1% to 16%. Performing these peritoneal biopsies results in over-staging of 4% to 7.1% (NP4). In the management of ovarian cancers at a presumed early stage, it is recommended to perform: omentectomy, peritoneal biopsies, cytology, appendectomy (grade C). In case of incomplete or incomplete initial staging, restaging including omentectomy, peritoneal biopsies and appendectomy (if not explored) is recommended; especially in the absence of a reported indication of chemotherapy. The lymph node invasion rate ranges from 6.3% to 22%. It is 4.5% to 18% for stages I and 17.5% to 31% in stages II. Between 8.5% and 13% of patients with suspected early stage ovarian cancer are reclassified to stage IIIA1 following the completion of lymphadenectomy (NP3). Pelvic and lumbo-aortic lymphadenectomy improves the survival of patients with ovarian cancer at a presumptive early stage (NP2). Pelvic and lumbo-aortic lymphadenectomy is recommended for presumed early ovarian stages (grade B). In case of initial treatment of early-stage ovarian cancer without lymph node staging, restadification including lymphadenectomy is recommended; especially in the absence of a stated indication of chemotherapy (grade B). No studies have shown any laparoscopic disadvantage compared to laparotomy for feasibility, safety, or postoperative rehabilitation (NP3) in surgical staging of patients with early-stage ovarian cancer. For the initial surgical management of these patients, the choice between laparoscopy or laparotomy depends on local conditions (tumor size) and surgical expertise. If complete surgery without risk of tumor rupture is possible, the laparoscopic approach is preferred (grade C). In the opposite case, median laparotomy is recommended. As part of surgical restadification, the laparoscopic approach is recommended (grade C). Intraoperative tumor rupture leads to a decrease in disease free survival (hazard ratio=2.28) and overall survival (hazard ratio=3.79) (NP2). It is recommended that all precautions be taken to avoid perioperative ovarian tumor rupture, including the intraoperative decision of laparoconversion (grade C). There is no specific study to answer the question of the feasibility of a one-time or two-time surgery during an extemporane diagnosis of an early stage ovarian cancer. The high sensitivity and specificity of this extemporane examination in this situation makes it possible to consider a surgical management of staging during the same operating time.

Association of lymphadenectomy and survival in epithelial ovarian cancer

PURPOSE

Lymph node metastasis has a significant contribution to the prognosis of epithelial ovarian cancer but the role of lymph node dissection in treatment is not clear. In this study, we aimed to retrospectively determine the effect of the number and localization of lymph nodes removed and the number of metastatic lymph nodes on survival.

METHODS

In this study, we retrospectively reviewed the data of 378 patients (210 patients with lymph node dissection and 168 patients with no dissection) who underwent primary surgery between 2004 and 2014 in various centers with epithelial ovarian cancer diagnosis and followed up in our medical oncology clinic. Demographic and histopathologic features, stage, Ca 125 levels, chemotherapy responses of these patients were examined and survival analyzes were performed.

RESULTS

The median age of the patients was 52 years (range 16-89) and median follow-up duration was 39 months (range 1-146). During the analysis, 156 patients (41%) died and 222 patients (59%) were alive. Patients who underwent lymphadenectomy had significantly improved progression free survival (PFS) (18 vs 31 months, P < 0.05) and overall survival (OS) (57 vs 92 months, P < 0.05). OS was longer in patients with >10 lymph nodes removed compared to patients with 1-10 lymph nodes removed (P = 0.005). Survival was found to be longer in patients with pelvic and paraaortic lymph node dissection compared to patients with only pelvic lymph node dissection (P < 0.05). Patients in stage I-II had no difference in PFS and OS. Patients in stage III-IV had no difference in PFS but there was a significant difference in OS (P = 0.02).

CONCLUSION

It may be a therapeutic effect of lymphadenectomy in advanced stage ovarian cancer. The number of lymph nodes removed and the removal of the paraaortic lymph nodes may also contribute to the treatment.

The effect of lymphadenectomy in advanced ovarian cancer according to residual tumor status: A population-based study

BACKGROUND

We investigated the effect of lymphadenectomy on the survival outcomes of patients with advanced epithelial ovarian cancer in the Surveillance, Epidemiology, and End Results database according to residual disease status.

METHODS

We evaluated 3048 patients with International Federation of Gynecology and Obstetrics stage-IIIC-IV epithelial ovarian cancer. We assessed the effect of lymphadenectomy stratified by residual disease size on cause-specific survival (CSS).

RESULTS

A total of 1904 (62.5%) patients received lymphadenectomy, and 1355 (71.2%) patients had nodal metastases. Lymph-node status had no significant association with residual tumor size in the lymphadenectomy group. In multivariate analysis, lymphadenectomy was associated with a significantly better CSS and was an independent prognostic factor for CSS. Patients with >10 lymph nodes removed had better CSS compared with non-lymphadenectomy and 1-10 lymph nodes removed groups. Lymphadenectomy was associated with a significantly better CSS in patients with no gross residual tumor, but not in patients with residual tumor ≤1 cm or >1 cm.

CONCLUSIONS

Lymphadenectomy is significantly associated with a better survival outcome in patients advanced ovarian cancer, but its positive effect diminishes as residual tumor size increases.

Impact of prognostic factors on survival rates in patients with ovarian carcinoma

PURPOSE

The aim of the present study was to invesitigate the impact of significant clinico-pathological prognostic factors on survival rates and to identify factors predictive of poor outcome in patients with ovarian carcinoma.

MATERIALS AND METHODS

A retrospective chart review of 74 women with pathologically proven ovarian carcinoma who were treated between January 2006 and April 2011 was performed. Patients were investigated with respect to survival to find the possible effects of age, gravida, parity, menstruel condition, pre-operative Ca-125, treatment period, cytologic washings, presence of ascites, tumor histology, stage and grade, maximal tumor diameter, adjuvan chemotherapy and cytoreductive success. Also 55 ovarian carcinoma patients were investigated with respect to prognostic factors for early 2-year survival.

RESULTS

The two-year survival rate was 69% and the 5-year survival rate was 25.5% for the whole study population. Significant factors for 2-year survival were preoperative CA-125 level, malignant cytology and FIGO clinical stage. Significant factors for 5-year survival were age, preoperative CA-125 level, residual tumor, lymph node metastases, histologic type of tumor, malignant cytology and FIGO clinical stage. Logistic regression revealed that independent prognostic factors of 5-year survival were patient age, lymph node metastasis and malignant cytology.

CONCLUSIONS

We consider quality registries with prospectively collected data to be one important tool in monitoring treatment effects in population-based cancer research.

Incidence and Impact of Lymph Node Metastases in Advanced Ovarian Cancer: Implications for Surgical Treatment

Background: This study aimed to clarify the impact of node involvement (affected to resected nodes) in optimally cytoreduced (residual tumour ≤1cm) stage IIIC/IV ovarian cancer. Methods: 108 consecutive patients with primary stage IIIC/IV ovarian cancer underwent stage-related surgery and got adjuvant platinum-based chemotherapy. Median follow-up: 53.5 months. All patients got systematic para-aortic and pelvic lymphadenectomy. Clinical parameters were retrospectively evaluated. Patients were stratified into 3 groups to evaluate node affection: 1) no (0%), 2) minor (>0%, ≤50%) >0 and 3) major (>50% of affected nodes). Kaplan-Meier survival curve was used to evaluate the prognostic value. Results: On average, 21.3 pelvic and para-aortic nodes were removed per patient (range 1-60 nodes). Minor nodal involvement (node ratio >0-≤0.5: (59%) was most often detected. Increasing node ratio leads to significant decreased overall survival (p<0.001). Significant best overall survival was associated with minor node involvement (node ratio >0 to ≤0.5). Complete cytoreduction correlated with node affection shows significant best prognostic impact in minor node affection compared to incomplete resection (R>0-≤1cm) independent to nodal status (OS p<0.001). Conclusion: Radical surgery is the main factor of improved overall and tumor free survival. Paraaortal and iliacal lymphadenectomy seems to play an important role for prognostic and therapeutic reasons: Prognostic in accurate staging and therapeutic in case of achieved optimal cytoreduction including lymph nodes with histology proven minor node involvement.

Staging Lymphadenectomy in Patients With Clear Cell Carcinoma of the Ovary

OBJECTIVE

The purpose of this study was to assess the rate of lymph node (LN) metastasis in comprehensively staged ovarian clear cell carcinoma (OCCC) clinically confined to the ovary and determine factors associated with LN metastasis.

METHODS

We identified all cases of OCCC treated at 4 institutions from January 1994 through December 2011. We included cases with disease grossly confined to the ovary that had surgical staging performed, including at least 10 LNs sampled. Clinical and pathologic data were abstracted from electronic medical records, and a deidentified data set was compiled and processed at a single institution. Factors potentially associated with LN metastasis were tested. Appropriate statistical tests were performed.

RESULTS

We identified 145 eligible cases that met the criteria for this analysis. Median age was 52.9 years (range, 30-81 years), and median total LN count was 19 (range, 10-74). Seven (4.8%) of 145 comprehensively staged cases had LN metastasis; 6 of these cases (4.1%) were isolated metastasis. Cytologic washings, peritoneal, omental, and fallopian tube involvement were not associated with nodal metastasis. Cases with ovarian surface involvement and positive cytology had a 37.5% incidence of LN positivity, which was statistically meaningful when compared with all other cases (P = 0.003).

CONCLUSIONS

Women who underwent comprehensive staging for clinical stage I OCCC had an LN metastasis rate of 4.8%. The subgroup of cases with both ovarian surface involvement and positive cytology had the highest incidence of LN metastasis. This may influence clinical decision making on whether to perform lymphadenectomy in patients with incidental OCCC found after salpingo-oophorectomy.

Incidence of Lymph Node Metastases in Apparent Early-Stage Low-Grade Epithelial Ovarian Cancer: A Comprehensive Review

Objectives

This study aimed to determine the incidence of lymph node (LN) metastases in presumed stage I-II low-grade epithelial ovarian cancer (EOC).

Methods

Eligible studies were identified from MEDLINE and EMBASE (time frame, 2015–1975), that analyzed patients with clinical or radiologic presumed early-stage EOC who underwent a complete pelvic and para-aortic lymphadenectomy as part of their surgical staging. The number and site of dissected and involved LNs and the correlation with overall outcome are analyzed. The termlow gradeand also the older termwell differentiatedwere used.

Results

Thirteen of 978 identified studies were selected, and 13 of 75 studies were identified as eligible. A total of 1403 patients were analyzed in these 13 retrospective studies. The final International Federation of Gynecology and Obstetrics staging after completed surgical staging was I to II in 912 patients (65%). A total of 338 patients (24%) had grade 1 tumors whereas 473 patients (34%) had grade 2, and 502 patients (36%) had grade 3 tumors. Systematic lymphadenectomy was performed in 1159 patients (83%), whereof 1142 (82%) were pelvic and para-aortic LN dissections.

In 185 patients (13%), an upstaging from an apparent clinical stage I-II to IIIC occurred because of LN involvement: 64 (35%) of the patients had only pelvic LNs metastases, 69 (37%) had only para-aortic LNs metastasis, and 51 (28%) had both a pelvic and para-aortic LN involvement. When analyzing only the patients with low-grade (grade 1 as the old classification) presumed early-stage disease (n = 273), only 8 patients (2.9%; range, 0–6.2) were identified with LNs metastases present.

Conclusions

The incidence of occult LN metastases in apparent early-stage low-grade EOC is 2.9% in a metaanalysis of retrospective studies. Future larger-scale prospectively assessed studies with established surgical quality of the LN dissection are warranted to establish the true incidence of LN metastasis in presumed early low-grade disease.

Prevalence and distribution pattern of nodal metastases in advanced ovarian cancer

The objective of this study was to examine the relevance of pelvic and para-aortic lymph node involvement and the tumour characteristics affecting nodal metastases and survival in primary advanced ovarian cancer. A total of 130 consecutive patients were retrospectively investigated. All the patients received stage-related surgery with pelvic and para-aortic lymphadenectomy. The median follow-up was 53.5 months. The clinicopathological parameters and distribution pattern of nodal metastases were evaluated. Lymph node metastases were detectable in 74.62% of the cases. Overall, both pelvic and para-aortic nodes were affected in 35.9% of the patients, whereas 13.3% had metastases only in the pelvic and 13.3% only in the para-aortic lymph nodes. Histological grade 1/2 and 3, serous and endometrioid histology were independent predictors of nodal metastasis. Serous and endometrioid cancers have shown a predilection for metastasis to the pelvic lymph nodes alone, both to the pelvic and the para-aortic nodes, or the para-aortic nodes alone. Overall survival was significantly positively affected by serous histology with positive nodes (P=0.043). It is crucial to investigate the risk factors and metastatic patterns of such patients in a multicenter analysis to evaluate individual subgroups. Prospective studies are required to investigate the prognostic effect of lymphadenectomy in advanced ovarian cancer and its association with histology and distribution pattern of nodal metastasis.

The effect of lymphadenectomy on survival and recurrence in patients with ovarian cancer: a systematic review and meta-analysis

OBJECTIVE

Our objective was to perform a meta-analysis examining the effectiveness of lymphadenectomy in patients with ovarian cancer.

METHODS

PubMed and CENTRAL databases were searched on 15 November 2015 using the terms 'lymphadenectomy', 'ovarian cancer', 'dissection', 'para-aortic', 'pelvic' and survival. Prospective and retrospective studies comparing the outcomes of surgery with or without lymphadenectomy were included. Outcomes were 5-year overall survival, progression-free survival and recurrence rate.

RESULTS

Of the 556 studies identified, 3 randomized controlled trials and 11 retrospective studies were included. Lymphadenectomy was associated with greater 5-year overall survival than no lymphadenectomy (pooled odds ratio = 1.58, 95% confidence interval: 1.41-1.77, p < 0.001). There was no difference in progression-free survival between the groups (pooled overall survival = 1.62, 95% confidence interval: 0.82-3.21, p = 0.168). Lymphadenectomy was associated with greater progression-free survival in randomized clinical trials (pooled overall survival = 1.57, 95% confidence interval: 1.11-2.21, p = 0.010), but not in retrospective studies. Lymphadenectomy was associated with a significantly lower recurrence rate (pooled overall survival = 0.51, 95% confidence interval: 0.30-0.85, p = 0.011). Lymphadenectomy was associated with greater 5-year overall survival in patients with both early and advanced stage cancer, but was associated with greater progression-free survival and lower recurrence rate only in patients with advanced stage cancer.

CONCLUSION

Lymphadenectomy is associated with greater 5-year overall survival in patients with early and advanced stage ovarian cancer, but an effect on progression-free survival and recurrence rate was only found in patients with advanced stage ovarian cancer.

The prognostic relevance of node metastases in optimally cytoreduced advanced ovarian cancer

PURPOSE

To delineate the relevance of pelvic and para-aortic node involvement in optimally cytoreduced (residual tumour <1 cm) stage IIIC ovarian cancer patients.

METHODS

Ninety-five consecutive optimally cytoreduced (R ≤ 1 cm) patients with primary stage IIIc ovarian cancer underwent stage-related surgery and got adjuvant platinum-based chemotherapy. Median follow-up: 53.5 months. All patients got systematic lymphadenectomy. On average, 24.7 pelvic and para-aortic lymph nodes were removed per patient (range 1-60 nodes). Patients were stratified into three groups to evaluate node involvement (ratio: affected to resected nodes): (1) (=0); (2) (>0-≤ 0.5) >0 and ≤ 50 % of affected nodes; (3) (>0.5-≤ 1) >50 % of affected nodes. Clinical parameters were retrospectively evaluated. Kaplan-Meier survival curve was used to evaluate the prognostic value.

RESULTS

Most often serous histology, histologic grade 3 and a node ratio >0-≤ 0.5 (61.1 %) were detected. Complete cytoreduction (R = 0 mm) has significant best prognostic impact compared to R > 0 mm-1 cm (OS: p = 0.047, PFS: p = 0.00). Node involvement was associated with serous histology and grade 3. Increasing node ratio leads to significant decreased OS (p = 0.019) and significant best OS was associated with node ratio >0-≤0.5.

CONCLUSIONS

The goal is optimal cytoreduction in advanced ovarian cancer. More extensive lymphadenectomy seems to play an important role in providing an accurate staging, and the node ratio might give prognostic information. Current prospective studies like the LION study (AGO-Ovar) had to investigate if these data have therapeutic implications and may be considered in future staging.

The Prognostic Role of Optimal Cytoreduction in Advanced, Bowel Infiltrating Ovarian Cancer

AIM

In locally advanced ovarian cancer with bowel involvement appropriate surgical treatment is still controversial. Objective was to delineate factors to select those most likely to benefit from radical surgery in patients with locally advanced ovarian cancer.

METHODS

Therefore, we retrospectively evaluated 207 consecutive patients with primary stage IIB-IV ovarian cancer who underwent primary surgery between 2000 and 2007. Every patient received stage-related surgery and adjuvant platinum-based chemotherapy. Median follow-up was 53.5 months. Data collected included stage, histology, extent of cytoreduction and type of bowel resection. Univariate survival analyses were performed to investigate variables associated with outcome.

RESULTS

Optimal cytoreduction (OCR) (R ≤ 1 cm) was achieved in 76.8%. Most patients presented histologic grade 2/3 (96.6%), serous ovarian cancers (84.1%) and lymph node involvement (52.2%). Complete cytoreduction (R = 0 mm) has significant best prognostic impact in FIGO IIB-IV (p = .026). Regarding bowel involvement, bowel resection was performed in 82 patients (39.6%). In this subgroup of patients complete cytoreduction led to significant better overall survival than R > 0 mm-1 cm, even in FIGO IIIC-IV patients (p = .027); this fact is independent of bowel resection. Noticeably, for survival bowel resection achieving residual tumor mass below 1 cm was also one main prognostic factor and even recurrence rate was associated with residual tumor mass.

CONCLUSION

Our findings suggest that the major prognostic factor in patients with advanced ovarian cancer needing colorectal resection is completeness of cytoreduction. Therefore, in advanced ovarian cancer patients, multivisceral surgery is indicated to achieve OCR (R ≤ 1 cm) with or without bowel resection with best prognostic impact.

Nodal status--its impact on prognosis in advanced ovarian cancer

PURPOSE

Prognostic impact of nodal status or lymphadenectomy in advanced ovarian cancer is still unclear. Known best prognostic impact in advanced ovarian cancer has the residual tumor mass. The aim of this retrospective study is to examine the importance of nodal status in correlation with residual tumor mass.

METHODS

One hundred and fifty-seven consecutive patients with primary stage III ovarian cancer underwent surgery between 01/2000 and 06/2007 at the Department of gynecology and obstetrics, University Hospital, Tübingen, Germany. All patients got stage-related surgery and platin-based chemotherapy. Median follow-up time was 53.5 months, and all patients were included in the study.

RESULTS

Resection status and nodal status are significant prognostic factors in our study (P < 0.001). In FIGO III, patients without residual tumor (R0) had significant best OS and PFS independent to node status (N0/N+; P = 0.002) compared to patients with residual tumor. In contrast, node status had significant positive impact on PFS in patients without residual tumor and node negativity. With the increase in residual tumor, the influence of lymphnode metastases on prognosis is decreasing.

CONCLUSION

Main intention of primary surgery is R0 resection with best prognosis in advanced stages. A systematic lymphadenectomy in cases with R0 resection or residual tumor <1 cm seems to be reasonable with positive impact on prognosis. Node status has impact on prognosis in patients with negative node after R0 resection with best PFS in FIGO III. Further prospective studies had to show whether systematic lymphadenectomy in suboptimally tumor-reduced patients can improve prognosis.