Thoracic metastasis in advanced ovarian cancer: comparison between computed tomography and video-assisted thoracic surgery

The thoracic surgeon: "The icing on the cake" in the treatment of epithelial ovarian cancer

In patients with ovarian cancer, VATS should be used to exclude or confirm the presence of supradiaphragmatic disease and possibly remove it completely. The simultaneous use of laparoscopy and VATS allows for an accurate selection of patients to be sent, in a very short time, to primary surgery or neoadjuvant chemotherapy. Therefore the thoracic surgeon should be part of the multidisciplinary team in every ovarian cancer center.

Extra-abdominal cytoreductive techniques in ovarian cancer: how far can (should) we go?

Complex surgery is an essential component in the management of advanced ovarian cancer. Furthermore, achieving complete gross resection in cytoreductive surgery appears to be associated with significant survival benefits in patients with advanced ovarian cancer. The goal of this review is to demonstrate the advancement of surgical techniques in gynecologic oncology surgery, including resection of disease within the intrathoracic and inguinal regions. This progress has expanded the option of surgery to more patients, especially those who would have previously been deemed inoperable. In this review we describe the most notable studies and reports of surgical resection of ovarian cancer involving cardiophrenic/supradiaphragmatic lymph nodes, mediastinum, lung pleura or parenchyma, and the inguinal region. We also describe the growing role that video-assisted thoracic surgery has played in advanced ovarian cancer diagnosis and management. The studies, series, and reports described demonstrate that comprehensive surgical procedures outside of the abdomen or pelvis can be both safe and feasible in properly selected patients. They also suggest that resection of disease outside of the abdomen or pelvis may benefit appropriately selected patients. Future studies are necessary to identify which patients may benefit most from upfront surgery versus neoadjuvant chemotherapy when ovarian cancer metastasis is present in the thoracic or inguinal regions.

A preoperative nomogram incorporating CT to predict the probability of ovarian clear cell carcinoma

OBJECTIVES

To evaluate clinical, laboratory, and radiological variables from preoperative contrast-enhanced computed tomography (CECT) for their ability to distinguish ovarian clear cell carcinoma (OCCC) from non-OCCC and to develop a nomogram to preoperatively predict the probability of OCCC.

METHODS

This IRB-approved, retrospective study included consecutive patients who underwent surgery for an ovarian tumor from 1/1/2000 to 12/31/2016 and CECT of the abdomen and pelvis ≤90 days before primary debulking surgery. Using a standardized form, two experienced oncologic radiologists independently analyzed imaging features and provided a subjective 5-point impression of the probability of the histological diagnosis. Nomogram models incorporating clinical, laboratory, and radiological features were created to predict histological diagnosis of OCCC over non-OCCC.

RESULTS

The final analysis included 533 patients with surgically confirmed OCCC (n = 61) and non-OCCC (n = 472); history of endometriosis was more often found in patients with OCCC (20% versus 3.6%; p < 0.001), while CA-125 was significantly higher in patients with non-OCCC (351 ng/mL versus 70 ng/mL; p < 0.001). A nomogram model incorporating clinical (age, history of endometriosis and adenomyosis), laboratory (CA-125) and imaging findings (peritoneal implant distribution, morphology, laterality, and diameter of ovarian lesion and of the largest solid component) had an AUC of 0.9 (95% CI: 0.847, 0.949), which was comparable to the AUCs of the experienced radiologists' subjective impressions [0.8 (95% CI: 0.822, 0.891) and 0.9 (95% CI: 0.865, 0.936)].

CONCLUSIONS

A presurgical nomogram model incorporating readily accessible clinical, laboratory, and CECT variables was a powerful predictor of OCCC, a subtype often requiring a distinctive treatment approach.

Prevalence, clinical characteristics, and outcome of pleural effusions in ovarian cancer

Objectives

The prevalence, clinical characteristics and prognosis of pleural effusions (PEs) associated with ovarian cancer (OC) have seldom been addressed systematically, as in the current investigation.

Methods

All records of consecutive women with a newly diagnosed OC in our institution over a 13-year period were retrospectively reviewed. Features of PEs on CT scans, pleural fluid analyses, need for definitive therapy of PEs, and the influence of PEs on the overall survival (OS) and progression-free survival (PFS) were evaluated.

Results

PEs were observed in 81 (43%) of 189 women with OC, either at presentation of cancer (55 patients) or during the course of the disease (26 patients). The causes of PEs were malignancy (55.5%), unknown (37%), or surgery-related (7.4%). The sensitivity of the cytologic diagnosis of malignant PEs was 79.1%. Sixty percent of malignant PEs required pleurodesis or indwelling pleural catheters for symptomatic relief. The presence of ascites strongly predicted PE development (odds ratio 43.2). Women with PEs fared much worse compared with those without PEs, in terms of OS (26.7 vs. 90.4 months), PFS (9.8 vs. 55.3 months) and tumor recurrences (86.4 vs. 43%). In multivariate analyses, PE remained as a relevant independent variable associated with poor outcome (hazard ratio 9.73 for OS, and 3.87 for PFS). Notably, PEs small enough to preclude tapping, and thus of unknown origin, had a similar bad prognosis as malignant PEs.

Conclusions

OC patients with PEs experience decreased survival, including those with trace effusions not amenable to tapping.

Video-assisted thoracic surgery in the primary management of advanced ovarian carcinoma with moderate to large pleural effusions: A Memorial Sloan Kettering Cancer Center Team Ovary Study

OBJECTIVES

We assessed the utility of video-assisted thoracic surgery (VATS) in defining extent of intrathoracic disease in advanced ovarian carcinoma with moderate-to-large pleural effusions.

METHODS

Beginning in 2001, VATS was performed on all patients with suspected advanced ovarian carcinoma and moderate-to-large pleural effusions, evaluating for macroscopic intrathoracic disease. The algorithm recommended primary debulking surgery (PDS) for ≤1 cm, neoadjuvant chemotherapy (NACT)/interval debulking surgery (IDS) for >1 cm intrathoracic disease. We reviewed records of patients undergoing VATS from 10/01-01/19. Differences between treatment groups were tested using standard statistical techniques.

RESULTS

One-hundred patients met eligibility criteria (median age, 60; median CA-125 level, 1158 U/mL; medium serum albumin, 3.8 g/dL). Macroscopic pleural disease was found in 70 (70%). After VATS, 50 (50%) underwent attempted PDS (PDS group), 50 (50%) received NACT (NACT/IDS group). Forty-seven (94%) underwent IDS. Median overall survival (OS) for the entire cohort (n = 100) was 44.5 months (95% CI: 37.8-51.7). The PDS group had significantly longer survival than the NACT/IDS group [45.8 (95% CI: 40.5-87.8) vs. 37.4 months (95% CI: 33.3-45.2); p = .016]. On multivariable analysis, macroscopic intrathoracic disease (HR 2.18, 95% CI: 1.14-4.18; p = .019) and age ≥ 65 (HR 1.98, 95% CI: 1.16-3.40; p = .013) were independently associated with elevated death risk. Patients with the best outcome had no macroscopic disease at VATS and underwent PDS (median OS, 87.8 months).

CONCLUSIONS

VATS is useful in therapeutic decision-making for PDS vs. NACT/IDS in advanced ovarian cancer with moderate-to-large pleural effusions.

Prognostic significance of supradiaphragmatic lymph nodes at initial presentation in patients with stage III high-grade serous ovarian cancer

PURPOSE

To identify the optimal size threshold and to assess the prognostic significance of supradiaphragmatic lymph nodes at initial presentation of patients with high-grade serous ovarian cancer (HGSC).

METHODS

This IRB-approved, HIPAA-compliant retrospective study included baseline pretreatment staging abdominal CTs of 88 women (mean age 62 years, SD 10.4, range 29-85) with FIGO stage III HGSC. Patients with stage IV disease were excluded due to worse prognosis and management guided by distant metastases. Two fellowship-trained radiologists independently reviewed abdominal CTs to record the presence of supradiaphragmatic nodes, abdominal lymphadenopathy, peritoneal carcinomatosis, and ovarian mass. Progression-free survival (PFS) and overall survival (OS) were recorded after median 79 months follow-up (IQR 58-115, range 13-144). The optimal short-axis size threshold for supradiaphragmatic lymphadenopathy was determined by correlating 3, 4, 5, 6, 7, and 10 mm thresholds with PFS and OS using Log-rank test. Prognostic significance of supradiaphragmatic lymphadenopathy was assessed using Cox proportional hazards models.

RESULTS

There was good interobserver agreement for presence (κ = 0.65, 95%CI 0.51-0.79) and size (ICC = 0.77, 95%CI 0.66-0.86) of supradiaphragmatic nodes. 5 mm short-axis size threshold was associated with significantly shorter PFS (median 14 months, IQR 11-17 vs. 23 months, IQR 12-59; p = 0.02) and OS (median 44 months, IQR 27-69 vs. 65 months, IQR 45-96; p = 0.03). Total 38/88 (43%) patients had supradiaphragmatic lymphadenopathy. On Cox proportion hazards analysis, supradiaphragmatic lymphadenopathy was significantly associated with shorter PFS (p = 0.02; HR 1.81, 95%CI 1.11-2.96) and OS (p = 0.008; HR 2.11, 95%CI 1.21-3.65).

CONCLUSION

In patients with stage III HGSC, supradiaphragmatic lymphadenopathy is associated with shorter PFS and OS. Further studies would help determine its implications on staging, decision regarding neoadjuvant therapy, and surgical technique.

Role of Video-Assisted Thoracoscopy in Advanced Ovarian Cancer: A Literature Review

Abstract

Tools that accurately predict the presence of metastatic ovarian cancer in the pleura are limited. Thus, we sought to summarize the current literature on video-assisted thoracoscopic surgery (VATS) and its applicability in patients with advanced ovarian cancer. A total of 187 patients with suspected ovarian cancer who underwent the VATS procedure were identified for this analysis. The median patient age was 59.4 years (range, 20.3–83 years). The median operative time for VATS was 32 minutes (range, 5–65 minutes). In 89 patients (48%), VATS revealed macroscopic disease in the pleural cavity. After VATS, 44 patients underwent neoadjuvant chemotherapy, and the remaining 143 patients underwent primary cytoreductive surgery. Video-assisted thoracoscopic surgery led to a change in disease stage or management in 76 patients (41%). Among patients with pleural effusions, VATS revealed pleural disease in 57% of patients, and 73% of patients with positive pleural cytology had evidence of pleural disease at the time of VATS. In addition, 23.5% of patients with negative pleural cytology had evidence of pleural disease at the time of VATS. Prospective trials are needed to accurately evaluate the impact of VATS on disease-free and overall survival in patients with advanced ovarian cancer. Video-assisted thoracoscopic surgery can help determine which patients are ideal candidates for surgical cytoreduction.

Preoperative Prediction of Cardiophrenic Lymph Node Metastasis in Advanced Ovarian Cancer Using Computed Tomography

OBJECTIVE

The aim of this study was to determine whether the preoperative diameter of cardiophrenic lymph nodes (CPLNs) along the short and long axes, determined via computed tomography (CT), predicts CPLN metastasis in patients with advanced epithelial ovarian cancer.

METHODS

A total of 31 patients with primary advanced ovarian cancer who had CPLN dissection underwent preoperative CT that was reviewed twice by a radiologist blinded to the final pathology. An array of CT features and clinical factors [age, cancer antigen 125 (CA 125)] were compared between metastasis-positive and metastasis-negative CPLNs using the t test and Fisher's exact test. The optimal CPLN dimensions that best predicted metastasis were calculated using a receiver operating characteristic (ROC) curve, and were applied to find the correlation with other CT findings. Results were validated in an independent test set of nine patients by using the best cutoff value to predict metastasis.

RESULTS

Pathological evaluation revealed metastasis-positive CPLNs in 19 patients and metastasis-negative CPLNs in 12 patients. Metastasis-positive CPLNs had significantly reduced short axes than those of negative CPLNs (5.6 ± 1.7 and 7.8 ± 2.2, respectively; p < 0.001). ROC curve analysis showed that a cutoff value of 7 mm for the short axis demonstrated the largest area under the curve (0.789; p < 0.0007), with 63.16 % sensitivity and 83.33 % specificity. The presence of peritoneal metastasis and abdominopelvic adenopathy strongly related with CPLN adenopathy. Accuracies were 66.7 % (six of nine patients) based on the cutoff value in the independent test set.

CONCLUSIONS

The probability of detecting CPLN metastasis in patients with advanced ovarian cancer was approximately 85 % when the short axis of the CPLN was >7 mm in preoperative CT scans. Patients with CPLNs of this size may be candidates for CPLN dissection in order to confirm the pathological diagnosis.

Radical surgery in ovarian cancer

While there is an ongoing debate regarding the timing of the maximal surgical effort in epithelial ovarian cancer, it is well established that patients with suboptimal tumor debulking derive no benefit from the surgical procedure. The amount of residual disease after cytoreductive surgery has been repeatedly identified as a strong predictor of survival, and accordingly, the surgical effort to achieve the goal of complete gross tumor resection has been constantly evolving. Centers that have adopted the concept of radical surgery in patients with advanced ovarian cancer have reported improvements in their patients' survival. In addition to the expected improvements in the pharmacologic treatment of this disease, some of the next challenges in the surgical management of ovarian cancer include the preoperative prediction of suboptimal debulking, improving the drug delivery to the tumor, and increasing access to centers of excellence in ovarian cancer regardless of geographical, financial, or other social barriers. This review will discuss an update on the role of surgery in the treatment of primary epithelial ovarian cancer as it has evolved since the emergence of the concept of surgical cytoreduction.

Imaging features of thoracic metastases from gynecologic neoplasms

Gynecologic malignancies are a heterogeneous group of common neoplasms and represent the fourth most common malignancy in women. Thoracic metastases exhibit various imaging patterns and are usually associated with locally invasive primary neoplasms with intra-abdominal spread. However, thoracic involvement may also occur many months to years after initial diagnosis or as an isolated finding in patients without evidence of intra-abdominal neoplastic involvement. Thoracic metastases from endometrial carcinoma typically manifest as pulmonary nodules and lymphadenopathy. Thoracic metastases from ovarian cancer often manifest with small pleural effusions and subtle pleural nodules. Thoracic metastases to the lungs, lymph nodes, and pleura may also exhibit calcification and mimic granulomatous disease. Metastases from fallopian tube carcinomas exhibit imaging features identical to those of ovarian cancers. Most cervical cancers are of squamous histology, and while solid pulmonary metastases are more common, cavitary metastases occur with some frequency. Metastatic choriocarcinoma to the lung characteristically manifests with solid pulmonary nodules. Some pulmonary metastases from gynecologic malignancies exhibit characteristic features such as cavitation (in squamous cell cervical cancer) and the "halo" sign (in hemorrhagic metastatic choriocarcinoma) at computed tomography (CT). However, metastases from common gynecologic malignancies may be subtle and indolent and may mimic benign conditions such as intrapulmonary lymph nodes and remote granulomatous disease. Therefore, radiologists should consider the presence of locoregional disease as well as elevated tumor marker levels when interpreting imaging studies because subtle imaging findings may represent metastatic disease. Positron emission tomography/CT may be helpful in identifying early locoregional and distant tumor spread.

Long non coding RNAs (lncRNAs) are dysregulated in Malignant Pleural Mesothelioma (MPM)

Malignant Pleural Mesothelioma (MPM) is an aggressive cancer that is often diagnosed at an advanced stage and is characterized by a long latency period (20–40 years between initial exposure and diagnosis) and prior exposure to asbestos. Currently accurate diagnosis of MPM is difficult due to the lack of sensitive biomarkers and despite minor improvements in treatment, median survival rates do not exceed 12 months. Accumulating evidence suggests that aberrant expression of long non-coding RNAs (lncRNAs) play an important functional role in cancer biology. LncRNAs are a class of recently discovered non-protein coding RNAs >200 nucleotides in length with a role in regulating transcription. Here we used NCode long noncoding microarrays to identify differentially expressed lncRNAs potentially involved in MPM pathogenesis. High priority candidate lncRNAs were selected on the basis of statistical (P<0.05) and biological significance (>3-fold difference). Expression levels of 9 candidate lncRNAs were technically validated using RT-qPCR, and biologically validated in three independent test sets: (1) 57 archived MPM tissues obtained from extrapleural pneumonectomy patients, (2) 15 cryopreserved MPM and 3 benign pleura, and (3) an extended panel of 10 MPM cell lines. RT-qPCR analysis demonstrated consistent up-regulation of these lncRNAs in independent datasets. ROC curve analysis showed that two candidates were able to separate benign pleura and MPM with high sensitivity and specificity, and were associated with nodal metastases and survival following induction chemotherapy. These results suggest that lncRNAs have potential to serve as biomarkers in MPM.