Pattern and clinical predictors of lymph node metastases in epithelial ovarian cancer

Abstract

Para-aortic lymphadenectomy is part of staging in early epithelial ovarian cancer (EOC) and could be part of therapy in advanced EOC. However, only a minority of patients receive therapy according to guidelines or have attendance to a specialized unit. We analyzed pattern of lymphatic spread of EOC and evaluated if clinical factors and intraoperative findings reliably could predict lymph node involvement, in order to evaluate if patients could be identified in whom lymphadenectomy could be omitted and who should not be referred to a center with capacity of performing extensive gynecological operations. Retrospective analysis was carried out of all patients with EOC who had systematic pelvic and para-aortic lymphadenectomy during primary cytoreductive surgery. One hundred ninety-five patients underwent systematic pelvic and para-aortic lymphadenectomy. Histologic lymph node metastases were found in 53%. The highest frequency was found in the upper left para-aortic region (32% of all patients) and between vena cava inferior and abdominal aorta (36%). Neither intraoperative clinical diagnosis nor frozen section of pelvic nodes could reliably predict para-aortic lymph node metastasis. The pathologic diagnosis of the pelvic nodes, if used as diagnostic tool for para-aortic lymph nodes, showed a sensitivity of only 50% in ovarian cancer confined to the pelvis and 73% in more advanced disease. We could not detect any intraoperative tool that could reliably predict pathologic status of para-aortic lymph nodes. Systematic pelvic and para-aortic lymphadenectomy remains part of staging in EOC. Patients with EOC should be offered the opportunity to receive state-of-the-art treatment including surgery.

Prevalence and distribution pattern of nodal metastases in advanced ovarian cancer

“…Overall, previous studies reported a rate of ~45-60% nodal involvement in advanced ovarian cancer (2,3,9,14). In the present study, collective nodal metastases were detected in 74.62% of the cases (Table I).…”

The Detection of Sentinel Nodes in Ovarian Cancer: A Feasibility Study

“…The detection of metastases is positively correlated with the number of lymph nodes removed (11,12). Complete pelvic and paraaortic lymphadenectomy was shown to result in the detection up to 250 or more lymph nodes (9). An overall incidence of lymph node metastasis of approximately 14% was reported in clinical early-stage EOC, with a higher incidence in grade III tumors (20%) and in the serous histologic subtype (23%) than in grade I (4%) and mucinous tumors (3%) (5).…”

“…Lymphatic metastases of EOC mainly occur in the paraaortic and paracaval lymph nodes, although they can also be found in the pelvic lymph nodes (5)(6)(7)(8)(9)(10). Tumor cells travel along the lymph vessels that accompany the ovarian artery and vein in the suspensory ligament up to the high paraaortic and paracaval regions.…”

Feasibility of Upfront Debulking Surgery versus Neoadjuvant Chemotherapy Followed by Interval Debulking Surgery for Advanced Ovarian Cancer

“…≤30% of the patients with apparently early epithelial ovarian cancer might be upstaged after comprehensive surgical staging [3] [4]. Previous reports by Cass et al and Maggioni et al showed that patients with even early ovarian tumor confined to ovary might have pelvic or even Para aortic lymph nodes metastases which making systemic lymphadenectomy improving progression-free survival and disease-free survival [5] [6]. Although advances in diagnosis and management of epithelial ovarian cancer have changed in the last 25 years, the overall survival has not been improved as approximately 65% to 70% of all ovarian cancer continues to be diagnosed with advanced stage (III or IV).…”