Significance of Lymph Node Sampling in Epithelial Carcinoma of the Ovary

doi:10.1006/gyno.1997.4633

Gynecologic Oncology

Volume 65, Issue 3, June 1997, Pages 467-472

https://doi.org/10.1006/gyno.1997.4633 Get rights and content

Abstract

From 1979 to 1984, 127 patients operated on for ovarian cancer underwent pelvic, para-aortic, or pelvic and para-aortic lymph node sampling. Forty-seven patients proved to be stage I (14 IA and 33 IC), 14 were stage II (3 IIA, 8 IIB, and 3 IIC), 58 were stage III (7 IIIA, 13 IIIB, and 38 IIIC), and 8 were stage IV. Positive lymph nodes were found in 4.2% of patients at stage I, 35.7% at stage II, 41.3% at stage III, and 87.5% at stage IV. With regard to grading, positive lymph nodes were found in 4.4% of G1, in 21.6% of G2, and in 49.1% of G3. A significant increase in survival (P= 0.04) was found for patients classified as stage IIIC only according to lymph node involvement compared to patients in peritoneal stage IIIC with positive lymph nodes (3-year survival: 46% vs 12%). A small increase in survival was observed for N− patients compared to N+ patients, at both stage III and IV, even with same residual tumor size, but the difference is not statistically significant. All other things being equal, because the prevalence of lymph node positivity depends closely on the number of lymph nodes removed and examined (OR = 3.9 for >10 lymph nodes removed compared to 1–5 lymph nodes removed), lymph node sampling does not seem to be a reliable method for evaluating the retroperitoneal status. With regard to the therapeutic role of systematic lymphadenectomy, few data in literature are available and, most important, are not derived from experimental studies. Probably, only randomized studies with a large number of patients will provide useful answers.

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Sentinel-node biopsy in apparent early stage ovarian cancer: final results of a prospective multicentre study (SELLY)
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To evaluate the sensitivity and specificity of sentinel-lymph-node mapping compared with the gold standard of systematic lymphadenectomy in detecting lymph node metastasis in apparent early stage ovarian cancer.
Multicenter, prospective, phase II trial, conducted in seven centers from March 2018 to July 2022. Patients with presumed stage I-II epithelial ovarian cancer planned for surgical staging were eligible. Patients received injection of indocyanine green in the infundibulo-pelvic and, when feasible, utero-ovarian ligaments and sentinel lymph node biopsy followed by pelvic and para-aortic lymphadenectomy was performed. Histopathological examination of all nodes was performed including ultra-staging protocol for the sentinel lymph node.
174 patients were enrolled and 169 (97.1 %) received study interventions. 99 (58.6 %) patients had successful mapping of at least one sentinel lymph node and 15 (15.1 %) of them had positive nodes. Of these, 11 of 15 (73.3 %) had a correct identification of the disease in the sentinel lymph node; 7 of 11 (63.6 %) required ultra-staging protocol to detect nodal metastasis. Four (26.7 %) patients with node-positive disease had a negative sentinel-lymph-node (sensitivity 73.3 % and specificity 100.0 %).
In a multicenter setting, identifying sentinel-lymph nodes in apparent early stage epithelial ovarian cancer did not reach the expected sensitivity: 1 of 4 patients might have metastatic lymphatic disease unrecognized by sentinel-lymph-node biopsy. Nevertheless, 35.0 % of node positive patients was identified only thanks to ultra-staging protocol on sentinel-lymph-nodes.
Epithelial ovarian cancer
2023, DiSaia and Creasman Clinical Gynecologic Oncology
Ovarian Cancer
2022, Oncologic Imaging: A Multidisciplinary Approach
Ovarian cancer usually affects postmenopausal females and is sporadic in 90% of cases. It remains the deadliest gynecologic cancer. Although tumors originating in the ovary, fallopian tube, and covering peritoneum fall under this category, their staging/prognosis may defer. Epithelial tumors account for 90% of ovarian malignancy overall. Other types of ovarian tumors include germ cell tumors, being most common in young females, and exemplified by cystic teratoma; and sex cord-stromal tumors, exemplified by granulosa cell tumor that is known for hormonal secretion. The role of screening in detecting ovarian cancer is still limited and controversial; and imaging is no different. The FIGO staging system was revised in 2014, with modification of the substages and definitions so to reflect current understanding and advances. The most common mode of ovarian cancer spread is intraperitoneal, and approximately 70% of patients have peritoneal metastases at staging laparotomy. The primary role of imaging in ovarian neoplasia is to detect the mass, identify malignancy features, and predict spread. MRI and PET/CT–in particular–have the greatest role in detecting recurrence. Management is a combination of staging cytoreductive surgery and chemotherapy. Some improvement in median survival time has been achieved over the last 3 decades, however the overall prognosis–particularly for patients presenting beyond stage II–remains unfavorable.
Sentinel-node biopsy in early-stage ovarian cancer: preliminary results of a prospective multicentre study (SELLY)
2019, American Journal of Obstetrics and Gynecology
Systematic paraaortic and bilateral pelvic lymphadenectomy is the standard of a comprehensive surgical staging in presumed early epithelial ovarian cancer, but no prospective randomized evidence suggests a possible therapeutic value. Moreover, this procedure is associated with potential severe morbidity. The Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial is a prospective study designed to test whether sentinel node detection can accurately predict nodal status in a cohort of women with early epithelial ovarian cancer.
We here present the results of the first part of the Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial, regarding the feasibility of the sentinel lymph node technique and the preliminary findings regarding its safety and accuracy.
The Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial is a prospective, phase II, single-arm study included patients with presumed stages I–II epithelial ovarian cancer planned for immediate or delayed minimally invasive comprehensive staging. The ovarian pedicle is injected with 2 mL of a 1.25 mg/mL indocyanine green solution. The pelvic and lumboaortic retroperitoneum is then accessed and inspected to identify and remove sentinel nodes. After sentinel node procedure, staging is completed including systematic pelvic and paraaortic lymphadenectomy. Assuming a sensitivity of 98.5% in predicting positive sentinel lymph nodes at histology, a pathological lymph node prevalence of 14.2%, a precision of estimate (ie, the maximum marginal error) d = 5%, a type I error α = 0.05, a sample size of 160 patients is needed to test the general hypothesis. Here we present the preliminary results on the first 31 patients enrolled.
Thirty-one patients were included. Sentinel node was identified in 21 patients (detection rate, 67.7%). The detection rate was significantly higher in women undergoing immediate vs delayed staging (88.9% vs 41.7%, P = .003). Four patients had positive nodes. In all the patients with lymphatic dissemination, a positive sentinel node was identified (sensitivity, 100%; false-negative rate, 0%; negative predictive value, 100%). One (3.2%) intra- and 2 (6.5%) postoperative grade I complications occurred.
Our data show that the detection of sentinel node in early epithelial ovarian cancer is low when patients are submitted to delayed-staging surgery. However, sentinel node procedure is feasible and has the potential to provide reliable and useful information on nodal status and may allow the avoidance of systematic lymphadenectomy in the majority of patients.
Borderline tumours of the ovary: Common practice in the Netherlands
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Citation Excerpt :
Despite the fact that bilateral pelvic, and high para-aortic/paracaval lymph node sampling is recommended, some respondents (+/− 20%) indicated that they would perform a less extensive sampling [only (ipsilateral) pelvic lymph node sampling or ipsilateral pelvic with high para-aortic/paracaval sampling], without major differences with respect to both histological subtypes (Pereira et al., 2007; Cass et al., 2001; UpToDate: Cancer of the ovary, fallopian tube, and peritoneum: Staging and initial surgical management, n.d.). Concerning the minimum number of removed lymph nodes, the majority of respondents prefer removal of at least 10 lymph nodes, which is also recommended by the Dutch guideline and some previous reports (Chan et al., 2007; Carnino et al., 1997). However, some of the respondents advocate removal of at least 20 lymph nodes, probably because the 5-year survival rate seems to improve in those cases (Kleppe et al., 2016).
Discordance between frozen section diagnosis and the definite histopathological diagnosis and the fact that the frozen section result is not always unambiguous, may contribute to differences in clinical practice regarding perioperative treatment and follow-up of borderline ovarian tumours (BOTs) patients amongst gynaecologic oncologists, which may lead to over- and undertreatment. The aim of the study was to map the Dutch gynaecologists' preferred treatment and follow-up strategy in case of BOTs.
A questionnaire was sent to all Dutch gynaecologists involved in ovarian surgery with perioperative frozen section analysis, and the outcomes were assessed using descriptive statistics.
Nearly half of the respondents (41.0%) would not perform a staging procedure in case of a BOT. In case of an ambiguous frozen section diagnosis, tending towards invasive carcinoma, a considerable number (sBOT 56.4%; mBOT 30.8%) would perform a lymph node sampling as part of the staging procedure. A relaparotomy/relaparoscopy, to perform a lymph node sampling in case of a serous or mucinous carcinoma after a BOT frozen section diagnosis, would be performed by 97.4% and 48.7% of the respondents, respectively.
A considerable number of gynaecologists would perform a staging procedure that is recommended for ovarian cancer in case of an ambiguous BOT frozen section diagnosis, especially for serous tumours. In addition, nearly all gynaecologists would perform a second procedure including a lymph node sampling in case of a serous invasive carcinoma after a BOT frozen section diagnosis, which applies to half of the gynaecologists in case of a mucinous carcinoma.
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2018, Clinical Gynecologic Oncology

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Regular ArticleSignificance of Lymph Node Sampling in Epithelial Carcinoma of the Ovary

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Regular Article
Significance of Lymph Node Sampling in Epithelial Carcinoma of the Ovary