Elsevier

Surgical Oncology

Volume 23, Issue 1, March 2014, Pages 40-44
Surgical Oncology

Review
The impact of pelvic retroperitoneal invasion and distant nodal metastases in epithelial ovarian cancer

https://doi.org/10.1016/j.suronc.2013.10.005Get rights and content

Abstract

Background

The absence of disease after debulking surgery is the most important prognostic factor in the treatment of advanced epithelial ovarian cancer (EOC). Occasionally, the presence of extra-abdominal disease complicates the ability to obtain a complete surgery, considering some locations of the metastatic disease as unresectable. The objective of the study was to estimate the survival impact of pelvic retroperitoneal invasion and extrapelvic and aortic distant nodal metastases in EOC patients. The anatomical landmarks of primary cytoreductive surgery will be discussed.

Material and methods

We reviewed data from 116 consecutive Mayo Clinic patients with epithelial ovarian cancer (EOC) stage IIIC and IV, undergoing primary cytoreduction surgery between 1996 and 2000. Univariate and multivariate analysis for patients with positive distant nodes and pelvic retroperitoneal invasion was performed, including 57 patients with no residual disease after surgery. Kaplan–Meier curves were used to estimate the probability of survival.

Results

The median patient's age was 65 years (range 24–87 years). The 5 years overall survival was 44.8% (range 30.1–57.9 months) and the median length of survival was 39.9 months (range 0.13–60 months, 95% confidence interval: 30.1–57.9). Pelvic retroperitoneal invasion was present in 22 EOC patients (18.9%) and distant positive nodes were noted in 11 (9.5%): suprarenal/celiac (5.2%), inguinal (4.3%) and supraclavicular (0.9%). Univariate and multivariate Cox regression analysis, identified distant positive lymph nodes and pelvic retroperitoneal invasion as factors statistically associated with overall survival (p = 0.002 and p = 0.025, respectively).

Conclusions

Metastatic distant nodes and pelvic retroperitoneal invasion are independent prognostic factors for survival in patients with advanced EOC.

Introduction

There is universal agreement that maximal removal of intraperitoneal disease has a survival benefit for patients with metastatic epithelial ovarian cancer (EOC), which is especially true when no visible disease remains at the completion of the operation [1], [2], [3]. There is also agreement that detection of nodal metastasis is important in patients with disease clinically limited to the pelvis, to determine surgical stage, prognosis and the need for adjuvant therapy [4], [5]. There however is controversy in the role of detection and removal of positive nodes in patients with advanced, metastatic intraperitoneal disease as this does not affect surgical stage and its therapeutic benefit remains unclear [6], [7].

In 2009, the International Federation of Gynecology and Obstetrics (FIGO) [8], revised and included in its staging classification of female genital cancers the prognostic significance of direct retroperitoneal tumor invasion in cervical, endometrial and vulvar cancer. Positive groin nodes were added to the staging of vulvar (stage III) and endometrial (stage IVB) cancers. EOC patients with “positive retroperitoneal or inguinal nodes” were included as stage IIIC [9]. The prognostic role of other metastatic nodal sites or retroperitoneal pelvic invasion in EOC remains unclear.

The objective of this study was to estimate the survival impact of pelvic retroperitoneal invasion and distant nodal metastases, other than that of the pelvic and para-aortic nodal regions in advanced EOC patients. The anatomical landmarks of primary cytoreductive surgery in EOC patients will be discussed.

Section snippets

Materials and methods

Data was collected retrospectively from 116 patients with primary EOC and positive nodes (FIGO stage IIIC: 81 and stage IV: 35), treated at Mayo Clinic between 1996 and 2000. Approval was granted by the Mayo Clinic Institutional Review Board. Abstracted data included patient's age, tumor type and grade, FIGO stage, extent of peritoneal disease before debulking (clinical stage) and size of maximal residual tumor diameter after cytoreductive surgery. All patients received adjuvant postoperative

Results

The median patient's age was 65 years (range 24–87 years). The median number of pelvic and/or aortic nodes removed was 31 (range 1–123) and the median number of metastatic nodes was 5 (range: 1–42). Demographics of the cohort and their survival have been previously reported [7], [11], [12].

Pelvic retroperitoneal invasion was present in 22 patients (18.9%), including ureteral obstruction with or without hydronephrosis (n = 10), proximal parametrial involvement (n = 5), proximal parametrial

Discussion

The radicality of primary surgical management in EOC has a direct effect on survival [13]. A previous report on this same cohort of EOC patients with positive nodes and advanced peritoneal disease >2 cm revealed that the extent of initial peritoneal spread and the radicality of the lymphadenectomy (>40 lymph nodes removed) were important prognostic factors for survival [7], [11], [12]. The present study showed two additional independent prognostic factors for survival, the presence of distant,

Conflict of interest statement

We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no financial support for this work that could have influenced its outcome.

Authorship statement

Guarantor of the integrity of the study: A. Pereira, T. Perez-Medina, L. Ortiz-Quintana.

Study concepts: A. Pereira, T. Perez-Medina.

Study design: A. Pereira, T. Perez-Medina.

Definition of intellectual content: A. Pereira, J.F. Magrina, P.M. Magtibay.

Literature research: A. Pereira, A. Rodriguez-Tapia.

Clinical studies: A. Pereira, J.F. Magrina, P.M. Magtibay.

Data acquisition: A. Pereira, A. Rodriguez-Tapia.

Data analysis: A. Pereira, T. Perez-Medina, F. Perez-Milan.

Statistical analysis: A.

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      The risk of bias and methodological quality of included single arm studies was based on the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (using the fields 1a, 3e, 3h and 4a that are applicable to single arm studies) [12]. Five articles were excluded from the present systematic review [13–17] as they did not investigate the outcomes of interest. Specifically, two articles investigated the impact of lymphadenectomy in primary staging of advanced EOC cases [13,16], one article focused in patients with neck lymphatic metastasis [15], another one investigated the impact of bulky lymph node resection and systematic lymphadenectomy in patients with recurrent EOC that also had other sites of involvement [17] and the last one investigated the impact of minimally invasive salvage lymphadenectomy for ILNR in patients with gynecological malignancies (including but not limited to EOC) [14].

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