Elsevier

Gynecologic Oncology

Volume 94, Issue 1, July 2004, Pages 161-166
Gynecologic Oncology

Lymphatic mapping and sentinel node identification as related to the primary sites of lymph node metastasis in early stage ovarian cancer

https://doi.org/10.1016/j.ygyno.2004.04.023Get rights and content

Abstract

Objective. We evaluated the primary sites of lymph node (LN) metastasis in patients during the early stage of ovarian cancer.

Methods. Study 1: patients with clinical stage I and II common epithelial ovarian carcinoma (n = 150) underwent systematic retroperitoneal LN dissection of the pelvic and paraaortic areas. The relationship between the incidence and location of LN metastasis and clinical and histological characteristics was examined. Study 2: we studied 11 women with endometrial or fallopian tube tumors. At laparotomy, activated charcoal solution was injected into the unilateral cortex of the ovary. Ten minutes later, the retroperitoneal spaces were opened and charcoal uptake within the pelvic lymph node (PLN) and paraaortic node (PAN) as far as the level of renal vein was examined.

Results. Study 1: The incidence of LN metastasis by stage was 6.5% (8/123) in stage I and 40.7% (11/27) in stage II. Among 19 patients with LN metastasis, 14 had only PAN, 2 had only pelvic LN, and 3 had both PAN and PLN metastases. Metastasis was limited to the ipsilateral side in 12 (63%) patients, but was bilateral in 5 (26%) and contralateral to the neoplastic ovary in 2 (11%). Positive peritoneal cytology was significantly (P < 0.05) correlated with lymph node metastasis. Study 2: Lymphatic channels along the ovarian vessels were identified in all injected ovaries. Charcoal was deposited in the LN of all patients. The locations of these nodes included PAN in all patients, common iliac node in three, and external iliac node in one.

Conclusion. PAN is the primary site of LN metastasis in ovarian cancer. Bilateral PAN dissections are necessary to determine the extent of tumors even in stage I ovarian carcinoma.

Introduction

The incidence of positive lymph nodes (LNs) in patients with early (stage I) ovarian cancer is 5.1–15% [1], [2]. Thus, over 85% of patients who undergo retroperitoneal lymphadenectomy (RPLND) and who do not benefit from the procedure must endure the associated increase in operative time and blood loss, as well as an increased risk of lymphocyst and lymphedema. In addition, the benefit of RPLND to the survival of patients with early ovarian epithelial cancer confined to the ovary has not been demonstrated. Thus, many gynecological oncologists perform only selective ipsilateral retroperitoneal sampling when disease is grossly confined to one ovary, although the most appropriate and reliable technique for assessing pelvic and paraaortic nodes (PANs) remains uncertain. However, metastasis to retroperitoneal lymph nodes is an important route of ovarian carcinoma spread. To elucidate how ovarian carcinoma spreads to the lymph nodes, we have been dissecting systematic pelvic and paraaortic nodes when the primary tumor could be surgically reduced to below 2 cm in diameter during an initial operative procedure, or at surgery after chemotherapy. Our aim was to reduce the amount of dissection required, so we evaluated the incidence and location of lymph node metastasis in patients with clinical stage I and II ovarian carcinomas to pursue the primary sites of lymph node metastasis during the early stage of the disease. We also designed a pilot study to investigate lymphatic drainage and to identify sentinel nodes.

Section snippets

Analysis of lymph node metastasis

Between April 1987 and April 2002, 150 patients (age range, 24–78 years; mean, 51.6 years) with clinical stage I and II epithelial ovarian carcinoma underwent systematic retroperitoneal lymph node dissection in the pelvic and paraaortic area during initial surgery at the Department of Obstetrics and Gynecology, Hokkaido University Hospital and affiliated Hospitals. According to the intra-abdominal status of the tumor and distant metastasis without consideration for lymph node status, 123

Incidence and location of lymph node metastasis

The total mean number of dissected lymph nodes was 64.7 ± 3.1 (mean ± SE) (Table 1). The mean numbers of dissected pelvic and paraaortic lymph nodes were 44.9 ± 2.3 and 18.6 ± 1.7, respectively. The mean number of dissected lymph nodes, tumor size, and volume of ascites did not significantly differ between patients with and without metastatic nodes (Table 1). Positive peritoneal cytology was significantly (P < 0.05) correlated with lymph node metastasis.

Table 2 shows histological findings and

Discussion

If the profile of lymphatic metastasis can be predicted from lymphatic drainage, areas of lymphadenectomy could be selected. Bergman [4] found a high incidence of pelvic lymph node metastasis in 86 autopsies, though he concluded that pelvic lymph node metastasis was the result of the secondary, retrograde spread of cancer cells after paraaortic node metastasis was established. Rose et al. [5] analyzed 428 autopsies and reported that paraaortic nodes were more frequently affected than pelvic

Acknowledgements

The authors thank Dr. I. Kawaguchi and Dr. N. Tsumura for their contributions to this article.

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