Retroperitoneal lymphatic involvement with epithelial ovarian tumors of low malignant potential

A comprehensive understanding of retroperitoneal lymphatic involvement is lacking in tumors of low malignant potential. This study was undertaken to evaluate retroperitoneal lymphatic involvement in patients with ovarian tumors of low malignant potential. One hundred seventy-one patients were diagnosed with epithelial ovarian tumors of low malignant potential between 1979 and 1989. Thirty-four (20%) of these patients underwent surgical staging which included lymph node sampling. The stage distribution was Stage I in 17 patients (50%), Stage II in 4 patients (12%), and Stage III in 13 patients (38%). The histology of the tumors was serous in 26 patients (76%), mucinous in 7 patients (21%), and seromucinous in 1 patient (3%). The incidence of retroperitoneal lymphatic involvement was 21%. The occurrence of positive pelvic and para-aortic nodes was 17 and 18%, respectively. Patients with localized intraperitoneal disease were upstaged in 22% of the cases based on retroperitoneal lymphatic involvement. Four of twenty-one patients (19%) with intraperitoneal disease confined to the ovary and two of six patients (33%) with intraperitoneal disease confined to the pelvis were upstaged to Stage III as a result of retroperitoneal lymphatic disease. Although the nodal status of patients did not significantly affect survival, those patients with localized intraperitoneal disease and nodal involvement had a higher incidence of recurrence which was statistically significant (P = 0.025). Accordingly, retroperitoneal lymph node sampling at the time of initial laparotomy may provide valuable prognostic information regarding recurrence in patients with tumors of low malignant potential.     

Is it necessary to do retroperitoneal evaluation in borderline epithelial ovarian tumors?

Objective Borderline epithelial ovarian tumors have good prognosis without any adjuvant therapy. The advantage of aggressive surgical staging, especially retroperitoneal lymph node sampling is questionable in patients with borderline ovarian tumors. We designed this study to evaluate the necessity of retroperitoneal pelvic and para-aortic lymph node dissection in the treatment of borderline epithelial ovarian tumors. Study design From 1998 to 2007, 57 women who were diagnosed with borderline epithelial ovarian tumor in our hospital were prospectively accrued and evaluated; 27 of them (47.3%) had full surgical staging procedure including para-aortic and pelvic node dissection. Student’s t-test was used to compare follow-up times. Results Median follow-up time was 54.6 (12–96) months for all patients in the study. There was one recurrence of disease, which was in the complete staging group. Follow-up times of patients were not statistically different between lymph node evaluated and non-evaluated groups (p = 0.10). We did not find any metastasis in lymph nodes in 27 women who had complete surgical staging procedure. Conclusion Patients with borderline epithelial tumors who had full surgical staging procedure do not have survival advantage over those who had no lymph node evaluation and yet were patients with malignant ovarian tumors.     

Interstitial thermoradiotherapy in recurrent gynecologic malignancies

In patients with ovarian carcinoma, the presence of metastatic disease in a retroperitoneal lymph node is indicative of a poor prognosis. Although a “staging laparotomy” is required for proper treatment, definitive information concerning para-aortic and pelvic lymph node metastasis often is not available. To determine the incidence of retroperitoneal lymph node metastases in untreated cases of ovarian carcinoma, a prospective study by selective nodal biopsy was undertaken in 61 unselected patients with the following distribution: Stage I, 11; Stage II, 10; Stage III, 31; and Stage IV, 9. The incidence of para-aortic node metastasis overall was 37.7% and of pelvic node metastasis, 14.8%. Of 23 patients with positive para-aortic nodes, 30.4% had no concomitant pelvic node involvement. Direct relationships between nodal metastasis and clinical stage, tumor grade, and histologic type of tumor were demonstrated. The incidence of positive para-aortic nodes in Stage I disease was 18.2%; in Stage II, 20.0%; in Stage III, 41.9%; and in Stage IV, 66.7%. The corresponding incidence of pelvic node metastasis was 9.1% in Stage I, 10.0% in Stage II, 12.9% in Stage III, and 33.3% in Stage IV. Grade 3 tumors were associated most frequently with nodal involvement, with an incidence of positive para-aortic nodes of 52.5% and of positive pelvic nodes of 15.5%. In patients with a serous type of malignancy, the frequencies of positive para-aortic/pelvic nodes were 44.4%/16.7%, respectively; in the undifferentiated type, 50.0%/10.0%; in the clear cell type, 25.0%/25.0%; and in the mucinous type, 14.3%/ 14.3%. In this small series, 32 patients (52.5%) had positive retroperitoneal nodal involvement. It is concluded that selective biopsies of the para-aortic and pelvic lymph nodes should be part of any “staging laparotomy” for ovarian carcinoma, and that the true incidence of nodal involvement in these patients awaits further investigation.     

Lymphadenectomy in ovarian cancer

Current guidelines for the surgical staging of ovarian cancer include the removal of retroperitoneal lymph nodes (pelvic and aortic). In most centres this is achieved by means of laparotomy, but advanced laparoscopic techniques have also been performed and still further prospective controlled studies with long-term follow-up are necessary to validate the efficacy. Lymph node sampling, short of complete dissection, should be avoided because it may be insufficient to detect metastasis. In any case, laparoscopic lymphadenectomy as well as open surgery, should be in the hands of properly trained subspecialists in gynaecologic oncology. Of 97 patients with ovarian carcinoma studied in our hospital, 68% were treated by means of complete staging laparotomy (FIGO). Lymphadenectomy was spared in 14 cases with stage I tumours (mainly serous) without changes in overall survival. In 15% metastases in pelvic lymph nodes were present. In the same proportion aortic lymph nodes were positive. In 5.5%, aortic metastases were present in the absence of pelvic involvement.     

The contribution of rapid intraoperative cytology to the improvement of ovarian cancer staging

OBJECTIVE: The goal of this work was to evaluate the use of intraoperative cytology in the improvement of ovarian cancer staging. METHODS: Fifty-two patients with clinical stage IA-IIB ovarian cancer underwent peritoneal washing (PW) cytology and imprint cytology performed on retroperitoneal lymph node samples, during primary surgical treatment. Cytologic specimens were stained by the May-Grünwald-Giemsa (MGG) and hematoxylin-eosin (HE) techniques. Pertinent histologic sections of the ovarian lesions, cell blocks prepared from PW sediments, and lymph node samples were studied and compared with the cytologic findings. RESULTS: Our study reveals that, when malignant cells are present in the peritoneal cavity, PW cytology has 84.6% sensitivity and 94.7% specificity in detecting them. Imprint cytology performed on lymph node samples presented 94.1% sensitivity and 94.1% specificity in the diagnosis of retroperitoneal metastasis of ovarian cancer. Only 7 patients (13.4%) were upstaged with either cytologic method. PW cytology alone upstaged 6 more patients, while imprint cytology alone upstaged 11 more patients. This corresponds to a total of 17 patients (32.6%) who benefit from the combined performance of both cytologic methods. HE stain presents lower values of sensitivity and specificity compared with MGG. CONCLUSION: Cytologic evaluation of intraperitoneal and retroperitoneal spread of ovarian cancer by use of PW cytology and imprint cytology performed on lymph node samples contributes to the improvement of ovarian cancer staging.     

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

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.     

Lymph node metastasis in stage I epithelial ovarian cancer

OBJECTIVES: A relatively high incidence of para-aortic and pelvic lymph node metastasis is found in epithelial ovarian cancer. This paper investigates the clinicomorphological features of intra-abdominal stage I epithelial ovarian cancer that may predict the occurrence of lymph node metastasis and the prognosis of patients in whom lymph node metastases are identified. METHODS: From November 1988 to December 1997 we performed systematic para-aortic and pelvic lymphadenectomy as primary surgery in 47 patients with intra-abdominal stage I epithelial ovarian cancer. The incidence of lymph node metastasis in these patients and the clinicomorphological features of the patients with lymph node involvement were examined. RESULTS: Five patients (10.6%) were metastasis positive (IC: four; IA: one), of whom four had serous adenocarcinoma. Serous adenocarcinoma was associated with a significantly higher incidence of metastases than other histological types (P < 0.05). The number of positive lymph nodes was one in four patients and two in one patient, and the metastatic sites ranged from the para-aortic to the suprainguinal lymph nodes. All five metastasis-positive patients were alive and disease free at the time of this report (survival 28-85 months: median 59 months). CONCLUSION: This clinical study suggests that serous adenocarcinoma carries a high risk of lymph node metastasis, requiring systematic lymphadenectomy for accurate staging in intra-abdominal stage I epithelial ovarian cancer.     

The utility of hand-assisted laparoscopy in ovarian cancer

INTRODUCTION: The traditional approach to patients with ovarian cancer is cytoreductive surgery and surgical staging through a vertical midline laparotomy. While laparoscopy has become an integral part of gynecologic surgery, debulking procedures have not been feasible to date with standard minimally invasive techniques. METHODS AND MATERIALS: Twenty-five patients with ovarian carcinoma underwent surgical staging and cytoreduction using hand-assisted laparoscopy. We review the surgical technique and clinical outcomes. RESULTS: Twenty-five patients were managed during this study time frame with hand-assisted laparoscopy. Six patients had apparent advanced stage ovarian cancer at the time of referral, and 17 patients had apparent early-stage ovarian cancer. Of the 19 patients with presumed early-stage disease, 5 patients were upstaged based on retroperitoneal lymph node involvement, 3 with disease to other pelvic structures, and 2 patients had microscopic disease in the omentum. Twenty-two patients had their surgeries completed via hand-assisted laparoscopy, and three cases required conversion to laparotomy for completion of debulking surgery. Complication rates were low with three complications requiring reoperation or hospitalization. The mean hospital stay was 1.8 days for the 22 patients who had a successful hand-assisted laparoscopic evaluation. Operating times were variable and ranged from 81 to 365 min. CONCLUSION: Hand-assisted laparoscopy may be employed in the initial management of early and advanced stage ovarian carcinoma. This approach allows for thorough evaluation of peritoneal and retroperitoneal structures and surgical cytoreduction while retaining the advantages of minimally invasive surgery.     

Positron emission tomography with FDG in the detection of peritoneal and retroperitoneal metastases of ovarian cancer

OBJECTIVE: The aim of this prospective study was to evaluate (18)F-FDG-PET, in comparison with CT, for the detection of peritoneal and retroperitoneal metastases of ovarian cancer. METHODOLOGY: 13 patients with primary (n = 7) or recurrent (n = 6) ovarian cancer underwent an attenuation-corrected (18)F-FDG-PET of the abdomen as well as a contrast-enhanced abdominal CT, followed by surgical staging. For data analysis, the abdomen was artificially divided into six regions (right and left subphrenic region, right and left paracolic gutter, retroperitoneum and central abdomen). All images were reviewed and each region was visually scored on (18)F-FDG-PET as well as on CT. (18)F-FDG-PET results were compared with those of CT, using the surgical data as gold standard. RESULTS: 73 regions were evaluable surgically and or histologically. Sensitivity was slightly better for CT than for (18)F-FDG-PET (74 vs. 66%). Metastases of <5 mm were missed with both techniques. Specificity, however, was clearly better for (18)F-FDG-PET than for CT (94 vs. 77%), especially in patients with recurrent disease, where postoperative changes (hematomas, adhesions, etc.) caused more false positive results on CT. Retroperitoneal lymph node involvement was found in 3/13 patients. The result of (18)F-FDG-PET for the retroperitoneal lymph nodes was correct in all cases, whereas CT was false positive in 2 patients. (18)F-FDG-PET is relatively inaccurate for the right and the left subphrenic region (missing tumor involvement in 5 patients compared to 2 patients for CT). CONCLUSION: Given the low sensitivity of both (18)F-FDG-PET and CT for the detection of peritoneal metastases, surgical staging remains the gold standard. Because of the better specificity, (18)F-FDG-PET might be preferred for evaluating residual or recurrent disease after surgery. (18)F-FDG-PET was more sensitive in the retroperitoneal region than intraperitoneal.     

卵巢恶性肿瘤二次剖腹探查术中行腹膜后淋巴结清除术的研究

目的　探讨卵巢恶性肿瘤腹膜后淋巴结清除术的最佳时机和临床价值。方法　回顾性分析了 5 0例二次剖腹探查术 (SLL)中行腹膜后淋巴结清除术的卵巢恶性肿瘤患者的临床资料。结果　患者中位数年龄 49岁 ,其 3年和 5年生存率分别为 72 %和 62 %。SLL阳性率为 40 % ( 2 0 / 5 0 ) ,其中临床分期 [国际妇产科联盟 (FIGO)标准 ]Ⅰ期SLL阳性率为 0 % ( 0 / 15 ) ,Ⅱ期和Ⅲ期分别为 40 %( 4/ 10 )、62 % ( 15 / 2 4) ,Ⅳ期为 1例中 1例。SLL阳性率与临床分期的期别呈正相关 ,其中Ⅰ～Ⅱ期( 16% ,4/ 2 5 )和Ⅲ～Ⅳ期 ( 64 % ,16/ 2 5 )患者SLL阳性率比较 ,差异有极显著性 (P <0 0 1)。腹膜后淋巴结转移率为 3 2 % ( 16/ 5 0 ) ,其中Ⅰ、Ⅱ、Ⅲ期分别为 0 % ( 0 / 15 )、2 0 % ( 2 / 10 )、5 4% ( 13 / 2 4) ,Ⅳ期为 1例中1例。SLL阳性患者中 ,4例 ( 8% )仅盆腹腔内有转移灶 ,淋巴结无转移 ;6例 ( 12 % )仅显微镜下淋巴结转移 ,而无盆腹腔转移灶。SLL中 ,行二次肿瘤细胞减灭术共 2 0例 ,其中术后 13例残留灶直径≤ 0 5cm ,7例残留灶直径 >0 5cm。中位数随访时间 44个月 ( 2 4～ 10 4个月 ) ,至随访截止日SLL阴性者 ( 3 0例 )均无肿瘤复发。结论　腹膜后淋巴结清除术在SLL术中进行比较合理 ,而且对降低SLL阴性患     

Lymph node metastasis in ovarian cancer: difference between serous and non-serous primary tumors

OBJECTIVE: To investigate the lymph node sites most susceptible to involvement relative to primary tumor histology in ovarian cancer. METHODS: The locations of metastatic lymph nodes were investigated in 208 patients with primary ovarian cancer who underwent systemic lymphadenectomy covering both the pelvic and para-aortic regions. RESULTS: Lymph node metastasis was present in 12.8% (20/156) of patients with stage I (pT1M0), 48.6% (18/37) with stage II (pT2M0), and 60% (9/15) with stage III (pT3M0) disease, thus in 22.6% (47/208) of all study patients. Isolated para-aortic nodal involvement was present in 23.3% (14/60) of patients with serous tumor and 4.1% (6/148) of those with non-serous tumor (P = 0.00002). In an analysis of 35 positive nodes from 25 patients with up to 3 positive nodes, 86.4% (19/22) of metastatic lymph nodes from patients with serous tumor were found in the para-aortic region, with 14 positive nodes located above the inferior mesenteric artery (IMA) and 5 below it, whereas metastasis to para-aortic lymph nodes accounted for 53.8% (7/13) of metastatic lymph nodes from patients with non-serous tumor (P = 0.0334). CONCLUSIONS: The locations of metastatic lymph nodes in ovarian cancer depend upon the histologic type of the primary cancer. In cases of serous tumor, the para-aortic region, particularly above the IMA, is the prime site for the earliest lymph node metastasis. However, the likelihood of pelvic node involvement is almost equal to that of para-aortic node involvement in cases of non-serous tumor.     

Clinical relevance of retroperitoneal involvement from epithelial ovarian tumors of borderline malignancy

Abstract. Rota SM, Zanetta G, Ieda N, Rossi R, Chiari S, Perego P, Mangioni C. Clinical relevance of retroperitoneal involvement from epithelial ovarian tumors of borderline malignancy.
Ovarian tumors of borderline malignancy have an outstanding prognosis. The need for aggressive surgical staging is questionable and the need for retroperitoneal node sampling is debated.
From 1982 to 1996, 81 women underwent surgical staging including retroperitoneal sampling. Three patients (3.7%) with serous tumor had microscopic nodal involvement. Retroperitoneal metastases were found in two intraperitoneal stage I tumors and in one stage IIIA tumor. Positive nodes were found in 1/31 (3.2%) women undergoing sampling of para-aortic nodes and in 2/69 (2.8%) women undergoing sampling of pelvic nodes. With a median follow-up of 79 months we observed five recurrences, but none involved the retroperitoneum. The three patients with positive nodes remain alive without disease. Among 236 patients with diagnosis of borderline tumor but without sampling of the nodes, we observed one retroperitoneal recurrence (0.4%) in a serous tumor. There are no indications for retroperitoneal sampling of mucinous borderline tumors. For serous tumors this procedure should only be performed as a part of prospective trials.
The clinical relevance of retroperitoneal involvement in borderline tumors appears minimal and does not justify routine aggressive surgery.     

Endometrial carcinoma under the age of 40: reappraisal for oophorectomy in stage I disease

Objective: To reappraise the rationale of castration and the necessity of retroperitoneal lymph node biopsy in patients with endometrial carcinoma under the age of 40 years.Methods: A retrospective review of 30 patients under the age of 40 among 815 patients who had primary endometrial cancer treatment was carried out. The review consisted of clinical data, surgical pathology, and survival rates, as well as a comparative study of the literature.Results: The average age was 35.1 years. Three-quarters of the patients (76.6%) had stage I disease. Almost half of them had risk factors for endometrial carcinoma. The pathologic type was adenocarcinoma in 83% and grade 1 in 57%. Among 23 patients with stage I disease, 7 (30.4%) had no residual disease. Even with 16 patients found to have residual disease, 10 had it confined to the endometrium. Ovarian malignancy was only seen in 2 instances. Five demonstrated corpus luteum. Only 3 (13%) had lymph node metastasis and all in advanced disease. Six (20%) of these patients had delayed treatment more than 6 months. The follow-up was 5 months to 19 years. All are living and free of disease in stage I and stage II. Both patients with stage III disease died.Conclusions: In view of low risks in these young women with stage I disease, a thorough surgical staging including lymph node resection is desirable and hysterectomy with ovarian preservation is the treatment of choice. Oophorectomy might be considered in patients with cancer of the ovaries or in advanced stages of disease.     

Lymph node metastasis in stage I ovarian cancer]

One hundred and sixteen cases of stage I Ovarian cancer from nine hospitals in all the China during Sept. 1982-April 1991 were investigated for their lymph node metastasis. There were 70 epithelial tumors, 36 malignant germ cell tumors, 8 from gonadal stroma and 2 undifferentiated. In 89 patients the ovarian tumor was confined to one ovary (stage Ia); in 6 cases both ovaries were involved (stage Ib); 21 cases was documented stage Ic. Systemic lymphadenectomy covering all pelvic groups of node together with aortic lymph node accomplished in 82 cases. In the remaining 34 cases only pelvic lymph node dissection was performed. There was 10.3 percent incidence of lymphatic metastasis in this series. The most common lesion was serous cystadenocarcinoma. All patients were follow-up for at least half year. The mortality rate in patients without lymph node metastasis was 2.8%, but 8.3% for those with lymph node metastasis. The clinical significance of retroperitoneal lymphadenectomy in early ovarian cancer was discussed.     

The relation of intraabdominal findings and retroperitoneal lymph node metastasis in the epithelial ovarian cancer patients

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Lymph node metastasis in patients with epithelial ovarian cancer macroscopically confined to the ovary: review of a single-institution experience

Background

To evaluate the patterns of lymphatic spread in epithelial ovarian cancer (EOC) macroscopically confined to the ovary and to determine risk factors for lymph node metastasis.

Materials and methods

All patients with clinically apparent stage IA/B/C EOCs who underwent staging surgery between January 2003 and February 2013 were retrospectively identified.

Results

Two hundred and thirty-six (n = 236) consecutive patients were operated for primary epithelial ovarian carcinoma. Sixty-two of these patients (26.2 %) who underwent a comprehensive staging procedure including pelvic and paraaortic lymphadenectomy were diagnosed with tumors confined to one or two ovaries (stage IA/B/C). Of these 62 patients, 17 (27.4 %) had upstaged disease and 8 (12.9 %) had lymph node metastasis. Tumor histology was serous in 25 patients (40.3 %), mucinous in 23 patients (37 %), endometrioid in 9 patients (14.5 %), and clear cell in 5 patients (8 %). Positive lymph node status was found in 20 % (5/25) of those with serous histology while this rate was only 8.1 % (3/37) in those with non-serous disease. Although the presence of ascites was not associated with an increased risk of lymph node involvement (p = 0.24), positive peritoneal cytology (p = 0.001) and grade 3 disease (p = 0.001) were significant predictors of lymph node involvement.

Conclusion

All patients diagnosed with EOC macroscopically confined to the ovary should be considered for comprehensive staging surgery including pelvic and paraaortic lymphadenectomy.     

Retroperitoneal lymph node metastasis in patients with ovarian cancer

From 1979 to 1987 retroperitoneal lymph node dissection was performed at the Tokyo University Hospital in 41 cases (pelvic lymph node biopsy was done in 4 cases, pelvic lymphadenectomy in 23 cases, pelvic and paraaortic lymphadenectomy up to the renal vessels in 14 cases) of Stage Ia to IV ovarian cancer following cytoreductive surgery. The incidence of retroperitoneal positive nodes was 11.1% (2/18) in Stage I, 50.0% (5/10) in Stage II, 50.0% (5/10) in Stage III and 0% (0/3) in Stage IV (FIGO criteria without considering the pathologic findings of retroperitoneal lymph nodes). The positive rate of lymph node involvement in Stage II and Stage III was significantly higher than that in Stage I. The tumors involving both ovaries were more likely to metastasize to retroperitoneal lymph nodes. Enlargement of tumors and increased ascites were not the risk factors of retroperitoneal lymph node metastasis. These data suggest that the occurrence of retroperitoneal lymphatic spread in ovarian cancer is comparable to that in uterine cancer and increased by involvement of both ovaries and extension to other pelvic tissues.     

Value of lymph node assessment in ovarian cancer: Status of the art at the end of the second millennium

Abstract. di Re F, Baiocchi G. Value of lymph node assessment in ovarian cancer: Status of the art at the end of the second millennium.
Available data on the incidence and the clinical value of lymph node assessment in ovarian cancer are reported. In early ovarian cancer, positive nodes are found in 4–25% of patients. Serous adenocarcinoma and poorly differentiated tumors are characterized by the highest incidence of node metastases. Five-year survival for stage IIIC disease with only retroperitoneal spread is clearly better than for stage IIIC with intraperitoneal dissemination. In advanced ovarian cancer, the rate of node involvement ranges from 55 to 75%. The percentage of positive nodes is significantly related to the amount of residual tumor after cytoreductive surgery, and node status seems to be an important prognostic factor for survival. Although data from retrospective studies advocate a therapeutic effect for systematic lymphadenectomy, results from prospective randomized trials are warranted. After chemotherapy a high percentage of patients (range, 25–77%) are found to have metastatic nodes. In particular, at second-look laparotomy, positive nodes are detected in 17–40% of patients who have no intraperitoneal disease.     

Retroperitoneal nodal metastasis in primary and recurrent granulosa cell tumors of the ovary

OBJECTIVE: To describe the incidence of retroperitoneal pelvic or paraaortic lymph node metastasis in patients with primary and recurrent ovarian granulosa cell tumors. METHODS: At Memorial Sloan-Kettering Cancer Center, we conducted a retrospective chart review of all patients with ovarian granulosa cell tumors managed as inpatients from January 1991 to July 2005. The initial date of diagnosis ranged from 1971 to 2005. RESULTS: We identified 68 patients with a median age of 49 years (mean, 47.5 years; range, 19-78 years). Sixty-four (94%) patients had adult type and 4 (6%) had juvenile granulosa cell tumors. Fifty-three (78%) patients had their initial surgery at another institution and 55 (81%) were incompletely surgically staged at diagnosis due to the absence of pelvic and/or aortic lymph node dissection. Patients were assigned an International Federation of Gynecology and Obstetrics (FIGO) stage that included IA, 39; IC, 15; IIB, 3; IIC, 3; IIIC, 1. In 7 patients, the original stage was not assigned. Only 16 (24%) patients had a pelvic lymph node sampling and 13 (19%) also had a paraaortic lymph node sampling at primary surgery or at restaging surgery performed shortly following initial diagnosis; however, in these cases, lymph nodes were negative for metastasis. The median number of pelvic lymph nodes removed was 10 (mean, 11.6 nodes; range, 0-36 nodes). The median number of paraaortic lymph nodes removed was 4 (mean, 6 nodes; range, 0-19 nodes). Nine of 15 (60%) of patients managed initially at our institution were surgically staged compared to 4 of 53 (7.5%) who were managed initially elsewhere (P < 0.001). Thirty-four patients with recurrent granulosa cell tumors were managed during the study, 31 (91%) had adult type granulosa cell tumor, and 3 had juvenile histology. Thirty-three of 34 patients who recurred were incompletely surgically staged at the initial operation. Original "clinical" FIGO stage for patients who recurred included IA, 15; IC, 8; IIB, 1; IIC, 3; IIIC, 1; and in 6 patients, the original stage was not available. The median disease-free interval to first recurrence was 63 months (mean,69.4 months; range, 4-170 months). First recurrence sites included pelvis, 24/34 (70%); pelvis and abdomen, 3 (9%); retroperitoneum only, 2 (6%); pelvis and retroperitoneum, 2 (6%); pelvis/abdomen/retroperitoneum, 1(3%); abdomen only, 1 (3%); and bone, 1 (3%). CONCLUSIONS: Complete surgical staging was performed in approximately 1/5 women with ovarian granulosa cell tumors; however, in those initially surgically staged, no nodal metastasis was identified. Clinical stage IA disease was the most common original diagnosis in women who recurred, and approximately 15% of first recurrences appear to involve the retroperitoneum.     

Contralateral pelvic and aortic lymph node metastasis in clinical stage I epithelial ovarian cancer.

Bilateral pelvic and aortic node lymphadenectomy is recommended for clinically localized unilateral epithelial ovarian adenocarcinoma (International Federation of Gynecologists and Obstetricians stage IA). The laterality of nodal metastasis in clinical stage I disease is rarely documented in the literature. Some authors have reported that ipsilateral node dissection is adequate for staging. A patient with contralateral pelvic and aortic lymph node metastasis and clinical stage I epithelial ovarian adenocarcinoma is presented. Pathologic findings were consistent with contralateral-only lymph node metastasis. This case illustrates the importance of bilateral lymph node sampling for appropriate staging of clinically localized epithelial ovarian cancer.