Surgical staging for epithelial ovarian tumors of low malignant potential

From January 1975 to December 1991, 34 patients with a diagnosis of epithelial ovarian tumors of low malignant potential (LMP) were admitted to the Istituto Nazionale Tumori of Milan. Eighteen of them (group 1) underwent complete staging laparotomy and retroperitoneal para-aortic and pelvic lymphadenectomy, as for ovarian cancer. In the remaining 16 cases (group 2), the surgical treatment ranged from unilateral oophorectomy to incomplete staging procedure. In group 1, nine patients (50%) were found to have retroperitoneal nodal involvement. In group 2, all patients had stage I disease. Patients were followed up for 20–222 months (mean 108, median 86). There were two recurrences in group 2 (after 5 years) and none in group 1 (NS). Currently all patients are alive and disease free. Nine of 18 group 1 patients were upstaged to stage III on the basis of lymph node involvement only. However, at least in this retrospective series, lymph node metastases did not affect prognosis or survival.     

Is it justified to classify patients to Stage IIIC epithelial ovarian cancer based on nodal involvement only?

BACKGROUND: Stage IIIC epithelial ovarian cancer is generally associated with upper abdominal tumor implants of greater than 2 cm and carries a grave prognosis. A subset of patients is upstaged to Stage IIIC because of lymph node metastases, in which prognosis is not well defined. We undertook this study to describe the clinical behavior of occult Stage IIIC. METHODS: All consecutive patients found to have Stage IIIC epithelial ovarian cancer during a 9-year period (1994-2002) were analyzed for surgical procedures, pathology, and disease-free (DFS) and overall survival (OS). RESULTS: Thirty-six patients were upstaged to Stage IIIC by virtue of positive nodes. Nine had small volume upper abdominal disease (IIIA/B before upstaging), 15 had disease limited to the pelvis and 12 had disease confined to the ovaries. 32/36 patients had no gross residual disease at the conclusion of surgery. The 5-year DFS and OS survivals were 52% and 76% respectively, for all patients. We observed no significant difference in outcomes between patients upstaged from IIIA/B versus I-II stage disease. The outcomes were superior to a control group of patients cytoreduced to either no gross RD or RD<1 cm, who had large volume upper abdominal disease at beginning of surgery (p<0.001). CONCLUSIONS: Patients upstaged to Stage IIIC epithelial ovarian cancer for node involvement have an excellent 5-year OS relative to all patients with Stage IIIC disease. These data demonstrate the necessity for stratifying patients classified as having Stage IIIC disease based solely on nodal disease when comparing outcomes. This information is particularly valuable when counseling patients regarding prognosis.     

Primary staging in ovarian tumors of low malignant potential

Surgical staging, consisting of peritoneal washings for cytology, infracolic omentectomy, and biopsies of diaphragm, extrapelvic peritoneum, and pelvic and aortic lymph nodes, was performed in 29 patients with ovarian tumors of low malignant potential, presumed to be either Stage I (25) or Stage II (4), in order to determine the incidence of unsuspected metastases in patients with localized disease. Fourteen patients had all and fifteen patients had one or more of these procedures performed. Overall, in stages I and II, positive peritoneal cytology was found in 7%, unexpected omental metastases in 13%, diaphragmatic metastases in 7%, positive pelvic lymph nodes in 27%, and positive aortic lymph nodes in 7%. Seven out of 29 (24%) patients with presumed localized disease, were upstaged by virtue of the staging procedures. Based on our findings, we conclude that surgical-pathologic staging to search for occult metastases in ovarian tumors of low malignant potential is justified from an investigational standpoint: however, its impact on therapeutic management is far from being defined.     

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.     

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.     

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 metastasis in epithelial ovarian carcinoma with respect to clinicopathological variables

OBJECTIVE: The purpose of this study was to evaluate the prognostic factors, and the patterns of lymphatic metastasis in EOC patients who were treated with systematic pelvic and paraaortic lymphatic dissection. METHODS: A total of 420 EOC patients was retrospectively evaluated. Clinical factors available were evaluated for a possible significance in terms of lymphatic metastasis and paraaortic involvement. RESULTS: Two-hundred and three patients were found to have lymphatic metastasis. In multivariable analysis, stage (P < 0.001), histology (P < 0.01 for serous; P = 0.02 for mixed, and P = 0.04, for Brenner), and Ca-125 level higher than 500 U/ml (P = 0.04) were found to be significantly related with the lymphatic involvement. Age and grade were significant factors for paraaortic metastasis both in univariable and multivariable analysis (P = 0.003 and P = 0.02, respectively). Most of the patients with unilateral tumors had contralateral pelvic and/or paraaortic metastasis. There were eleven patients with lymphatic metastasis in stage I-II disease, and five had paraaortic metastasis while an additional five patients had contralateral pelvic nodal metastasis. However, there was no lymphatic involvement in Stage IA, Grade I-II disease (0/63). Survival analysis revealed no significant difference by the number of metastatic lymph nodes. CONCLUSION: In multivariable analysis, lymphatic involvement was predicted independently by stage, histology, and Ca-125 level. In apparently stage I-II disease, a considerable part of patients were upstaged due to lymphatic involvement. Although routine systematic lymphadenectomy is suggested for patients with early stage disease, further series are needed for a definite regimen in patients with stage IA G1-2 disease since we did not detect any lymphatic involvement in this unique group.     

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.     

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.     

Platinum-Based Chemotherapy for Advanced-Stage Serous Ovarian Carcinoma of Low Malignant Potential

Purpose: To evaluate the effect of platinum-based chemotherapy on tumor response in patients with advanced-stage serous ovarian carcinoma of low malignant potential. Patients and methods: We conducted a retrospective review of hospital records, pathology slides, and office charts of patients identified as having Stage III or IV serous ovarian cancer of low malignant potential. Results: Between November 1979 and April 1993, 21 patients with advanced-stage serous ovarian carcinoma of low malignant potential received platinum-based chemotherapy following initial cytoreductive surgery. The amount of residual disease was recorded in 20 patients; 8 (40%) had macroscopic residual tumor <2 cm in largest diameter, and 12 (60%) had only microscopic disease. Sixteen patients underwent a second-look laparotomy following chemotherapy; 10 (62.5%) had no evidence of disease, 1 (6%) had a partial response, 2 (12.5%) had stable disease, and 3 (19%) had progressive disease. During a mean follow-up of 64 months, only 1 patient had died of disease. She had progressive disease noted at second-look laparotomy. Five of 6 patients who did not have a complete response to initial chemotherapy underwent further therapy with oral etoposide (1), intraperitoneal platinum (2), intraperitoneal mitoxantrone (1), or both (1). The sixth patient received no further therapy. Three of the patients subsequently receiving salvage intraperitoneal therapy underwent a third-look laparotomy. Two had partial responses noted, while the third patient had stable disease. Conclusions: Platinum-based chemotherapy is effective in achieving surgically documented responses in patients with advanced-stage serous ovarian tumors of low malignant potential. The benefit of this therapy in improving survival is unproven.     

A retrospective study of 27 ovarian tumors of low malignant potential

INTRODUCTION: This study was undertaken to retrospectively review the fertility-sparing surgical treatment and long-term outcome of 27 patients with ovarian tumors of low malignant potential treated at the 1st Department of Obstetrics and Gynecology of Semmelweis University Faculty of Medicine between 1990 and 2000. MATERIALS AND METHODS: Between 1990 and 2000, 163 patients with epithelial ovarian tumors were diagnosed and treated. Of these, 27 patients were diagnosed as having low malignant potential (LMP) ovarian tumors. The authors evalutated the effect of histopathologic parameters (histologic type, grade of nuclear atypia, tumor size and tumor growth on the ovarian surface) and clinical parameters (age at diagnosis, stage of disease, and treatment modalities) on prognosis in this group of patients with a long observation time. We reviewed our experience to assess the safety of conservative surgical management of patients younger than age 40 with early stage disease, and to determine the long-term outcome of low malignant potential ovarian tumors. Medical records were reviewed on all 27 patients to determine age, gravidity, size of tumor, bilaterality, sites of extraovarian involvement, stage of disease and the operative procedure. Follow-up information was obtained from hospital records, and in some cases, by direct patient contact. Statistical comparisions were made by the chi2 test. RESULTS: The incidence of LMP tumors in our patient population was 16.5%. The patients ranged in age from 15 to 82 years (median, 45 years). The lesions were staged according to FIGO. The stage distribution was Stage IA in 20 patients, Stage IB in one patient, Stage IC in one patient, Stage IIA in one patient, Stage IIB in one patient, Stage IIC in one patient and Stage IIIA in two patients. The ovarian tumors ranged in size from 3 to 19 cm (median 9 cm) and 15% of the tumors were bilateral. All patients with LMP ovarian tumors were treated with primary surgery; those who were older than 40 (14 patients) were treated with total trans-abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH and BSO), while patients younger than 40 with early stage disease (12 patients) who wished to retain their fertility potential were treated with fertility-sparing surgery, namely unilateral salpingo-oophorectomy (USO). One patient who was younger than 40 with a Stage IIIA LMP ovarian tumor was also treated with TAH and BSO. Follow-up information was available for all 27 patients with LMP ovarian tumors. Only those patients with a minimum of two years of follow-up were included. Follow-up information from two to ten years (median, 6 years; mean, 6.5 years) revealed that all 27 patients were alive. During the period of follow-up one patient who initially had stage IIIA disease developed recurrent tumor. Fifty percent of patients who underwent conservative fertility-sparing surgical treatment (6/12) subsequently conceived. CONCLUSIONS: This study confirms the excellent prognosis for patients with low malignant potential ovarian tumors. Conservative fertility-saving surgical treatment can be offered to young patients (< 40 years) with early stage (stage I-II) disease who wish to retain their fertility potential. Up to 50% of women in this study who underwent conservative surgery subsequently conceived. The long-term outcome of LMP ovarian tumors is extremely favorable, even when long-term follow-up is extended to ten years.     

Prognostic significance of morphology of tumor and retroperitoneal lymph nodes in epithelial carcinoma of the ovary: I. Correlation with lymph node metastasis

The prognostic indices based on a morphologic study of tumor and retroperitoneal lymph nodes in 63 patients with epithelial carcinoma of the ovary are reported. The purpose of the study was to identify those variables most frequently related to nodal involvement. The cases in the series consisted of 11 Stage I, 10 Stage II, 34 Stage III, and 8 Stage IV. Histologic distribution was 60.4% serous type, 11.1% mucinous, 6.3% endometrioid, 6.3% clear cell and 15.9% unclassified. All patients had maximal surgery and selective biopsy of para-aortic and pelvic lymph nodes. The results showed statistically significant variables associated with nodal metastasis in both primary tumor and regional lymph nodes. The indices in primary tumor were grade of tumor, vascular invasion, lymphocytic infiltration, and stromal fibrosis; those in lymph node were type of lymph node reaction, sinus histiocytosis, and fibroblastic proliferation. The nodes with lymphocyte depletion were associated with nodal spread in 81.3% of cases. It is concluded that morphologic study of tumor and lymph node could identify prognostic factors predicting regional nodal metastasis in ovarian carcinoma.     

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

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Ovarian epithelial tumors of low malignant potential

Forty-one patients with epithelial ovarian tumors of low malignant potential are discussed. Twenty-three patients presented with Stage I, four with Stage II and 14 with Stage III disease. All patients with Stage I disease were solely treated surgically. Twelve patients with Stage II and III disease also received postoperative chemotherapy. Four of ten patients had persistent disease at second look laparotomy. Chemotherapy was not used in six patients with Stage II and III disease when the tumor was considered to have been removed completely. Forty of the 41 patients are currently alive and free of disease at two to nine years of follow-up study. Vigorous and, at times, multiple surgical procedures remain the primary treatment of ovarian tumors of low malignant potential.     

Ovarian serous borderline epithelial tumors with multiple retroperitoneal nodal involvement: metastasis or malignant transformation of epithelial glandular inclusions?

One of four patients who underwent lymph node excision at exploration for ovarian serous borderline epithelial tumor (OSBT) at Baystate Medical Center was found to have FIGO Stage III C lesion associated with extensive ovarian external (surface) papillary growth, peritoneal implants in the omentum and cul-de-sac, and involvement of multiple pelvic and periaortic lymph nodes by the tumor. Histologically, the lymph nodes showed an admixture of endosalpingeal glandular inclusions with neoplastic tissue identical to the ovarian tumor. The exact histogenesis and the prognostic significance of the nodal involvement by OSBT are still not fully understood. Although there is a small number of reported cases of lymph node involvement associated with OSBT, they are described as examples of nodal metastases or independent primary foci of malignant transformation. This paper presents an interesting association of OSBT with extensive pelvic and periaortic nodal involvement and reviews the relevant literature.     

Evidence for the efficacy of adjuvant therapy in epithelial ovarian tumors of low malignant potential

During the 10-year period from January 1975 through December 1985, 48 patients with low malignant potential epithelial ovarian tumors were treated on the Gynecology Service at Memorial Sloan-Kettering Cancer Center. No patients were lost to follow-up and the mean duration of follow-up was 42 months. Twenty-nine patients were Stage I, 5 patients were Stage II, 11 patients were Stage III, 1 patient was Stage IV, and 2 patients were unstaged. Patients were divided into those with no residual disease after initial surgical treatment (29), microscopic residual disease (7), and gross residual disease (12). No patient without residual disease died from cancer. Of the 19 patients with residual disease, all received adjunctive chemotherapy alone, radiation therapy alone, or a combination of both. Three of 19 patients died from cancer. Twelve patients with residual disease were found to be free of disease at second-look surgical reassessment following adjunctive therapy. This review indicates that adjunctive therapy can eradicate residual disease in patients with epithelial ovarian tumors of low malignant potential.     

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.     

Combined PET/CT for detecting recurrent ovarian cancer limited to retroperitoneal lymph nodes

OBJECTIVE: To evaluate the utility of combined positron emission tomography/computed tomography (PET/CT) for detecting recurrent epithelial ovarian cancer limited to retroperitoneal adenopathy. METHODS: Fourteen patients (median age = 53 years) with rising serum CA125 levels, and negative or equivocal conventional CT imaging > or = 6 months after primary therapy were retrospectively identified as having recurrent disease limited to retroperitoneal lymph nodes by combined PET/CT and underwent surgical reassessment of targeted nodal basins. Fisher's Exact Test was used to measure the ability of PET/CT to predict isolated retroperitoneal nodal disease. RESULTS: The median increase in serum CA125 from baseline nadir was 14 U/ml (range = 2-76 U/ml). There were 29 target nodes in 15 nodal basins identified with increased metabolic uptake on combined PET/CT. Eleven patients (78.6%) had recurrent ovarian cancer in retroperitoneal lymph nodes targeted by PET/CT. Of 143 nodes retrieved, 59 contained recurrent ovarian cancer (median nodal diameter = 2.5 cm, range = 0.8-5.2 cm). For all target nodal basins, the sensitivity, specificity, positive and negative predictive values, and accuracy for recurrent ovarian cancer in dissected lymph nodes were: 40.7% (24/59), 94.0% (79/84), 82.8% (24/29), 69.3% (79/114), and 72.0% (103/143) (P < 0.001). PET/CT failed to identify microscopic disease in 59.3% of pathologically positive nodes. CONCLUSION: Combined PET/CT demonstrates high positive predictive value in identifying recurrent ovarian cancer in retroperitoneal lymph nodes when conventional CT findings are negative or equivocal. The high incidence of occult disease within the target nodal basins suggests that regional lymphadenectomy may be necessary for complete secondary cytoreduction of recurrent disease.     

Staging laparotomy in early epithelial ovarian carcinoma

It is well known that ovarian carcinoma may have subclinically metastasized at the time of the initial surgical operation when all tumor seemed to be confined to the ovary. A retrospective review of 650 ovarian carcinoma patients from 1976 to 1984 revealed 25 staging laparotomies for early epithelial ovarian carcinoma. Sixteen patients had invasive epithelial ovarian carcinoma, and nine had borderline ovarian carcinomas. Five patients had the stage of their disease changed whereas 20 remained unchanged. Among the staging laparotomy patients, 50% of cases of ovarian carcinoma with ruptured capsules were upstaged as were 33% with those with ascites. Twenty-five percent of cases with invasive epithelial ovarian carcinoma and 12% with borderline ovarian carcinoma were upstaged by a staging laparotomy. As a result of staging laparotomy, 72% of patients were spared treatment. No patient with disease truly confined to the ovaries showed recurrence in spite of receiving no treatment. All patients with disease apparently confined to the ovaries should undergo a staging laparotomy. Only disease remote from the ovary need be treated. If a staging laparotomy is not done, treatment is recommended for apparent Stage I disease.     

Pattern of lymph node metastases in clinically unilateral stage I invasive epithelial ovarian carcinomas

PURPOSE: There is controversy regarding the pattern of lymphatic spread in unilateral stage I invasive ovarian carcinomas. The purpose of this study is to describe the incidence and distribution of lymph node (LN) metastases in ovarian carcinomas clinically confined to one ovary. METHODS: Ninety-six patients with disease visibly confined to one ovary were identified. Pathology reports were reviewed to identify metastatic LN involvement, number of involved nodes, and their locations. Patients with gross disease in the pelvis or abdomen or those who had grossly positive LNs removed for debulking were excluded from this review. RESULTS: Fourteen of ninety-six patients (15%) had microscopically positive LNs on pathologic review. All of these 14 patients had grade 3 tumors. Grade 3 tumors were more commonly seen in LN-positive versus LN-negative patients (P < 0.001). Pelvic nodes were positive in 7 patients (50%), paraaortic nodes in 5 patients (36%), and both in 2 patients (14%). Forty-two patients had LN sampling only on the side ipsilateral to the neoplastic ovary, 4 of whom (10%) had LN metastases. Fifty-four patients had bilateral sampling performed, 10 of whom (19%) had LN metastases. Of these 10 patients, isolated ipsilateral LN metastases were seen in 5 (50%) cases. Isolated contralateral LN metastases were seen in 3 (30%) cases, and bilateral metastases were seen in 2 (20%). CONCLUSIONS: In this cohort of patients with clinical stage I ovarian carcinoma with disease limited to one ovary, bilateral LN sampling increased the identification of nodal metastases. Ipsilateral sampling may result in the understaging of patients. Bilateral pelvic and paraaortic LN sampling is recommended to accurately stage ovarian carcinoma.