Is surgical lymph node assessment necessary for women with mucinous ovarian cancer?

We will discuss “Surgical lymph node assessment in mucinous ovarian carcinoma staging: a systematic review and meta-analysis” by Hoogendam and co-workers from 26 October 2016 for 7 days.

*This paper is now free-to-view. The linked mini-commentary by Nagar H on this paper can also be found via this research report.

We are now on LinkedIn too: http://linkd.in/1BVrpad (simply ask to join)!

Start date: 26 October 2016 (the discussion will continue for 7 days between 26 October- 2 November 2016)

First hosted discussion session(s) on Twitter starts at GMT+1 (British Summer Time) 8pm on 26 October 2016 (using hashtag #BlueJC)

Host: @BlueJCHost

Platforms: Twitter, Facebook and LinkedIn 

BJOG_BlueJC_160x600WebBanner_Mar15_(reoriented)_3The Blue Journal Club is an international journal club on women’s health research based on Twitter (as @BlueJCHost). We start our conversation on the last Wednesday of every month and use the hashtag #BlueJC for our tweets. Simply add this hashtag (“#BlueJC”) to each tweet and we will capture it. Each #BlueJC opens for 7 days with an advertised start time. All BJOG #BlueJC papers also have complementary slide sets suitable for face-to-face journal clubs with your local colleagues. You can access the slide set of this paper here (click on the “supporting information” tab).

The discussion points are attached below (quoted from the published Journal Club guide)

Scenario

A 50-year-old woman attended your gynaeoncology clinic regarding the management of a complex ovarian mass. A staging CT confirmed a unilateral mass with features suggestive of malignancy. There was no radiological evidence of metastasis. Multidisciplinary team discussion suggested upfront surgery. She had no comorbidity.

How would you counsel this woman about the proposed operation?

Description of research

Participants Women diagnosed with mucinous ovarian carcinoma undergoing surgical staging
Intervention Studies with ≥10 mucinous ovarian carcinoma cases and surgical lymph nodal assessment
Comparison No surgical lymph nodal assessment
Outcomes Prevalence of lymph node metastases, stage shift based on lymph node assessment and survival data
Study design Systematic review and meta-analysis
Authors’ conclusion Less than 1 in 100 (0.8%) women with stage 1-2 mucinous ovarian cancer undergoing lymph node assessment had metastases in resected lymph nodes.

Discussion Points

  • How do you currently assess the risks of malignancy in women presenting with ovarian masses?
  • How do the different subtypes of ovarian cancers differ in terms of clinical presentation and underlying genetic aberrations? (see suggested reading)
  • What did the Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies of Interventions (ACROBAT-NRSI) show?
  • What are the strengths and weaknesses of this meta-analysis?
  • Is lymph node dissection a more sensitive method to detect metastases, compared to lymph node sampling?
  • How common is lymph node metastasis in women with other subtypes of ovarian cancer?
  • How often do we know an ovarian mass is likely to be mucinous carcinoma prior to surgery?
  • How may the results influence the current management pathway of women with ovarian masses?

Suggested reading

  • Scottish Intercollegiate Guidelines Network. Critical Appraisal: notes and checklists. Methodology checklist 1: Systematic reviews and meta-analyses. http://www.sign.ac.uk/methodology/checklists.html (Last access 20 July 2016)
  • Vaughan S, Coward JI, Bast RC Jr, Berchuck A, Berek JS, Brenton JD, Coukos G, Crum CC, et al. Rethinking ovarian cancer: recommendations for improving outcomes. Nat Rev Cancer. 2011 Sep 23;11(10):719-25.
  • Royal College of Obstetricians and Gynaecologists. Green-Top Guideline No. 34. Management of suspected ovarian masses in post-menopausal women (July 2016)

 

For those who want to understand hashtags, this may be a useful guide. For an introduction to #BlueJC, please refer to BJOG 2013;120:657–60. Follow @BlueJCHostthis blog and our Facebook page to receive news about #BlueJC.

2 thoughts on “Is surgical lymph node assessment necessary for women with mucinous ovarian cancer?

  1. Discussion points

    1. Current assessment of risk of malignancy would be based upon.
    a. Preliminary data of the patient vis a vis age and BRCA positivity and relevant family history. Pre or post Menopausal status.
    b. Clinical exam findings: ECOG status, Obvious Nodal mets, variegated consistency of the Adenexal mass.
    c. Tumor Marker profile: Age more than 40 years: CA125 and Ca 19.9.
    Age less than 40 years: Additional AFP, Ldh,BHCG.
    d. TVS: Solid elements, papillary projections, ascites, RI on color doppler, Thick Septa.
    e. Imaging or dissemination: CT whole abdomen or CXRay suggesting disseminated deposits.

    2. Different histopathological subtypes of Ovarian cancer with clinical presentation.
    Serous: More common 75-80 percent, high risk of metastasis and disseminated disease on first presentation. BRCA linked, heriditofamilial. Older age group, Ca 125 positivity.
    Mucinous : 10-15 percent, localized disease on primary presentation 1-2, extraovarian origin to be excluded, low risk of Nodal Mets range (0.8- 1.5 percent max 2.6 percent), CA 19.9 positivity, K RAS Mutation.
    Endometriod: Rare, Association with Type 1 Ca Endometrium, similar prognosis as compared to serous ovarian cancer.
    Clear cell: Rare, ARID1 linked, associated wi th endometriosis, low risk of nodal mets and poor prognosis in view of rapidly dissemination of disease and propensity for recurrence.

    3. No comment.

    4. Strengths: High level of evidence. Good statistical design and methodology, gradation of risk of bias, low risk of heterogeneity of included studies. Definitive indication towards change of surgical practice with regards to nodal assessment. Inclusion of 5 year disease free survival outcomes.
    Weakness: Applicability only in centers with facility of definative frozen section facility for determination of histolopathology during staging. Small number of patients limit adequate powering of study. No comparison of outcomes between staged or unstaged patients. There is no data on a significant number of patients who undergo completion ( re -surgery) after primary surgery.

    5.It is important to note that 1/3 rd patients of Nodal positivity are microscopic in nature and cannot be detected through palpation alone. Hence lymph node dissection is more important method of Nodal assessment in view of Nodal yield and possible therapeutic benefit by reducing risk of recurrence.

    6. Risk of Nodal.Recurrence:
    Serous: Dubois :pelvic 11 percent, Para-aortic
    32 percent. Kleppe: 23.3 percent.
    Endometriod and clear cell: 6.5. and 14.4 percent according too Kleppe et al.

    7. In bilateral masses with Ca 19.9 positivity. May indicate mucinous histology but difficult to predict without intraaoperative frozen section as only 10-15 percent of the masses are Mucinous. Note provision of a core biopsy for HPE diagnosis is advanced disease on radiological staging.

    8. Implications of current study on clinical practice, possibly omission of nodal assessment during re- staging surgery if patient accepts the risk, however Appendectomy is essential. Furthermore, designing a RCT for nodal assessment if similar risk found in pilot study in view of acceptable surgical risk.

    • Thank you for your comments and thorough appraisal of the paper! I hope this was useful for your professional development.

      I also agree with you the caveat is that we don’t normally know which ovarian cancer subtype we are dealing with pre-operatively. Moreover, many centres do not perform repeat re-staging surgery for ovarian cancer.

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