Comprehensive Lymphadenectomy Often Not Necessary in Surgical Management of Primary Endometrioid Ovarian Carcinoma
Key findings
- This retrospective study characterized patterns of lymph node metastasis in 63 patients who had endometrioid ovarian carcinoma confirmed by central expert pathologist review
- No lymph node metastases were detected and no patient had a tumor upstaged by lymphadenectomy or omentectomy; four patients, including three with grade 2 endometrioid histology, had tumors upstaged from IA to IC by positive peritoneal washings
- Complete staging, defined as pelvic and peri-aortic lymphadenectomy, omentectomy and peritoneal washings, had no impact on progression-free survival and overall survival
- The decision to perform lymphadenectomy during initial surgery should depend on clinical factors, including confidence in the strength of the intraoperative pathologic diagnosis, the clinical stage, and the patient's risk of perioperative morbidity
- When a diagnosis of clinically ovarian-confined endometrioid ovarian carcinoma is made postoperatively, it may be reasonable to counsel the patient against the utility of a staging reoperation
Staging and treatment recommendations for endometrioid carcinoma of the ovary are the same as for high-grade serous ovarian carcinoma, according to National Comprehensive Cancer Network guidelines, even though their clinical behavior is substantially different. These recommendations are designated category 2B, reflecting limited evidence.
Subscribe to the latest updates from OB/GYN Advances in Motion
Massachusetts General Hospital researchers retrospectively studied the metastatic patterns of primary endometrioid ovarian cancer, concluding that comprehensive lymphadenectomy may not justify the associated morbidity. Varvara Mazina, MD, a gynecologic oncologist at the Mass General Cancer Center and Department of Obstetrics and Gynecology, Marcela G. del Carmen, MD, MPH, also a gynecologic oncologist at the Cancer Center and Department, president of the Massachusetts General Physicians Organization and executive vice president of Mass General Brigham, and colleagues report in the International Journal of Gynecological Cancer.
Methods
The researchers identified 63 patients diagnosed with primary endometrioid carcinoma of the ovary between January 2012 and June 2021. All patients underwent primary hysterectomy without neoadjuvant chemotherapy.
Tumors were subject to central expert pathologic review. 20 patients had grade 1 tumors, 27 had grade 2, and 16 had grade 3. Stage IA/B disease was present in 20 patients, stage IC in 23, stage II in 16, and stage III in four.
All patients with stage IC and higher disease received adjuvant platinum-based chemotherapy, except two patients with grade 1 stage IC tumors who chose observation. Neither experienced recurrence. All patients with stage III disease had macroscopic metastatic disease noted at surgery and underwent complete cytoreduction to no gross residual disease.
Cancer Staging
67% of patients with clinically pelvic-confined disease underwent complete staging, defined as pelvic and para-aortic lymphadenectomy, omentectomy, and peritoneal washings.
41 patients underwent pelvic lymphadenectomy, 32 underwent para-aortic lymphadenectomy and 22 had no lymphadenectomy. A median of 12 pelvic lymph nodes (range, 1–46) and six para-aortic lymph nodes (range, 1–46) were removed; all were negative for carcinoma.
Omentectomy was performed in 58 patients (92%) and was positive in four patients with grade 3 disease (7% of those undergoing omentectomy). No patient had their cancer upstaged because of omentectomy.
Peritoneal washings were performed in 52 patients (83%) and were positive for malignant cells in eight (15%). Four tumors (one grade 1 and three grade 2) were upstaged from 1A to 1C because of positive peritoneal washings. That grade 1 tumor was the only one of the 20 grade 1 endometrioid carcinomas upstaged by any component of staging.
BRCA Mutations
Two patients had a pathogenic germline mutation, one in BRCA1 and one in BRCA2. Both were originally diagnosed as having grade 3 endometrioid carcinomas, raising the possibility that the tumors represented high-grade serous carcinomas with a pseudo-endometrioid morphology, as previously suggested in Gynecologic Oncology.
Survival
Median follow-up time was 42 months (range, 4–70 months). Four patients died of the cancer, with median overall survival of 31 months. For the entire cohort, progression-free survival was 42 months and overall survival was 44 months.
Comprehensive cancer staging had no effect on progression-free survival and overall survival when compared with partial staging (a staging procedure with any of the components missing) or no staging.
Conclusions
Lymphadenectomy is associated with increased perioperative complications, including operative time, blood loss, need for transfusion, lymphocyst and lymphedema. As lymph node metastases were not detected in this study regardless of tumor grade, the value of comprehensive staging for survival must be called into question.
A precise pathologic diagnosis is challenging to make intraoperatively, and surgeons may decide for or against comprehensive lymphadenectomy based on a combination of clinical factors. These include confidence in the strength of the intraoperative diagnosis, the clinical stage, and the patient's risk of perioperative morbidity.
When a diagnosis of clinically ovarian-confined endometrioid ovarian carcinoma is made postoperatively, clinicians can consider counseling patients against the utility of a staging reoperation.
view original journal article Subscription may be required
Learn more about the Center for Gynecologic Oncology
Refer a patient to the Department of Obstetrics and Gynecology