br Background br Despite of improvements in treatment
Despite of improvements in treatment of epithelial ovarian cancer, it is still the most common gynecological cancer that results in death,1 because most of the patients present with bulky intraperitoneal advanced-stage disease. More than two-thirds of patients with EOC are diagnosed at advanced stage due to lack of symptoms and effective screening methods.2 Five-year survival is 80% at early stage, while it is approximately 30% at advanced stage.3
Major type of spread in EOC is intraperitoneal but retroperitoneal spread is also frequent at all stages. It is the cancer among genital cancers in which spread via Chloramphenicol nodes is most commonly seen.4 Lymph node metastasis is related with poor prognosis.1,5–8 It is present in 10%-15% of the cancers that are localized in ovary and in 50% of advanced-stage cancers.9
The standard treatment is primary cytoreductive surgery with combined chemotherapy con-taining taxane and platin. Surgical treatment is individualized, as dissemination of each tumor and characteristics of the disease are different.10 Although lymph node dissection is required for accurate staging and adequate treatment in early-stage ovarian cancer, its effect on survival is not clear.11 Lymph node dissection comprises an important part of an optimal cytoreduction in advanced stage patients. However, there has been no consensus yet regarding whether sys-tematic lymphadenectomy leads to improvement in survival.1,12,13 In this study, we aimed to investigate the role of lymphadenectomy on survival in patients followed-up with EOC in our clinic.
Materials and methods
The data of 474 stage I-IV primary epithelial ovarian cancer patients treated and followed in our medical oncology clinic between 2004 and 2014 were retrospectively collected. Patients who had borderline ovarian malignancy or were receiving neoadjuvant chemotherapy or had not un-dergone primary surgery was excluded from the study. We analyzed the remaining 378 patients’ data. All patients had primary surgery and were surgically staged according to the International Federation of Gynecology and Obstetrics system.
The following features were analyzed and reported: demographic features, preoperative serum Ca 125 levels, type of surgery, chemotherapy, residual disease after primary cytoreduc-tive surgery, International Federation of Gynecology and Obstetrics stage, histological type, tu-mor grade, number of resected lymph nodes, lymphadenectomy region, optimal or suboptimal surgery, recurrence, progression free survival time, and overall survival times. r> After primary surgery 299 patients (79%) received adjuvant chemotherapy—carboplatin (area under the curve; 5-6) and paclitaxel (175 mg/m2) based systemic combination chemotherapy, every 3 weeks for 3-9 cycles. At the end of the surgical and/or adjuvant treatment, the treat-ment response was evaluated as partial response, complete response or progression. Residual
disease after primary surgery was described as optimal surgery (no gross residual disease or residual disease size 0.1-1 cm in the largest diameter) or suboptimal surgery (residual disease size >1 cm in the maximal diameter of the largest tumor nodule). Optimal surgery rate was 90% (340 out of 378 patients). One hundred eighty six (49%) patients were operated in the gy-necologic oncology department of our hospital and 192 patients (51%) were operated at different centers. Therefore, there may be surgical differences between patients due to different surgeons and applied techniques. The decisions of lymphadenectomy, lymph node sampling, or dissection were given by the surgeon based on intraoperative tumor prevalence.
We retrospectively reviewed the operative pathology reports of patients in the medical oncol-ogy clinic. Patients were divided into 2 groups according to lymph node dissection performed or not. Two hundred ten patients had lymph node dissection and 168 patients did not have lymph node dissection. Patients with at least 1 lymph node removed were grouped according to num-ber of lymph nodes removed as ≤10 and >10. Additionally, patients were grouped according to the stage of the disease as early stage (stage I-II) and advanced stage (stage III-IV). They were also evaluated in 2 groups according to the regions that lymphadenectomy was performed to pelvic region and pelvic + paraaortic region.
For descriptive statistics of data, mean, standard deviation, median lowest value, median highest value, frequency, and rates were used. Various clinical and pathologic factors were com-pared with Pearson’s χ 2 test for categorical data. Independent samples t test and Mann Whitney U test statistic for continuous data according to normality. Overall survival (OS) and progression-free survival (PFS) were calculated using the Kaplan-Meier method. Prognostic factors were com-pared using the log-rank test in univariate analysis. Univariate and multivariate analysis for as-sessing the influence of various prognostic factors on survival was performed using the Cox pro-portional hazards model. All P values were 2-sided in the tests and P values of less than 0.05 were considered to be statistically significant. For statistical analyses SPSS version 17.0 was used.