Surgical management of cardiophrenic lymph nodes in patients with advanced ovarian cancer

doi:10.1016/j.ygyno.2016.03.012

Gynecologic Oncology

Volume 141, Issue 2, May 2016, Pages 271-275

https://doi.org/10.1016/j.ygyno.2016.03.012 Get rights and content

Highlights

•
Importance of complete resection in primary ovarian cancer
•
Excision of suspicious cardiophrenic lymph nodes via a transdiaphragmatic approach
•
Feasibility, management and complications of resection

Abstract

Objective

Debulking surgery for advanced ovarian cancer does not routinely include opening of the thorax. Even systematic lymphadenectomy does not commonly extend to lymph nodes above the diaphragm. We evaluated the outcome of systematic resection of suspicious cardiophrenic lymph nodes detected on preoperative CT-scan in patients with advanced epithelial ovarian cancer (EOC).

Methods

Single-center, prospective series of 196 consecutive patients with EOC undergoing primary debulking surgery between June 2013 and June 2015. Suspicious cardiophrenic lymph nodes were defined as ≥ 10 mm on the short axis diagnosed in pre-operative CT-scan and were removed if intra-abdominal debulking resulted in complete resection or residual tumor < 10 mm and the patients' performance status allowed this additional procedure. Removal of suspicious cardiophrenic lymph nodes was performed via a trans-diaphragmatic approach.

Results

Thirty (15%) out of 196 EOC patients had radiologically suspicious cardiophrenic lymph nodes ≥ 10 mm and complete resection or residual tumor < 10 mm. Twenty-seven out of the thirty patients had at least one confirmed metastatic cardiophrenic lymph node. Metastatic cardiophrenic lymph nodes were associated with extensive intra-abdominal tumor spread in the upper abdomen.

Conclusions

Patients with suspicious cardiophrenic lymph nodes detected by preoperative CT-scan had histologically confirmed metastasis in 90% of cases. The surgical procedure is feasible without major complications if performed by experienced gyneco-oncologists. The prognostic value of this procedure should be evaluated in larger controlled studies.

Introduction

Epithelial ovarian, fallopian and peritoneal cancer (EOC) is the second most common gynecologic malignancy in the Western World and the most common cause of death due to gynecologic malignancies [1]. Approximately 75% of patients with ovarian cancer are diagnosed with advanced stage (FIGO IIIC–IV) (Fédération Internationale de Gynécologie et d'Obstétrique, [2]) disease. The most important prognostic factor next to FIGO stage is debulking surgery leaving no macroscopic residual disease [3]. The latter often requires extensive surgical procedures such as diaphragmatic stripping, splenectomy, atypical liver resection, excision of bulky lymph nodes and bowel resection. These procedures improve complete resection rate and subsequent survival of patients with advanced EOC [4]. The prognostic impact of systematic paraaortic and pelvic lymphadenectomy in optimally debulked patients with radiologically and clinically negative lymph nodes is unclear at the moment. In contrast, removal of bulky lymph nodes is indicated if complete resection can be achieved elsewhere in the abdomen [3].

Terminology for lymph nodes at the low anterior mediastinum is not yet uniform, as they are frequently described as precordial, paracardial, mediastinal, retrosternal, epiphrenic, supradiaphragmatic, or cardiophrenic-angle lymph nodes. In the present study these lymph nodes are referred to as cardiophrenic lymph nodes. Cardiophrenic lymph nodes have been described in patients with lung, esophageal and colorectal cancer and in patients with lymphoma [5]. In patients with EOC, enlarged cardiophrenic lymph nodes have been described as a possible predictive parameter for the failure of optimal debulking surgery [6] and are associated with impaired overall survival [7].

We report on our experiences with surgical evaluation of cardiophrenic lymph nodes in patients undergoing upfront debulking surgery for advanced EOC.

Section snippets

Patients and methods

A consecutive series of 196 patients with advanced EOC treated between 6/2013 and 6/2015 at the Department of Gynecology and Gynecologic Oncology, Kliniken Essen-Mitte, Germany was investigated. Data were retrieved from the prospectively maintained clinical tumor database. Patients with non-invasive, non-epithelial ovarian cancer or borderline tumors, as well as patients who had undergone surgery other than upfront debulking and/or received pre-operative chemotherapy and patients with

Results

During the two-year observation period, 196 patients with advanced EOC stage (FIGO IIIC/IV) who were fit for multivisceral surgery underwent upfront debulking. In 30 (15.3%) patients cardiophrenic lymph nodes were resected and histologically evaluated (Table 1). The median patient age was 59 years and all but one patient had an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0. Median operating time was 465 (240–660) minutes. Complete macroscopic tumor resection was achieved

Discussion

The only important prognostic factor in advanced ovarian cancer which might be influenced by therapeutic intervention is macroscopic complete resection [4]. Therefore, macroscopic complete resection is the major goal of debulking surgery in patients with advanced EOC [3]. This is not limited only to intraabdominal disease but has also been postulated for resection of extraabdominal lesions in FIGO stage IV disease [16]. However, after reviewing literature about cardiophrenic lymph nodes and

Disclosure

The authors declare that none of them has any potential conflict of interest with respect to the subject of this manuscript.

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Citation Excerpt :
CPLND via the transdiaphragmatic route – as employed by our team –is the most widely adopted approach and has been well described [42,43]. Evidence supports the feasibility and safety of this technique, reporting minimal additional morbidity in the context of ultra-radical surgery – and, importantly, no added delay in progression to adjuvant chemotherapy [13,28–31,34,44,45]. On evaluating the impact of CPLN dissection on survival, however, we did not prove a statistically significant therapeutic benefit.
Our paper evaluates the relationship between radiologically abnormal cardiophrenic lymph nodes (CPLN) in advanced ovarian cancer and pattern of disease distribution, tumour burden, surgical complexity, rates of cytoreduction and same-site recurrence. Impact of suspicious CPLN and CPLN dissection on overall survival also determined.
Retrospective review of index CT imaging for 151 consecutive patients treated for stage III/IV ovarian malignancy in a large UK cancer centre to identify radiologically abnormal CPLN. Corresponding surgical, histo-pathological and survival data analysed.
42.6% of patients had radiologically ‘positive’ CPLN on index CT. Radiological identification of CPLN involvement demonstrated a sensitivity of 82% within our centre. Patients with cardiophrenic lymphadenopathy on pre-operative CT had significantly more co-existing ascites (p = 0.003), omental (p = 0.01) and diaphragmatic disease (p < 0.0001). At primary debulking (PDS), suspicious CPLN were associated with significantly higher surgical complexity scores, without feasibility of complete cytoreduction being impacted. Cardiophrenic involvement at initial diagnosis was associated with same-site relapse at recurrence (p = 0.001). No significant difference in overall survival was demonstrated according to CPLN status following either PDS or delayed debulking (DDS). CPLN dissection did not improve patient outcomes.
Radiological identification of abnormal CPLN is reliable. Suspicious CPLN appear to represent a surrogate marker of tumour volume – in particular, heralding upper abdominal disease – and should prompt anticipation of high complexity surgery and referral to an appropriate centre. Patients with prior CPLN involvement are more likely to develop same-site recurrence at relapse. Our survival data suggests cardiophrenic LN disease does not worsen patient prognosis and that the therapeutic benefit of CPLN dissection remains unclear.
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Surgical management of cardiophrenic lymph nodes in patients with advanced ovarian cancer

Highlights

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Patients and methods

Results

Discussion

Disclosure

Ann. Oncol.

Eur. J. Surg. Oncol.

Gynecol. Oncol.

Eur. J. Cancer

Gynecol. Oncol.

Eur. J. Cancer

Gynecol. Oncol.

Clin. Radiol.

Clin. Radiol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Cancer statistics, 2015

CA Cancer J. Clin.