Feasibility, safety and clinical outcomes of cardiophrenic lymph node resection in advanced ovarian cancer

doi:10.1016/j.ygyno.2017.09.001

Gynecologic Oncology

Volume 147, Issue 2, November 2017, Pages 262-266

https://doi.org/10.1016/j.ygyno.2017.09.001 Get rights and content

Highlights

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CPLN resection during PCS for ovarian cancer is feasible and safe.
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CPLN resection may be associated with improved surgical and survival outcomes.
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CPLN should be done at an expert center by a multidisciplinary team of specialists.

Abstract

Objectives

Surgical resection of enlarged cardiophrenic lymph nodes (CPLNs) in primary treatment of advanced ovarian cancer has not been widely studied. We report on a cohort of patients undergoing CPLN resection during primary cytoreductive surgery (CRS), examining its feasibility, safety, and potential impact on clinical outcomes.

Methods

We identified all patients undergoing primary CRS/CPLN resection for Stages IIIB-IV high-grade epithelial ovarian cancer at our institution from 1/2001–12/2013. Clinical and pathological data were collected. Statistical tests were performed.

Results

54 patients underwent CPLN resection. All had enlarged CPLNs on preoperative imaging. Median diameter of an enlarged CPLN: 1.3 cm (range 0.6–2.9). Median patient age: 59y (range 41–74). 48 (88.9%) underwent transdiaphragmatic resection; 6 (11.1%) underwent video-assisted thoracic surgery. A median of 3 nodes (range 1–23) were resected. A median of 2 nodes (range 0–22) were positive for metastasis. 51/54 (94.4%) had positive nodes. 51 (94.4%) had chest tube placement; median time to removal: 4d (range 2–12). 44 (81.4%) had peritoneal carcinomatosis. 19 (35%) experienced major postoperative complications; 4 of these (7%) were surgery-related. Median time to adjuvant chemotherapy: 40d (range 19–205). All patients were optimally cytoreduced, 30 (55.6%) without visible residual disease. Median progression-free survival: 17.2mos (95% CI 12.6–21.8); median overall survival: 70.1mos (95% CI 51.2–89.0).

Conclusions

Enlarged CPLNs can be identified on preoperative imaging and may indicate metastases. Resection can identify extra-abdominal disease, confirm Stage IV disease, obtain optimal cytoreduction. In the proper setting it is feasible, safe, and does not delay chemotherapy. In select patients, it may improve survival.

Section snippets

Background

Women with suspected advanced epithelial ovarian cancer (EOC) should be evaluated by a gynecologic oncologist to determine the appropriate initial treatment modality [1]. This evaluation usually includes imaging of the chest, abdomen, and pelvis, to determine the extent of disease and the feasibility of optimal surgical resection [1], [2]. A 2001 survey of gynecologic oncologists revealed that the presence of upper abdominal disease and/or disease in “hazardous locations” were the most common

Methods

After Institutional Review Board approval, we identified patients with Stage IIIB-IV ovarian cancer who underwent primary CRS for high-grade EOC at our institution (Memorial Sloan Kettering Cancer Center) from January 2001 to December 2013. Patients were included if they had undergone a supradiaphragmatic resection with the intent of removing one or more CPLN(s) for diagnosis and/or treatment of ovarian cancer. Patients were excluded if they received neoadjuvant chemotherapy (NACT). Patients

Results

Of the 985 patients at our institution who underwent primary CRS for Stage IIIB-IV high-grade EOC from January 2001 to December 2013, we identified 54 patients who underwent surgical resection of the CPLN(s). The median age in this group was 59 years (range 41–74). In all 54 cases, enlarged or suspicious CPLNs were documented on preoperative CT reports. The median diameter of an enlarged CPLN was 1.3 cm (range 0.6–2.9). Preoperative pleural effusion was noted in 13 (24%) patients. Peritoneal

Discussion

While there is ongoing debate about whether NACT or CRS constitutes the best treatment approach for advanced EOC in the primary setting, we believe that a combination surgical/systemic therapeutic intervention provides the best opportunity for potential cure of this disease. At our institution we offer CRS as primary treatment to medically fit patients with resectable disease, at the time of diagnosis. Data have shown that CRS resulting in minimal (< 1 cm) or microscopic residual disease

Conflict of interest statement

None of the authors declare any conflicts of interest.

Dr. Chi serves on the Medical Advisory Board of Bovie Medical Corporation, and on the Medical Advisory Board of Verthermia. He has no conflicts of interest pertinent to this work.

Funding support

This study was funded in part through the NIH/NCI Support Grant P30 CA008748.

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All patients with FIGO IIA-IVB EOC diagnosed between March 2014 and January 2021 at our certified gynaecological cancer centre, who underwent FDG PET/CT before primary surgery were retrospectively included.
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This study was designed to investigate the response to chemotherapy of supradiaphragmatic disease diagnosed by preoperative imaging. As secondary objectives, oncologic outcomes of patients affected by supradiaphragmatic disease and their pattern of recurrence were also evaluated.
Data of consecutive patients with newly diagnosed FIGO stage IV (for supradiaphragmatic disease) epithelial ovarian cancer undergoing either primary debulking surgery or neoadjuvant chemotherapy plus interval debulking surgery between 2004 and 2021, were retrospectively collected. All patients were preoperatively evaluated by chest/abdominal CT scan or ¹⁸F-FDG PET/CT preoperatively and at follow-up to evaluate response to chemotherapy. At follow-up visits, site of recurrence diagnosed by imaging techniques was systematically recorded as it occurred. Progression-free and overall survival were measured by using Kaplan-Meier and Cox models.
A total of 130 patients was included in this study with a median (range) follow-up of 32.9 (12.8–176.7) months. Complete or partial response was achieved in most of the patients after 3 cycles (77.7%) and 6 cycles (85.4%) of chemotherapy. At follow-up, recurrence occurred in 96 (73.8%) patients and the main site of recurrence was abdomen only in 64 (66.7%) patients. At multivariate analysis, residual disease after surgery was the only variable influencing survival outcomes.
Supradiaphragmatic disease respond to chemotherapy in most patients affected by advanced EOC and recurrence mainly occurs in the abdomen. Results from this study confirms that abdominal optimal cytoreduction is the main surgical goal in the treatment of women affected by FIGO stage IV EOC.
What are the implications of radiologically abnormal cardiophrenic lymph nodes in advanced ovarian cancer? An analysis of tumour burden, surgical complexity, same-site recurrence and overall survival
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Citation Excerpt :
In the context of radiologically positive CPLNs, the literature reports that the finite number of suspicious nodes does not independently impact on patient outcome [18]. Whilst we, and other recent studies, applied a discriminatory LN diameter of 5 mm to align with ESUR guidance (2010) – the radiological cut-off for the identification of CPLN positivity in EOC is yet to be standardised [23,28–33]. Other evaluators have instead opted to adhere to RECIST guidance (2009), setting the measurement threshold at 10 mm [12,34,35].
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.
Right upper quadrant cytoreductive procedures and cardiophrenic lymph node resection in primary debulkig surgery for ovarian cancer
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Upfront debulking surgery followed by adjuvant chemotherapy still remains as the mainstay approach to patients with advanced ovarian cancer (Eisenhauer et al., 2006).
Upper abdominal surgery is often required to achieve complete gross resection and there are several studies in the literature reporting increased survival, as well as a minimal but acceptable increase in morbidity, as a result of this shift in the surgical paradigm (Chi et al., 2009).
Cardiophrenic lymph nodes (CPLNs), also referred to as paracardiac and supradiaphragmatic lymph nodes, are located just above the diaphragm. In diseases such as advanced ovarian cancer, where there is often considerable abdominal and peritoneal tumor burden, these lymph nodes can harbor metastases. These nodes are usually larger than 5 mm in diameter and are easily identified on computed tomography.
Evidence suggests that this finding should not preclude primary debulking surgery (if resectable disease in the abdomen) as it is associated with an increased median overall survival even in stage IV disease (Cowan et al., 2017, Prader et al., 2016).
We present a video highlighting one of the most commonly performed debulking procedures in the upper abdomen – right diaphragmatic peritoneal stripping (the patient had multiple small implants in both the diaphragmatic peritoneum and Morisońs Pouch peritoneum, so en bloc resection was performed) – followed by a transabdominal excision of an enlarged right cardiophrenic lymph node. The defect was closed with a 2-0 polypropylene running suture.
Postoperative chest liver herniation after cardiophrenic lymph node resection by a transdiaphragmatic approach following primary cytoreductive surgery for advanced endometrioid ovarian cancer: A case report
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Citation Excerpt :
The low serologic level of albumin of this patient (20 g/l for a normal standardized value of 30 g/l) may be considered as a factor contributing to this complication. CPLN resection is a feasible procedure with low morbidity and low rates of postoperative complications, being the pleural effusion the most frequent (Cowan et al., 2017). Chylothorax is an infrequent complication with a rate of mortality around 10%, mainly observed in medical disorders such as infectious diseases or thoracic duct obstruction due to mediastinal malignancies and also in patients undergoing thoracic surgery (Shah et al., 2012).
Resection of enlarged cardiophrenic lymph nodes (CPLN) is a procedure required to obtain complete cytoreduction in selected patients affected by advanced ovarian cancer. Their resection by transdiaphragmatic approach has been demonstrated to be feasible with low rates of morbidity. The main complications associated with this procedure are pleural effusion, pneumothorax, and rarely, chylothorax.
This case describes a postoperative chylothorax and chest liver herniation in a patient who underwent a cytoreductive surgery for advanced endometrioid ovarian cancer, which included a right transdiaphragmatic CPLN resection. Surgical management by thoracotomy was required to repair the right diaphragmatic defect combined with conservative management of the chylothorax. The diaphragmatic closure was achieved employing interrupted stitches with a non-absorbable suture. No prosthetic material was required.

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Feasibility, safety and clinical outcomes of cardiophrenic lymph node resection in advanced ovarian cancer

Highlights

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Background

Methods

Results

Discussion

Conflict of interest statement

Funding support

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Clin. Radiol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol. Rep.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Ann. Oncol.