Patterns of metastasis in sex cord-stromal tumors of the ovary: Can routine staging lymphadenectomy be omitted?

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Abstract

Objective

Given the paucity of data regarding the patterns of metastasis from ovarian sex cord-stromal tumors (SCSTs), we sought to determine the risk of lymph node metastasis in patients with SCSTs.

Methods

A retrospective chart review was performed after clinical and pathology databases were queried for ovarian SCST patients who were treated at our institution between 1985 and 2005.

Results

We identified 262 patients with pathology-confirmed ovarian SCSTs; 5 had additional non-stromal histology and were excluded, leaving 257 evaluable patients. Of these patients, 178 had adult granulosa cell tumors, 27 had juvenile granulosa cell tumors, 31 had Sertoli-Leydig cell tumors, 6 had sex cord tumors with annular tubules, 13 had mixed SCSTs, and 2 had SCSTs not otherwise specified. Our evaluation showed that 111 patients underwent a complete or partial staging procedure; 75 had stage I disease, 11 had stage II disease, and 25 had stage III disease. Fifty-eight of these 111 patients (52%) had lymph nodes removed as part of the staging procedure. Of the 58 patients who had lymph nodes sampled during the primary surgery, none had positive nodes. Of 117 patients whose disease eventually recurred, 6 patients (5.1%) had nodal metastases at the time of recurrence. Three of these patients had negative lymph nodes at initial staging.

Conclusions

Lymph node metastasis in ovarian SCSTs is rare. These findings suggest that lymphadenectomy may be omitted when staging patients with ovarian SCSTs.

Introduction

Ovarian sex cord-stromal tumors (SCSTs) are rare, accounting for only 7% of ovarian malignancies [1]. These tumors can occur as an isolated histologic subtype or as a combination of subtypes, including adult or juvenile granulosa cell tumors, Sertoli-Leydig cell tumors, sex cord tumors with annular tubules, or SCSTs not otherwise specified [2]. Many of these tumors are clinically indolent and are associated with a good long-term prognosis, but they often occur in adolescents or in women of reproductive age, thereby necessitating careful consideration of individual treatment with emphasis on safe fertility-sparing therapy. Some of these patients may also relapse on multiple occasions with long disease-free intervals between recurrences. This spectrum of neoplasms, then, has a different biology than that of the more common epithelial ovarian cancer [3]. Details of the biological nature of SCSTs are lacking, as research has been limited in this area.

Current guidelines for the treatment of any ovarian malignancy include the recommendation to surgically stage and debulk the cancer. Comprehensive surgical staging in patients with clinically apparent early-stage disease includes peritoneal cytology; inspection and palpation of the abdominopelvic contents; bilateral pelvic and para-aortic lymphadenectomy; omentectomy; and peritoneal biopsy or removal of any suspicious lesion [4]. If the cancer appears to be confined to one ovary and the patient desires future fertility, the uterus and apparently healthy ovary may be preserved; however, this conservative surgical approach does not obviate the need for staging.

These recommendations extend to ovarian sex cord-stromal tumors [5], [6], [7], [8], [9]. Despite these guidelines, many SCSTs are not completely staged during the initial surgery, often because a pathologic diagnosis has not yet been made or because a trained gynecologic oncologist is not present. When a patient with an unstaged or incompletely staged SCST is referred for definitive consultation after her first surgery, the gynecologic oncologist must decide whether to recommend a second surgery for complete staging or to recommend imaging and surveillance. Such decisions have important implications for the patient's outcome, given the potential risks of additional surgery and/or chemotherapy [5]. Additionally, the extent of the staging procedure must be carefully considered; if the risk of nodal involvement is low, the potential morbidity of a formal lymphadenectomy may not be warranted.

However, little is known about the risk of nodal involvement in SCST, and thus, decisions about staging surgeries are based on factors such as convention and generalizations derived from paradigms for treating epithelial ovarian cancer. Clinicians could make better decisions about treating patients with ovarian SCSTs if the risk of nodal involvement was better understood. Our anecdotal experience has suggested that lymph node metastasis from SCSTs is rare, but to our knowledge, no study has addressed this issue. Therefore, we designed a retrospective study to determine the risk of lymphatic metastasis in patients with ovarian SCSTs.

Section snippets

Materials and methods

We retrospectively reviewed the medical records of all consecutive patients who were diagnosed with ovarian SCSTs at The University of Texas M. D. Anderson Cancer Center from January 1985 through July 2005. Patient data were obtained from the institution's medical records and pathology databases. We collected demographic information; clinical, surgical, chemotherapy, and radiation therapy information; and dates and nature of follow-up. Included in this information was the presence of lymph node

Patients and demographics

We identified 262 patients with ovarian stromal malignancies. Five patients were excluded because additional nonstromal ovarian malignancies were present, which left 257 evaluable patients. Characteristics of the 257 evaluable patients at the time of diagnosis are summarized in Table 1. A review of the patients' pathology reports confirmed at the M.D. Anderson Cancer Center revealed that 178 of these patients had adult granulosa cell tumors (AGCTs), 27 had juvenile granulosa cell tumors

Discussion

Our findings suggest that nodal metastasis is rare in patients with ovarian stromal tumors. Indeed, among the patients with full initial surgical staging, none had nodal metastasis at that time. The identified patterns of metastasis and recurrence clearly suggest either a surface or hematogenous route of spread but not a mechanism of primary lymphatic spread. Furthermore, the patterns of metastasis and recurrence seen here have specific treatment implications.

The goal for patient care in

Conflict of interest statement

The authors declare that there is no conflict of interest.

References (17)

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This manuscript was presented in part at the 38th Annual Meeting of the Society of Gynecologic Oncologists, 38th Annual Meeting on Women’s Cancer, San Diego, CA, USA, March 2007.

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