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Patients with macroscopic lymph node metastasis expect poor prognosis after neoadjuvant chemotherapy in advanced ovarian cancer: a retrospective cohort study based on a single gynecological team

BMC Cancer volume 25, Article number: 832 (2025) Cite this article

Abstract

Objective

To investigate the prognostic impact of metastatic lymph nodes (MLNs) on advanced epithelial ovarian cancer (EOC) patients receiving neoadjuvant chemotherapy (NACT).

Methods

This was a retrospective cohort study using data from patients managed by a single gynecological team between June 2012 and June 2023. Among EOC patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIC or IV disease, patients who received NACT and who underwent complete cytoreduction during interval debulking surgery were included (the NACT cohort), together with patients who received primary debulking surgery (PDS, including those with both complete and incomplete cytoreduction). Clinically suspicious lymph nodes at diagnosis and/or debulking surgeries were resected. Differences in terms of clinicopathological features, survival profiles, and recurrence patterns were analyzed between groups with different lymph node statuses.

Results

The NACT cohort comprised 166 patients (53.6% underwent lymphadenectomy), of whom 58 presented with MLNs (the MLN group) and 108 did not (the NLN group). Among those who underwent lymphadenectomy, a median of 24 pelvic lymph nodes and 13 para-aortic lymph nodes were resected. The MLN group was significantly associated with inferior progression-free survival (PFS) and time to platinum-resistant recurrence (TTPR), even when adjusted by multivariate models. The hazard ratio (95% confidence interval) was 1.90 (1.06–3.41) for the multivariate PFS analysis and 2.50 (1.22–5.13) for the multivariate TTPR analysis. For the PDS cohort (143 patients, 68.5% underwent lymphadenectomy), a median of 25 pelvic lymph nodes and 14 para-aortic lymph nodes were resected. The MLN group (66 patients) manifested non-inferior PFS and TTPR outcomes compared to the NLN group (77 patients).

Conclusions

MLNs may have a negative impact on the prognosis of patients receiving NACT. For such patients, PDS is a preferred choice to delay recurrence and platinum resistance.

Peer Review reports

Introduction

Ovarian cancer (OC) is the most lethal gynecologic malignancy worldwide, with a 5-year survival rate of less than 40% [1, 2]. When first diagnosed, 75% of patients are already in the advanced stage, with carcinoma being the most common histological type [3, 4]. Currently, primary debulking surgery (PDS) is recommended for newly diagnosed OC patients when possible [5]. However, certain patients are poor candidates for PDS because of the high tumor burden, leading to increased perioperative complications and difficulty in achieving optimal cytoreduction [6]. Compared with PDS, neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) has been implemented after several randomized controlled trials demonstrated noninferior survival outcomes compared with PDS [7, 8]. Nevertheless, concerns have risen regarding the unfavorable impacts of platinum resistance caused by NACT. Initially, OC is highly sensitive to platinum-based chemotherapy, but resistance eventually evolves in most patients, leading to a dismal prognosis [9]. Presurgical chemotherapy may even accelerate this process through various mechanisms, although the relevant risk factors remain unclear [10]. Retrospective studies have suggested inferior survival benefits for patients receiving NACT-IDS, especially when compared with patients receiving completely cytoreduced PDS [11, 12]. Considering the significant increase in the application of NACT-IDS in OC patients [12, 13], questions remain regarding patient selection for NACT-IDS.

On the other hand, metastatic lymph nodes (MLNs) have long been considered to respond poorly to platinum-based chemotherapy [14]. Baiocchi et al. conducted systematic lymphadenectomy during second-look laparotomies and found that MLNs remained even when intraabdominal disease regressed fully after chemotherapy [15]. In addition, another clinical trial indicated that the rates of node involvement may not differ significantly before or after chemotherapy [16]. A more recent study investigating the pathological responses of the ovary and retroperitoneal nodes revealed that compared with tumor lesions in the ovary, lesions in lymph nodes (LNs) become more scattered through chemotherapy, but the level of tissue fibrosis is lower, indicating incomplete responses to chemotherapy [17, 18]. Hence, investigations are needed to explore whether patients with MLNs can benefit from NACT-IDS, but relevant studies are lacking.

Based on existing evidence, we hypothesized that presurgical chemotherapy may interact with MLNs, contributing to platinum resistance and an inferior prognosis. We retrospectively collected advance-stage epithelial OC (EOC) patients who received NACT-IDS as primary management and who achieved complete cytoreduction during IDS. These patients were all managed by similar principles and followed up by our team. Survival and recurrence outcomes were collected and compared to either support or contradict this hypothesis. In addition to the NACT cohort, patients receiving PDS with or without residual disease were also enrolled in this study for further validation.

Methods

Cohort and selection criteria

This was a retrospective cohort study using medical data from patients who underwent debulking surgeries and were followed up regularly by gynecologists on our team. The inclusion criteria were as follows: (1) patients diagnosed with EOC between June 2012 and June 2023; (2) receiving NACT-IDS or PDS, and IDS must achieve complete cytoreduction (R0 resection); (3) clinically staged IIIC or IV according to the International Federation of Gynecology and Obstetrics (FIGO) by imaging at diagnosis; and (4) scored 0–2 according to the Eastern Cooperative Oncology Group (ECOG). After first-line chemotherapy, patients must be followed up for at least 180 days, and events of recurrence or progression were documented with evidence of imaging and/or persistent elevated serum CA125 levels according to the Gynecology Cancer Intergroup (GCIG) [19]. Patients who were followed up for less than 6 months and who did not experience recurrence or progression during this period were excluded. The end date of the last follow-up was 31 st October 2023.

This study was ethically approved by the Peking Union Medical College Hospital Ethics Committee (Approval No. K2803).

Data collection and variables

Before primary management, recorded clinicopathological characteristics consisted of age, Charlson comorbidity index (CCI) according to Charlson et al. [20], ECOG performance score, symptoms, presence of ascites, presence of hydrothorax, and levels of CA125. Decisions of PDS or NACT-IDS were made by assessments of performance status and tumor resectability by gynecologists in our team together with patients’ informed consent. For IDS or PDS, suspicious tumor sites were resected based on positive imaging findings preoperatively and/or gross involvement observed during surgeries. Notably, tumor sites in specific regions were resected if imaging evidence had suggested suspected LN metastasis pre-NACT and/or preoperatively, regardless of intraoperative findings. Such regions included the celiac trunk, hepatic hilum, cardiophrenic angle, and groin. The surgery complex score (SCS) was calculated and graded as low (≤ 3 points), intermediate (4–7 points), or high (≥ 8 points) according to Aletti et al. [21]. The primary disease sites and histological categories of EOC were determined by pathology. When genetic test results were available, the BRCA mutation status were retrieved. BRCA mutations were defined as somatic or genetic BRCA 1/2 mutations that were pathogenic or possibly pathogenic. For therapeutic details, the number of chemotherapy cycles of NACT and the duration from the last day of NACT to the date of IDS (denoted as NACT-IDS intervals) were recorded.

The status of LN metastasis (denoted as the LN status) was the independent variable in this study and was defined by pathological evidence of PDS or IDS. Patients were regarded as having MLNs at diagnosis if pathological results revealed metastatic LNs (denoted as the MLN group). Otherwise, patients were regarded to have no metastatic LNs when first diagnosed if pathology was negative for all resected LNs or if no LNs were resected during PDS/IDS (denoted as the NLN group). Lymphadenectomy was waived for patients with normal-sized LNs (short-axis ≤ 1 cm on CT) without any suspicious abnormalities on both preoperative imaging and intraoperative inspection. In contrast, for patients with suspicious LNs, complete lymphadenectomy was performed in the affected regional area, irrespective of intraoperative findings. Notably, for patients receiving IDS, lymphadenectomy could not be waived if suspicious LNs were detected before NACT.

For outcome variables, overall survival (OS) was defined from the date of treatment (PDS or NACT) to the date of death from any cause. Progression-free survival (PFS) was defined from the date of treatment to the date of progression or recurrence. In accordance with the NCCN guideline [5], our follow-up protocol included patient visits every 3 months for the first 2 years, every 6 months for the next 3 years, and annually after 5 years. Recurrence detection is based on rising CA-125 levels and suspicious findings on CT imaging. In addition, the range of recurrence sites was categorized according to whether LNs were included by imaging techniques (enhanced or positron emission tomography-computed tomography) or pathological biopsy. The duration from the last day of platinum-based chemotherapy to the next recurrence or progression was defined as the platinum-free interval (PFI). If the PFI was < 180 days, recurrence was considered platinum-resistant recurrence (PRR). The duration from the date of treatment to the first platinum-resistant recurrence was defined as the time to the first platinum-resistant recurrence (TTPR). The number of lines of chemotherapy administered before the first PRR was recorded. For survival data, surviving patients without any signs of progression, recurrence, or death were censored at the date of the last follow-up visit.

In this study, the primary endpoint was PFS, while the secondary endpoints were OS and TTPR. Other relevant endpoints included the range of recurrence sites and lines of chemotherapy before the first PRR.

Statistical analysis

Statistical analysis was performed by R software version 4.3.0 (The R Foundation for Statistical Computing, Vienna, Austria). Continuous variables are presented as medians (interquartile ranges, IQRs) and were compared between groups by the Wilcoxon rank sum test. Categorical variables are described as counts (percentages) and were compared between groups by Fisher’s exact test. Survival outcomes, including OS, PFS, and TTPR, were calculated using the Kaplan‒Meier method, with differences determined by the log-rank test. HRs and 95% confidence intervals (95% CIs) were computed by Cox proportional hazard analysis to investigate the prognostic factors affecting survival. Significant factors in the univariate model, along with imbalanced factors at diagnosis between the MLN and NLN groups, were further incorporated into the multivariate Cox analysis. For comparison, P values < 0.05 were considered to indicate statistical significance.

Results

Clinicopathological characteristics of patients receiving NACT

Overall, a total of 309 patients were ultimately identified out of 674 patients, as illustrated in Fig. 1. The NACT cohort included 166 patients who received NACT and underwent complete cytoreduction during IDS, while the PDS cohort included 143 patients who received PDS with or without gross residual tumor.

Fig. 1
figure 1

Flow chart of patient selection

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For the NACT cohort, 34.9% of patients belonged to the MLN group, whose demographic, clinical, and pathological features are presented in Table 1 in comparison with those of the NLN group. In the NLN group, 81.3% (77/108) did not undergo lymphadenectomy due to neither suspicious imaging nor macroscopic abnormalities. Among patients in the NACT cohort who underwent lymphadenectomy, a median of 24 pelvic lymph nodes and 13 para-aortic lymph nodes were resected. The surgical extent and corresponding pathological findings are detailed in Table S1. At diagnosis, the MLN group was younger (median age was 52 years vs 59 years, P 0.028), presented a lower rate of ascites (29.3% vs 52.8%, P 0.005), and had a more advanced FIGO stage (50.0% vs 23.1% at stage IV, P 0.001). These imbalanced factors (i.e., age, presence of ascites, and FIGO stage) were incorporated into the multivariate models below together with the significant factors in the univariate models. During IDS, surgical complexity in the MLN group was generally lower, although 4 patients in the NLN group experienced a high level of surgical complexity (P 0.004). The pathological features, gene mutation profiles, and NACT details were similar between the two groups. For events of PRR, 18 patients in the MLN group and 16 patients in the NLN group had PRR, and the distribution of chemotherapy lines before the first PRR did not differ significantly.

Table 1 Clinicopathological characteristics of patients receiving NACT
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Survival analysis

The median follow-up time for the entire NACT cohort was 32.5 months (32.2 months in the MLN group and 32.5 months in the NLN group). As shown in Fig. 2, the MLN group was correlated with inferior PFS and TTPR profiles. The median PFS for the MLN group was 21.1 months compared with 31.7 months for the NLN group (HR 1.84, P 0.0052). For TTPR, although median TTPR was not reached in either group, a significant difference was observed according to the Kaplan‒Meier curve, with an HR of 2.13 (P 0.0304). Limited death events were documented (11 in the MLN group vs 8 in the NLN group), and the OS profile did not differ significantly. In addition, in patients with clinically positive LNs, the PFS analysis revealed a trend toward worse prognosis in those with persistent lymph node metastasis after NACT, though the difference did not reach statistical significance (Fig. S1, HR 1.65, P 0.1026).

Fig. 2
figure 2

Kaplan–Meier curves for the NACT cohort according to different statuses of lymph node metastasis. (A) OS; (B) PFS; (C) TTPR. The hazard ratio and 95% CI were determined by the Cox proportional hazards model, and the P value was calculated by the log-rank test

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To further examine factors impacting PFS, univariate and multivariate Cox analyses were conducted, as shown in Table 2. According to the univariate model, the significant factors were BRCA mutation, which was a protective factor (HR 0.459, 95% CI 0.246–0.856), and MLNs, which was a risk factor (HR 1.84, 95% CI 1.20–2.82). BRCA mutation status and LN status were further included in the multivariate model together with imbalanced factors at diagnosis (i.e., age, ascites, and FIGO stage). The computed results showed that BRCA mutation status and LN status were the only factors that significantly impacted PFS.

Table 2 Univariate and multivariate analyses of PFS in the NACT cohort
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Similar analyses were conducted for TTPR, as presented in Table 3, except that several variables were omitted due to the focus of the PRR. According to the univariate and multivariate models, LN status was the only independent risk factor, and no protective factor was identified. The HR for the MLN group was 2.50 (95% CI 1.22–5.13) compared with that for the NLN group after adjusting for imbalanced factors at diagnosis.

Table 3 Univariate and multivariate analyses of  TTPR in the NACT cohort
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Recurrence patterns

The pattern of involved tumor sites either with or without LNs at the first recurrence is presented in Table 4. Although the difference between groups was not significant, more events with LN recurrence were observed in the MLN group proportionally (60.6% vs 43.5%, P 0.137). The distribution of recurrent LNs was similar between the MLN and NLN group in terms of the dissected areas during previous IDS (P 1.000) and distant metastatic sites (P 1.000).

Table 4 Recurrence patterns according to different LN statuses
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Clinical outcomes of the MLN group in the PDS cohort

For the PDS cohort, there were 66 patients in the MLN group and 77 patients in the NLN group, and their clinicopathological features are shown in Table S2. Of note, 58.4% (45/77) of patients in the NLN group did not receive lymphadenectomy. Among patients in the PDS cohort who underwent lymphadenectomy, a median of 25 pelvic lymph nodes and 14 para-aortic lymph nodes were resected. The surgical extent and corresponding pathological findings are detailed in Table S3. Overall, the MLN group was in a more advanced setting at diagnosis (43.9% vs 14.3% in stage IV, P < 0.001) and had more complicated surgeries (18.2% vs 14.3% of patients had a high SCS, P 0.009). The presence of residual disease in the PDS group and other clinicopathological characteristics were similar between the two groups. Notably, the median follow-up period of the MLN group was significantly longer (42.6 months) than that of the NLN group (28.4 months) (P 0.003).

Although clinically more severe and monitored for a longer time, the outcomes of OS, PFS, and TTPR were similar between the MLN group and the NLN group, as shown in Fig. 3. The median PFS was 32.4 months in the MLN group and 25.4 months in the NLN group, while the median OS and TTPR were not reached in either group. Furthermore, in the subset of PDS patients who achieved complete cytoreduction, there was no significant difference in PFS between the MLN and NLN groups (Fig. S2, HR 1.04, P 0.8945).

Fig. 3
figure 3

Kaplan–Meier curves for the PDS cohort according to different statuses of lymph node metastasis. (A) OS; (B) PFS; (C) TTPR. The hazard ratio and 95% CI were determined by the Cox proportional hazards model, and the P value was calculated by the log-rank test

Full size image

Discussion

In this retrospective study, we sought to determine whether MLNs at diagnosis could be a risk factor for patients receiving NACT. To verify this hypothesis, we selected patients who received NACT and underwent complete cytoreduction during IDS to avoid the impact of residual tumor on prognosis. Survival analyses revealed that patients with MLNs had worse PFS and TTPR outcomes. These results were further validated by univariate and multivariate Cox models identifying MLNs as the only independent risk factor. In contrast, MLNs did not seem to significantly alter prognosis in the PDS cohort, although the MLN group in this cohort was in a more advanced setting. In summary, these findings suggest that lymph node metastasis may serve as an important indicator of potential chemoresistance and poor prognosis for NACT. Therefore, PDS should be favored for these patients when feasible.

Patient selection for NACT has been heatedly debated in recent years, and no consensus has yet been reached. Common indications for NACT are poor physical status and heavy tumor burden, possibly considering the importance of residual disease to prognosis [22, 23]. However, such criteria vary significantly among different surgical teams, and more research is required to investigate other factors. There are inevitable differences in terms of tumor burden and physical status between the NACT and PDS cohorts [24, 25], even after implementing strategies such as propensity score matching [26, 27]. Therefore, instead of investigating differences in LN status between the NACT and PDS cohorts, we conducted analyses within the NACT cohort, followed by preliminary validation within the PDS cohort.

The main difference between NACT-IDS and PDS lies in the use of presurgical chemotherapy, and LN metastasis has been proven to be interestingly impacted by platinum-based chemotherapy. On the one hand, early reports found that MLNs are generally chemoresistant lesions in OC [14, 16]. Although the detailed underlying mechanisms remain unclear, studies in animal models have suggested that intravenous drugs often have difficulty entering the lymphatic system [28]. Pathologically, MLNs also exhibited inferior responses to platinum-based chemotherapy compared with those at the original tumor sites in the ovaries [17]. On the other hand, carboplatin treatment, which is the standard regimen for NACT of OC, has been found to induce lymphangiogenesis near both primary tumor sites and LNs, leading to metastasis [29]. Hence, in terms of pathophysiological mechanisms, it is plausible to regard MLNs at diagnosis as a risk factor for receiving NACT.

However, based on the findings of clinical studies, the impact of MLNs on the prognosis of OC patients remains controversial. For patients receiving PDS, Ayhan et al. [30] and Gasmli et al. [31] reported an insignificant correlation between MLNs and survival outcomes. Zhuang et al. suggested that MLNs may be a risk factor for both survival and platinum resistance, but the P value was not significant when adjusted for other possible confounders in multivariate models [32]. Conversely, other studies have shown that MLNs are risk factors for survival and platinum resistance [33, 34]. For patients receiving NACT-IDS, Vincent et al. reported that para-aortic LN invasion was associated with inferior OS in a univariate model, but multivariate analysis results were missing [35]. Studies conducted by Eoh et al. [36] and Komatsu et al. [37] suggested that pathologic LN involvement was an independent risk factor for PFS and OS, although in relatively small cohorts. Both studies also revealed that suspicious LNs, defined by enlarged LN sizes on pretreatment imaging, were not associated with inferior survival outcomes.

In the present study, we conducted analyses in both the NACT and PDS cohorts, enabling cross-cohort comparisons. To mitigate the confounding effect of residual disease, we included only R0 patients in the NACT cohort as the primary focus, where MLNs were found to be significantly associated with adverse prognosis. In contrast, within the PDS cohort, the LN status did not demonstrate a significant association with prognosis, irrespective of whether the analysis was restricted to R0 patients or included the entire group. This observation suggests that the prognostic impact of MLNs may differ depending on the primary treatment strategy employed. Moreover, uniform management by a single surgical team reduced heterogeneity among patients due to the consistency in surgical decision-making and technique, thereby increasing the credibility of the results.

However, concerns may arise regarding the criteria defining MLNs. In the present study, we believe that after selective lymphadenectomy, if all resected LNs were pathologically negative or no LNs were resected (i.e., clinically negative), the patients could be regarded as lacking MLNs (i.e., the NLN group) in terms of prognostic analyses. This perspective was largely based on the findings of The Lymphadenectomy in Ovarian Neoplasms (LION) trial, which suggested that grossly normal LNs before and during surgery did not significantly impact OS and PFS profiles, although 55.7% of LNs with normal macroscopic traits exhibit microscopic metastasis [38]. For patients receiving NACT-IDS in particular, selective lymphadenectomy also showed noninferior survival outcomes compared with systematic lymphadenectomy [39]. Moreover, as the newly released CARACO trial suggests, resecting clinically normal LNs pre- and intra-operatively should be omitted for patients receiving NACT [40]. Therefore, although microscopic metastases may be present in clinically normal LNs, existing evidence suggests that their prognostic impact may be limited in advanced OC.

Nevertheless, in our study, we considered patients with MLNs at IDS to have MLNs at diagnosis, inevitably underestimating the rates of patients with MLNs at diagnosis as some patients with initial lymph node involvement may have been reassigned to the NLN group due to chemotherapy-induced regression. Consequently, the poor prognosis observed in the MLN group may, partially, reflect patients of persistent lymph node metastases with limited chemotherapy response. However, for predicting MLNs before NACT, relevant studies are scarce. Preliminary evidence has shown that the accuracy of predicting retroperitoneal MLNs before NACT is only 64.6% for enlarged LN sizes [37]. Besides, predicting LN statuses using CT generated a pooled sensitivity of 0.47 in a meta-analysis [41]. Hence, to avoid introducing extra biases, we used pathological LN status during IDS as the LN status before NACT, and additional studies exploring MLN prediction before NACT are needed.

Notably, our study does not provide recommendations for patients who presented with nodal metastasis before NACT yet achieved complete regression in the lymph nodes at IDS. However, in real-world settings, predicting and assessing the response of suspicious lymph nodes to NACT is challenging. Current evidence is insufficient to guide the decision on whether to resect lymph nodes that have regressed to a clinically negative status at IDS. The LION trial and the CARACO trial, which have significant implications in guiding lymphadenectomy principles, focused on patients without suspicious LNs pre- and intra-operatively and thus did not provide direct evidence for this subgroup based on current published data. Therefore, further clinical trials and studies with larger sample sizes are necessary to explore the optimal management and prognostic implications for these patients.

We acknowledge other limitations in our study, including selection bias and confounders due to its retrospective nature. Although we attempt to minimize these biases by incorporating imbalanced factors into multivariate models, this strategy may require refinement, and potential errors may exist.

Conclusions

Patients with MLNs at diagnosis are poor candidates for NACT considering the inferior PFS and TTPR profiles compared with those without MLNs. For such patients, PDS patients should be strived for so as to expect a better prognosis.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to the privacy regulations of the Peking Union Medical College Hospital, but are available from the corresponding author on reasonable request.

Abbreviations

OC:

Ovarian cancer

EOC:

Epithelial ovarian cancer

PDS:

Primary debulking surgery

NACT:

Neoadjuvant chemotherapy

IDS:

Interval debulking surgery

MLN:

Metastatic lymph node

LN:

Lymph node

FIGO:

International Federation of Gynecology and Obstetrics

CCI:

Charlson comorbidity index

SCS:

Surgery complex score

OS:

Overall survival

PFS:

Progression-free survival

PFI:

Platinum-free interval

TTPR:

Time to the first platinum-resistant recurrence

PRR:

Platinum-resistant recurrence

IQR:

Interquartile range

CI:

Confidence interval

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Acknowledgements

We are sincerely grateful to all the patients who took part in this research.

Funding

This research is funded by National High Level Hospital Clinical Research Funding (Grant No.: 2022-PUMCH-B-083 and 2022-PUMCH-C-045).

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Authors and Affiliations

  1. Department of Obstetrics and Gynecology, National Clinical Research Center for Obstetric & Gynecologic Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China

    Wen Guo, Jie Yin, Yu Gu, Yin Shan, Wei Wang, Yan Li, Meng Qin, Jiayu Chen, Ying Jin & Lingya Pan

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  1. Wen Guo
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  2. Jie Yin
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Contributions

Conceptualization: WG, JY, YG, and YJ; Data curation: JY, YG, YS, WW, YL, MQ, JYC, and YJ; Formal analysis: WG, JY; Methodology: WG, JY and YG; Project administration and supervision: YJ and LYP; Writing-original draft: WG; Writing-review & editing: all authors. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Ying Jin.

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Ethics approval and consent to participate

The study design followed the international regulations of The Declaration of Helsinki. The ethics approval was obtained from the Peking Union Medical College Hospital Ethics Committee, which also waived informed patient consent due to the observational and non‑interventional nature of this study (Approval No. K2803).

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Not applicable.

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The authors declare no competing interests.

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Supplementary Information

12885_2025_14237_MOESM1_ESM.docx

Additional file 1: Table S1. Surgical range and pathological outcomes of lymph nodes in patients of the NACT cohorta. Table S2. Clinicopathological characteristics of patients receiving PDS. Table S3. Surgical range and pathological outcomes of lymph nodes in patients of the PDS cohort. Fig. S1. Progression-free survival in the NACT patients with clinically positive lymph nodes by lymph node statuses. Fig. S2. Progression-free survival in the PDS patients with complete cytoreduction by lymph node statuses.

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Guo, W., Yin, J., Gu, Y. et al. Patients with macroscopic lymph node metastasis expect poor prognosis after neoadjuvant chemotherapy in advanced ovarian cancer: a retrospective cohort study based on a single gynecological team. BMC Cancer 25, 832 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12885-025-14237-2

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Keywords

BMC Cancer

ISSN: 1471-2407

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