title: Occult tumor cells in bone marrow of patients with locoregionally restricted ovarian cancer predict early distant metastatic relapse.
abstract: OBJECTIVE
  Based on conventional tumor staging, primary ovarian cancer is viewed as an intraperitoneal disease that rarely spreads to extraperitoneal organs. However, autopsy studies reveal a much higher rate of occult metastasis, indicating that extraperitoneal spread occurs with much greater frequency than previously appreciated. Consequently, we investigated the incidence of early hematogenous dissemination and its association with distant disease-free and overall survival.
  
  
  METHODS
  Bone marrow aspirates from 108 patients newly diagnosed with International Federation of Gynecology and Obstetrics stage I to III ovarian cancer were prospectively analyzed with the novel anti-cytokeratin (CK) antibody A45-B/B3. We investigated the frequency of CK-positive tumor cells in bone marrow and their effect on prognosis in relation to established risk factors for tumor progression.
  
  
  RESULTS
  Tumor cells in bone marrow were detected in 32 (30%) of 108 patients. A CK-positive finding was unrelated to established risk parameters, except for poor nuclear grading of the primary tumor. At a median follow-up of 45 months (range, 12 to 77 months), the presence of occult metastatic cells in bone marrow was associated with the occurrence of clinically overt, extraperitoneal (predominantly extraskeletal) distant metastasis (relative risk [RR], 16.5; 95% confidence interval [CI], 6.2 to 56.9; P < .0001) and death from cancer-related causes (RR, 2.3; 95% CI, 1.2 to 4.3; P = .01). Multivariate analysis identified a positive bone marrow finding as an independent prognostic factor of reduced distant disease-free survival for all patients (RR, 13.8; 95% CI, 5.4 to 52.9; P < .0001) and for the 64 stage R0-1 patients (RR, 7.3; 95% CI, 1.5 to 56.8; P = .0021).
  
  
  CONCLUSIONS
  Our data signal that hematogenous dissemination of tumor cells occurs early and throughout all stages of ovarian cancer. The clinical significance of our findings is supported by the unfavorable prognosis in association with the presence of occult metastatic cells, especially in those patients who received an effective locoregional therapy.
authors.affiliation: I. Frauenklinik and Institute of Immunology, Ludwig-Maximilians-Universität München, Munich, Germany. stephan.braun@Irz.tum.de
authors.forename: S
authors.initials: S
authors.lastname: Braun
authors.forename: C
authors.initials: C
authors.lastname: Schindlbeck
authors.forename: F
authors.initials: F
authors.lastname: Hepp
authors.forename: W
authors.initials: W
authors.lastname: Janni
authors.forename: C
authors.initials: C
authors.lastname: Kentenich
authors.forename: G
authors.initials: G
authors.lastname: Riethmüller
authors.forename: K
authors.initials: K
authors.lastname: Pantel
mesh_terms: D000328:Adult; D000368:Aged; D000912:Antibodies, Neoplasm / Q000378:metabolism; D001853:Bone Marrow / Q000473:pathology*; D005260:Female; D006801:Humans; D007150:Immunohistochemistry; D007633:Keratins / Q000276:immunology; D008875:Middle Aged; D015999:Multivariate Analysis; D009362:Neoplasm Metastasis; D009367:Neoplasm Staging; D009360:Neoplastic Cells, Circulating / Q000276:immunology; D010051:Ovarian Neoplasms / Q000276:immunology / Q000473:pathology*; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D016019:Survival Analysis
chemical_list: D000912:Antibodies, Neoplasm; D007633:Keratins