Role of pelvic and para-aortic lymphadenectomy in epithelial ovarian cancers
Keywords:Epithelial ovarian cancer, Lymphadenectomy, Para-aortic, Pelvic
Background: Lymphadenectomy in epithelial ovarian cancers has remained a controversial subject. Lack of robust evidence on survival benefits and surgical morbidity associated questions its role in the era of adjuvant chemotherapy. The present study assessed pelvic and para-aortic lymph node removal in epithelial ovarian cancer in Indian women and tried to find clinicopathological correlation of nodal involvement and postoperative implications of lymphadenectomy.
Methods: Thirty patients with diagnosis of epithelial ovarian cancer posted for primary debulking surgery were recruited and underwent staging laparotomy along with pelvic and para-aortic lymphadenectomy. Nodal involvement was confirmed on histopathology and various parameters which could predict nodal metastasis were assessed. Patients were followed up for 12 months post-surgery.
Results: Nodal yield was ten for pelvic and four for paraaortic nodes. Pelvic node involvement was seen in 26.6% (8/30) of the patients and para-aortic in 15% (3/20) of the patients. Serous histology, higher grade, stage 3 and above, positive peritoneal cytology, omental involvement showed a higher lymph node involvement though not statistically significant. Para-aortic lymphadenectomy was associated with increased operating time, blood loss and longer hospital stay.
Conclusions: Lymphadenectomy increases morbidity and decision should be based on predictors of nodal involvement.
Jemal A, Siegel R, Ward E, Hao Y, Xu J, Murray T, et al. Cancer Statistics, 2008. CA Cancer J Clin. 2008;58(2):71-96.
Morice P, Joulie F, Camatte S, Atallah D, Rouzier R, Pautier P, et al. Lymph node involvement in epithelial ovarian cancer: analysis of 276 pelvic and paraaortic lymphadenectomies and surgical implications. J Am Coll Surg. 2003;197(2):198-205.
Berek JS. Lymph node-positive stage IIIC ovarian cancer: a separate entity? Int J Gynecol Cancer Off J Int Gynecol Cancer Soc. 2009;19 Suppl 2:S18-20.
Mikami M. Role of lymphadenectomy for ovarian cancer. J Gynecol Oncol. 2014;25(4):279-81.
Prat J. FIGO’s staging classification for cancer of the ovary, fallopian tube, and peritoneum: abridged republication. J Gynecol Oncol. 2015;26(2):87-9.
Trimbos B, Timmers P, Pecorelli S, Coens C, Ven K, van der Burg M, et al. Surgical staging and treatment of early ovarian cancer: long-term analysis from a randomized trial. J Ntl Cancer Inst. 2010;102(13):982-7.
Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187-9.
Baek SJ, Park JY, Kim DY, Kim JH, Kim YM, Kim YT, et al. Stage IIIC epithelial ovarian cancer classified solely by lymph node metastasis has a more favorable prognosis than other types of stage IIIC epithelial ovarian cancer. J Gynecol Oncol. 2008;19(4):223-8.
du Bois A, Reuss A, Harter P, Pujade-Lauraine E, Ray-Coquard I, Pfisterer J. Potential role of lymphadenectomy in advanced ovarian cancer: a combined exploratory analysis of three prospectively randomized phase III multicenter trials. J Clin Oncol. 2010;28(10):1733-9.
Beral V, Doll R, Hermon C, Peto R, Reeves G. Collaborative group on epidemiological studies of ovarian cancer. Ovarian cancer and oral contraceptives: collaborative reanalysis of data from 45 epidemiological studies including 23,257 women with ovarian cancer and 87,303 controls. Lancet Lond Engl. 2008;371(9609):303-14.
Goff BA, Mandel LS, Drescher CW, Urban N, Gough S, Schurman KM, et al. Development of an ovarian cancer symptom index: possibilities for earlier detection. Cancer. 2007;109(2):221-7.
Pereira A, Magrina JF, Rey V, Cortes M, Magtibay PM. Pelvic and aortic lymph node metastasis in epithelial ovarian cancer. Gynecol Oncol. 2007;105(3):604-8.
Roscigno M, Shariat SF, Freschi M, Margulis V, Karakiewizc P, Suardi N, et al. Assessment of the minimum number of lymph nodes needed to detect lymph node invasion at radical nephroureterectomy in patients with upper tract urothelial cancer. Urology. 2009;74(5):1070-4.
Yavuzcan A, Baloglu A, Cetinkaya B. The investigation of the factors affecting retroperitoneal lymph node metastasis in stage IIIC and IV epithelial ovarian cancer. Arch Gynecol Obstet. 2009;280(6):939-44.
Powless CA, Aletti GD, Bakkum-Gamez JN, Cliby WA. Risk factors for lymph node metastasis in apparent early-stage epithelial ovarian cancer: Implications for surgical staging. Gynecol Oncol. 2011;122(3):536-40.
Zhou J, Sun J-Y, Wu S-G, Wang X, He Z-Y, Chen Q-H, et al. Risk factors for lymph node metastasis in ovarian cancer: Implications for systematic lymphadenectomy. Int J Surg. 2016;29:123-7.
Ulker V, Kuru O, Numanoglu C, Akbayır O, Polat I, Uhri M. Lymph node metastasis in patients with epithelial ovarian cancer macroscopically confined to the ovary: review of a single-institution experience. Arch Gynecol Obstet. 2014;289(5):1087- 92.
Ayhan A, Gultekin M, Taskiran C, Celik NY, Usubutun A, Kucukali T, et al. Lymphatic metastasis in epithelial ovarian carcinoma with respect to clinicopathological variables. Gynecol Oncol. 2005;97(2):400-4.
Mitchell DG, Hill MC, Hill S, Zaloudek C. Serous carcinoma of the ovary: CT identification of metastatic calcified implants. Radiology. 1986;158(3):649-52.
Tempany CM, Zou KH, Silverman SG, Brown DL, Kurtz AB, McNeil BJ. Staging of advanced ovarian cancer: comparison of imaging modalities- report from the radiological diagnostic oncology group. Radiology. 2000;215(3):761-7.
Bipat S, Glas AS, van der Velden J, Zwinderman AH, Bossuyt PMM, Stoker J. Computed tomography and magnetic resonance imaging in staging of uterine cervical carcinoma: a systematic review. Gynecol Oncol. 2003;91(1):59-66.
Yang WT, Lam WW, Yu MY, Cheung TH, Metreweli C. Comparison of dynamic helical CT and dynamic MR imaging in the evaluation of pelvic lymph nodes in cervical carcinoma. AJR Am J Roentgenol. 2000;175(3):759-66.
Reinhardt MJ, Ehritt-Braun C, Vogelgesang D, Ihling C, Högerle S, Mix M, et al. Metastatic lymph nodes in patients with cervical cancer: detection with MR imaging and FDG PET. Radiology. 2001;218(3):776-82.
Ricke J, Sehouli J, Hach C, Hänninen EL, Lichtenegger W, Felix R. Prospective evaluation of contrast-enhanced MRI in the depiction of peritoneal spread in primary or recurrent ovarian cancer. Eur Radiol. 2003;13(5):943-9.
Kim SH, Kim SC, Choi BI, Han MC. Uterine cervical carcinoma: evaluation of pelvic lymph node metastasis with MR imaging. Radiology. 1994;190(3):807-11.
Burghardt E, Girardi F, Lahousen M, Tamussino K, Stettner H. Patterns of pelvic and paraaortic lymph node involvement in ovarian cancer. Gynecol Oncol. 1991;40(2):103-6.
Gao J, Yang X, Zhang Y. Systematic lymphadenectomy in the treatment of epithelial ovarian cancer: a meta-analysis of multiple epidemiology studies. Jpn J Clin Oncol. 2015;45(1):49-60.
Harter P, Sehouli J, Lorusso D, Reuss A, Vergote I, Marth C, et al. A Randomized Trial of Lymphadenectomy in Patients with Advanced Ovarian Neoplasms. N Engl J Med. 2019;380(9):822-32.
Maggioni A, Benedetti Panici P, Dell’Anna T, Landoni F, Lissoni A, Pellegrino A, et al. Randomised study of systematic lymphadenectomy in patients with epithelial ovarian cancer macroscopically confined to the pelvis. Br J Cancer. 2006;95(6):699-704.
Nelson G, Dowdy SC, Lasala J, Mena G, Bakkum-Gamez J, Meyer LA, et al. Enhanced recovery after surgery (ERAS®) in gynecologic oncology - Practical considerations for program development. Gynecol Oncol. 2017;147(3):617-20.