Systematic lymphadenectomy in advanced epithelial ovarian cancer: two decades of uncertainty resolved.

Abstract

The overall long-term survival rates for patients with advanced epithelial ovarian cancer remain poor, despite modern advances in both surgery and chemotherapy. Maximal surgical cytoreduction ( 1 ) and primary platinum-based chemotherapy are powerful determinants of survival. For two decades, however, there has been a debate on the value of including systematic aortic and pelvic lymphadenectomy as part of the initial ovarian cancer debulking procedure in patients with advanced disease ( 2 ) . It is clear that more than 50% of such patients will have positive lymph nodes and that the more extensive the intraperitoneal tumor burden, the higher the chance of retroperitoneal lymph node positivity. Although many investigators feel that it is the intrinsic biologic aggressiveness of the tumor (of which nodal metastasis represents just one marker), coupled with its chemosensitivity, that largely determines outcome, other investigators have raised the possibility that the retroperitoneal space may represent a sanctuary for chemoresistance ( 3 – 5 ) . If so, systemic lymphadenectomy could improve survival. Indeed, several retrospective studies have shown that there may be a survival advantage to including systemic lymphadenectomy in the primary surgery ( 2 , 5 – 7 ) . However, retrospective studies have many recognized inherent flaws, including the fact that the decision to proceed with this procedure intraoperatively is dependent on many factors, potentially leading to substantial bias.