CORRESPONDENCE

Re: Systematic Aortic and Pelvic Lymphadenectomy Versus Resection of Bulky Nodes in Optimally Debulked Advanced Ovarian Cancer: A Randomized Clinical Trial

Denis Querleu, Gwenael Ferron

Affiliation of authors: Department of Surgery, Institut Claudius Regaud, Toulouse, French Guiana

Correspondence to: Denis Querleu, MD, Department of Surgery, Institut Claudius Regaud, 20 rue du Pont Saint Pierre, Toulouse, 31052, France (e-mail: querleu{at}icr.fnclcc.fr).

Benedetti Panici et al. (1) should be commended for having tried to address the controversial issue of the therapeutic value of lymph node dissection in patients with optimally or completely debulked stage IIIC ovarian carcinoma. They conclude—and this finding could be considered from now on as the current state of the art—that node dissection does not improve survival rates, although it does increase the disease-free interval.

The design of the study, however, raises questions about the validity of conclusions. The conclusions would have been clearer if randomization had taken place after palpation. This approach would have eliminated from the control group the subgroup of patients with enlarged nodes that require at least selective removal and impact prognosis. As the number and specific outcome of these patients are not available, a separate comparative analysis of patients with enlarged nodes in both groups should be provided. As a consequence, the results of the analysis of the remaining patients, with no enlarged nodes, may be altered.

The most disputable conclusions are not in the original article, however, but rather in the statements in the associated editorial (2)—in particular, the statement that "the body of evidence does not favor including systematic lymphadenectomy as part of front-line maximal surgical debulking in the management of advanced ovarian cancer." Considering the dismal long-term prognosis of advanced ovarian cancer and the adverse effects on quality of life of recurrences and their medical management, interval-free survival is a most relevant endpoint that must not be neglected. In this regard, the Benedetti Panici et al. study can be read as a strong argument to perform node dissection in optimally or completely debulked patients, provided that their general condition at the end of surgical cytoreduction is good enough. Indeed, the additional risks of node dissection affect mainly the operative period and do not worsen the postoperative period, as evidenced by the finding that hospital stay is not increased in the group of patients with node dissection.

In addition, Chambers' disputable statement that node dissection is useless in advanced ovarian cancer will inevitably be exploited by surgeons without adequate training in surgical oncology, who may apply the same conclusion to patients with early ovarian cancer. The risk is that the proportion of patients managed by surgeons without adequate experience in aortic dissection will consequently increase. This may result in a lowering of the standard of care for all ovarian cancer patients, including the group of patients who still require debulking of enlarged nodes by experienced surgeons.

Management of malignancies should be directed not only at lengthening life but also at improving quality of life. Disease-free interval is an essential component of enjoying life for advanced ovarian cancer patients. Most adjuvant therapies in oncology, such as radiation therapy in patients with breast cancer or with cervical or endometrial carcinoma with positive pelvic nodes, do not increase survival. They are still widely used, notwithstanding a long-term complication rate comparable to the long-term complication rate of node dissection in ovarian cancers. We therefore suggest that node dissection remain a standard of care in patients with optimally debulked advanced ovarian cancers. Careful operative technique may reduce intraoperative blood loss, which is the main complication observed in the Benedetti Panici et al. study, and modify the balance of risk-benefit in favor of node dissection.

REFERENCES

(1) Benedetti Panici PL, Maggioni A, Hacker N, Landoni F, Ackerman S, Campagnutta E, et al. Systematic aortic and pelvic lymphadenectomy versus resection of bulky nodes only in optimally debulked advanced ovarian cancer: a randomized clinical trial. J Natl Cancer Inst 2005;97:560–6.[Abstract/Free Full Text]

(2) Chambers SK. Systematic lymphadenectomy in advanced epithelial ovarian cancer: two decades of uncertainty resolved. J Natl Cancer Inst 2005;97:548–9.[Free Full Text]



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