Affiliations of authors: Departments of Surgery (PM, DC) and Gynecology (PP, CL), Institut Gustave Roussy, Villejuif, France
Correspondence to: Philippe Morice, MD, Department of Surgery, Institut Gustave Roussy, 39 rue Camille Desmoulins, 94805, Villejuif, France (e-mail: morice{at}igr.fr).
We read with great interest the article by Benedetti Panici et al. (1) on the results of systematic lymphadenectomy in advanced-stage ovarian cancer. We also read the editorial about this trial by Chambers (2), but we do not totally agree with her conclusions.
This trial confirms the high rate of nodal involvement in advanced-stage ovarian cancer (70% of patients in the lymphadenectomy arm versus 42% in the no lymphadenectomy arm). Given this rate, nodal spread would have been misdiagnosed in approximately half of the patients with nodal metastases if only bulky nodes had been removed. Such a result is consistent with data in the literature, which show that half of advanced-stage ovarian cancer patients with nodal involvement have no suspicious nodes during macroscopic examination at the time of the surgical procedure (3).
The quality of the surgical resection of disseminated disease is critical for optimizing the survival of patients treated for this disease. The size of residual disease at the end of debulking surgery is a powerful prognostic factor (4). Recent series suggest that the aim of debulking surgery is not simply to achieve optimal surgery (i.e., residual disease <1 cm) but rather complete removal of all macroscopic disease (5). If a surgical effort is expended to achieve complete resection of peritoneal disease, this effort should also theoretically include retroperitoneal areas. If only bulky nodes are removed, half of the patients with nodal spread would be undertreated, and complete resection would therefore not be achieved in such patients (even if all peritoneal disease is removed).
Chambers concludes that systematic lymphadenectomy should be abandoned because, although optimal debulking improves disease-free survival, it does not have an impact on overall survival. However, important information that was not included in the article by Benedetti Panici et al. should be considered before firm conclusions are drawnnamely, the second-line chemotherapy modalities used and the surgical debulking procedures used (which reflect the extent of peritoneal disease). But above all, an issue not mentioned in the article by Benedetti Panici et al. is the impact on survival of lymphadenectomy in the subgroup of patients in whom this procedure may perhaps be the most useful, i.e., the group of 159 patients who underwent complete surgical resection.
Chambers underlined the higher rate of complications in the lymphadenectomy arm. The surgical procedure was longer; however, the number of intraoperative complications was similar in the two arms. The rates of blood loss and transfusion were higher in the lymphadenectomy arm. However, these increases were related to the use of an additional procedure and should not be questioned if the procedure added is considered essential to optimize the survival of patients. Furthermore, there was no impact of lymphadenectomy on the duration of hospitalization. Finally, the rate of late complications directly related to lymphadenectomy was very low (14/221 or 6%). The authors did not differentiate lymphocysts from lymphoedema, but if the majority of late complications were lymphocysts then the existence of these late complications should not put into question the use of lymphadenectomy because they are easily curable.
Finally, like Benedetti Panici et al., we believe that lymphadenectomy should be integrated into the surgical procedure for advanced stage ovarian cancer (provided complete removal of peritoneal disease is feasible). At any rate, although we are still waiting for data that could demonstrate the therapeutic value of lymphadenectomy in terms of overall survival, this trial at least confirms its prognostic value because the survival of patients with nodal involvement was different from that of patients without nodal spread. Systematic lymphadenectomy could therefore help to optimize the treatment of patients with nodal involvement by identifying the subgroup of patients with the worst prognosis (patients with nodal involvement).
NOTES
The authors acknowledge Lorna Saint Ange for editing this letter.
REFERENCES
(1) Benedetti Panici P, Maggioni A, Hacker N, Landoni F, Ackerman S, Campagnutta E, et al. Systematic aortic and pelvic lymphadenectomy versus resection of bulky nodes in optimally debulked advanced ovarian cancer: a randomized clinical trial. J Natl Cancer Inst 2005;97:5606.
(2) Chambers SK. Systematic lymphadenectomy in advanced epithelial ovarian cancer: two decades of uncertainty resolved. J Natl Cancer Inst 2005;97:5489.
(3) 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 para-aortic lymphadenectomies and surgical implications. J Am Coll Surg 2003;197:198205.[CrossRef][ISI][Medline]
(4) Bristow RE, Tomacruz RS, Armstrong DK, Trimble EL, Montz FJ. Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era; a meta-analysis. J Clin Oncol 2002;20:124859.
(5) Chi D, Huh J, Hamilton C, Haddad L, Abu-Rustum N, Sonoda Y, et al. What is the optimal goal of primary cytoreductive surgery for bulky stage IIIC epithelial ovarian carcinoma. Proceedings of the 36th Annual Meeting of the Society of Gynecologic Oncologists; 2005, Mar 1923; Miami (FL). Gynecol Oncol 2005;96:9345.
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