European Journal of Obstetrics & Gynecology and Reproductive Biology
Review articleThe role of systematic pelvic and para-aortic lymphadenectomy in the management of patients with advanced epithelial ovarian, tubal, and peritoneal cancer: A systematic review and meta-analysis
Introduction
Epithelial ovarian, tubal, and peritoneal cancers have been recognised as one neoplastic entity, mainly because of the common histopathologic characteristics that they share [1]. They account for the most deaths from gynaecologic malignancies in women, as the majority of cases are diagnosed at an advanced stage, reducing the 5-year survival rate as low as 30 % [2]. The only reliable therapeutic option for women with advanced ovarian cancer is primary debulking surgery followed by adjuvant platinum-based systemic chemotherapy. The goal of primary surgery is to resect all macroscopically visible tumour to zero residual disease (complete cytoreduction). Complete cytoreduction has been proven to be one of the most critical prognostic factors for advanced ovarian cancer [3].
Lymphatic spread is a characteristic feature of epithelial ovarian cancer (EOC) even at early stages [4]. Lymphadenectomy is thus a crucial component of surgical staging, as well as a necessary procedure for diagnosis of FIGO stage IIIa disease. Studies aiming to assess nodal involvement in all stages, by performing systematic lymphadenectomy, have reported up to 55% rates of pelvic and para-aortic nodal metastases in patients with stage III and IV disease [5]. The results published by those series have led surgeons in recent years towards more radical primary debulking surgeries involving the complete resection of pelvic and para-aortic nodes. However, the results published by retrospective studies regarding the survival of women treated with systematic pelvic and para-aortic lymphadenectomy have been controversial [6], [7], [8], [9]. As a result, there is still not enough data in order to establish systematic lymphadenectomy as a mainstay of primary debulking surgery.
In this study, we aim to investigate whether systematic pelvic and para-aortic lymphadenectomy offers superior survival rates, which could outweigh possible peri-operative complications, in patients with advanced EOC.
Section snippets
Methods
This systematic review is reported in accordance with the PRISMA 2020 statement [10].
Study characteristics
Our search identified a total of 1973 articles. After initial screening and application of inclusion and exclusion criteria, we identified 2 eligible RCTs, that reported a total of 1074 patients [18], [19]. The PRISMA flow diagram can be accessed at the Supplementary appendix (Supplementary Fig. 1).
Panici et al. 2005 was a multi-centre randomised trial conducted in Australia, Germany, Italy, and United Kingdom. Sixteen participating institutions enrolled a total of 452 women from 1991 to 2003,
Discussion
This meta-analysis demonstrated no survival benefit of patients with advanced EOC treated with either therapeutic approach, both in terms of overall survival and progression-free survival. Regarding peri-operative morbidity, the “no lymphadenectomy” arm was associated with fewer events of lymphoedema or lymphocysts formation and lower rates of blood transfusion. No statistically significant difference was observed in the rates of fistula formation between the two arms. Finally, as far as
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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