**5. What is the role of lymphadenectomy in apparent early stage ovarian cancer?**

A number of women will undergo surgery for an apparently benign ovarian cyst. Postoperatively, those women with confirmed malignancy can be offered staging including lymphadenectomy. Approximately, 30% of women with ovarian cancers apparently confined to the ovaries will be upstaged following further surgery including a pelvic/para aortic node dissection/sampling (Pommel type B1) with a gynaecological oncologist [8].

curve. Perhaps, the biggest advantage is the use of instruments that fully articulate at the end in the manner of a human wrist allowing fine delicate movements. This is particularly important in the obese patient, where the increased thickness of the anterior abdominal wall produces an increased torque effect leading to decrease manoeuvrability of standard laparoscopic instruments. Robotic platforms have been used in staging apparent ovarian cancer and

The Role of Lymphadenectomy in Ovarian Epithelial Cancer

http://dx.doi.org/10.5772/intechopen.72702

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Maggioni et al. [20] reported a randomised controlled trial of 268 women with apparent stage 1 or 2 ovarian epithelial cancer. The women were randomised to either a random sampling of pelvic and PA nodal basin or systematic dissection (pommel type A) of the same areas. Positive nodes were found in 9% of the control group and in 22% of the SLD group. No significant difference was recorded in 5 years year overall survival (84.2 vs. 81.3%) or progression free survival (PFS) (78.3 vs. 71.3). The SLD group had a significantly longer operating time,

In view of the results of this study, SLD should not be offered over more limited dissection/

The goal of surgery in advanced ovarian cancer is to remove all visible disease including a removal of all enlarged lymph nodes. This requires intraoperative assessment of the bilateral

Given that the nodal basin is considered by some to be relatively chemotherapy insensitive, this to the question whether removal of all involved microscopically and macroscopically

Panici et al. [21] reported a randomised controlled trial of 268 women with apparent stage IIIB, IIIC/IV cancer. The women were randomised to either resection bulky of pelvic and PA nodes or systematic dissection of the same areas. Positive nodes were found in 42% of the control group and in 42% of the SLD group. No significant difference was recorded in 5 years year overall survival (47 vs. 48.4%). A significant 7-month extension in progression free survival (PFS) was demonstrated (29.4 vs. 22.4 months). The SLD group had a significantly longer operating time, blood loss and blood transfusion. Subsequently, the authors have suggested

Working in close proximity to the large blood vessels poses a risk of major haemorrhage. Reducing this risk involves an appropriate surgical incision with a good operative exposure involving dissection/identification of anatomical structures. This allows easier identification

that the study may be underpowered to detect an overall survival difference.

**6. What is the role of lymphadenectomy in advanced ovarian cancer?**

sampling (pommel B) in women with apparent early ovarian cancer.

pelvic nodes and the para aortic region (pommel type C1–B1).

appear comparable to laparoscopic surgery [16–19].

blood loss and blood transfusion.

involved nodes has a therapeutic benefit.

**7. Common complications**

**7.1. Vascular injury**

It is important to understand that lymph node status is not the only factor that determines the need for adjuvant chemotherapy. Many centres offer chemotherapy to women with stage Ic or above cancers, high-grade lesions and all clear cell cancers of the ovary [9].

However, node status is important for a number of reasons: it may influence whether or not chemotherapy is given, the number of cycles or types of chemotherapy and it may result in complete cytoreduction of the cancer. Node status also partially determines the true FIGO stage and prognosis.

The ACTION trial was a randomised controlled trial (RCT) of 448 women with stage IA, IB grades 2–3, all IC, IIA and all clear cell cancer stage I–IIA and compared the administration of adjuvant chemotherapy with a control arm. The main finding showed overall survival was significantly better with the administration of chemotherapy. A subset analysis revealed that stage I patients with complete surgical staging did not benefit from chemotherapy contrast to patients that underwent incomplete staging [10]. Long-term follow-up of this study has confirmed these results [11]. It has been surmised that patients that have not being staged harbour more advanced disease, and therefore have a poorer prognosis and chemotherapy does not compensate for incomplete staging.

In older women with complex masses or those felt to have a high risk of cancer, an intraoperative frozen section histopathological analysis may be performed. A study from the Gateshead Gynaecological Oncology Centre reported a with a sensitivity of 92%, specificity of 88%, positive predictive value of 82% and negative predictive value of 95% for frozen section analysis [12]. This is equally important in determining which women should not be exposed to unnecessary surgery such as a para aortic node dissection.

Laparoscopic staging is possible, though requires a high degree of specialist training. Several centres have reported on full laparoscopic staging and have found it feasible [13, 14]. Chi et al. performed a case control study comparing staging via laparoscopy or laparotomy in 80 women [13]. They found no difference in specimen sizes and lymph nodal counts. The laparoscopic group had levels of reduced blood loss and a reduced hospital stay. A laparoscopic nodal dissection/sampling should include both the pelvic and para aortic basins to the level of the renal vessels. A case series by Nezhat et al. [15] concluded that laparoscopic staging when performed by a gynaecological oncologist did not compromise survival.

Robotically assisted laparoscopic surgery is an evolution of minimal access surgery rather than a revolution. Perceived benefits include three-dimensional vision, control of the laparoscope by the operating surgeon, more precise instrument movement and a shortened learning curve. Perhaps, the biggest advantage is the use of instruments that fully articulate at the end in the manner of a human wrist allowing fine delicate movements. This is particularly important in the obese patient, where the increased thickness of the anterior abdominal wall produces an increased torque effect leading to decrease manoeuvrability of standard laparoscopic instruments. Robotic platforms have been used in staging apparent ovarian cancer and appear comparable to laparoscopic surgery [16–19].

Maggioni et al. [20] reported a randomised controlled trial of 268 women with apparent stage 1 or 2 ovarian epithelial cancer. The women were randomised to either a random sampling of pelvic and PA nodal basin or systematic dissection (pommel type A) of the same areas. Positive nodes were found in 9% of the control group and in 22% of the SLD group. No significant difference was recorded in 5 years year overall survival (84.2 vs. 81.3%) or progression free survival (PFS) (78.3 vs. 71.3). The SLD group had a significantly longer operating time, blood loss and blood transfusion.

In view of the results of this study, SLD should not be offered over more limited dissection/ sampling (pommel B) in women with apparent early ovarian cancer.
