Clinical Pearls & Morning Reports
Harter et al. conducted the Lymphadenectomy in Ovarian Neoplasms (LION) trial, which randomly assigned patients with newly diagnosed advanced ovarian cancer, who had complete resection of macroscopically visible tumor and normal-appearing lymph nodes both before and during surgery, to trial groups that either did or did not undergo systematic pelvic and paraaortic lymphadenectomy at the time of primary surgery. Read the NEJM Original Article here.
Q: What is the mainstay of treatment for advanced ovarian cancer?
A: The mainstay of treatment of advanced ovarian cancer is primary surgery with the aim of complete resection of all macroscopically visible tumor, followed by chemotherapy that includes carboplatin and paclitaxel. More recently, systemic therapy with bevacizumab, an anti–vascular endothelial growth factor antibody, combined with chemotherapy and thereafter used as maintenance therapy has been proposed.
Q: What have prior studies shown regarding pelvic and paraaortic lymphadenectomy for advanced ovarian cancer?
A: Some retrospective analyses have suggested a potential survival benefit from systematic pelvic and paraaortic lymphadenectomy in patients with macroscopically completely resected advanced ovarian cancer, although a prospectively randomized trial did not show an overall survival benefit. However, the latter trial evaluated only the extent of lymphadenectomy (systematic removal vs. removal of enlarged lymph nodes only) and included both patients with macroscopically complete resection and those with residual tumors of up to 1 cm in diameter after surgery.
A: In the LION trial, the median overall survival was 65.5 months in the lymphadenectomy group and 69.2 months in the no-lymphadenectomy group (hazard ratio for death in the lymphadenectomy group, 1.06; 95% CI, 0.83 to 1.34; P=0.65 by stratified log-rank test with stratification according to age and performance status). The analysis of the secondary end point, progression-free survival, also did not show a significant between-group difference in benefit, with a median of 25.5 months in both groups (hazard ratio for death or progression in the lymphadenectomy group, 1.11; 95% CI, 0.92 to 1.34; P=0.29). The procedure did not provide a benefit, even though the rate of positive nodes in the trial was 55.7%.
A: In the LION trial, the addition of open lymphadenectomy to the debulking surgery had a significant effect on the median duration of surgery, median blood loss, the percentage of patients receiving transfusions or fresh-frozen plasma, and the percentage of patients with postoperative admission to an intermediate or intensive care unit — all in favor of the no-lymphadenectomy group. The authors also found that the lymphadenectomy group had a higher incidence of infections treated with antibiotics, lymph cysts at discharge, and repeat laparotomies for complications, as well as a significantly higher 60-day mortality.