Warwick et al.1 are to be commended for their thoughtful paper on lymph node surgery in apparent early ovarian cancer. Several aspects were particularly gratifying — the acknowledgement that this intervention carries risk, the needs for tangible benefit to justify this, the endorsement of frozen section as a necessary prerequisite before lymph nodes are removed, and the obvious belief that removing lymph nodes should not simply be part of ritualistic ‘staging’, but should influence treatment.
However, two issues deserve comment.
Firstly, although Maggioni et al.2 found positive nodes in 18% of patients with apparent stage-1 disease, they do not describe the results of any other staging investigations. Of the 18% who had nodal disease in apparent early ovarian cancer, how many had synchronous positive results from other simpler, and safer, intraperitoneal staging investigations? This omission on their part is unfortunate. Faught et al.3 have shown that one can rely on peritoneal cytology, peritoneal biopsies and omental biopsies to upstage the overwhelming majority of patients with apparent stage-1a disease who need upstaging, and only two of 128 patients were upstaged on the basis of nodal disease alone. Although their study assessed the role of node sampling rather than systematic lymphdenectomy, their results raise the possibility that Warwick et al. have overstated the INDEPENDENT impact of systematic lymphadenectomy.
Secondly, their choice of language in describing adjuvant chemotherapy as ‘potentially life saving’ should be seen in context. If 100 systematic lymphadenectomies identify six women who need chemotherapy, and prescribing chemotherapy to these six women improves their 5-year survival from 77% to 85%, the 5-year survival of the 100 women will increase by 0.48%. Is the associated morbidity worth it?