A bilateral pelvic and periaortic lymph node sampling must be done when the tumor nodules outside the pelvis are less than or equal to 2 cm (presumed stage IIIB) and in apparent stage I disease to exclude the possibility of microscopic nodal metastasis, which can occur in up to one third of patients with apparent early-stage disease. The role of lymph node resection has not been fully defined in advanced epithelial ovarian cancer. In their analysis of 93 patients who underwent lymph node assessment, Aletti and associates26 showed that removing obviously involved lymph nodes in patients with residual disease near 1 cm appears to offer a survival advantage. The role of systematic aortic and pelvic lymphadenectomy in patients with optimally debulked advanced ovarian cancer has been addressed by a randomized clinical trial in which 427 eligible patients with optimally debulked FIGO stage IIIB-C and IV epithelial ovarian carcinoma were randomly assigned to undergo systematic pelvic and para-aortic lymphadenectomy or resection of bulky nodes only. The authors of the study did confirm the high prevalence of both pelvic and para-aortic lymph node metastases in patients with advanced ovarian cancer, but they were unable to detect any difference in overall survival between the two treatment arms27 (Fig. 7-18). Therefore, patients with stage IV disease and those with tumor nodules outside the pelvis that are greater than 2 cm do not require pelvic or periaortic lymph node biopsies unless a clinically enlarged lymph node is discovered—in which case it must be resected.
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