Box 29-1 Master Surgeon's Corner
Complete surgical staging including lymph node dissection, omentectomy, appendectomy, and staging biopsies should be performed for all patients with apparent early-stage epithelial ovarian carcinomas because nearly a third of patients will have metastatic disease that was not appreciated visually or by palpation.
The extent of surgical staging for endometrial carcinoma remains controversial as to when pelvic and/or para-aortic lymph nodes should be removed. Surgeons managing patients with endometrial carcinoma should be prepared for the possibility of performing these procedures in all cases.
Accurate and complete surgical staging is a crucial part of managing patients with gynecologic malignancies and allows for appropriate informed discussions regarding further interventions and accurate risk stratifi cation of patients on clinical trials.
Currently, ovarian and endometrial carcinomas are recommended to be surgically staged cancers by the International Federation of Obstetrics and Gynecology (FIGO). This requires removal of the primary site and any area of spread or potential spread when possible. Surgical staging is a crucial portion of the treatment for these gynecologic malignancies. Accuracy and completeness of staging ensures objective data, which helps guide appropriate administration of adjuvant therapies and development of clinical trials.
For patients with ovarian cancer, Young et al1 established the importance of surgical staging. These investigators performed systematic restaging on 100 patients and showed a 31% rate of upstaging after patients were fully surgically staged, which included multiple peritoneal biopsies and removal of pelvic and para-aortic lymph nodes. In addition, 77% of these 31 patients actually had stage III disease. Prior to this study, the staging of ovarian cancer was either not performed or relied on bipedal lymphangiography, intravenous pyelography, barium enemas, and peritoneoscopy (laparoscopy). Today, in early-stage ovarian cancer, comprehensive staging as defined by the National Cancer Institute–sponsored Gynecologic Oncology Group (GOG) includes a systematic evaluation and biopsies to determine a need for adjuvant therapy. In advanced-stage ovarian cancer, an attempt at optimal cytoreduction is the standard of care and is addressed in detail elsewhere in this text.
Prior to 1988, endometrial cancer was clinically staged through uterine sounding and imaging to determine possible spread. It was treated with a combination of preoperative radiation followed by surgery. The GOG helped transition from clinical staging to surgical staging through a prospective cohort that underwent a staging surgery; the GOG found surgical staging to be more beneficial to patients.2 In 1988, FIGO changed the staging to a surgical-pathologic system which has not been changed until recently.3 In 2009, FIGO updated the staging of endometrial cancer. Most recently, a GOG prospective randomized controlled trial (LAP2) showed that a laparoscopic approach to endometrial cancer shows no difference in detecting advanced-stage disease compared with an open approach.4
Vulvar and vaginal cancer staging is discussed elsewhere in this text.