Case 37-2004: Postmenopausal Bleeding and a Cystic Ovarian Mass
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《新英格兰医药杂志》
To the Editor: Although the words "careful staging," "full staging procedure" and "optimal staging" were used in the discussion of Case 37-2004 (Dec. 9 issue),1 that of a woman who appeared to have early-stage ovarian cancer, one point deserves amplification. As Cannistra pointed out in his review of the management of ovarian cancer in the same issue, "biopsy of the para-aortic nodes is especially important in patients with disease that otherwise appears to be limited to the ovary, since such patients may have more advanced disease."2
The patient described in the Case Records may indeed have had an early-stage tumor, but she did not undergo the operation required to determine the full extent of her disease with certainty. A positive para-aortic lymph-node biopsy makes the difference between stage IA and stage IIIC disease.
Surgical staging of ovarian cancer is based on an understanding of its patterns of spread. Disease that is apparently confined to the pelvis affects para-aortic nodes with a predictable frequency.3 The appropriate management of this disease by specialists in gynecologic oncology can improve outcome and survival.4
Fredric V. Price, M.D.
Pittsburgh Gynecologic Oncology
Pittsburgh, PA 15224
fvprice@nauticom.net
References
Case Records of the Massachusetts General Hospital (Case 37-2004). N Engl J Med 2004;351:2531-2538.
Cannistra SA. Cancer of the ovary. N Engl J Med 2004;351:2519-2529. [Full Text]
Young RC, Decker DG, Wharton JT, et al. Staging laparotomy in early ovarian cancer. JAMA 1983;250:3072-3076.
Junor EJ, Hole DJ, McNulty L, Mason M, Young J. Specialist gynaecologists and survival outcome in ovarian cancer: a Scottish national study of 1866 patients. Br J Obstet Gynaecol 1999;106:1130-1136.
The authors reply: We completely agree that full staging of epithelial ovarian cancer requires nodal dissection. In fact, the patient did undergo bilateral pelvic-node dissection, as well as para-aortic node exploration as part of her staging laparotomy; no involved nodes were detected.
In the study cited by Price, 28 percent of patients who were thought to have stage I disease on the basis of macroscopic examination were found to have a higher stage of disease when careful pathological staging was performed.1 In a seminal study of the incidence of advanced disease in patients with apparent stage I ovarian cancer, 11 percent were found to have diaphragmatic metastases; 13 percent, aortic lymph-node metastases; 8 percent, pelvic lymph-node metastases; 3 percent, microscopic omental metastases; and 33 percent, malignant peritoneal washings.2
In a 1993 study involving patients with ovarian cancer who were undergoing systematic aortic and pelvic lymphadenectomy, positive nodes were found in 14 percent of patients who were initially thought to have stage I disease.3 Lymphatic spread was ipsilateral to the tumor in all cases, suggesting that rational regional dissection is appropriate and should always include the para-aortic nodes, since the ovarian lymphatics drain with the ovarian veins to the renal vein on the left and the inferior vena cava on the right.
Richard T. Penson, M.D.
Dushyant Sahani, M.D.
Debra A. Bell, M.D.
Massachusetts General Hospital
Boston, MA 02114
The patient described in the Case Records may indeed have had an early-stage tumor, but she did not undergo the operation required to determine the full extent of her disease with certainty. A positive para-aortic lymph-node biopsy makes the difference between stage IA and stage IIIC disease.
Surgical staging of ovarian cancer is based on an understanding of its patterns of spread. Disease that is apparently confined to the pelvis affects para-aortic nodes with a predictable frequency.3 The appropriate management of this disease by specialists in gynecologic oncology can improve outcome and survival.4
Fredric V. Price, M.D.
Pittsburgh Gynecologic Oncology
Pittsburgh, PA 15224
fvprice@nauticom.net
References
Case Records of the Massachusetts General Hospital (Case 37-2004). N Engl J Med 2004;351:2531-2538.
Cannistra SA. Cancer of the ovary. N Engl J Med 2004;351:2519-2529. [Full Text]
Young RC, Decker DG, Wharton JT, et al. Staging laparotomy in early ovarian cancer. JAMA 1983;250:3072-3076.
Junor EJ, Hole DJ, McNulty L, Mason M, Young J. Specialist gynaecologists and survival outcome in ovarian cancer: a Scottish national study of 1866 patients. Br J Obstet Gynaecol 1999;106:1130-1136.
The authors reply: We completely agree that full staging of epithelial ovarian cancer requires nodal dissection. In fact, the patient did undergo bilateral pelvic-node dissection, as well as para-aortic node exploration as part of her staging laparotomy; no involved nodes were detected.
In the study cited by Price, 28 percent of patients who were thought to have stage I disease on the basis of macroscopic examination were found to have a higher stage of disease when careful pathological staging was performed.1 In a seminal study of the incidence of advanced disease in patients with apparent stage I ovarian cancer, 11 percent were found to have diaphragmatic metastases; 13 percent, aortic lymph-node metastases; 8 percent, pelvic lymph-node metastases; 3 percent, microscopic omental metastases; and 33 percent, malignant peritoneal washings.2
In a 1993 study involving patients with ovarian cancer who were undergoing systematic aortic and pelvic lymphadenectomy, positive nodes were found in 14 percent of patients who were initially thought to have stage I disease.3 Lymphatic spread was ipsilateral to the tumor in all cases, suggesting that rational regional dissection is appropriate and should always include the para-aortic nodes, since the ovarian lymphatics drain with the ovarian veins to the renal vein on the left and the inferior vena cava on the right.
Richard T. Penson, M.D.
Dushyant Sahani, M.D.
Debra A. Bell, M.D.
Massachusetts General Hospital
Boston, MA 02114