ORIGINAL ARTICLE – GYNECOLOGIC ONCOLOGY Systematic Para-aortic and Pelvic Lymphadenectomy in Early Stage Epithelial Ovarian Cancer: A Prospective Study Antonino Ditto, MD 1 , Fabio Martinelli, MD 1 , Claudio Reato, MD 2 , Shigeky Kusamura, MD 3 , Eugenio Solima, MD 1 , Rosanna Fontanelli, MD 1 , Edward Haeusler, MD 4 , and Francesco Raspagliesi, MD 1 1 Department of Gynecologic Oncology, IRCCS National Cancer Institute, Milan, Italy; 2 Department of Gynecology and Obstetrics, Treviglio Hospital, Bergamo, Italy; 3 Department of Surgery, IRCCS National Cancer Institute, Milan, Italy; 4 Department of Anesthesiology, IRCCS National Cancer Institute, Milan, Italy ABSTRACT Background. Lymphadenectomy is important in the sur- gical treatment of apparent early epithelial ovarian cancers (eEOC); however, its extent is not well defined. We eval- uated the role of systematic lymphadenectomy, the risk factors related with lymph node metastases, the implica- tions, and the morbidity of comprehensive surgical staging. Methods. We prospectively recruited 124 patients diag- nosed with apparent eEOC [International Federation of Gynecology and Obstetrics (FIGO) stage I and II] between January 2003 and January 2011. Demographics, surgical procedures, morbidities, pathologic findings, and correla- tions with lymph node metastases were assessed. Results. A total of 111 patients underwent complete sur- gical staging, including lymphadenectomy, and were therefore analyzed. A median of 23 pelvic and 20 para- aortic nodes were removed. Node metastases were found in 15 patients (13.5 %). The para-aortic region was involved in 13 (86.6 %) of 15 cases. At univariate analysis, age, menopause, FIGO stage, grading, and laterality were found to be significant factors for lymph node metastases, while CA125 of [35 U/ml and positive cytology were not. No lymph node metastases were found in mucinous histotypes. At multivariate analysis, only bilaterality (p = 0.018) and menopause (p = 0.032) maintained a statistically sig- nificant association with lymph node metastases. Lymphad- enectomy-related complications (lymphocyst formation and lymphorrhea) were found in 14.4 % patients. Conclusions. The data of this prospective study demon- strate the prognostic value of lymphadenectomy in eEOC. Menopause, age, bilaterality, histology, and tumor grade are identifiable factors that can help the surgeon decide whether to perform comprehensive surgical staging with lymph node dissection. These parameters may be used in planning subsequent treatment. International Federation of Gynecology and Obstetrics (FIGO) surgical stage is the most relevant prognostic factor for disease-free and overall survival of patients with apparent early epithelial ovarian cancer (eEOC). Thorough surgical staging is crucial for choosing the appropriate treatment and ensuring optimal survival. Less extensive surgical proce- dures may fail to detect further spread of the disease. Several articles have reported the risk of unrecognized occult dis- ease, with a 30 % likelihood of upstaging at repeated surgery. 1 Lymph node evaluation is recommended in the surgical treatment of eEOC according to FIGO criteria; however, the radicality of the lymphadenectomy remains unclear. It is known that ovarian cancer can spread in two ways, intraperitoneal and retroperitoneal. 2 Data on the incidence of nodal metastases in ovarian cancer were first reported by Bergman on cadavers. 3 In the past, reports documented the clinical importance of node involvement in ovarian cancer patients. 4 In addition, numerous reports provided data on the diagnostic and prognostic value of lymph node assessment in ovarian cancer. Recently, a randomized study showed that sys- tematic lymphadenectomy detects lymph node metastases in 22 % of patients with eEOC. 5 In previous retrospective studies, we found that sys- tematic pelvic and para-aortic lymphadenectomy detects lymph node metastases in 15.6 % of patients apparently Ó Society of Surgical Oncology 2012 First Received: 16 December 2011; Published Online: 16 June 2012 A. Ditto, MD e-mail: antonino.ditto@istitutotumori.mi.it Ann Surg Oncol (2012) 19:3849–3855 DOI 10.1245/s10434-012-2439-7