CG122 Ovarian cancer SRL podcast: Mr Charles Redman
Podcast recording with Mr Charles Redman, a Gynaecological Cancer Surgeon and Clinical Lead for the Ovarian Cancer GDG.
This podcast will focus specifically on exploring the role of lymph node assessment and systematic retroperitoneal lymphadenectomy from a consultant perspective.
This podcast was added on 27 Apr 2011
Ovarian cancer clinical guideline - podcast on lymph node assessment and systematic retroperitoneal lymphadenectomy
Podcast recording Mr Charles Redman – a Gynaecological Cancer Surgeon and Clinical Lead for the Ovarian Cancer GDG.
(This transcript is a direct translation of the podcast).
Hello and welcome to this NICE podcast on the Ovarian Cancer Clinical Guideline. This podcast will focus specifically on exploring the role of lymph node assessment and systematic retroperitoneal lymphadenectomy from a consultant perspective.
I am Katie Perryman Ford the NICE Implementation Adviser for this guideline and with me is Mr Charles Redman, a gynaecological cancer surgeon at University Hospital of North Staffordshire and a Council member of the British Gynaecological Cancer Society. Charles is the Clinical lead on the guideline development group for the NICE ovarian cancer clinical guideline.
Throughout this pod cast we will refer to Lymph node assessment as LNA and systematic retroperitoneal lymphadenectomy as SRL for ease.
There are two recommendations concerning LNA and SRLs
- Firstly - Perform retroperitoneal lymph node assessment as part of optimal surgical staging in women with suspected ovarian cancer whose disease appears to be confined to the ovaries and
- Secondly – ‘Do not’ include systematic retroperitoneal lymphadenectomy as part of standard surgical treatment in women with suspected ovarian cancer whose disease appears to be confined to the ovaries.
Question 1 - so Charles, could you explain why this guideline has been developed?
This particular guideline has been developed because at the stakeholder meetings that where held at the beginning of this process. It was identified that there is considerable variation in practice on how women with suspected early ovarian cancer are managed. This perception is based partly on anecdotal evidence and also to some degree on audits that have been performed in different parts of the country. I think it is important to mention that the NICE guidelines here are not a comprehensive text book on how ovarian cancer should be managed, but rather to focus on those areas where there is variation or controversy in how such patients should be managed and that is why this particular topic was chosen.
Question 2 - what is the difference and the relationship between LNA and SRL?
Well in general terms, I suppose that can be summarised by intention and extent. Perhaps the easiest thing to do is to explain what an SRL is supposed to be. This is supposed to be a systematic removal of all the retroperitoneal lymphatic tissue from the pelvis up through the abdomen up to the level of the renal arteries. This is a major surgical procedure, and like everything in surgery the more you do, the greater the morbidity that is associated with it. On the other hand, lymph node assessment or LNA, this is where one performs instead of a systematic removal of all of the tissue, is to perform an assessment which will involve inspection and palpation, and if that is entirely normal to perform in a sense random biopsies. In other words, you have not removed the whole area but you do have histological evidence that can be used.
Question 3 – so LNA is recommended as part of optimal surgical staging - what are the other components?
Well, surgical staging involves laporatomy which means that one will perform a through exploration of the whole of the abdominal cavity using both inspection and palpation. In addition to that there are other certain surgical procedures. In general terms these would include hysterectomy, removal of both the ovaries and the tubes, an omentectomy and in addition to that peritoneal washings, as well as lymph node assessment.
Question 4 – why is SRL a ‘do not do’ recommendation?
It is a ‘do not do’ recommendation because we looked at the evidence and the question that was being asked, is that given that SRL is a much more extensive procedure which carries necessarily a greater morbidity. Is there evidence that demonstrates that this has a therapeutic and staging value, and our extensive review of the evidence did not suggest that this was the case. Just because you can do it, doesn’t necessarily mean that you should.
So, in other words, the issue here is “if in doubt should you do or don’t”. The view is that the additional morbidity, the extra costs involved both to the patient and to the system are not justified on the basis of the evidence that we have reviewed.
Question 5 - can you give us some background about the ACTION trial and why it was not considered as part of the evidence for SRL when developing this guideline?
The Action study was an important prospective randomised study performed by the EORTC in other words it was a European wide study. This was a prospective randomised study that was specifically designed to answer the question does adjuvant chemotherapy help those women that apparently have early stage ovarian cancer. The authors concluded that in the group as a whole it appeared that adjuvant chemotherapy conferred additional survival benefit in patients with early stage ovarian cancer. But, a sub group analysis identified that this was only accrued in those patients who had sub optimal staging. In other words, it appeared that those women who had occult disease that had not been recognised because they had inadequate staging benefited from this treatment and this is of course an important finding. However, what has to be mentioned here is that this was a sub group analysis which was not in actual fact addressing the question that the study was designed to do. And because of this, the guideline development group felt that these results would be difficult to interpret with certainty. It was because of that reservation that although we mention the Action study that we have not based our conclusions on those particular findings.
Question 6 - are there any occasions when SRL should be used?
Well, first of all in the context of early ovarian cancer the answer is that outside of clinical research ‘no’ SRL should not be done. I think what we have to remember here, is that our guidelines are evidence based and what we were saying is there isn’t the evidence to support the use of SRL. That is not to say that SRL does not have a value. It’s just that there is no evidence to say that it does. I believe that guidelines are there to say what should happen in general terms but certainly in a research context I think that this is an area where people should look at to see does SRL confer a survival benefit. And it may do, it’s just that we don’t have the evidence at the moment to say that. So therefore the answer to your question for women with suspected early ovarian cancer is that SRL should be performed but only in a research setting.
So, what I have said so far has really just been in the context of women with suspected early ovarian cancer. Questions have been asked about whether SRL has a role in advance disease. The answer is, it may do, it may not but this was not something that was specially looked at by the guideline development group because it was outside of the scope.
Question 7 - what will the recommendation on SRL mean for clinical practice, how will practice need to change?
Quite simply, in routine clinical practice in women who are suspected of having early ovarian cancer where the disease is confined to the ovaries, there is no justification for performing SRL.
Question 8 – is this the kind of issue which may be looked at as part of peer review?
Yes, I mean, this is an important area of practice, peer review is usually about establishing common ways of working and the guidelines are very clear on this. That in women who have suspected early ovarian cancer, lymph node assessment should be performed.
Thank you very much Charles. We hope that you have enjoyed this podcast and found the information useful and that it will help you when putting the guideline into practice. For more information about the ovarian cancer clinical guideline and for access to the implementation tools please visit the NICE website, www.nice.org.uk.
This resource should be used alongside the published guidance. The information does not supersede or replace the guidance itself.
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