Gianluca Donatiello

Lymphadenectomy in early-stage ovarian cancer: is there still a role?

The role of systematic pelvic and para-aortic lymphadenectomy in presumed early-stage ovarian cancer remains controversial due to the lack of high-quality prospective evidence. No therapeutic benefit has been confirmed for systematic lymphadenectomy during surgical staging for apparent early-stage ovarian cancer. Lymphadenectomy may improve progression-free survival but has demonstrated no impact on overall survival, except for clear cell ovarian cancer, where a potential survival benefit has been suggested in retrospective studies. Systematic lymphadenectomy retains a diagnostic role in identifying occult nodal metastases (9% to 30% across series) undetected on pre-operative imaging or intra-operative assessment. The decision to perform lymphadenectomy should be individualized based on several factors, including histological sub-type, tumor grade, stage, and biomarker profile. Key considerations include the anticipated risk of lymph node metastasis, the opportunity to tailor adjuvant treatment by either omitting chemotherapy or offering maintenance targeted therapy, peri-operative morbidity, long-term sequelae impacting quality of life (eg, lower limb lymphedema), and cost-effectiveness. Systematic lymphadenectomy is guideline-recommended for high-grade tumors, including high-grade serous, high-grade endometrioid, and clear cell histologies, whereas it can be omitted in low-grade endometrioid and expansile mucinous sub-types. Its significance in low-grade serous and infiltrative mucinous ovarian cancers remains unclear, although guidelines frequently advocate for lymphadenectomy in these cases. To optimize patient selection, large-scale prospective studies with proper stratification by histotype and molecular profile are required. Emerging approaches to lymph node assessment, such as sentinel lymph node biopsy, artificial intelligence-assisted pre-operative imaging, and liquid biopsy, hold promise for improving staging accuracy.

Is less already enough? Minimally invasive interval debulking surgery for advanced ovarian cancer

Minimally invasive surgery (MIS), including laparoscopy and robotic-assisted techniques, has increasingly been explored as an alternative to laparotomy for interval debulking surgery (IDS) following neoadjuvant chemotherapy (NACT) in advanced epithelial ovarian cancer (EOC). This systematic review evaluates the current evidence on the surgical feasibility, patient selection, perioperative outcomes, and oncological safety of MIS in this setting. Following PRISMA guidelines, a systematic search of PubMed, Embase, Scopus, Cochrane Library, and ClinicalTrials.gov was conducted for studies published between January 2015 and June 2025. Eligible studies included prospective and retrospective cohorts, randomized trials, and meta-analyses reporting outcomes of MIS for IDS in FIGO stage III-IV EOC patients after NACT. Data extraction and risk of bias assessment were independently performed by two reviewers. Sixteen studies involving 9299 patients were included. MIS demonstrated high rates of complete cytoreduction (R0: 85-100 %) in selected patients, with significantly lower estimated blood loss, shorter hospital stays, fewer major complications, and earlier resumption of chemotherapy compared to open surgery. Operative times were generally longer, and conversion rates varied by tumor burden and selection criteria. Oncologic outcomes, including progression-free and overall survival, were comparable between MIS and laparotomy across multiple studies. Robotic-assisted IDS showed similar feasibility and outcomes, but evidence for this approach was mainly derived from small, retrospective cohorts. In appropriately selected patients and experienced centers, MIS for IDS appears to be a feasible and oncologically safe alternative to open surgery, offering meaningful perioperative benefits. Further randomized studies are needed to confirm long-term oncological equivalence.