1. Laparoscopic Surgery in Gynaecologic Oncology An Added Value?
VVOG – PUS
Gent,
Laparoscopic Surgery in Gynaecologic Oncology An Added Value?
Philippe De Sutter

2. Laparoscopic surgery in gynaecologic oncology
’Some disputable applications and one fruitful indication’ D. Dargent
…LS has not become wide spread
…Results confirm that LS reduces risks without jeopardizing chances for cure
…First-level of evidence is still missing
Because we can, we should consider LS
…Radical operations are disputable indications
…Laparoscopic staging is an authentic breaktrough
D. Dargent, Editorial in Gynecol Oncol 2005
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

3. SGO survey Appropriate laparoscopic procedures?%
SGO members (336)
Fellows (57)
Performing laparoscopy 84
> 50% of procedures 3
Assessment of adnexal mass 81 97
Prophylactic BSO
LAVH + LND endometrial cancer 56 83
TLH + LND endometrial cancer 16 33
Trachelectomy cervical cancer 19
Staging only cervical cancer 30 26
LARVH + LND cervical cancer 11 18
Second look ovarian cancer 52 74
Staging ovarian cancer / debulking 4
Frumovitz, Gynecol Oncol 2004
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

4. Minimal Access Surgery Less invasive … more radical?
Laparoscopic / vaginal surgery
Advantages
Less blood loss
Lower overal morbidity and complications
Shorter duration of hospital admission
Faster recovery
Disadvantages
Longer operative time
Longer learning curve
Laparoscopic specific complications
BMI > 30-35
Conversion to laparotomy
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

5. Laparoscopic surgery in gynaecologic oncology?
Not essential, even possible harmfull
 Laparotomy
Not essential, but feasable and safe
 Advantages of the laparoscopic approach
 Advantages of avoiding laparotomy
 At least equal oncologic safety
Essential, because of the added value
 New diagnostic / therapeutic strategies
 Better and refined oncologic results
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

6. Laparoscopic Surgery in Gynaecologic Oncology The suspect adnexal mass and ovarian cancer

7. The adnexal mass Laparoscopic management?
Rupture of an ovarian malignant tumour is a significant prognostic factor and should be avoided
Laparoscopic removal of ovarian cysts should be restricted to patients with preoperative evidence that the cyst is benign
Vergote, Lancet 2001
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

8. The adnexal mass Laparoscopic management?
Laparoscopic management of adnexal masses: a gold standard?
The surgical diagnosis is the key to adequate management of adnexal tumours
Laparoscopy and gynaecologic cancer: is it still necessary to debate or only convince the incredulous?
The inadequate surgical management performed by laparoscopy as well as by laparotomy may worsen the prognosis of early ovarian cancer
The prognosis of cancer is more related to its biology than to the surgical approach
Canis, Sem Surg Oncol 2000
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

9. The adnexal mass Lifetime risk
5-10 % of women will undergo surgery for an adnexal mass
13 – 21 % of these will have an ovarian malignancy
75% of ovarian cancers are presenting with advanced disease
True stage I is rare
< 1% of apparently benign adnexal masses are “unexpected” ovarian carcinomas
 The majority (>95%) of adnexal masses are benign !
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

10. The adnexal mass Preoperative assessment of malignancy
Risk of malignancy index
Age
Size
Ultrasound / doppler / CT / MRI
CA125
1. Obviously malignant
2. Definitely not malignant
Non-suspect
Benign
3. The suspect adnexal mass
Not obvious malignant
Probably benign but could be malignant!
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

11. The adnexal mass Value of preoperative assessment
Only final histology is proof that a mass is (not) malignant
Every adnexal mass is considered malignant until proven otherwise by final histology
Management according to the highest probability
Laparoscopic diagnosis is always worthwhile
Increased diagnostic power by refined inspection of ovary and peritoneum
Avoiding unnecessary laparotomies
Choise of incision
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

12. The suspect adnexal mass Laparoscopic procedure1
Laparoscopic inspection primary tumour and peritoneum
Irregular contours / vascularisation
Extracystic vegetations / extra ovarian local spread or invasion
Peritoneal fluid / ascites
Peritoneal metastases
Peritoneal cytology / washing
Complete adnexectomy without tumour spill
No puncture, incision, rupture or morcellation
Extraction of mass “in toto” through “endobag”
Maximum diameter 12cm
Primary 10 mm trocar for cystic mass
Colpotomy for large or solid mass
Macroscopy + frozen section
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

13. The suspect adnexal mass Detection of malignancy
Proceed to immediate surgical staging procedure
Extraovarian spread
 Laparotomy
No extraovarian spread
 Laparoscopic staging
Patient consent
Oncologic surgeon available
Operating room staff prepared
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

14. Laparoscopy for a malignant adnexal mass
Laparoscopy for a malignant adnexal mass Surgical (re)staging of presumed stage I 2
Inspection of abdominal cavity
Peritoneal washings
Peritoneal biopsies
Contralateral adnexectomy
Omentectomy
Lymphadenectomy
LAV Hysterectomy
Tozzi, Gynecol Oncol 2004
Leblanc, Gynecol Oncol 2004
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

15. Laparoscopy for advanced ovarian cancer
Laparoscopy for advanced ovarian cancer Assessment of optimal operability 3
Diagnostic Open Laparoscopy
Visual assesment by oncologic surgeon
Biopsies
Optimal primary debulking surgery possible
Laparotomy  Chemotherapy (6x)
Optimal primary debulking surgery not possible
Chemotherapy (3x)  Interval debulking  Chemotherapy (3x)
Possible advantages
 Avoiding unnecessary laparotomy and delay in chemotherapy
 Increased succes rate of secundary cytoreductive surgery?
 Decreased peri-operative morbidity?
 Selection of chemoresistance?
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

16. Laparoscopy for advanced ovarian cancer
Laparoscopy for advanced ovarian cancer Assessment of optimal operability
61% Optimal primary debulking surgery possible
96% optimal debulking achieved
87% survival (FU 22 months)
39% Optimal primary debulking surgery not possible
26% progressive  no surgery
74% partial response  interval debulking
6% trocar metastasis
80% optimal debulking achieved  81% survival
60% overall survival
 Less surgery: 90%
 More optimal cytoreduction: 82%
Angioli, Gynecol Oncol 2006
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

17. Laparoscopy for ovarian cancer Port site metastases
1% ….19%
Causes ?
Spread and capture of malignant cells
Related to advanced stage, ascites, cyst spill
Positive pressure / chimney effect
Tissue fragmentation during extraction
Role of preventive measures are unclear
"Open" laparoscopy
Endobag for tissue extraction
Instrument decontamination / Irrigation of ports
Low pressure / Gasless laparoscopy
Closure of (midline) port incisions
Incisional recurrence also after laparotomy
No necessary negative effect on survival
Ramirez, Gynecol Oncol 2003
Abu-Rustrum, Obstet Gynecol 2004
Vergote, Int J Gynecol Cancer 2005
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

18. Laparoscopy for ovarian cancer Port site metastases
Review 31 papers / 58 cases
40 Ovarian cancer
83% advanced stage
71% ascites
97% peritoneal carcinomatosis
Median time 17 days
12 Cervical cancer
75% therapeutic laparoscopy
Median time 5 months
4 Uterine cancer
Median time 13,5 months
Ramirez, Int J Gynecol cancer 2004
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

19. Laparoscopic Surgery in Gynaecologic Oncology Cervical Cancer

20. Cervical cancer Laparoscopic lymphadenectomy
4-5
Allows a vaginal approach for treatment of early stage:
Conisation
conservative treatment of micro-invasive stage Ia2
Radical vaginal trachelectomy
stage Ib1 with desire to preserve fertility
Radical vaginal hysterectomy
stage Ia2 - Ib1
Allows a surgical staging for advanced stage:
Selection for radio- / chemotherapy
Selection for pelvic exenteration
Curative / palliative intend
Sentinel node sampling
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

21. Laparoscopic Assisted Radical Vaginal Hysterectomy
Selected cases
Small cancers (Ia2-Ib1)
Sufficient vaginal access
Limited uterine size
Obesity / comorbidity
Increased intra- operative complications
Equal outcome
Node yield
Radicality / recurrence
Renaud, Gynecol Oncol Spirtos, Am J Obstet Gynecol 2002
Steed, Gynecol Oncol Jackson, Gynecol Oncol 2004
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

22. Laparoscopic Assisted Radical Vaginal Hysterectomy
Laparoscopy 71
Laparotomy 205
Blood loss (ml)
300
500
OR time (min)
210
150
Intraoperative complication (%) 13 4
Postoperative complication(%) 14 7
DFSR(%) 94 93
Steed, Gynecol Oncol 2004
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

23. Laparoscopic Assisted Radical Vaginal Hysterectomy
Laparoscopy 50
Laparotomy
50 match controls
Blood loss (ml)
350
875
OR time (min)
180
120
Nodal yield 15 16
Clear margin
90%
98%
Intraoperative complication 8%
(4% conversion) 2%
Postoperative complication
26%
DFSR
94%
96%
Jackson, Gynecol Oncol 2004
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

24. Cervical cancer Selection for radical trachelectomy
Small cancer stage Ib1
< 2cm
Ectocervical
Preferably squamous
Young (reproductive) age
Strong desire for future pregnancy
Informed consent
Radical treatment if LN+ or involved margins
>1987, Dargent, Cancer 2000
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

25. Cervical cancer Outcome radical trachelectomy
Review on 319 patients
Median FU 44 months
Recurrence rate: 4,1%
Death rate: 2,5%
Pregnancy outcomes on 72 RVT
31(43%)women, 50 pregnacies
36(72%) third trimester deliveries (8% <32w)
12(25%) first trimester miscarriages / termination
2(4%) second trimester miscarriages
53(74%)women no children!!
19(26%) one or more children
Plante, Gynecol Oncol
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

26. Laparoscopic Surgery in Gynaecologic Oncology Endometrial Cancer

27. Endometrial cancer Laparoscopic surgery6
Allows a surgical staging / treatment for clinical early stage:
Peritoneal cytology / biopsies
Pelvic (para-aortic) lymphadenectomy
Adnexectomy
LAVH
Feasible in 90% of stage I
Conversion 5,8%
Complications 10,5%
Similar surgical outcomes and survival
No trocar-site or vaginal vault recurrence
(…GOG LAP2 RCT: LAVH vs. TAH)
Magrina, Am J Obstet gynecol 1999
Eltabbakh, Cancer 2000
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

28. Endometrial cancer Laparoscopy and outcome
RCT Stage I
FU 44 months
Laparoscopy
Laparotomy
DFSR
91,2%
93,8%
OSR
86,3%
89,7%
Tozzi, J Minim Invasive Gynecol 2005
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

29. Endometrial cancer Laparoscopy and obesity
BMI > 30
Difficult entry, limited Trendelenburg and visualization
Conversion to laparotomy: 7,5%
Compared to laparotomy controls
Longer operative time
Less complications
Similar surgical outcomes
Limitations
BMI > 60
Para-aortic lymphadenectomy
Eltabbakh, Gynecol Oncol 2000
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

30. Laparoscopic surgery in gynaecologic oncology Added value
1. Management of adnexal masses
2. Surgical (re)staging of stage I ovarian cancer
3. Assessment of optimal operability for advanced ovarian cancer
4. Allows a vaginal approach for treatment of early stage cervical cancer
5. Allows a surgical staging for advanced stage cervical cancer
6. Allows a surgical / pathological staging for treatment of clinical early stage endometrial cancer
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

31. Laparoscopic surgery in gynaecologic oncology Conclusion
Oncologic safety
Initial treatment  final outcome
Exception is not the rule
Appropriate selection of cases!!
Clinical stage
Vaginal access!
Meaningful indication
Anticipation of unsuspected findings
….. Conversion to laparotomy
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology