1. Laparoscopic Surgery in Gynaecologic Oncology
Laparoscopic Surgery in Gynaecologic Oncology The suspect adnexal mass and ovarian cancer
Philippe De Sutter

2. 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(a) is rare
< 1% of apparently benign adnexal masses are “unexpected” ovarian carcinomas
 The majority (>95%) of adnexal masses are benign !
The adnexal mass Lifetime risk
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

3. 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
Minimal Access Surgery Less invasive … more radical?
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

4. The adnexal mass Laparoscopy versus laparotomy
Systematic review and meta-analysis
487 trials – 23 relevant studies
Inclusion of only 6 RCT involving 324 cases
Laparoscopy is associated with reduction:
Febrile morbidity
Urinary tract infection
Postoperative pain and complications
Days in hospital (-3)
Total cost
Increased operative time (+11min)
The adnexal mass Laparoscopy versus laparotomy
Medeiros, Int J Gynecol Cancer 2008
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

5. 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
The adnexal mass Laparoscopic management?
Vergote, Lancet 2001
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

6. 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
The adnexal mass Laparoscopic management?
Canis, Sem Surg Oncol 2000
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

7. The adnexal mass Preoperative assessment of malignancy
Assess risk of malignancy (index)
Age (87% > 45y)
Size
TV Ultrasonography/ Color doppler / CT / MRI / …
CA125
Conclusion:
1. Obviously malignant
2. Definitely not malignant
Non-suspect
Benign
3. The “suspect “adnexal mass
Not obvious malignant
Probably benign
… But could be malignant!
The adnexal mass Preoperative assessment of malignancy
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

8. The adnexal mass Choise … not chance!
Benign
Malignant
Obvious benign
Suspicious
Obvious malignant
Laparoscopy or
Laparotomy
Expectant management or
Laparoscopy
Gyn Onco
and
Surgical staging
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

9. The adnexal mass Relative value of preoperative assessment
Expert evaluation is not
Always and everywhere available
100% failure proof
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
The adnexal mass Relative value of preoperative assessment
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

10. The suspect adnexal mass Laparoscopic procedure
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 / cyst spill
No puncture, incision, rupture or morcellation
Extraction of mass “in toto” through “endobag”
Maximum diameter 12,7cm
Primary 10 mm trocar for cystic mass
Colpotomy for large or solid mass
Macroscopy + frozen section
The suspect adnexal mass Laparoscopic procedure 1
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

11. 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 ….
The suspect adnexal mass Detection of malignancy
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

12. Laparoscopy for a malignant adnexal mass Tumour spill
No spill
Delay of treatment will probably not alter prognosis
Acute spill
 Intended / controlled puncture / aspiration
Minimal /theoretical contamination
Will probably not alter the prognosis
If appropriate staging is immediately performed
Chronic spill
 unintended capsule rupture / incomplete resection
Clear / chronic contamination
May worsen the prognosis
Type and amount of spill
Upstaging by extra-ovarian spread
If appropriate treatment is delayed
> 8-17 days
Laparoscopy for a malignant adnexal mass Tumour spill
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

13. 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 / O²
Closure of (midline) port incisions
Incisional recurrence also after laparotomy
No necessary negative effect on survival
Laparoscopy for ovarian cancer Port site metastases
Ramirez, Gynecol Oncol 2003
Abu-Rustrum, Obstet Gynecol 2004
Vergote, Int J Gynecol Cancer 2005
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

14. 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
Laparoscopy for ovarian cancer Port site metastases
Ramirez, Int J Gynecol cancer 2004
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

15. Laparoscopy for adnexal mass Does size matter?
Size (n= 186)
10-20cm: 169 (91%)
20-30cm: 13 (7%)
> 30cm: 4 (2%)
No exclusion for US features or elevated CA125!
Histology / size
Benign: 161 (86,6%) 10cm (10-36)
LMP: 8 (4,3%) 22,5cm (10-40)
Malignant: 16 (8,6%) 10,2cm (10-28)
10 > CA125
12 > US+
 avoid 9/10 unnecessary laparotomies
Laparoscopy for adnexal mass Does size matter?
Ghezzi, BJOG 2008
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

16. Laparoscopy for a suspect adnexal mass Surgical management
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

17. Procedure is feasible and surgical outcomes are equal
Inspection of abdominal cavity
Peritoneal washings
Peritoneal biopsies
Contralateral adnexectomy
Omentectomy
Lymphadenectomy
LAV Hysterectomy
Upstaging ~10-20%
Oncologic safety?
Laparoscopy versus Laparotomy ? Surgical (re)staging of presumed stage I 2
Querleu, BJOG 2003
Tozzi, Gynecol Oncol 2004
Leblanc, Gynecol Oncol 2004
Park, Int J Gynecol Cancer 2008
Nezhat, AJOG 2008
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

18. 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?
Laparoscopy for advanced ovarian cancer Assessment of optimal operability 3
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology

19. Laparoscopy for a (suspect) adnexal mass Conclusions
Is a pragmatic and therefore standard approach
 ~100% Se, Sp, NPV
Avoid unnecessary laparotomy
Benefits of minimal access surgery
Not minimally invasive surgery
Feasible, safe and benificial if :
Cases are carefully selected
Referral if necessary
Strict adherence to protocol
No delay of appropriate staging procedure if malignancy is detected
Laparoscopy for a (suspect) adnexal mass Conclusions
Ph. De Sutter Laparoscopic Surgery in Gynaecologic Oncology