2. Laparoscopic Surgical Management of Epithelial Ovarian Cancer Cagatay Taskiran, MD, Assoc. Prof. VKV American Hospital, Division of Gynecologic Oncology

3. L/S & EOC  Primary trt for early stage disease  Restaging  Primary cytored’n for advanced disease  Surgical trt for recurrent disease  To assess resectability: Neoadjuvant CT  VATS

4. Early Stage is Rare

5.  Comprehensive surgical staging Exploration - Cytology and biopsies Hyst-BSO- fertility sparing surgery PPLND- Total Omentectomy Appendectomy Standard Surgery for Early Stage Ovarian Cancer

6. Schuler et al, 1999, EJOGRB 401 patients, 24% up-staging  Diaphragma  Omentum  PPALN  Cytology Up-staging

8. Distribution of LN Metastasis

9. Early stage ovarian cancer & Laparoscopy  Retrospective series  Case-control studies  Meta-analysis  Cochrane review Literature

10. Early stage ovarian cancer & Laparoscopy 1994, Querleu-Leblanc 9 patients  Still small series, number low  11 studies, 9-42 pt, 88 multicenter  Approximately 400 patients Literature

11. Chi, AJOG, 2005, 50 pt LN number, omental size: no problem No conversion to L/T Survival rates similar Park, Ann Surg Oncol, 2008, 36 pt LN number, omental size: no problem Upstaging rate is same No recurrence within 20 months Comparative Studies & Feasibility

13. Whole Literature

14. Endometrial cancer – randomized studies EBL lower Shorter hospital stay Fewer postoperative complications Improved QOL Faster return to normal function Similar for ovarian cancer – no RCT, shorter interval to adjuvant chemotherapy Benefits of Laparoscopy

15. Ghezzi, 2 012, 88 pt Blood tx rate 2.8% vs 19.2% Postoperative complications 3.2% vs 31% Febrile morbidity Ileus Wound dehiscence Wound infection Benefits of Laparoscopy

16. Cost Complications Hospital stay Performance – return to work – CT ?? Improved fecundity after fertility sparing surgery - adhesions Potential Benefits & Some Conflicts

17. Rupture – IC – Chemo – survival is worsened  L/T 10% and L/S 15-20%  Size and endobag usage  Rupture vs puncture ?? Possible Risks & Rupture

19. 11 studies EBL lower Upstaging rate 23% Conversion to L/T 3.7% Recurrence rate 9.9% (6.7-14) Intraop rupture 25% !!!!! Only 1 port site-metastasis Meta-Analysis & Accepted 4 April AJOG

20. Overall 12 hasta Borderline8 pt EOC4 pt (all restaging) LN number31-84 Omentectomyno problem No conversion No intra-postop comp Median time 5 hr Data

25. Trocar Sites

29.  >20 cases PLN number satisfactory, time shorter, complications decrease; LN number: 17-22  Paraaortic LN number increase by years:6----19 Transperitoneal LA & Learning curve Kohler, GO, 2004

30. Transperitoneal LA & Duration Kohler, GO, 2004

31. 14 studies 1971-1994 Re-staging & Up-staging

32. Timing of Restaging Lehner 1998 max. 15 days Kinderman 1996 max. 8 days Adequate staging is very important

33. Primary Debulking for Advanced Disease Fanning, 2011, GO  CT: omental metastasis – ascites  25 cases – 2 conversions: severe omental-RS  36% no residual  Hospiatal stay median 1 day  Blood loss 340 ml  Median OS: 3.5 years

34. Primary Debulking for Advanced Disease Nezhat, JSLS, 2010  28 pt, 11 open after diagnostic L/S  %88 optimal  Time and complication rates are same  Blood loss and hospital stay less  9 NED, 6 AWD, 2 DOD

36. Secondary Cytoreduction Magrina, 2013, GO, 2006-2010  L/S: 9, Robot:10, L/T:33 patients  15 types of different procedures  No conversion  No difference: Op. Time, comp’n, complete debulking, survival  Endoscopy: Blood loss and hospital stay  L/T: 3 major procedures, upper and lower quadrants

37. Secondary Cytoreduction Nezhat, JSLS, 2012, only L/S  1999-2009, secondary 20, tertiary 3 cases  %82 optimal  200 min, 75 ml, stay 2 days  1 conversion  No intraop complication  NED:12  AWD:6  DOD:4  Median DFS: 72 months

44. Conclusion  There is limited data on the role laprascopic surgery for early stage ovarian cancer  Although it was started at nearly the same time periods with EC and CC it was not populirezed  It seems feasible for surgical procedures, upstaging rates, adequacy of lymphadenectomy and omentectomy  Survival rates are similar with laparotomy  Port site metastasis is rare, Major problem is tumor rupture

45. Conclusion  There is limited data on the value of laparoscopic surgery for recurrent disease. It seems feasible for highly selected patients at very experienced centers  It may be good way to assess resectability for advanced cases both before primary surgery and after NACT  VATS should be performed for patients having moderate to severe pleural effusion beforre abdominal cytoreduction

46. Thanks for your attention ….

47. The Effect of Cyst Rupture on Survival ImportantNot Important seriesnsriesn Gleeson NC23Sevelda P60 Lehner R70Kruitwagen RF219 Leminen A154Ahmed FY194 Vergote I1545Abu-Rustum NR289

48.  Steinberg, GO, 1986  Normally seen omentum: 22% involvement  Leblanc, Semin Surg Oncol, 2000  Clinical stage I 5 %  Ayhan, AJOG, 2007  Stage I-II 3.6% occult metastasis Up-staging & Omentum

49. Lymphatic Metastasis  Poor prognostic factor  Paraaortic LN metastasis is frequent  Lymph node size is not related with metastasis  Imaging is not sufficient

50. LN Metastasis at Stage I n #LN metastasis % Pickel H 2825 Burghardt E 3724 Bendetti-Panici P 3514 Petru E 40(44% ≤ 2mm) 23 Onda T 3321 Baiocchi G 24213.2 Faught W 1286.25 Pickel H, Baillieres Clin Obstet Gynaecol, 1989; Burghardt E, Gynecol Oncol, 1991; Bendetti-Panici P, Gynecol Oncol, 1993; Petru E, Am J Obstet Gynecol, 1994; Onda T, Cancer, 1996; Baiocchi G, Gynecol Oncol, 1998; Faught W, J Obstet Gynaecol Can, 2003

51. LN Metastasis & Laterality