Laparoscopic restaging of early stage invasive adnexal tumors: a 10-year experience

Current treatment strategies for ovarian cancer in the East Asian Gynecologic Oncology Trial Group (EAGOT)

Ovarian cancer, notable for its severe prognosis among gynecologic cancers, has seen substantial progress in treatment approaches recently. Enhanced protocols in chemotherapy and the introduction of poly (ADP-ribose) polymerase (PARP) inhibitors for maintenance therapy have markedly improved outcomes for patients with specific genetic profiles, such as those positive for BRCA mutations or exhibiting homologous recombination deficiency (HRD). Additionally, the method of intraperitoneal chemotherapy administration has emerged as a valuable alternative to traditional transvenous routes, showing promise for wider clinical adoption. The field of surgery has also evolved, with increasing exploration into the benefits and feasibility of laparoscopic methods over more invasive traditional surgeries, aiming for complete tumor removal but with reduced patient impact. The hereditary nature of ovarian cancer underscores the importance of genetic testing, which has become integral in tailoring treatment strategies, particularly in determining suitability for PARP inhibitors. The formation of the East Asian Gynecologic Oncology Trial Group (EAGOT) aims to optimize treatment across Japan, Korea, China, and Taiwan. The ovarian cancer committee of EAGOT shared the current policies, focusing on 5 topics: 1) strategies for maintenance therapy after initial surgery and chemotherapy, 2) drug regimens for platinum-sensitive and platinum-resistant recurrence, 3) intraperitoneal chemotherapy, 4) laparoscopic surgery as an alternative to laparotomy, and 5) current status of genetic testing (BRCA, HRD, and panel tests) for ovarian cancer and its prospects. EAGOT's multi-national trials aim to harmonize these evolving treatment strategies, ensuring that the latest and most effective protocols are accessible across the region, thereby significantly impacting patient outcomes in East Asia.

Is minimally invasive surgical approach a reasonable option in apparent early stage epithelial ovarian cancer restaging? Results from a multicentric retrospective study

INTRODUCTION

To perform surgical staging of early stage ovarian cancer (EOC), conventional laparoscopy (LS) and robot-assisted laparoscopy (RLS) appear to be reliable procedures compared to open surgery. But oncologicals results with long-term follow up are limited in the literature. The objective of this study is to evaluate the surgical and long-term survival for patients managed by minimally invasive surgery (MIS).

MATERIALS AND METHODS

We conducted a multicentric retrospective study in 6 institutions. All patients referred for epithelial EOC (apparent stage I-IIa) managed with LS and RLS were involved.

RESULTS

From December 2008 to December 2017, 140 patients were included (109 in LS group and 31 in RLS group). A total of 27 (19.2 %) patients were upstaged to an advanced ovarian cancer (FIGO stage > IIA), and 73 % of patients received chemotherapy. Mean operative time was 265,8 ± 88,4 min and significantly longer in RLS group (LS = 254,5 ± 86,8; RLS = 305,6 ± 85,5; p = 0,008). Rate of severe post-operative complications (grade 3) was 5,7 %. Thirteen conversion to laparotomy occurred, including one per-operative hemorrhaege. After a mean follow-up of 60,7 months, 29 (20.7 %) patients recurred, with a time to recurrence was >24 months in 51,7 % of cases. Overall survival (OS) was 88.6 % and disease-free survival (DFS) was 79.3 %. Oncologic outcomes were similar between LS and RLS group (OS: p = 0,504 and DFS: p = 0,213).

CONCLUSION

Surgical staging of EOC by LS or RLS approach has long-term equivalent surgical and oncological approach. These results seem to be equivalent to open surgery according to literature review.

Laparoscopic versus laparotomic surgical treatment in apparent stage I ovarian cancer: a multi-center retrospective cohort study

BACKGROUND

Laparoscopic treatment shows non-inferior survival outcomes and better surgical outcomes in apparent stage I ovarian cancer (OC) in some studies but has not been well defined.

METHODS

We conducted a retrospective study of patients with apparent stage I OC treated in two hospitals between 2012 and 2022. The surgical and oncologic outcomes were evaluated between patients receiving laparoscopic and laparotomic surgery.

RESULTS

We identified 37 patients with apparent stage I OC, including 15 (40.5%) serous carcinomas, 9 (24.3%) mucinous cancers, 3 (8.1%) endometroid cancers, 2 clear cell carcinomas, and 8 (21.6%) non-epithelial cancers. Sixteen patients received laparoscopic surgery and the other 21 patients underwent laparotomic surgery. The median age (44.5 vs. 49.0 years), mean mass size (10.5 vs. 11.3 cm), and median follow-up time (43.5 vs. 75.0 months) showed no statistically significant differences between patients in laparoscopic and laparotomic groups (all P > 0.05). All the patients underwent comprehensive surgical staging surgery, and the mean surgical time (213.5 vs. 203.3 min, P = 0.507), number of lymph nodes sampling (18.6 vs. 17.5, P = 0.359), proportion of upstaging (12.5% vs. 19.0%, P = 0.680), and postoperative complications (no Accordion Severity Grading System grade ≥ 3) were comparable between two surgical groups. Moreover, patients in the laparoscopic group had significantly less intraoperative blood loss (231.3 vs. 352.4 mL, P = 0.018), shorter interval between surgery and postoperative adjuvant chemotherapy (7.4 vs. 9.5 days, P = 0.004), shorter length of hospital stay (9.9 vs. 13.8 days, P < 0.001) than those treated with laparotomic surgery. During a median follow-up of 54.0 months, 9 (24.3%) relapsed and 1 (2.7%) died, with a 5-year recurrence-free survival (RFS) and disease-specific survival (DSS) rate of 70.6% and 100%, respectively. However, the 5-year RFS (93.3% vs. 58.8%, P = 0.084) and DSS (100% vs. 100%, P = 0.637) rates did not significantly differ between the two groups.

CONCLUSION

Laparoscopic surgical treatment had less intraoperative blood loss, earlier postoperative adjuvant chemotherapy administration, shorter hospitalization time, and non-inferior survival outcomes in apparent stage I OC when compared with laparotomic surgery.

The role of minimally invasive surgery in epithelial ovarian cancer treatment: a narrative review

Objectives

The aim of this narrative review is to summarize the available evidence on the use of minimal invasive surgery (MIS) in the management of epithelial ovarian cancer (EOC).

Background

MIS is currently performed to stage and treat EOC at different stage of presentation. We will evaluate risks and benefits of minimally invasive surgery for early stage EOC treatment, then potential advantages provided by staging laparoscopy in identifying patients suitable for primary cytoreductive surgery (PDS) will be discussed. Finally we will investigate the growing role of MIS in the treatment of advanced EOC after neoadjuvant chemotherapy (NACT) and in the treatment of EOC recurrence.

Methods

An electronic database search was performed on PubMed, Medline, and Google Scholar for relevant studies up to December 2022.

Conclusion

LPS represents a feasible surgical procedure for the staging and treatment in early, advanced and EOC relapse in selected patients treated in high-volume oncological centers by surgeons with adequate experience in advanced surgical procedures. Despite the increasing use of MIS over the last few years, randomized clinical trials are still needed to prove its effectiveness.

Comparison of Laparoscopy and Laparotomy in the Management of Early-stage Ovarian Cancer

Objectives

The objective of this study was to assess the feasibility of minimally invasive surgery for early-stage ovarian cancer (EOC) by comparing the surgical and survival outcomes between laparoscopy and laparotomy.

Materials and Methods

This was a retrospective, single-center observational study that included all patients who underwent surgical staging for EOC by laparoscopy or laparotomy between 2010 and 2019.

Results

Forty-nine patients were included; of which 20 underwent laparoscopy, 26 laparotomy, and three conversion from laparoscopy to laparotomy. No significant differences were observed between the two groups regarding operative time, number of lymph nodes dissected, or intraoperative tumor rupture rate, while estimated blood loss and transfusion requirements were lower in the laparoscopy group. The complication rate tended to be higher in the laparotomy group. Patients in the laparoscopy group had a faster recovery, with earlier urinary catheter and abdominal drain removal, shorter hospital stay, and a trend toward earlier tolerance of oral diet and mobilization. At a mean follow-up of 45.7 months, 14 patients had disease recurrence, with no differences in the mean progression-free survival between the two groups (36 months for laparoscopy vs. 35.5 months for laparotomy, P = 0.22).

Conclusion

Laparoscopic surgery performed by a trained gynecological oncologist is a safe and effective surgical approach for comprehensive staging of EOC, with the additional benefits of a faster recovery compared to laparotomy.

Laparoscopic and Laparotomic Restaging in Patients With Apparent Stage I Epithelial Ovarian Cancer: A Comparison of Surgical and Oncological Outcomes

Objective

To assess the surgical and oncological outcomes of laparoscopic restaging compared with laparotomy for apparent early-stage epithelial ovarian cancer.

Methods

A retrospective chart review was undertaken of patients who underwent laparoscopic (laparoscopy group) or laparotomic (laparotomy group) restaging at the Peking Union Medical College Hospital, China, between January 2012 and December 2017. All patients had apparent stage I epithelial ovarian cancer that was incompletely staged at the initial surgery.

Results

A total of 157 patients were included, with 50 in the laparoscopy group and 107 in the laparotomy group. Baseline characteristics were similar between the groups. No cases were converted from laparoscopy to laparotomy. The laparoscopy group had a significantly shorter operating time (p<0.001), less estimated blood loss (p<0.001), and a shorter postoperative hospitalization duration (p<0.001) than the laparotomy group. Transfusions were required in only eight laparotomy patients. No significant differences in postoperative complications were observed between the two groups (p=0.55). Eighteen (11.5%) patients were upstaged to stage II or stage III after surgery. A total of 123 (78.3%) patients received postoperative platinum-based chemotherapy. During the follow-up period, 15 (9.6%) patients experienced disease recurrence, and 3 patients died of disease progression. Five-year disease-free survival (p = 0.242, log-rank test) and overall survival (p = 0.236, log-rank test) were not affected by the surgical approach.

Conclusions

Laparoscopic restaging showed more favorable operative outcomes than laparotomy. Surgical restaging via laparoscopy versus laparotomy was not associated with worse survival in women with apparent stage I epithelial ovarian cancer.

Role of minimally invasive surgery in early ovarian cancer

Despite having revolutionized the management of multiple types of gynecologic cancers laparoscopy and robotic surgery have had limited utility in ovarian cancer until recently. The development in medical technology allows surgeons to perform minimally invasive surgery (MIS) not only in early ovarian cancer, but also in advanced ovarian cancer. Thus far, most prospective studies showed feasible results of MIS in ovarian cancer. Even with many proven advantages of the MIS, there is no concrete evidence of the disparity in survival rate between laparoscopic, robotic surgery and laparotomy surgery. We reviewed the results of MIS in ovarian cancer thus far and suggest how the gynecologists can apply MIS in ovarian cancer in the future. Until the further prospective studies show solid evidence of safety in the MIS in ovarian cancer, comprehensive discussion about the benefits and risk with the patient and the level of surgical skill of the gynecologist should be considered in determining the type of surgery.

Ovarian mucinous neoplasms, intestinal type, in premenopausal patients, develop in abnormal ovaries

Although several studies have addressed different aspects of mucinous neoplasms arising in the ovary, such as their clinicopathologic features, immunohistochemical profile, and molecular characteristics, no study has presented an analysis of the ovarian tissue where these neoplasms arise. In this study, we included 196 cases of intestinal-type ovarian mucinous neoplasms in premenopausal patients. Our main goal was to perform a rigorous examination of the ovarian tissue surrounding these neoplasms. We also reviewed the clinicopathologic features of these cases. For comparison, the background ovarian tissue in 85 cases of ovarian serous neoplasm and in 29 cases of metastatic neoplasms to the ovary, as well as 57 normal ovaries, was examined. All the patients in this study, which included those with mucinous and with serous neoplasms primary in the ovary, those with metastatic tumors to the ovaries, and those with normal ovaries, were also premenopausal. Patients affected by ovarian mucinous neoplasms ranged in age from 13 to 52 years (median = 36 years). Nulligravidity was seen in 50%, 32%, and 22% of patients with mucinous carcinomas, mucinous borderline neoplasms, and mucinous cystadenomas, respectively. Ovarian mucinous intestinal neoplasms arise in abnormal ovaries characterized by two important features: (1) an abnormal ovarian cortex, seen in 95% of the cases, which is hypocellular or with no distinction between the cellular cortex and medulla, and (2) a remarkable paucity of primordial follicles. The abnormalities detected in the background ovarian tissue might provide insights into the tumorigenesis of these neoplasms and might facilitate their distinction from metastasis to the ovary, in premenopausal patients.

A novel laparoscopy-based model for the prediction of optimal cytoreduction and prognosis of epithelial ovarian cancer in a Chinese population

OBJECTIVES

This study aimed to investigate the predictive value of laparoscopy for the prediction of optimal cytoreduction and prognosis of epithelial ovarian cancer (EOC) in a Chinese population.

STUDY DESIGN

This study enrolled 162 EOC patients in Obstetrics and Gynecology Hospital of Fudan University from January 2015 to December 2016. All patients underwent preoperative CT scans and laparoscopic assessments. Each patient was scored according to the CT-based predictive model by Bristow and laparoscopy-based predictive model by Fagotti. The specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV) and area under the curve (AUC) of each model were calculated. The predictive scores and clinicopathologic factors were all analyzed using the Kaplan-Meier method and multivariate Cox analysis. A prognostic predictive nomogram was formulated in R software.

RESULTS

The AUCs of the laparoscopy-based predictive model and CT-based predictive model was 0.955 and 0.755 respectively. At a laparoscopic score ≥ 10, the possibility of optimal cytoreduction was 0, and the risk of unnecessary explorative attempts was 6%. Additionally, laparoscopic score, independent of residual tumor size and FIGO stage, was an independent prognostic factor for both overall survival (OS) and recurrence-free survival (RFS) in EOC. Notably, the predictive nomogram that we established further confirmed the prognostic value of laparoscopy for prognostic predictions in EOC.

CONCLUSIONS

Laparoscopy has a better discriminating performance than CT in the prediction of optimal cytoreduction in EOC. Moreover, the laparoscopic score is directly correlated with the survival of EOC patients. The laparoscopic score-based nomogram we established showed good potential to predict the prognosis of EOC patients.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for omentectomy - A case series

BACKGROUND AND OBJECTIVE

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has been applied massively in the gynecological field in recent years. The aim of the current study is to present the surgical technique of vNOTES omentectomy and to evaluate the feasibility of this procedure.

METHODS

A case series study of the first 5 vNOTES omentectomy procedures performed for surgical staging of suspicious early stage ovarian cancer, at Rambam Health Care Campus (Israel) and Imelda Hospital (Belgium) between November 2018 and August 2019. Sociodemographic and clinical data were retrieved from patients' electronic charts. Primary points of interest included intra-operative bleeding, length of surgery, length of hospitalization, and surgical complications.

RESULTS

The median age was 61 years (range 50-72), and the median BMI was 27 kg/m² (range 23-33). All the operations were carried out to completion through the vaginal GelPOINT, without insertion of an assistant abdominal trocar or conversion to another surgical approach. The median omentectomy time was 45 min (range: 39-52). The median estimated intraoperative blood loss was 150 ml (range: 20-200). The median hospital stay was 2 days (range: 1-3).

CONCLUSIONS

vNOTES is a feasible technique for omentectomy in early stage ovarian cancer, with low rates of complications and improved cosmetic results.

Evidence for the use of robotically assisted surgery in gynecologic cancers

PURPOSE OF REVIEW

Robotically assisted laparoscopy has been introduced in the armamentarium of gynaecologic oncology surgeons. A lot of studies compared robotic surgery and laparotomy when the real issue is to demonstrate the interest and added value of robotically assisted laparoscopy versus standard laparoscopy. In this review, we will describe the most meaningful indications and advantages of robotically assisted laparoscopy in gynaecologic oncology.

RECENT FINDINGS

The learning curve for advanced procedures in robot-assisted laparoscopy is shorter and easier than with the standard laparoscopy, especially for beginners. In most of the series, operating time is longer with robot, but complication rates are often decreased, especially in obese patients with a conversion rate to laparotomy that is decreased compared with standard laparoscopy. Robot-assisted laparoscopy can be used for surgery of high-risk endometrial cancer, staging of early-ovarian cancer, and pelvic exenteration in case of recurrent malignancies. Furthermore, more recent robots allow performing sentinel node biopsy in endometrial or cervical cancer using fluorescence detection with indocyanine green.

SUMMARY

The spreading of robotic surgery led to an enhancement of minimal invasive surgical approach in general, and to the development of new indications in gynaecologic oncology. The superiority of robot-assisted laparoscopy still has to be demonstrated with properly designed trials.

Laparoscopy versus laparotomy for FIGO stage I ovarian cancer

BACKGROUND

This is an updated version of the original review that was first published in the Cochrane Database of Systematic Reviews 2008, Issue 4. Laparoscopy has become an increasingly common approach to surgical staging of apparent early-stage ovarian tumours. This review was undertaken to assess the available evidence on the benefits and risks of laparoscopy compared with laparotomy for the management of International Federation of Gynaecology and Obstetrics (FIGO) stage I ovarian cancer.

OBJECTIVES

To evaluate the benefits and harms of laparoscopy in the surgical treatment of FIGO stage I ovarian cancer (stages Ia, Ib and Ic) when compared with laparotomy.

SEARCH METHODS

For the original review, we searched the Cochrane Gynaecological Cancer Group Trials (CGCRG) Register, Cochrane Central Register of Controlled Trials (CENTRAL 2007, Issue 2), MEDLINE, Embase, LILACS, Biological Abstracts and CancerLit from 1 January 1990 to 30 November 2007. We also handsearched relevant journals, reference lists of identified studies and conference abstracts. For the first updated review, the search was extended to the CGCRG Specialised Register, CENTRAL, MEDLINE, Embase and LILACS to 6 December 2011. For this update we searched CENTRAL, MEDLINE, and Embase from November 2011 to September 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs), quasi-RCTs and prospective cohort studies comparing laparoscopic staging with open surgery (laparotomy) in women with stage I ovarian cancer according to FIGO.

DATA COLLECTION AND ANALYSIS

There were no studies to include, therefore we tabulated data from non-randomised studies (NRS) for discussion as well as important data from other meta-analyses.

MAIN RESULTS

We performed no meta-analyses.

AUTHORS' CONCLUSIONS

This review has found no good-quality evidence to help quantify the risks and benefits of laparoscopy for the management of early-stage ovarian cancer as routine clinical practice.

Outcomes of laparoscopic fertility-sparing surgery in clinically early-stage epithelial ovarian cancer

Objective

Fertility-sparing surgery (FSS) is becoming an important technique in the surgical management of young women with early-stage epithelial ovarian cancer (EOC). We retrospectively evaluated the outcome of laparoscopic FSS in presumed clinically early-stage EOC.

Methods

We retrospectively searched databases of patients who received laparoscopic FSS for EOC between January 1999 and December 2012 at Samsung Medical Center. Women aged ≤40 years were included. The perioperative, oncological, and obstetric outcomes of these patients were evaluated.

Results

A total of 18 patients was evaluated. The median age of the patients was 33.5 years (range, 14 to 40 years). The number of patients with clinically stage IA and IC was 6 (33.3%) and 12 (66.7%), respectively. There were 7 (38.9%), 5 (27.8%), 3 (16.7%), and 3 patients (16.7%) with mucinous, endometrioid, clear cell, and serous tumor types, respectively. Complete surgical staging to preserve the uterus and one ovary with adnexa was performed in 4 patients (22.2%). Two out of them were upstaged to The International Federation of Gynecology and Obstetrics stage IIIA1. During the median follow-up of 47.3 months (range, 11.5 to 195.3 months), there were no perioperative or long term surgical complications. Four women (22.2%) conceived after their respective ovarian cancer treatments. Three (16.7%) of them completed full-term delivery and one is expecting a baby. One patient had disease recurrence. No patient died of the disease.

Conclusion

FSS in young patients with presumed clinically early-stage EOC is a challenging and cautious procedure. Further studies are urgent to determine the safety and feasibility of laparoscopic FSS in young patients with presumed clinically early-stage EOC.

Laparoscopic fertility-sparing surgery for early ovarian epithelial cancer: A multi-institutional experience

OBJECTIVE

There is as yet limited evidence about fertility-sparing surgery for early ovarian cancer (EOC) carried out laparoscopically. We sought to investigate the safety, adequacy and fertility outcome of ovarian cancer patients who underwent fertility-saving laparoscopic surgical staging using a multi-institutional sample.

METHODS

Prospectively collected data in five gynecologic oncology service databases were searched for epithelial EOC patients undergoing laparoscopic fertility-preserving surgery. Surgical, pathologic, oncologic and reproductive outcome data were analysed.

RESULTS

The study cohort consisted of 65 women. Median age of the patients was 33 (range: 21-42) years. In this cohort 36 (55.4%) and 29 (44.6%) patients were at low risk (FIGO stage IA G1-2) and high-risk (FIGO stage IA G3 or more), respectively. The disease was reclassified to a higher stage in 4 (6.1%) women. After a median follow up period of 38months (range: 2-144), the overall survival was 95.4% and recurrence-free survival 84.6%. Overall, there were 23 pregnancies in 22 women. After ovarian cancer treatment, 64.8% women reported pregnancy intent and 60% of these conceived spontaneously.

CONCLUSIONS

Laparoscopic staging may represent a viable option for premenopausal women seeking fertility preservation in the setting of early ovarian cancer. More research is needed to determine whether laparoscopy may offer reproductive benefits to this particular population.

Laparoscopic Versus Laparotomic Surgical Staging for Early-Stage Ovarian Cancer: A Case-Control Study

STUDY OBJECTIVE

To evaluate the oncologic outcomes of patients with early-stage ovarian cancer (eOC) managed by laparoscopy or laparotomy in a single high-volume gynecologic cancer center.

DESIGN

Retrospective case-control study (Canadian Task Force classification II-2).

SETTING

Catholic University of the Sacred Hearth, Rome, Italy.

PATIENTS

Data of consecutive women with eOC undergoing comprehensive laparoscopic staging between 2007 and 2013 were matched with a cohort of patients undergoing open surgery between 2000 and 2011. Four-year survival outcomes were analyzed using the Kaplan-Meier method.

MEASUREMENTS AND RESULTS

Sixty women undergoing staging via laparoscopy were compared with a cohort of 120 patients undergoing open surgery. Baseline characteristics were similar between groups. Seventy percent of patients underwent adjuvant platinum based chemotherapy without differences between the 2 groups. Operative time (p = .01), estimated blood loss (p = .032), and median hospital stay (p = .001) were higher in patients submitted to laparotomic versus laparoscopic staging. As of October 2015, median duration of follow-up was 38 months (range, 24 -48), recurrent disease was documented in 16 patients (13.3%) in the laparotomic group and in 5 patients (8.3%) in the laparoscopic group (p = .651), without differences in the pattern of recurrence presentation. Four-year progression-free survival (PFS) and overall survival (OS) rates were 89% and 92% in the laparoscopic group, respectively, and 81% and 91% in the laparotomic group, without any statistical significant difference between the groups (4-year PFS p = .651; 4-year OS p = .719).

CONCLUSION

The findings of the present study suggests that in the surgical treatment of FIGO stage I ovarian cancer, laparoscopy is associated with equivalent oncologic outcome compared with a conventional abdominal approach.

Health Care Disparities in Hysterectomy for Gynecologic Cancers: Data From the 2012 National Inpatient Sample

OBJECTIVE

To examine hysterectomies in the United States performed for gynecologic malignancies and identify factors associated with the use of minimally invasive techniques.

METHODS

This is a cross-sectional analysis of the 2012 National Inpatient Sample, the largest national all-payer database of hospital discharges. International Classification of Diseases, 9th Revision, Clinical Modification codes for any type of hysterectomy performed for gynecologic malignancy were used to abstract pertinent observations. Weighted multivariable logistic regression models were used to examine the associations between demographic and clinical factors and mode of hysterectomy by cancer diagnosis.

RESULTS

In 2012, there were an estimated 46,450 hysterectomies for gynecologic malignancy in the United States. Of these, 28,285 (61%) were performed for uterine, 4,275 (9%) for cervical, 12,370 (27%) for ovarian cancer, and 1,520 (3%) for other gynecologic malignancies. Minimally invasive hysterectomy was used in 50% of uterine, 43% of cervical, and 8.5% of ovarian cancer cases. Black women had decreased odds of undergoing minimally invasive hysterectomy for uterine (adjusted odds ratio [OR] 0.50, 95% confidence interval [CI] 0.40-0.0.63, P<.001) and cervical (adjusted OR 0.56, 95% CI 0.33-0.96, P=.03) cancers. Those without insurance or with Medicaid had decreased odds of undergoing minimally invasive hysterectomy (P<.001) for uterine cancer. As compared with the Northeast, patients in the South (adjusted OR 0.72, 95% CI 0.53-0.98, P=.04) were less likely to undergo minimally invasive hysterectomy for uterine cancer, whereas those in the West more likely (adjusted OR 1.48, 95% CI 1.10-1.99, P=.009).

CONCLUSION

Minimally invasive hysterectomy for gynecologic malignancies remained underused in 2012; there were striking racial disparities associated with use of minimally invasive hysterectomy for uterine and cervical cancers.

LEVEL OF EVIDENCE

III.

Fertility-sparing surgery in epithelial ovarian cancer

Since the last two decades, the feasibility of fertility-sparing surgery in early-stage epithelial ovarian cancer has been explored by several teams. Despite the impossibility of conducting a randomized trial to validate this management, evidence-based data suggest that in selected cases, the preservation of the uterus and at least one part of the ovary does not lead to a high risk of relapse. Conservative surgery maintains organ function, enables patients of childbearing age to preserve their fertility and improves their quality of life. In this review, we analyze the main series in the literature on this topic in order to highlight the selected criteria for conservative management and to summarize oncological and fertility outcomes.

The Role of Completion Surgery in Ovarian Cancer

INTRODUCTION

Patients referred with inadequately staged ovarian malignancies present a clinical dilemma. We report our experience with completion surgery in ovarian cancer.

AIMS AND OBJECTIVES

To determine the benefits and risks of completion surgery in women with ovarian cancer who presented after having had inadequate primary surgery.

METHODS

A retrospective case series of 30 women with ovarian cancer and one with fallopian tube cancer who had inadequate primary surgery underwent completion surgery at gynaecologic oncology unit in a tertiary level hospital in Tamil Nadu, India. Electronic medical records of patients with ovarian cancer who underwent completion surgery between January 2011 and September 2014 for ovarian were reviewed. Forty-five patients with initial inadequate surgery were identified of whom 31 underwent completion surgery; the remaining 14 did not return to our hospital.

RESULTS

Thirty-one women with a mean age of 37 years (17-53) and median parity of 2 (0-4) with inadequately staged ovarian malignancy underwent completion surgery. Complex ovarian mass was the most common indication for initial surgery (94 %). The tumours were epithelial in 27 (87 %), germ cell in 3 (10 %) and sex cord stromal in 1 (3 %). In view of extensive disease at presentation, 19 % (6/31) were referred for neoadjuvant chemotherapy and underwent interval debulking. With regard to surgical complexity, 52 % (16/31), 38 % (12/31) and 10 % (3/31) underwent simple, intermediate and complex surgeries, respectively. Optimal cytoreduction (R0 and R1) was performed in 25 patients (81 %). Twelve (39 %) had upstaging of disease. Six patients required no further adjuvant treatment following surgical restaging. Complications included bladder injury (1), iliac vessel injury (1) and surgical site infections (2). During the study period of 45 months, 7 patients (23 %) presented with disease recurrence. There were 2 recorded deaths.

CONCLUSIONS

In inadequately staged ovarian malignancies, completion surgery should be considered based on the patients' performance status and disease assessment. Considering the low specificity of imaging and Ca 125, completion surgery provides information to plan adjuvant therapy, besides allowing optimal cytoreduction but delays initiation of adjuvant therapy.

Comparison of the prognosis and recurrence of apparent early-stage ovarian tumors treated with laparoscopy and laparotomy: a meta-analysis of clinical studies

Background

This meta-analysis aimed to evaluate the prognosis and recurrence of apparent early-stage ovarian tumors treated with laparoscopy compared with laparotomy.

Methods

Clinical studies published in English were retrieved from the computerized databases Medline and Embase. A meta-analysis was performed to investigate the differences in the efficacy and safety of laparoscopy versus laparotomy in terms of postoperative complications, lengths of hospital stay, recurrence rates, and disease-free survival times using the random effects model. The studies were independently reviewed by two investigators. Data from the eligible studies were extracted, and the meta-analysis was performed using the Comprehensive Meta-Analysis program, version 2 (CMA-2; Biostat, Englewood, NJ, USA).

Results

A total of 8 studies were included in the analysis. The results showed that laparoscopic surgery was significantly associated with lower rates of complications (OR = 0.433, P = 0.019) and shorter postoperative hospital stays (weighted mean difference [WMD] = −0.974, P < 0.001). There was no significant difference in the rates of recurrence (OR = 0.707, P = 0.521) between patients with apparent early-stage ovarian tumors who were treated using laparoscopy and those who underwent laparotomy. No publication bias was detected.

Conclusions

Laparoscopic surgery shows favorable prognostic outcomes in terms of postoperative complication rates and postoperative hospital stay durations. Further studies with longer follow-up periods are required to confirm recurrence and survival outcomes after laparoscopic surgery in patients with apparent early-stage ovarian tumors.

Feasibility and efficacy of laparoscopic restaging surgery for women with unexpected ovarian malignancy

OBJECTIVE

To evaluate the feasibility, surgical outcomes and complications of laparoscopic restaging surgery for women with unexpected ovarian malignancy.

STUDY DESIGN

We conducted a retrospective chart review of 14 women with unexpected ovarian malignancy who underwent laparoscopic restaging surgery including peritoneal washing cytology, laparoscopic pelvic and paraaortic lymphadenectomy up to the left renal vein level, omentectomy, and multiple peritoneal biopsies, and hysterectomy except three fertility saving surgery.

RESULTS

The median age and median body mass index women were 49 years (range, 22-63) and 24.2m/kg(2) (range, 18.9-25.3), respectively. The median operating time was 230min (range, 155-370). The median numbers of harvested pelvic and paraaortic lymph nodes were 26 (range, 6-41) and 18 (range, 2-40), respectively. The median return of bowel activity was 28h (range, 21-79). Four of the women were upstaged from the initial presumed stage. There were two intraoperative complications, laceration of the inferior vena cava and cisterna chyli rupture. There was one postoperative complication, port-site metastasis. There was no conversion to laparotomic surgery. The median follow-up period was 33 months. Thirteen of the patients have no evidence of recurrences, however one patient died after 22 months after the surgery.

CONCLUSION

Laparoscopic restaging surgery, performed by a specialized laparoscopic oncologist with sufficient laparoscopic experience and a well-trained operating team, is both feasible and effective in the management of unexpected ovarian malignancies.

Mucinous tumors of the ovary: current thoughts on diagnosis and management

Mucinous tumors of the ovary represent a spectrum of neoplastic disorders, including benign mucinous cystadenoma, pseudomyxoma peritonei, mucinous tumors of low malignant potential (borderline), and invasive mucinous ovarian carcinoma. These tumors are related closely to each other and are distinct from other histologic subtypes of epithelial ovarian neoplasms from a clinical, histologic, and molecular standpoint. A continuum appears to be present from benign to borderline to malignant, which is different from other types of epithelial ovarian cancer. Mutational profiles are also distinct, as KRAS mutations are common, but p53 and BRCA mutations are infrequent. These characteristics lead to specific biologic behavior and guide both clinical management and research efforts in patients with mucinous ovarian tumors.

Laparoscopic and Open Abdominal Staging for Early-Stage Ovarian Cancer: Our Experience, Systematic Review, and Meta-analysis of Comparative Studies

Objectives

The aim of this study was to analyze perioperative and long-term survival outcomes after either laparoscopic or open abdominal staging for apparent early-stage ovarian cancer.

Methods

Data of consecutive women with early-stage ovarian cancer undergoing comprehensive laparoscopic staging between 2003 and 2010 were matched with a historical cohort of patients undergoing open surgery. Five-year survival outcomes were analyzed using the Kaplan-Meier method. In addition, a systematic review of the literature and meta-analysis of comparative studies was performed

Results

A total of 35 women undergoing staging via laparoscopy were compared with a cohort of 32 patients undergoing open surgery. Baseline characteristics were similar between groups. Spillage occurred in 6 and 4 patients in laparoscopic and open group, respectively (P = 0.59). Patients undergoing laparoscopy experienced longer operative time (P < 0.001), shorter hospital stay (P = 0.03), and lower postoperative complication rate (3% vs 28%; P = 0.005) than patients undergoing staging via open surgery. The median (range) follow-up period was 64 (37–106) and 100 (61–278) months for case and control, respectively (P < 0.001). Five-year disease-free survival (P = 0.12, log-rank test) and overall survival (P = 0.26, log-rank test) were not influenced by surgical approach. Pooled analyses of the literature results corroborate our results suggesting an improvement of perioperative results in the laparoscopic group in comparison with the open abdominal one. In comparison with open surgery, laparoscopy did not influenced spillage (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.35–1.73) and upstaging rate (OR, 0.7; 95% CI, 0.38–1.27). No between-group differences in survival were observed (OR, 0.5; 95% CI, 0.21–1.21).

Conclusions

Laparoscopy upholds open surgery in long-term oncologic control, reducing morbidity.

Evaluation of single-port laparoscopy for peritoneal carcinomatosis assessment in advanced ovarian cancer

OBJECTIVES

Ovarian cancers are usually diagnosed at an advanced stage. The extent of the disease before surgery partly determines the ability to perform a complete cytoreduction. The peritoneal cancer index (PCI) is used to evaluate peritoneal carcinomatosis and has been validated in ovarian cancer and correlated with resectability. The aim of our study was to assess the feasibility of single-port laparoscopy (SPL) for suspicion of advanced ovarian cancer and to describe the ability to calculate the PCI score at the time of laparoscopy.

STUDY DESIGN

Between February 2011 and January 2013, 33 patients underwent SPL for suspected advanced ovarian cancer. Individual records for all patients were prospectively reviewed and analyzed. For each patient, we determined the PCI score.

RESULTS

33 patients underwent initial SPL, 85% had increased carcinological markers and 67% a radiological suspicion of peritoneal carcinomatosis. The median operative time was 90min. During SPL, 76% of patients underwent ascites evacuation; all patients had peritoneal cytology and peritoneal biopsies. Only 3 patients experienced perioperative complications. Two open conversions were recorded. Quotation of the PCI score was possible for all patients. Eighteen patients (55%) had a PCI score below 10; one had a maximal PCI score of 39. The PCI score was null for 9 patients. Non-browsing areas marked 8 procedures.

CONCLUSIONS

SPL appeared to be feasible, with satisfying immediate results and postoperative outcome, compared to conventional laparoscopy. It allowed a satisfying exploration of the abdomino-pelvic cavity and a good description of peritoneal carcinomatosis with only a few non-browsing PCI areas.

Laparoscopic fertility-sparing surgery for early stage ovarian cancer: a single-centre case series and systematic literature review

Background

There is as yet limited evidence about fertility-sparing surgery for early ovarian cancer (EOC) carried out laparoscopically. We sought to analyze recurrence patterns and fertility outcome in a cohort of ovarian cancer patients who underwent fertility-saving laparoscopic surgical staging.

Methods

We conducted a retrospective analysis of prospectively collected data on all patients undergoing fertility-sparing laparoscopic staging procedures for presumed EOC at a single gynecologic oncology service. Oncologic safety and reproductive outcome were the main outcome measures. The pertinent literature is reviewed.

Results

The study cohort consisted of 12 women. Cases included 5 invasive epithelial tumors and 7 nonepithelial tumors. The disease was reclassified to a higher stage in one woman. After a median follow up period of 38 months (range: 14–108), the overall survival was 100% and recurrence-free survival 90.9%. Five (100%) of patients who attempted pregnancy conceived spontaneously. Three of them had uneventful term pregnancy delivering healthy babies. The literature search yielded 62 cases of laparoscopic fertility conserving surgery for ovarian cancer. There were 4 (6.2%) recurrences. Cumulative pregnancy and live birth rate were not estimable as earlier publications lack essential data.

Conclusions

Laparoscopic staging may represent a viable option for premenopausal women seeking fertility preservation in the setting of early ovarian cancer. More research is needed to determine whether laparoscopy may offer reproductive benefits to this particular population.

Comparison of Laparoscopy and Laparotomy in the Surgical Management of Early-Stage Ovarian Cancer

Objective

The aim of this study is to investigate the safety and efficacy of laparoscopy in the treatment of early-stage ovarian cancer (EOC).

Methods

We retrospectively analyzed the clinical data of patients who underwent laparoscopy (35 patients) or laparotomy (40 patients) for the comprehensive surgical staging of EOC in Zhujiang Hospital during the period of 2002 to 2010 and compared the 2 surgical approaches in operative time, intraoperative blood loss, number of dissected lymph nodes, tumor rupture rate, length of hospital stay, time of gastrointestinal function recovery, wound healing condition, complication rate, upstaging rate, rate of postoperative chemotherapy, and postoperative follow-up condition.

Results

The laparoscopy group had significantly shorter hospital stay and time of first postoperative flatus and had significantly lower rate of poor wound healing than the laparotomy group. The 2 groups did not show significant differences in operative time, intraoperative blood loss, number of dissected lymph nodes, tumor rupture rate, complication rate, upstaging rate, and rate of postoperative chemotherapy.

Conclusions

Laparoscopy is safe and effective for the comprehensive surgical staging of EOC and has the advantages of shorter hospital stay, faster recovery of gastrointestinal function, and good wound healing.

Prevalence and Prognostic Impact of Lymphadenectomy and Lymph Node Metastasis in Clinically Early-Stage Ovarian Clear Cell Carcinoma

Objectives

The objective of this study was to estimate the prevalence and prognostic impact of lymphadenectomy and lymph node involvement in patients with ovarian clear cell carcinoma (OCCC) grossly confined to the ovary.

Methods

Patients with a diagnosis of OCCC grossly confined to the ovary were identified from Surveillance, Epidemiology, and End Results program from 1988 to 2007. Only surgically treated patients were included. Statistical analysis using Studentttest, Kaplan-Meier survival methods, and Cox proportional hazards regression were performed.

Results

One thousand eight hundred ninety-seven patients with OCCC who have undergone surgical treatment and deemed at time of the surgery to have disease grossly confined to the ovary were included: 538 (28.3%) had no lymphadenectomy (LND −1), and 1359 (71.7%) had lymphadenectomy. Of the 1359 patients who had lymphadenectomy, 1298 (95.5%) were International Federation of Gynecology and Obstetrics (FIGO) surgical stage I (LND +1), and 61 (4.5%) were upstaged to FIGO stage IIIC due to nodal metastasis (LND +3C). The 5-year disease-specific survival was 84.9% for LND −1, 88.0% for LND +1, and 65.0% for LND +3C (P< 0.001). Among those with histologically negative lymph nodes, the 5-year disease-specific survival was 85% for patients with 1 to 10 nodes removed, and 91% for those with more than 10 nodes removed (P= 0.054). On multivariate analysis after controlling for stage, age, and race, lymph node metastasis was an independent predictor of poor disease-specific survival (hazard ratio, 3.1; 95% confidence interval, 1.86–5.28;P< 0.001). On other hand, there was a trend toward an improved survival when more extensive lymphadenectomy is performed in patients with histologically negative nodes (1–10 vs >10 nodes), but it did not reach statistical significance (hazard ratio, 0.71; 95% confidence interval, 0.49–1.02;P= 0.064).

Conclusions

Lymph node metastasis was uncommon in patients diagnosed with OCCC grossly confined to the ovary; however, patients with positive nodes were more likely to die compared to those with negative nodes. More extensive lymphadenectomy plays an important role in providing accurate staging and prognostic information.

Staging laparoscopy for the management of early-stage ovarian cancer: a metaanalysis

OBJECTIVE

We sought to perform a quantitative analysis on operative outcomes of laparoscopic staging surgery in patients with presumed early-stage ovarian cancer using a metaanalysis.

STUDY DESIGN

Electronic searches for studies of laparoscopic staging surgery in patients with ovarian cancer were performed within 3 electronic databases (Medline, Embase, and the Cochrane Library) using the key words "ovarian cancer," "early stage," "laparoscopy," "staging surgery," "staging laparoscopy," and "recurrence." Two authors independently screened articles, and those meeting the defined inclusion/exclusion criteria were included in the metaanalysis.

RESULTS

We identified 11 observational studies. The combined results of 3 retrospective studies showed that the estimated blood loss in laparoscopy was significantly lower than that for laparotomy (P < .001). The overall upstaging rate after laparoscopic surgery was 22.6% (95% confidence interval [CI], 18.1-27.9%) without significant heterogeneity among all study results. The overall incidence of conversion from laparoscopy to laparotomy was 3.7% (95% CI, 2.0-6.9%). The overall rate of recurrence in studies with a median follow-up period of ≥19 months was 9.9% (95% CI, 6.7-14.4%).

CONCLUSION

Through our quantitative analysis, we concluded that the operative outcomes of a laparoscopic approach in patients with early-stage ovarian cancer could be compatible with those of laparotomy. In the future, further randomized controlled trials may be needed.

GEICO (Spanish Group for Investigation on Ovarian Cancer) treatment guidelines in ovarian cancer 2012

In 2006, under the auspices of The Spanish Research Group for Ovarian Cancer (Spanish initials GEICO), the first "Treatment Guidelines in Ovarian Cancer" were developed and then published in Clinical and Translational Oncology by Poveda Velasco et al. (Clin Transl Oncol 9(5):308-316, 2007). Almost 6 years have elapsed and over this time, we have seen some important developments in the treatment of ovarian cancer. Significant changes were also introduced after the GCIG-sponsored 4th Consensus Conference on Ovarian Cancer by Stuart et al. (Int J Gynecol Cancer 21:750-755, 2011). So we decided to update the treatment guidelines in ovarian cancer and, with this objective, a group of investigators of the GEICO group met in February 2012. This study summarizes the presentations, discussions and evidence that were reviewed during the meeting and during further discussions of the manuscript.

Safety and efficacy of video laparoscopic surgical debulking of recurrent ovarian, fallopian tube, and primary peritoneal cancers

Laparoscopy is technically feasible and can be utilized to optimally cytoreduce recurrent ovarian, fallopian, or primary peritoneal cancers in a well-selected patient population.

Background and Objective:

Studies on the role of laparoscopy in secondary or tertiary cytoreduction for recurrent ovarian cancer are limited. Our objective is to describe our preliminary experience with laparoscopic secondary/tertiary cytoreduction in patients with recurrent ovarian, fallopian, and primary peritoneal cancers.

Methods:

This is a retrospective analysis of a prospective case series. Women with recurrent ovarian, fallopian tube, or primary peritoneal cancers deemed appropriate candidates for laparoscopic debulking by the primary surgeon(s) were recruited. The patients underwent exploratory video laparoscopy, biopsy, and laparoscopic secondary/tertiary cytoreduction between June 1999 and October 2009. Variables analyzed include stage, site of disease, extent of cytoreduction, operative time, blood loss, length of hospital stay, complications, and survival time.

Results:

Twenty-three patients were recruited. Only one surgery involved conversion to laparotomy. Seventeen (77.3%) of the patients had stage IIIC disease at the time of their initial diagnosis, and 20 (90.9%) had laparotomy for primary debulking. Median blood loss was 75 mL, median operative time 200 min, and median hospital stay 2 d. No intraoperative complications occurred. One patient (4.5%) had postoperative ileus. Eighteen (81.8%) of the patients with recurrent disease were optimally cytoreduced to < 1cm. Overall, 12 patients have no evidence of disease (NED), 6 are alive with disease (AWD), and 4 have died of disease (DOD), over a median follow-up of 14 mo. Median disease-free survival was 71.9 mo.

Conclusions:

In a well-selected population, laparoscopy is technically feasible and can be utilized to optimally cytoreduce patients with recurrent ovarian, fallopian, or primary peritoneal cancers.

Laparoscopy versus laparotomy for FIGO stage I ovarian cancer

BACKGROUND

This is an updated version of the original review that was first published in the Cochrane Database of Systematic Reviews 2008, Issue 4. Laparoscopy has become an increasingly common approach to surgical staging of apparent early-stage ovarian tumours. This review was undertaken to assess the available evidence on the benefits and risks of laparoscopy compared with laparotomy for the management of International Federation of Gynaecology and Obstetrics (FIGO) stage I ovarian cancer.

OBJECTIVES

To evaluate the benefits and risks of laparoscopy compared with laparotomy for the surgical treatment of FIGO stage I ovarian cancer (stages Ia, Ib and Ic).

SEARCH METHODS

For the original review, we searched the Cochrane Gynaecological Cancer Group Trials (CGCRG) Register, Cochrane Central Register of Controlled Trials (CENTRAL 2007, Issue 2), MEDLINE, EMBASE, LILACS, Biological Abstracts and CancerLit from 1 January 1990 to 30 November 2007. We also handsearched relevant journals, reference lists of identified studies and conference abstracts. For this updated review, we extended the CGCRG Specialised Register, CENTRAL, MEDLINE, EMBASE and LILACS searches to 6 December 2011.

SELECTION CRITERIA

Randomised controlled trials (RCTs), quasi-RCTs and prospective case-control studies comparing laparoscopic staging with open surgery (laparotomy) in women with stage I ovarian cancer according to FIGO.

DATA COLLECTION AND ANALYSIS

There were no studies to include, therefore we tabulated data from non-randomised studies (NRS) for discussion.

MAIN RESULTS

We performed no meta-analyses.

AUTHORS' CONCLUSIONS

This review has found no good-quality evidence to help quantify the risks and benefits of laparoscopy for the management of early-stage ovarian cancer as routine clinical practice.

Mucinous cystadenocarcinoma of ovary: Changing treatment paradigms

Traditionally, all carcinomas arising from the surface epithelial layer of the ovary have been grouped together. This grouping has led to a single therapeutic strategy that is used for all epithelial ovarian cancers. However mucinous cancers appear to be distinct from serous cancers in their clinical behaviour and molecular signatures. In comparison to serous tumours, early stage mucinous tumours tend to be localised at diagnosis with a higher overall survival. But when metastatic at presentation or after recurrence, the outcome of mucinous tumours is far inferior to serous tumours. With standard platinum based chemotherapy the response rate and survival is far worse in mucinous cancers. The precise biological and molecular explanation for this difference remains unanswered. There is urgent need for testing and adoption of therapeutic approaches tailored to molecular characteristics of mucinous carcinomas so that patient survival can be optimised.

Systematic para-aortic and pelvic lymphadenectomy in early stage epithelial ovarian cancer: a prospective study

BACKGROUND

Lymphadenectomy is important in the surgical treatment of apparent early epithelial ovarian cancers (eEOC); however, its extent is not well defined. We evaluated the role of systematic lymphadenectomy, the risk factors related with lymph node metastases, the implications, and the morbidity of comprehensive surgical staging.

METHODS

We prospectively recruited 124 patients diagnosed with apparent eEOC [International Federation of Gynecology and Obstetrics (FIGO) stage I and II] between January 2003 and January 2011. Demographics, surgical procedures, morbidities, pathologic findings, and correlations with lymph node metastases were assessed.

RESULTS

A total of 111 patients underwent complete surgical staging, including lymphadenectomy, and were therefore analyzed. A median of 23 pelvic and 20 para-aortic nodes were removed. Node metastases were found in 15 patients (13.5 %). The para-aortic region was involved in 13 (86.6 %) of 15 cases. At univariate analysis, age, menopause, FIGO stage, grading, and laterality were found to be significant factors for lymph node metastases, while CA125 of >35 U/ml and positive cytology were not. No lymph node metastases were found in mucinous histotypes. At multivariate analysis, only bilaterality (p = 0.018) and menopause (p = 0.032) maintained a statistically significant association with lymph node metastases. Lymphadenectomy-related complications (lymphocyst formation and lymphorrhea) were found in 14.4 % patients.

CONCLUSIONS

The data of this prospective study demonstrate the prognostic value of lymphadenectomy in eEOC. Menopause, age, bilaterality, histology, and tumor grade are identifiable factors that can help the surgeon decide whether to perform comprehensive surgical staging with lymph node dissection. These parameters may be used in planning subsequent treatment.

Dual-console robotic surgery: a new teaching paradigm

Robotic surgery has emerged as an alternative option in minimally invasive gynecologic surgery. The development of the dual-console da Vinci Si Surgical System(®) has enabled modification of the training atmosphere. We sought to investigate operative times and surgical outcomes while operating with the dual-console model in a training environment for our first fifty cases. We identified the first fifty patients who underwent robot-assisted total hysterectomy (TRH), with or without bilateral salpingo-oophorectomy (BSO), with or without pelvic and para-aortic lymph node dissection (PPALND), by use of the dual-console robotic system. Records were reviewed for patient demographics and surgical details. All surgery was conducted using the dual-console system and performed by staff physicians and fellows. Operative time was calculated from robotic docking until completion of the procedure. Cases were identified from November 2009 through July 2010. Mean age was 56.2 years (SD 13.35, 95 % CI 52.46-59.86). Mean BMI was 29.5 (SD 7.67, 95 % CI 27.35-31.61). Seventy-eight percent of these patients were considered overweight, including 12 defined as obese (BMI 30-34.9) and 10 patients classified as morbidly obese (BMI ≥ 35). Surgery completed included PPALND alone (n = 1); radical hysterectomy (n = 1); TRH only (n = 3); TRH/BSO (n = 25); and TRH/BSO/PPALND (n = 20). Mean total operating room time was 188.8 min (SD 55.31, 95 % CI 173.45-204.11). Mean total surgical time for all cases was 118.1 min (SD 44.28, 95 % CI 105.87-130.41). Two vascular injuries were encountered, with one requiring conversion to laparotomy. These results compare favorably with historically reported outcomes from single-console systems. Utilizing the dual-console enables use of an integrated teaching and supervising environment without compromising operative times or patient outcomes.

Is comprehensive surgical staging needed for thorough evaluation of early-stage ovarian carcinoma?

OBJECTIVE

Patients with ovarian cancer may have occult metastasis at the time of surgery. Our purpose was to determine the prevalence and sites of occult metastasis in epithelial ovarian cancer grossly confined to the ovary and examine the significance of routine omentectomy and peritoneal biopsies as part of a comprehensive staging procedure.

STUDY DESIGN

Data were retrospectively abstracted from patients presenting to University of Texas Southwestern Medical Center Hospitals from 1993 through 2009 with ovarian cancer without gross spread beyond the ovary who underwent comprehensive surgical staging.

RESULTS

A total of 86 patients with ovarian cancer grossly confined to the ovary who underwent complete surgical staging were identified. Of patients, 29% were upstaged following comprehensive surgical staging; 6% had metastatic disease in uterus and/or fallopian tubes, 6% in lymph nodes, and 17% in peritoneal, omental, or adhesion biopsies.

CONCLUSION

Patients with epithelial ovarian cancer should continue to undergo comprehensive surgical staging, since it identifies occult metastasis in a significant number of patients.

Adnexal masses suspected to be benign treated with laparoscopy

OBJECTIVE

Guidelines for referring women with pelvic masses suspicious for ovarian cancer to gynecologic oncologists have been developed by the American College of Obstetrician Gynecologists (ACOG). We set out to evaluate the negative predictive value of these guidelines and to assess a modified algorithm involving minimally invasive surgery in the treatment of women with masses suspected to be benign.

METHODS

257 consecutive patients with adnexal masses of 8cm to 13cm on preoperative ultrasound examination meeting Triage Criteria set forth in ACOG Committee Opinion 280. Patients meeting the selection criteria were scheduled for operative laparoscopy, washings, adnexectomy, bagging, and colpotomy. A total of 240 patients successfully completed intended treatment (93.38%), and 234 of these did not require admission (97.5%). There was a low incidence of significant complications: 97.50% of women were successfully treated as outpatients, 97.92% of surgeries lasted <136 minutes, and <97.08% had blood loss <200mL. The negative predictive value of ACOG Committee Opinion 280 Triage Criteria as a deselector for having invasive ovarian malignancy in our population was 95.57% for premenopausal and 90.91% for postmenopausal women.

CONCLUSIONS

Laparoscopic adnexectomy, bagging, and colpotomy is a desirable goal for patients with ovarian masses in the 8cm to 13cm range meeting selection criteria affording a minimally invasive approach with attendant benefits including outpatient treatment (97.5%), few complications, low likelihood of iatrogenic rupture of the ovarian capsule (1.25%), and low necessity for reoperation after final pathology is evaluated (6.03%). Negative predictive value of ACOG Committee Opinion 280 is confirmed in a community gynecology practice and is recommended to form the basis of a new treatment algorithm for women with adnexal masses.

Laparoscopic staging of early ovarian cancer: results of a multi-institutional cohort study

BACKGROUND

Minimal access surgery to stage early ovarian cancer (EOC) is still regarded as investigational among many gynecologic oncologists. Reporting outcome data from large cohorts is currently the only practical way to further define the appropriateness of minimally invasive surgery for EOC patients. We sought to investigate the safety, adequacy, and outcome of laparoscopic staging of EOC by using a multi-institutional sample.

METHODS

Prospectively collected data in three gynecologic oncology service databases were searched for EOC patients undergoing laparoscopic staging. Surgical, pathologic, and oncologic outcome data were analyzed.

RESULTS

The study cohort consisted of 82 women. The mean operative time was 263 ± 81 minutes. The median estimated blood loss was 100 (range 20-3000) ml. The median number of pelvic and para-aortic lymph nodes collected was 23 (3-39) and 13 (3-43), respectively. The disease was reclassified to a higher stage in 21 women (25.6%). No conversion to laparotomy occurred, and one patient had intraoperative hemorrhage requiring blood transfusion. Thirteen patients (15.8%) experienced postoperative complications. The median follow-up period was 28.5 (range 3-86) months. Overall survival and disease-free survival for the entire cohort were 98.8% and 95.1%, respectively. In the subgroup of patients who had reached or exceeded 3 years' follow-up (n = 34), 3-year overall survival and 3-year disease-free survival were 97% and 91.2%, respectively.

CONCLUSIONS

When performed by appropriately skilled surgeons, laparoscopic comprehensive staging of EOC seems feasible and adequate, with surgicopathologic results that are reproducible in different practice settings.

Peritoneal carcinosis of ovarian origin

Epithelial ovarian cancer (EOC) is the second most common genital malignancy in women and is the most lethal gynecological malignancy, with an estimated five-year survival rate of 39%. Despite efforts to develop an effective ovarian cancer screening method, 60% of patients still present with advanced disease. Comprehensive management using surgical cytoreduction to decrease the tumor load to a minimum, and intraperitoneal chemotherapy to eliminate microscopic disease on peritoneal surface, has the potential to greatly improve quality of life and to have an impact on survival in ovarian cancer patients. Despite achieving clinical remission after completion of initial treatment, most patients (60%) with advanced EOC will ultimately develop recurrent disease or show drug resistance; the eventual rate of curability is less than 30%. Given the poor outcome of women with advanced EOC, it is imperative to continue to explore novel therapies.

Increasing experience in laparoscopic staging of early ovarian cancer

We assessed the effect of increasing experience of a single surgeon (learning curve) in the laparoscopic staging procedure for women with early ovarian cancer and compared the results with the literature. We retrospectively analysed a total of 25 women with apparent early-stage ovarian cancer who underwent a laparoscopic staging procedure by the same surgeon. Three time periods, based on date of surgery, were compared with respect to operating time, amount of lymph nodes harvested and surgical outcome. There was no significant difference in operation time, estimated blood loss and hospital stay between the three periods. There was, however, a significant increase in the median number of pelvic and para-aortal lymph nodes harvested (group1 = 6.5, group 2 = 8.0 and group 3 = 21.0; P < 0.005). For the total period, median operation time was 235 min and median estimated blood loss was 100 ml. The median length of hospital stay was 4.0 days. Two intraoperative and two postoperative complications occurred. The upstaging rate was 32%. The mean interval between initial surgery and laparoscopic staging was 51.2 days. Mean duration of follow-up was 43 months, range (1–116 months). Five (20%) patients had recurrences, and two (8%) patients died of the disease. In conclusion, there is a significant learning curve for the laparoscopic full staging procedure in ovarian cancer. In our study this is mainly reflected in the amount of lymph nodes harvested and not in the total operating time.

Early stage (IA-IB) primary carcinoma of the fallopian tube: case-control comparison to adenocarcinoma of the ovary

OBJECTIVE

Early stage primary carcinoma of the fallopian tube (PCFT) is an uncommon condition when strict criteria are applied. The aim of this study was to compare the outcome stage IA-IB PCFT to a matched group of ovarian cancer (OC).

METHODS

Between 1990 and 2008, 32 patients with stage IA-IB of PCFT were recorded in the database of three French Institutions. A control group of patients with OC was constituted.

RESULTS

Eleven eligible PCFT cases and 29 OC controls fulfilled the stringent inclusion criteria. Median follow-up was 70.2 months. Five-year overall survival was 83.3% (95% confidence interval [CI], 27.3 to 97.5) for PCFT and 88.0% (95% CI, 66.9 to 96.0) for OC (p=0.93). In the subgroup of patients with grade 2-3, the outcome was similar in PCFT compared to OC patients (p=0.75). Five-year relapse-free survival was respectively 62.5% (95% CI, 22.9 to 86.1) and 85.0% (95% CI, 64.6 to 94.2) in the PCFT and OC groups (p=0.07). In the subgroup of patients (grade 2-3), there was no difference between PCFT and OC (p=0.65).

CONCLUSION

The findings did not reveal any difference in prognosis between early stage of PCFT and OC when grade is taken into account. Management of PCFT should mirror that of ovarian carcinoma.