Influence of delayed staging laparotomy after laparoscopic removal of ovarian masses later found malignant

Outcome and prognostic factors of unexpected ovarian carcinomas

BACKGROUND

We investigated risk factors influencing the outcome of unexpected ovarian carcinomas.

METHODS

We reviewed the ovarian carcinoma patients treated at atertiary medical institution between 2000 and 2017 and analyze the clinico-pathological characteristics, treatment strategies, recurrence status, and outcome.

RESULTS

A total of 112 women (65 primary laparoscopic surgery [LSC] and 47 laparotomic surgery [LAPA]) were included in the analysis. The LSC group had smaller ovarian tumors (10.5 ± 7.3 cm vs. 16.6 ± 8.7 cm, p = 0.031) and higher incidence of subsequent staging surgery (56.9% vs. 25.5%, p = 0.0001) compared to the LAPA group. There were 98/112 (86.6%) of early stages (I/II) diseases. The difference between the recurrent rate (27.7% vs. 31.9%), disease-free survival (DFS), and overall survival (OS) were not significant among surgical groups. In the multivariate analysis, FIGO stage (stage II hazard ratio [HR] 6.61, p = 0.007; stage III HR 8.40, p = 0.002) was the only prognostic factor for DFS. FIGO stage (stage II HR 20.78, p = 0.0001; stage III HR 7.99, p = 0.017), histological type (mucinous HR 12.49, p = 0.036), and tumor grade (grade 3 HR 35.01, p = 0.003) were independent prognostic factors for OS, while women with latency >28 days from primary to staging surgery had significantly poorer OS (p = 0.008). Women with latency >28 days between primary surgery and adjuvant chemotherapy had similar DFS (p = 0.31) and a trend of poorer OS (p = 0.064).

CONCLUSIONS

The prognosis of unexpected ovarian cancer is independent from the primary surgical procedure and comprehensive staging surgery should be performed at close proximity after the diagnosis of unexpected ovarian malignancy.

Accuracy of frozen section diagnosis and factors associated with final pathological diagnosis upgrade of mucinous ovarian tumors

Objective

To determine the accuracy of frozen section diagnosis and factors associated with final pathological diagnosis upgrade in patients with mucinous ovarian tumors.

Methods

This study included 1,032 patients with mucinous ovarian tumors who underwent frozen section diagnosis during surgery. Sensitivity, specificity, and diagnostic accuracy of frozen section diagnosis was calculated. Univariate and multivariate regression analyses were performed to determine factors associated with diagnosis upgrade in the final pathology report.

Results

The sensitivity and specificity of frozen section diagnosis were 99.1% (95% confidence interval [CI]=98%–99.6%) and 82.2% (95% CI=77.9%–85.7%), respectively, for benign mucinous tumors; 74.6% (95% CI=69.1%–79.4%) and 96.7% (95% CI=95.2%–97.8%), respectively, for mucinous borderline ovarian tumors; and 72.5% (95% CI=62.9%–80.3%) and 98.8% (95% CI=97.9%–99.3%), respectively, for invasive mucinous carcinomas. The multivariate analysis revealed that mixed tumor histology (odds ratio [OR]=2.8; 95% CI=1.3–6.3; p=0.012), tumor size >12 cm (OR=2.5; 95% CI=1.5–4.3; p=0.001), multilocular tumor (OR=2.9; 95% CI=1.4–6.0; p=0.006), and presence of a solid component in the tumor (OR=3.1; 95% CI=1.8–5.1; p<0.001) were independent risk factors for final pathological diagnosis upgrade.

Conclusions

Mixed tumor histology, tumor size >12 cm, multilocular tumor, and presence of a solid component in the tumor were independent risk factors for final pathological diagnosis upgrade based on frozen section diagnosis.

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.

Effects of a simulated CO2 pneumoperitoneum environment on the proliferation, apoptosis, and metastasis of cervical cancer cells in vitro

BACKGROUND

This study aimed to investigate the growth curve, cell colony formation, cell cycle, apoptosis, anti-anoikis, and ability of invasion, adhesion, and migration of cervical cancer cells after exposure to a model of a simulated CO2 pneumoperitoneum environment with different pressures and at different times.

MATERIAL AND METHODS

The cervical cancer cells were cultured in groups with 8 and 16 mmHg of 100% CO2 for 1, 2, 3, and 4 h in a model of a simulated environment of CO2 pneumoperitoneum. The cells in the control group were cultured in a standard environment. The growth curve was drawn through constant survival cell counts for 7 days, and the group with most obvious change was selected for subsequent experiments to detect cell colony formation, cell cycle apoptosis, and anti-anoikis, and the ability of invasion, adhesion, and migration.

RESULTS

After a brief inhibition, the proliferation of cervical cancer cells was markedly increased and had no relationship with different CO2 pressures. Compared with the control group, the early apoptosis rate in the experimental group was higher, and the ability of invasion, migration, and adhesion decreased significantly.

CONCLUSIONS

Cervical cancer cells stimulated by a CO2 pneumoperitoneum environment in vitro have an increased the ability to proliferate after a short period of inhibition and have reduced abilities of invasion, migration, and adhesion.

Unexpected ovarian malignancy following laparoscopic excision of adnexal masses

STUDY QUESTION

What are the frequency of, and the prognosis for, ovarian malignancies among patients who have undergone laparoscopic surgery for an adnexal mass?

SUMMARY ANSWER

The rate of unexpected ovarian malignancy resected by laparoscopy was 1.5%, and the presence of an early-stage unexpected ovarian malignancy did not alter patient prognosis.

WHAT IS KNOWN ALREADY

Even when laparoscopic surgery is used for the resection of an adnexal mass that is most likely benign, some patients are found to have malignant tumors post-operatively.

STUDY DESIGN, SIZE, DURATION

The pathologic reports of 884 women who underwent laparoscopic resection of an adnexal mass between May 2007 and September 2013 at the Department of Obstetrics and Gynecology of Aichi Medical University Hospital, Nagakute, Japan, were reviewed retrospectively.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We conducted a systematic review of the medical records of patients diagnosed post-operatively with ovarian malignancies and abstracted their demographic, clinical and pathologic data.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1128 adnexal masses were resected, and 13 patients (1.5%) had ovarian malignancies: 6 ovarian cancer (1 mucinous, 1 endometrioid G1, 1 granulosa cell and 3 carcinoid) and 7 borderline tumors (BOTs; 5 mucinous and 2 serous). Of these, two patients with mucinous BOTs underwent fertility-sparing surgery and six patients underwent staging laparotomy. Due to cyst rupture during surgery, nine patients (69.2%) were upgraded to tumor stage IC. Secondary surgeries were performed in eight patients, with a mean interval of 88.9 days (range, 39-182 days) between the surgeries. All patients were alive and without evidence of disease at follow-up (mean follow-up, 38 months; range, 6-80 months).

LIMITATIONS, REASONS FOR CAUTION

This was a retrospective study with a small case number and a short follow-up period.

WIDER IMPLICATIONS OF THE FINDINGS

The presence of an early-stage unexpected ovarian malignancy did not alter the patient's prognosis, even if there was a significant delay in surgical staging after the finding of an unexpected malignancy during laparoscopy.

STUDY FUNDING/COMPETING INTERESTS

No funding was obtained for this study and the authors report no conflicts of interest.

Prognostic factors in early-stage ovarian cancer

The purpose of this study was to identify the main prognostic factors in patients with early-stage epithelial ovarian cancer. Data were extracted from 222 patients with initial stage (I-IIA) invasive epithelial ovarian cancer treated with primary surgery followed or not followed by adjuvant therapy, from 1 January 1980 to 31 December 2008, at the Division of Obstetrics and Gynecology, Spedali Civili, Brescia, Italy; the median follow-up was 79 months (SD ± 35,945, range 20-250 months). The negative prognostic factors that were statistically significant (p<0.050) in univariate analysis were grade 2, 3, and X (clear cell in our study); stage IB, IC, IIA; positive peritoneal cytology, age equal to/greater than 54; dense adhesions; capsule rupture (pre-operative or intra-operative) and endometrioid histotype (only for disease-free survival (DFS)). Positive cytology was strongly associated with peritoneal relapses, while adhesions were associated with pelvic relapses. A positive prognosis was associated with the mucinous histotype. Conservative treatment had been carried out in 52% of patients under 40 years of age, and we detected only two relapses and three completions of surgery after a few weeks among 31 women in total. Our study indicated a possible execution in patients with patients with cancer stage IA G1-G2 (p=0.030) or IC G1 (p=0.050), provided well staged. Adjuvant chemotherapy improved the survival of cancers that were not IA G1. The positive prognostic role of taxanes must be emphasised, when used in combination with platino.

Laparoscopy as the most effective tool for management of postmenopausal complex adnexal masses when expectancy is not advisable

Postmenopausal women with adnexal masses suspicious for malignancy must undergo surgery for histopathologic confirmation. The low positive predictive value for malignancy of the currently available preoperative examinations results in 5 to 220 surgeries performed for each case of pelvic malignancy detected, depending on the evaluation method and patient selection. Although extensively reviewed as an effective tool for the investigation and treatment of adnexal masses, laparoscopy is still underused for this purpose in postmenopausal women. Some reasons are uncertainty about the incidental diagnosis of a malignant lesion during laparoscopy, concern about the effect of laparoscopy over the course of a pelvic malignant lesion, and inadequate referral of patients at high risk to specialized centers with oncologic gynecologists. Identification of patients at low risk might also be inadequate, causing them to undergo unnecessary laparotomy. Herein we demonstrate through a comprehensive literature review that laparoscopy is a highly effective tool for investigation and treatment of suspected adnexal masses in postmenopausal women, both in general medical settings without oncologic backup and in specialized centers. The indications for laparoscopy in this context can be further expanded without oncologic harm if patients at low and high risk are appropriately selected for surgery at general and specialized settings, respectively.

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.

Laparoscopy versus laparotomy for FIGO Stage I ovarian cancer

BACKGROUND

Over the past ten years laparoscopy has become an increasingly common approach for the surgical removal of early stage ovarian tumours. There remains uncertainty about the value of this intervention. This review has been undertaken to assess the available evidence of the benefits and harms of laparoscopic surgery for the management of early stage ovarian cancer compared to laparotomy.

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 STRATEGY

Trials were identified by searching the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library Issue 2, 2007, MEDLINE (January 1990 to November 2007), EMBASE (1990 to November 2007), LILACS (1990 to November 2007), BIOLOGICAL ABSTRACTS (1990 to November 2007) and Cancerlit (1990 to November 2007). We also searched our own publication archives, based on prospective handsearching of relevant journals from November 2007. Reference lists of identified studies, gynaecological cancer handbooks and conference abstract were also scanned.

SELECTION CRITERIA

Studies including patients with histologically proven stage I ovarian cancer according to the International Federation of Gynaecology and Obstetrics (FIGO).Studies comparing laparoscopic surgery with laparotomy for early stage ovarian cancer were only available from 1990. It was anticipated that a very small number of randomised controlled trials (RCTs) were conducted studying the management of early stage ovarian cancer. Therefore, non-randomised comparative studies, cohort studies and case-controls studies, but not studies with historical controls, were also considered.

DATA COLLECTION AND ANALYSIS

Data extraction was performed independently by five review authors (LRM, DDR, MIR, MCB and MIE) who assessed study quality and quality of extracted data. Extracted data included trial characteristics, characteristics of the study participants, interventions and outcomes. The quality of non RCTs was assessed using appropriate quality evaluations tools from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and from the Newcastle-Ottawa tool for observational studies (NOS).

MAIN RESULTS

No RCTs were identified. Three observational studies were identified.

AUTHORS' CONCLUSIONS

This review has found no evidence to help quantify the value of laparoscopy for the management of early stage ovarian cancer as routine clinical practice.

Laparoscopic treatment and staging of early ovarian cancer

STUDY OBJECTIVE

To review the laparoscopic staging procedure in a series of patients with early ovarian cancer and compare results with the literature.

DESIGN

A prospective single-center study (Canadian Task Force classification II-2).

SETTING

A hospital in Spain.

PATIENTS

A total of 20 patients with apparent early stage ovarian cancer from January 2003 through November 2007. The histologic tumor types were epithelial tumors (18 patients) and dysgerminoma (2 patients). Among the epithelial tumors, 11 were invasive and 7 were borderline (3 serous and 4 mucinous).

INTERVENTIONS

Comprehensive laparoscopic staging was performed in all patients according to the International Federation of Gynecology and Obstetrics guidelines.

MEASUREMENTS AND MAIN RESULTS

Seventeen patients had previous adnexal surgery and diagnosis and surgical staging were performed in only 3 patients during the same surgery. The patients' median age was 42.8 years (range 16-67). Eight (40%) patients desired to maintain fertility and a conservative approach was performed for this group. Laparoscopic staging was completed in 19 (95%) patients. In 1 case, a conversion to laparotomy was necessary as the para-aortic lymphadenectomy was completed because of a vessel lesion that was repaired without difficulty. The median operative time was 223 minutes (range 180-320) for radical surgery and 188 minutes (range 120-240) for the conservative approach. The mean hospital stay was 3 days. Of the 20 total patients, 4 (20%) were upstaged. The median follow-up was 24.7 months (range 1-61), with a disease-free survival of 95% and an overall survival of 100%. One recurrence was observed.

CONCLUSION

A comprehensive surgical staging procedure is clearly indicated in cases of early ovarian cancer and oncologic guidelines should be respected. The laparoscopic approach could be a valid alternative to laparotomy.

Ovarian cancer

Ovarian cancer accounts for 4% of all cancers in women and is the leading cause of death from gynaecologic malignancies. Because early-stage ovarian cancer is generally asymptomatic, approximately 75% of women present with advanced disease at diagnosis. Survival is highly dependent on stage of disease: 5-year survival in patients with early-stage is 80-90% compared to 25% for patients with advanced-stage disease. For all patients, a comprehensive surgical staging should be performed to obtain the histological confirmation of diagnosis and to evaluate the extent of disease. Patients with early-stage should both be optimally staged and be treated with adjuvant platinum-based chemotherapy if they have a medium or high-risk tumour. For advanced disease the currently recommended management is primary cytoreductive surgery followed by platinum-paclitaxel combination chemotherapy. Appropriate salvage therapy is based on the timing and nature of recurrence and the extent of prior chemotherapy. Surgical resection should be considered in patients with long-term remission, especially in those with isolated recurrences and good performance status. Platinum-based combination represents the standard second-line chemotherapy in patients with platinum-sensitive relapsed ovarian cancer. Salvage chemotherapy in platinum-refractory patients usually results in low response rates and short survival.

Impact of different pressures and exposure times of a simulated carbon dioxide pneumoperitoneum environment on proliferation and apoptosis of human ovarian cancer cell lines

BACKGROUND

This study aimed too evaluate the proliferation and apoptosis of human ovarian cancer cell lines HO8910 and SKOV3 after exposure to a simulated laparoscopic carbon dioxide (CO2) pneumoperitoneum environment at different pressures and lengths of exposure time.

METHODS

The effects of the simulated laparoscopic CO2 pneumoperitoneum environment at different CO2 pressures (0-16 mmHg) and exposure times (1-4 h) on tumor cell growth and apoptosis were assessed by 3-[4,5-Dimethylthiazol]-2; 5-diphenyltetrazolium bromide (MTT) chromometry and proliferative index (PI) staining or Annexin V and PI double-staining flow cytometry. Cells cultured in a standard environment were used as the control group.

RESULTS

In this study, HO8910 cell growth tended to slow down with the increase in CO2 pressure and exposure time. A significantly lower PI was observed at 72 h of culture after exposure to both 8 and 16 mmHg of pressure, as compared with the control and 0 mmHg pressure group (p < 0.05). The PI of SKOV3 cells tended to decline after exposure. Significantly lower PI was observed in the group with exposure to 16 mmHg for 4 h over a 72-h period, as compared with the control groups exposed to 0 mmHg (p < 0.05). The inhibition of cell growth was associated with an increase in the proportion of cells at stage G1. The apoptotic index and the percentage of apoptotic cells tended to increase with an increase in pressure and a prolonged time of exposure.

CONCLUSIONS

The results suggest inhibited cell proliferation and increased cell apoptosis of human ovarian cancer cells were positively related to CO2 pressure and exposure time.

Minilaparotomy versus laparoscopy in the treatment of benign adnexal cysts: a randomized clinical study

OBJECTIVE

To determine advantages and disadvantages of minilaparotomy and laparoscopy in managing patients affected by benign adnexal masses.

STUDY DESIGN

Prospective, randomized, clinical trial on 127 patients affected by adnexal cysts. Patients were submitted to adnexal surgery through a laparoscopic or minilaparotomy approach on a random basis.

RESULTS

Hundred and twenty-seven patients were enrolled in the study and randomly assigned to laparoscopy (63 patients) or minilaparotomy (64 patients). Characteristics of the patients and of the cysts were homogeneous between the two groups. No significant differences between the two groups were recorded in terms of operative time, intraoperative complications, ileus, length of stay and recovery time. The intraoperative rupture rate of the cyst was significantly higher in the laparoscopy group only in a subgroup of patients affected by cysts greater than 7 cm in diameter (p=0.01). Three patients randomized to laparoscopy required conversion to laparotomy. Concerning postoperative outcomes, postoperative pain and minor complications were significantly less in patients undergoing laparoscopy (p=0.001 and 0.04).

CONCLUSIONS

Operative laparoscopy appears to be the preferable approach for the management of adnexal cysts. Minilaparotomy can be considered a mini-invasive approach as well, with acceptable operative and postoperative outcomes, and is a suitable alternative in case of contraindications to laparoscopy.

Faisabilité et limites du traitement cœlioscopique des tumeurs frontières de l'ovaire

Borderline ovarian tumours (BOT) are mainly diagnosed in young women with early stage disease. Due to the absence of specific pre operative criteria for BOT, a laparoscopy is usually performed. A review of the literature found no pejorative data on laparoscopic approach for BOT. Strict surgical procedures must be performed to avoid incomplete surgical staging, cells dissemination and port-site metastases. The limits of the laparoscopic management are the stage of disease and the tumour size. Laparoscopic treatment of BOT for women with early stage disease is feasible. This treatment should be evaluated in specialized centres for women with advanced stage diseases and/or peritoneal implants.

Impact of initial surgical access on staging and survival of patients with stage I ovarian cancer

The aim of this study was to compare staging by laparoscopy and laparotomy, and to compare survival in patients with laparoscopy versus laparotomy as the first surgical access. We conducted a retrospective analysis of patients with stage I ovarian cancer treated surgically between 1985 and 2001, and we included those patients with stage I epithelial cancer for whom follow-up data were available. For each patient, we recorded whether initial surgical staging was by laparoscopy or by laparotomy, the procedures done at initial staging surgery, and the outcomes. The data were evaluated by analysis of variance, Chi-square test or Fisher's exact test, logistic regression, Cox model, and log-rank test, using SPSS 7.5 and STATA. Initial staging was by laparoscopy in 34 patients, laparotomy in 114 patients, and laparoscopy converted to laparotomy in 30 patients. In the laparotomy group, patient age was significantly greater and tumor size significantly larger, as compared to the laparoscopy group. Staging after first surgery was often inadequate; most notably para-aortic lymph node dissection was done in 0% of laparoscopy patients, 18% of laparotomy patients, and 33% of conversion patients. Restaging surgery has been indicated in 88% of laparoscopy patients, 48% of laparotomy patients, and 46% of conversion ones. After a mean follow-up of 40 months, survival rates were not significantly different among the three patient groups. No deleterious influence of laparoscopy as first surgical access was detected by univariate or multivariate analysis. Despite of inaccurate radicality and staging during initial laparoscopy, this study found no harmful influence of laparoscopy as first initial access on outcomes of patients with stage I ovarian cancer.

Vascular atypia and irregularity on surface as signs of malignant adnexal mass: a complementary method of laparoscopic assessment

STUDY OBJECTIVE

To evaluate the risk of malignancy associated with the main macroscopic findings observed on adnexal masses during a laparoscopic approach.

DESIGN

Prospective series of consecutive patients (Canadian Task Force classification II-2).

SETTING

Tertiary care university hospital.

PATIENTS

One hundred fifteen patients were included. Ninety-eight had benign and 17 malignant adnexal masses.

INTERVENTIONS

Diagnostic and operative laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Adnexal images were obtained during laparoscopy, recorded, and analyzed according to irregularity on surface, presence of atypical vessels, lobular form, absence of coral-like surface, implants, large-volume ascites, and cloudy or hemorrhagic ascites. A logistic regression was applied, and the independent findings associated with malignant disease were atypical vessels (OR 16.37; 95% CI 2.85-94.13; p <.01) and irregularity on tumor surface (OR 43.41; 95% CI 8.02-234.96; p <.05). In this way, 95% of the cases were correctly diagnosed.

CONCLUSIONS

Atypical vessels and irregularity on tumor surface were important criteria of malignancy during laparoscopic treatment of adnexal masses. The recognition of these features can be helpful in choosing the ideal surgical approach mainly when the preoperative evaluation is unsatisfactory.

Laparoscopic Management of Extremely Large Ovarian Cysts

OBJECTIVE

To assess the feasibility and outcome of laparoscopic surgery for the management of extremely large ovarian cysts.

METHODS

From July 2000 to December 2003, 21 patients with extremely large ovarian cysts were managed laparoscopically. The masses were cystic or complex, reached the umbilicus or higher, and were not associated with ascites or enlarged pelvic or para-aortic lymph nodes on computed tomography scan. Serum CA 125 levels were within the normal range or mildly elevated (< 130 mIU/mL). The mean and median ages of the patients were 45 +/- 20 and 46 years, respectively (range 17-89 years). Seven women were postmenopausal and the rest were premenopausal. The patients underwent cystectomy or adnexectomy depending on each patient's age and obstetric history.

RESULTS

Two laparoscopies were converted to laparotomy, one because of ovarian malignancy and the second because of technical difficulties related to morbid obesity and severe intra-abdominal adhesions. The postoperative recovery was uneventful in all women.

CONCLUSION

With proper patient selection, the size of an ovarian cyst is not necessarily a contraindication for laparoscopic surgery.

Are borderline tumors of the ovary safely treated by laparoscopy?

OBJECTIVES

To evaluate the risk of the laparoscopic approach to patients with borderline ovarian tumors compared to the laparotomic management.

METHODS

We treated or followed in our institution 479 women with borderline ovarian tumor. Sixty-two patients had fertility-sparing surgery followed by restaging or follow-up intervention: 30 operated by laparoscopy, 32 by laparotomy. Restaging surgery was performed in five cases and second-look surgery in 57.

RESULTS

The diameter of the cyst is significantly lower in patients treated by laparoscopy, especially in women who underwent cystectomy (4.7 cm) compared to oophorectomy (10 cm, P = 0.008). Rupture of the cyst and stage IC were more frequent in the laparoscopic group. After a median follow-up of 61 months for the laparoscopic group and 77 months for the laparotomic group, we observed 11 patients (37%) with persistent disease after primary laparoscopy (adnexa, five cases; peritoneal implants, three cases; both patterns, three cases). After primary laparotomy, no patients showed early persistence of tumor, and ovarian relapses were diagnosed in seven women (22%) 33-138 months after laparotomy. The univariate analysis for the risk of neoplastic persistence after primary laparoscopy shows that patients with cysts greater than 5 cm have a higher risk (odds ratio 9.7, P = 0.02) compared to smaller cysts. No other factors proved significant, but the odds ratios for patients with serous tumor (5.8), stage IC (2.0), and those undergoing cystectomy (1.9) suggest a relationship to the probability of persistence.

CONCLUSION

Laparoscopic treatment in borderline ovarian tumors should be reserved to masses not greater than 5 cm. When conservative therapy is desired, the entire affected ovary should be removed. If the neoplasia is bilateral, cystectomy could be allowed in women who wish to preserve fertility, although they are at high risk of relapse.

Laparoscopic training and practice in gynecologic oncology among Society of Gynecologic Oncologists members and fellows-in-training

OBJECTIVE

To determine the proportion of Society of Gynecologic Oncologists (SGO) members performing laparoscopic procedures and to determine SGO members' and fellows' opinions regarding indications for and the adequacy of training in laparoscopy.

METHODS

Surveys were mailed to SGO members and fellows-in-training in December 2002. Anonymous responses were collected by mail or through a Web site. The survey was mailed twice and was estimated to take 5 min to complete. The data were analyzed using frequency distributions and nonparametric tests.

RESULTS

Three hundred thirty-six SGO members (45%) and fifty-seven fellows (49%) responded. Among SGO members, 272 (84%) currently performed laparoscopic surgeries. Reasons cited for performing laparoscopy were decreased length of hospital stay (74%), improved patient quality of life (57%), patient preference (48%), improved cosmesis (46%), and better visualization (18%). Among those who did not perform laparoscopy, 50% cited increased operating time as their main reason. When asked to indicate the laparoscopic procedure most commonly performed in their practice, 69% reported diagnosis of an adnexal mass; 11%, prophylactic bilateral salpingo-oophorectomies; and 10%, laparoscopically assisted vaginal hysterectomy and lymph node staging for uterine cancer. Only 3% of SGO respondents performed more than 50% of their procedures laparoscopically, and all respondents reported converting from laparoscopy to laparotomy less than 25% of the time. Most respondents had limited laparoscopic training during their fellowships: 39% received none, and 46% received limited (less than five procedures per month) training. Nevertheless, 78% of SGO respondents rated their laparoscopic skills as either very good or good. Among fellows, only 25% believed they were receiving very good or good laparoscopic training. Eighty percent of SGO respondents believe that at least six procedures per month were necessary for adequate training, yet only 33% of fellows performed that many procedures.

CONCLUSIONS

Most SGO respondents used laparoscopy for selective indications, and most developed their laparoscopic skills after their fellowship training. SGO respondents believed laparoscopic instruction is an important part of training, but most fellows perceived their laparoscopic training as inadequate.

Correlation between MIB1-determined tumor growth fraction and incidence of tumor recurrence in early ovarian carcinomas

PURPOSE

The decision concerning adjuvant therapy remains difficult in patients with very early stage ovarian carcinomas [Fédération Internationale de Gynécologie et d' Obstétrique (FIGO) Ia/b]. Therefore, we compared the MIB1-determined tumor growth fraction in archival tumor tissue with tumor recurrence and outcome of disease, and in relationship to other stages and clinical and morphological findings.

PATIENTS AND METHODS

Ninety-two patients were followed in early stages of ovarian carcinomas (FIGO I and II) with no tumor residuals and were analyzed for tumor recurrences and long-term overall survival (mean 6.0 years, median 5.5). Fifty-eight patients had stage I tumors, among these were 38 in the sub-stages Ia/b. Tumor growth fraction (MIB1) in tissues from primary surgery was compared with the status of patients and disease, histology, and immunohistochemistry for carcinoembryonic antigen (CEA), CA125, CA153, steroid hormone receptors, and angiogenesis (chisquare test, Kaplan-Meier and discriminant analyses).

RESULTS

Tumor-associated deaths occurred in 27 cases, tumor recurrences occurred in 35 cases. In contrast to the advanced stages of disease, the MIB1-determined tumor growth fraction outweighted all other parameters in the prediction of the course of disease (p < 0.001), followed by tumor grading (p = 0.001) and FIGO-substages (p = 0.026) in this retrospective study. Particularly in the very early stages, MIB1 predicted tumor recurrences in 84% of the cases (p < 0.001). Recurrences were not observed below a tumor growth fraction of 10% but prevailed in cases of more than 15%.

CONCLUSION

Our data suggest MIB1 as an interesting additional tool for the decision of adjuvant therapy in patients with very early stages of ovarian carcinomas, which should be tested in prospective trials.

Laparoscopic Excision of Adnexal Masses

STUDY OBJECTIVE

The purpose of the present study was to evaluate a prospective series of consecutive patients with adnexal masses selected with strict preoperative clinical and ultrasonographic criteria.

DESIGN

Prospective series of consecutive patients (Canadian Task Force classification II-2).

SETTING

Tertiary care university hospitals.

PATIENTS

Six hundred and eighty-three consecutive patients under 40 years of age with ultrasonographic evidence of an adnexal cystic mass without thick septa, internal wall papillation, or solid components, except for sonographic pattern suggestive of dermoid.

INTERVENTIONS

Operative laparoscopy and follow-up.

MEASUREMENTS AND MAIN RESULTS

After initial diagnostic laparoscopy in 13 patients with stage 4 endometriosis and extensive bowel adhesions, in 2 patients with large-volume dermoids, and in 1 patient with suspect ovarian and peritoneal implants, the procedure was converted to laparotomy. Therefore, 667 patients were completely managed by laparoscopy. There were 1069 cysts excised. Histologic diagnosis was endometrioma in 57% of the excised cysts, serous cyst in 13%, dermoid in 12%, paratubal in 8%, mucinous cysts in 5.3%, functional cyst in 2.8%, other benign histotypes in 1.1%, and ovarian malignancies (seven borderline tumors and one endometrioma with a microfocus of G1 endometrioid carcinoma) in 0.7% of the cysts and 1.2% of the patients. These last patients are alive with no evidence of disease after a mean follow-up of 62 months.

CONCLUSIONS

In the present series, with accurate preoperative and intraoperative selection, the rate of unexpected borderline or focally invasive malignancies was 1.2% of the patients, and the laparoscopic management of these adnexal masses did not adversely impact on prognosis.

Laparoscopic treatment of early ovarian cancer: surgical and survival outcomes

OBJECTIVES

To investigate the feasibility and safety of laparoscopic surgery in patients with early ovarian cancer.

PATIENTS AND METHODS

Between 05-1996 and 06-2003, 24 patients with ovarian cancer FIGO stage IA-B underwent either primary treatment or completion of staging by laparoscopy. Laparoscopic staging was performed according to the FIGO guidelines, which entails one-sided oophorectomy or bilateral salpingo-ophorectomy with laparoscopic-assisted vaginal hysterectomy, pelvic lymphadenectomy, infrarenal para-aortic lymphadenectomy, complete resection of the infundibulo-pelvic ligament, appendectomy and partial omentectomy.

RESULTS

Eleven out of 24 patients (45.8%) underwent completion of staging after a mean of 12 days (range 4-21) after primary surgery, while 13 patients out of 24 (54.2%) underwent primary laparoscopic management of an adnexal mass, diagnosed as ovarian cancer by frozen section. Mean operative time was 166 min (range 118-206) for completion of staging and 182 min (range 141-246) for primary surgery. No major intraoperative complication occurred. One out of 24 patients (4.1%) developed chylos ascites postoperatively, which was managed conservatively. Five out of 24 patients (20.8%) received adjuvant chemotherapy after a median time of 7 days (mean 5-14) following surgery. No trocar metastasis occurred. Median follow-up is 46.4 months (range 2-72). Two out of 24 patients (8.3%) developed recurrence, which was treated with resurgery and chemotherapy. After a median follow-up of 46 months, disease-free survival is 91.6% and overall survival 100%.

CONCLUSIONS

Laparoscopic management of early ovarian cancer is safe and effective and survival outcome seems acceptable.

Management of port-site metastasis after laparoscopic surgery for ovarian cancer

OBJECTIVE

The purpose of this study was to define the clinical features and long-term prognosis of port-site metastasis after primary laparoscopic surgery for ovarian cancer.

STUDY DESIGN

All the patients with epithelial ovarian cancer or borderline malignancy who had undergone primary laparoscopic surgery at our institution were reviewed. The clinicopathologic parameters, flow cytometric parameters, p53, p27, bax, HER-2/neu, and bcl-2 by immunostaining, presentation of port-site implants, management of the individual patient, and long-term outcome were analyzed. CANCERLINE and MEDLINE (1960-2002) were searched for related papers.

RESULTS

Between 1993 and 2001, of the 31 patients with epithelial ovarian cancer or borderline malignancy who underwent primary laparoscopic surgery at Chang Gung Memorial Hospital, 6 (19.4%) had port-site metastasis. The other 2 patients were referred after port-site metastasis. Tumors with port-site recurrences had higher S-fraction than those without (median: 18.2% vs 9.9%, P =.003; relative risk ratio: >15.5% vs <or=15.5% = 38.33; 95% CI, 3.3-449.2). Those patients who have port-site metastasis develop during chemotherapy (n = 2) or after adequate chemotherapy had been given (n = 2) all died of cancer. Two patients have been currently alive without disease, the tumors of whom were p27-positive and p53-, HER-2/neu -, bcl-2-negative.

CONCLUSION

Port-site metastasis after laparoscopic surgery, during chemotherapy or when adequate chemotherapy has been given, is usually associated with poor outcome. Further investigations are necessary to define the mechanisms and effective management to prevent and treat this serious complication.

The effect of various insufflation gases on tumor implantation in an animal model

OBJECTIVE

The expanded use of laparoscopy has led to reports of tumor dissemination and spread to laparoscopic port sites. We previously showed that carbon dioxide insufflation produced tumor dissemination compared with laparotomy. It is unknown whether the type of gas used influences this dissemination. Although carbon dioxide is commonly used during laparoscopy, helium and nitrous oxide could be used. This study was undertaken to compare the effects of carbon dioxide, helium, and nitrous oxide gas on tumor spread in an animal model to determine whether the type of gas used for the pneumoperitoneum would affect tumor spread.

STUDY DESIGN

Viable MATB mammary adenocarcinoma cells were injected into the peritoneal cavity of Fisher 344 rats (1 x 10(5) cells/rat). The animals were then divided into three groups. Four 18-gauge angiocaths were inserted into each of four quadrants of the peritoneal cavity, and induction of pneumoperitoneum with helium, nitrous oxide, or carbon dioxide gas was done at approximately 7 mm Hg for 2 hours. Animals were killed at 7 days and the ventral peritoneal wall and abdominal cavity were examined for evidence of tumor formation. Tumor implants were counted for each of the four quadrants on the anterior peritoneal wall and for the total abdominal cavity.

RESULTS

A total of 39 rats were studied with 13 animals per group. The total number of implants was calculated for the groups: carbon dioxide, n = 57; helium, n = 62; nitrous oxide, n = 66. There was no significant difference in the total number of implants according to the type of gas or the size of implants. When implants that were <5 mm were analyzed, the four quadrants of the anterior peritoneum showed a random difference in tumor disbursement between one quadrant in the helium (n = 15) and one quadrant in the nitrous group (n = 23). However, when the three gasses were compared with all four quadrants, there was no statistical significance (carbon dioxide, n = 35; helium, n = 38; nitrous oxide, n = 44).

CONCLUSION

There is no difference in tumor implantation when with use of carbon dioxide, helium, or nitrous oxide gas in an animal model. Thus, carbon dioxide insufflation does not appear to increase tumor spread compared with other gasses.

Impact of pneumoperitoneum on visceral metastasis rate and survival. Results in two ovarian cancer models in rats

OBJECTIVE

To compare the impact of CO2 laparoscopy, gasless laparoscopy, and midline laparotomy on the development of distant metastases and on survival in two ovarian carcinoma models.

DESIGN

A prospective randomised study in rats.

MATERIAL

and methods Two ovarian cancer xenografts were obtained by intraperitoneal injection of IGR-OV1 or NIH-OVCAR-3 cells. Experimental surgical procedures were performed on day 7 (IGR-OVI model) or day 14 (NIH: OVCAR-3 model) after intraperitoneal injection: CO2 laparoscopy (pneumoperitoneum (PNP) with unheated CO2 at a pressure of 8 mmHg for 1 hour); gasless laparoscopy (consisting in abdominal wall expansion by a balloon for 1 hour); midline laparoscopy (consisting in bowel exteriorisation on a mesh for one hour following xyphopubic laparotomy). The control group underwent general anaesthesia alone. The animals were killed by CO2 inhalation as soon as they became moribund.

MAIN OUTCOME MEASURES

Pathological examination was carried out on the liver, lungs and pleura as well as the retroperitoneal nodes. Survival was determined from the time of surgery to the sacrifice of the animal. Statistical analysis used ANOVA, Fisher exact test, Bonferonni method and the log-rank test.

RESULTS

In the IGR-OV1 model, distant metastases were rare, and were not promoted by CO2 laparoscopy. With the NIH: OVCAR-3 model, pleural, pulmonary and para-aortic metastases were not enhanced by CO2 PNP when compared with other approaches. Conversely, midline laparotomy and laparoscopy significantly increased liver involvement when compared with gasless laparoscopy (P = 0.04 and P = 0.008). Survival was comparable no matter what kind of surgery had been performed in the IGR-OV1 model (P = 0.7) or in the NIH: OVCAR-3 model (P = 0.5).

CONCLUSIONS

CO2 laparoscopy had a minor impact on distant and nodal metastases in the two models. Similarly, survival was similar for all surgical groups.

[Management of adnexal tumors: role and risks of laparoscopy]

The laparoscopic management of adnexal tumeurs remains controversial because of the potentials risks of cancer dissemination suggested by many case reports and national surveys. From experimental data, the laparoscopic treatment of gynecologic cancer has potential advantages and disadvantages. The risk of dissemination appears high when a large number of malignant cells are present so that adnexal tumors with external vegetations, and bulky lymph nodes may be considered as contra-indications to CO2 laparoscopy. Laparoscopic surgery has become the gold standard in the treatment of benign adnexal tumeurs, whereas laparotomy remains the standard for the treatment of malignant tumors. The surgical diagnosis is the key to adequate management of adnexal tumeurs. In our experience, after a careful preoperative evaluation, the laparoscopic diagnosis of malignancy is reliable. Moreover in national surveys, many malignant tumeurs were considered as benign despite suspicious laparoscopic findings. Using strict guidelines, laparoscopic diagnosis can be proposed for both non suspicious and complex tumeurs, thus avoiding many unnecessary laparotomies for benign tumeurs suspicious at ultrasound. The more controversial limits of laparoscopic treatment are discussed. If a laparotomy was performed for all tumeurs suspicious at surgery, 80% of the cases would be treated by laparoscopy. The role of laparoscopy for restaging and second look operations for ovarian cancer requires further evaluation.

Prognostic importance of degree of differentiation and cyst rupture in stage I invasive epithelial ovarian carcinoma

BACKGROUND

Previous studies on prognostic factors in stage I invasive epithelial ovarian carcinoma have been too small for robust conclusions to be reached. We undertook a retrospective study in a large international database to identify the most important prognostic variables.

METHODS

1545 patients with invasive epithelial ovarian cancer (International Federation of Gynaecology and Obstetrics [FIGO] stage I) were included. The records of these patients were examined and data extracted for univariate and multivariate analysis of disease-free survival in relation to various clinical and pathological variables.

FINDINGS

The multivariate analyses identified degree of differentiation as the most powerful prognostic indicator of disease-free survival (moderately vs well differentiated hazard ratio 3.13 [95% CI 1.68-5.85], poorly vs well differentiated 8.89 [4.96-15.9]), followed by rupture before surgery (2.65 [1.53-4.56]), rupture during surgery (1.64 [1.07-2.51]), FIGO 1973 stage Ib vs Ia 1.70 [1.01-2.85]) and age (per year 1.02 [1.00-1.03]). When the effects of these factors were accounted for, none of the following were of prognostic value: histological type, dense adhesions, extracapsular growth, ascites, FIGO stage 1988, and size of tumour.

INTERPRETATION

Degree of differentiation, the most powerful prognostic indicator in stage I ovarian cancer, should be used in decisions on therapy in clinical practice and in the FIGO classification of stage I ovarian cancer. Rupture should be avoided during primary surgery of malignant ovarian tumours confined to the ovaries.

Imaging evaluation of ovarian masses

Adnexal masses present a special diagnostic challenge, in part because benign adnexal masses greatly outnumber malignant ones. Determination of a degree of suspicion for malignancy is critical and is based largely on imaging appearance. Endovaginal ultrasonography (US) is the most practical modality for assessment of ovarian tumors because it is readily available and has a high negative predictive value. Morphologic analysis of adnexal masses is accurate for identifying masses as either low risk or high risk. The most important morphologic features are non-fatty solid (vascularized) tissue, thick septations, and papillary projections. Color Doppler US helps identify solid, vascularized components in a mass. Spectral Doppler waveform characteristics (eg, resistive index, pulsatility index) correlate well with malignancy but generally add little information to morphologic considerations. Computed tomography can help assess the extent of disease in patients before and after primary cytoreductive surgery. Magnetic resonance (MR) imaging is better reserved for problem solving when US findings are nondiagnostic or equivocal because, although it is more accurate for diagnosis, it is also more expensive. The signal intensity characteristics of ovarian masses make possible a systematic approach to diagnosis. Mature cystic teratomas, cysts, endometriomas, leiomyomas, fibromas, and other lesions can be accurately diagnosed on the basis of T1-weighted, T2-weighted, and fat-saturated T1-weighted MR imaging findings.

Laparoscopic surgery for gynecologic cancers

In conclusion, laparoscopic techniques are useful for the evaluation and treatment of selected gynecologic malignancies and provide major benefits to patients. The benefits, however, can be expected only from gynecologic oncologists well-versed in advanced laparoscopic techniques. Results must be interpreted cautiously, depending on the laparoscopic expertise of the reporting authors. Numerous questions remain unanswered, particularly those associated with long-term recurrences and survival. The use of laparoscopic procedures for gynecologic malignancies must be considered investigational until adequate long-term survival data are available.

Laparoscopic surgery for complex ovarian masses

STUDY OBJECTIVE

To assess the value of laparoscopy in managing complex ovarian masses.

DESIGN

Retrospective, observational analysis (Canadian Task Force classification II-2).

SETTING

University-based, tertiary level center for endoscopic surgery.

PATIENTS

Two hundred eleven consecutive women.

INTERVENTIONS

Laparoscopic surgery including ovary-preserving surgery, salpingo-oophorectomy, adhesiolysis, and pelvic lymphadenectomy.

MEASUREMENTS AND MAIN RESULTS

Patients were selected on the basis of preoperative ultrasound findings. Intraoperative appearance of the tumors as well as results from frozen section examinations were compared with histologic results. Two hundred sixteen pelvic masses were benign. In 10 patients, early ovarian cancer, borderline tumors, tubal cancer, or secondary ovarian, nongynecologic pathology was managed primarily by laparoscopy and confirmed histologically. Three of these 10 women underwent standard radical open surgery within 1 week. The true nature of masses was not recognized at the time of laparoscopy in three patients with malignant findings. Patients with malignant tumors were followed for 5 years.

CONCLUSION

Although most complex ovarian masses can be managed by laparoscopy, the possibility of overlooking malignancy remains, even with frozen section examination. Whether or not laparoscopy compromises clinical outcome compared with laparotomy is not fully understood. Prospective studies to address this important clinical question are urgently needed.