Laparoscopy in Staging and Restaging of 95 Patients with Ovarian Carcinoma

Laparoscopic Surgery for Ovarian Neoplasms - What is Possible, What is Useful?

The use of minimally invasive surgical techniques is becoming increasingly important in gynecologic oncology due to technical advances and the increasing level of surgical expertise. In addition to laparoscopic approaches for the treatment of benign neoplasms, minimally invasive surgical methods have also become established in some areas for treating gynecologic malignancies. For tumor entities such as endometrial and cervical carcinoma, there are conclusive studies emphasizing the role of laparoscopy in surgical therapy. By contrast, due to a lack of prospective data with survival analyses, no clear conclusions can be drawn on the significance of laparoscopy in the surgical treatment of ovarian carcinoma. However, some smaller, mostly retrospective case-control studies and cohort studies open the way for a discussion, positing the possibility that laparoscopic surgical procedures, particularly for early ovarian carcinoma, are technically feasible and of a quality equivalent to that of conventional longitudinal laparotomy, and may also be associated with lower perioperative morbidity. In this article we discuss the most important aspects of using minimally invasive surgical techniques for ovarian carcinoma based on the current literature. In particular we look at the relevance of laparoscopy as a primary approach for surgical staging of early ovarian carcinoma, and we evaluate the role of diagnostic laparoscopy in assessing the operability of advanced ovarian carcinoma.

Laparoscopy Combined with Peritoneal Cytology in Staging and Restaging Ovarian Carcinoma

The merits of laparoscopy, with inspection of the diaphragmatic leaves, and of peritoneal cytology (free fluid or washing) in staging and restaging were studied in 153 patients with ovarian carcinoma. Of 153 patients examined, 83 were new cases, 34 were restaging in patients without clinical and/or radiological signs of disease, and 36 in patients with evident disease. The conversion rate for diaphragmatic metastases alone was 6%. Information about the spread of disease (diaphragmatic metastases) was obtained in 33 new cases (39.7%). In pretreated patients, laparoscopy was positive in 4 of 34 NED restaging and in 24 of 36 ED restaging. The conversion rate for peritoneal cytology was 6.6%, but information about the cellular intraperitoneal spread of the disease was obtained in 31 new cases (37.8%). In pretreated patients, peritoneal cytology was positive in 4 of 34 NED restaging and in 13 of 36 ED restaging.

Accuracy of the Double Contrast Enema in Evaluation of the Abdominal Diffusion of Ovarian Carcinoma

The results of 103 double contrast enemas in 72 patients with ovarian carcinoma (stage III and IV) were compared with laparoscopic and/or laparotomic findings at comparable times. The evaluation of the validity of radiology in detecting the presence of abdominal disease showed an 84% overall accuracy, 75% specificity and 86% sensitivity. The accuracy in detecting signs of adhesion and parietal infiltration of the large bowel was 76.3%, due to the limited size of most of the lesions. Forty-seven of the 72 patients underwent a double contrast enema and laparoscopy during presurgical staging: accuracy in detecting lesions was the same for both examinations (80.4%). When double contrast enema and laparoscopy were used together in the evaluation of abdominal extension of the disease, the diagnostic accuracy rose to 93.6%.

Role of Ultrasound in the Management of Ovarian Carcinoma

The ultrasound findings of the pelvis, upper abdomen and peritoneal cavity were correlated with second-look laparotomy in 85 patients with Stage III or Stage IV ovarian carcinoma. High values of accuracy were obtained for the pelvis (90%) and liver (91%) but ultrasound was insensitive to peritoneal disease unless ascites was present.

Peritoneal cancer treatment

INTRODUCTION

In the past, peritoneal surface malignancy (PSM) was considered as a final stage of cancer, and patients were offered the best supportive care. Recently, a new therapeutic alternative approach based on the combination of surgery with chemotherapy was developed. In this curative intent, the macroscopic disease was treated with cytoreductive surgery (CRS) combined with perioperative chemotherapy, including neoadjuvant chemotherapy, hyperthermic intraoperative intraperitoneal chemotherapy, extensive intraoperative peritoneal lavage and early postoperative intraperitoneal chemotherapy

AREAS COVERED

This article reviews the mechanisms of the formation of PSM, quantitative estimation of PSM and residual disease, multimodal treatment, value of laparoscopy, prognostic factors and patients' selection for the multimodal therapy.

EXPERT OPINION

Recent studies show that CRS plus intraperitoneal chemotherapy applications confer prolonged survival in patients with PSM from colorectal, gastric, ovarian, appendiceal mucinous carcinoma and diffuse malignant peritoneal mesothelioma. The comprehensive treatment is now justified as state-of-the-art for patients with peritoneal metastasis.

Second-look laparotomy for epithelial ovarian cancer: a reappraisal

Although second-look laparotomy (SSL) has been used in the management of ovarian cancer for over three decades, its current clinical use is limited. On average, over 50% of patients with a clinical complete response are noted to have disease at the time of SLL, emphasizing our lack of accurate noninvasive methods for determining pathologic response. Although findings at SLL have some prognostic significance, there is no definitive evidence that those patients undergoing SLL have improved survival, and even 50% of patients with negative findings at SLL have recurrences. The lack of survival advantage for patients enduring SLL highlights the need to identify consistently effective salvage and consolidation regimens. Few published studies provide definitive evidence regarding efficacy of treatment. Prospective, randomized, controlled trials are needed to evaluate the various therapies available. In general, the performance of SLL should be confined to those patients enrolled in clinical trials.

Second look for ovarian cancer: laparoscopy or Laparotomy? A prospective comparative study

OBJECTIVE

The objective of this study was to evaluate, for patients with ovarian cancer, the feasibility, reliability, and complications of a laparoscopic second look and to compare them with those of a second look by laparotomy.

METHODS

Twenty patients treated by initial surgery and adjuvant chemotherapy for ovarian carcinoma underwent a laparoscopic second look, immediately followed by a comparative laparotomy. All were in complete remission after chemotherapy. Both operations were performed according to a predefined checklist, identical for both surgical techniques and for each patient: after liberation of adhesions, an exhaustive intraperitoneal inspection was performed, with systematic peritoneal cytology and biopsies. Each patient therefore was her own control for the two techniques.

RESULTS

The positive predictive value of laparoscopy for the diagnosis of residual disease was 100% (6 of 6 cases), while the negative predictive value was 86% (2 false-negative cases out of 14). Because of the presence of postoperative adhesions, the rate of complete intraperitoneal investigation was 95% for laparotomy versus 41% for laparoscopy. The complication rate of laparoscopy requiring laparotomy was 5.3%.

CONCLUSIONS

After treatment of ovarian cancer, a laparoscopic second look appears to be less reliable than one performed by laparotomy. The presence of severe postoperative adhesions is the main obstacle to an exhaustive, reliable, and safe laparoscopic second look.

Operative laparoscopy in gynaecological oncology

Initial reports on the role of laparoscopy in gynaecological malignancies have centred around staging procedures. Laparoscopic lymphadenectomy, both pelvic and para-aortic, appears to be feasible and adequate. It appears that laparoscopy may play an important role in reviving the radical vaginal hysterectomy for patients with early cervical cancer. Similarly, an abdominal incision may be avoided in patients with early endometrial carcinoma by employing laparoscopic staging with vaginal hysterectomy. The role laparoscopy will play in ovarian cancer is still to be defined, and laparoscopic advocates must be cautious in this subset of patients. However, for those gynaecological oncologists employing second-look procedures, it appears that beginning with laparoscopy may make laparotomy unnecessary in the majority of patients. Survival data for patients with gynaecological malignancies managed using laparoscopy in lieu of laparotomy are still lacking. It is imperative that survival is not compromised by employing a new surgical technique. Cost data comparing laparoscopy to laparotomy in our subspeciality is unavailable. This increasingly important aspect of medical care may influence the future of laparoscopy. These and other important issues need to be addressed by future trials before the role of laparoscopy in gynaecological oncology can be determined.

Staging and treatment of ovarian carcinoma

The staging and treatment of ovarian cancer is reviewed with special attention to developments during the last decade. Pathways of spread, presurgical and surgical staging are described and discussed, as are the biologic characters of the different histologic subtypes. Principles of surgery, endoperitoneal and external radiotherapy, single-drug and multiple-drug systemic chemotherapy (therapeutic and adjuvant), intraperitoneal chemotherapy, second-line chemotherapy, hormone therapy and the use of biologic response modifiers are reported and discussed with background of recent clinical trials. It is concluded that considerable progress has been made concerning diagnosis, staging and treatment of ovarian cancer. The proportion of cases in advanced stages has thus decreased and the survival rate increased. However, it is also obvious that the long-term prognosis for patients with advanced disease has not significantly improved over the last 10 years, despite introduction of multiple-drug regimens with high initial response rates. Ovarian cancer remains the most important gynecologic cause of death in the Western countries.

Staging laparotomy in early epithelial ovarian carcinoma

It is well known that ovarian carcinoma may have subclinically metastasized at the time of the initial surgical operation when all tumor seemed to be confined to the ovary. A retrospective review of 650 ovarian carcinoma patients from 1976 to 1984 revealed 25 staging laparotomies for early epithelial ovarian carcinoma. Sixteen patients had invasive epithelial ovarian carcinoma, and nine had borderline ovarian carcinomas. Five patients had the stage of their disease changed whereas 20 remained unchanged. Among the staging laparotomy patients, 50% of cases of ovarian carcinoma with ruptured capsules were upstaged as were 33% with those with ascites. Twenty-five percent of cases with invasive epithelial ovarian carcinoma and 12% with borderline ovarian carcinoma were upstaged by a staging laparotomy. As a result of staging laparotomy, 72% of patients were spared treatment. No patient with disease truly confined to the ovaries showed recurrence in spite of receiving no treatment. All patients with disease apparently confined to the ovaries should undergo a staging laparotomy. Only disease remote from the ovary need be treated. If a staging laparotomy is not done, treatment is recommended for apparent Stage I disease.

Peritoneoscopy in the management of ovarian cancer

The results obtained from the routine use of peritoneoscopy in the initial evaluation and follow-up of 99 patients with ovarian cancer treated at the National Cancer Institute between 1970 and 1978 have been analyzed. Prior to treatment, peritoneoscopy documented new sites of involvement undetected by conventional radiologic and isotopic procedures in 42 patients (48%) and provided the only evidence for follow-up of disease in 25 patients (28%). Twenty-one percent of patients referred with Stages I and II disease were upstaged to Stage III on the basis of diaphragmatic disease detected at peritoneoscopy. In the 66 restaging (posttreatment) peritoneoscopies, residual disease was found in 33 (50%) and peritoneoscopic findings provided the only evidence for disease in 24 cases (36%). These patients were spared an unnecessary second-look laparotomy. Twenty-two patients with negative peritoneoscopies underwent laparotomy. Residual ovarian cancer was found in 12 (55%), mainly in the pelvis and mesentery. Thus, a negative peritoneoscopy must be followed by a laparotomy before a patient with ovarian cancer can be considered disease free. Peritoneoscopy was found to be a safe and feasible procedure, even in patients who had prior laparotomies. It could not be performed for technical reasons in only 6% of the patients. There were few serious complications and in only 2.5% of the cases was medical therapy required to deal with a complication. There were no deaths or perforations of the viscus and no patient required surgical exploration because of a peritoneoscopy complication.

Surgery for common epithelial tumors of the ovary

The objectives of the initial surgical procedure in patients with common epithelial carcinomas of the ovary are determination of the intraabdominal extent of the cancer and the reduction of tumor masses to the smallest residuum before initiating further therapy. Since ovarian cancer is a disease of the entire abdominal cavity, biopsy of selected sites will often detect unsuspected involvement by microscopic foci of metastatic carcinoma. Tumor-reductive surgery resulting in a small tumor residuum before initiating chemotherapy is thought to improve the changes for inducing a complete response. The retroperitoneal operative approach enhances the surgeon's effort to remove tumor bulk. Between July 1, 1972, and September 1, 1978, 104 patients with FIGO Stage III or IV carcinomas of the ovary were treated with melphalan. The conditions of 38 patients were evaluated by second-look laparotomy. This analysis attempts to define tumor-reductive surgery and relates the outcome of the results of the operative procedure to patients treated with melphalan.

Carcinoma of the ovary--correlation of ultrasound with second look laparotomy

In a series of twenty-six patients with Stage III or IV carcinoma of the ovary, results of ultrasound examination of the pelvis and abdomen were correlated with second look laparotomy. All of these patients had responded clinically to a course of chemotherapy. Elective surgery was used to restage and debulk tumour. Ultrasound examination was done before surgery. Ultrasound was sensitive in detecting ovarian tumour in the pelvis and had an 84 per cent correlation with laparotomy. It was also sensitive in detecting liver and right diaphragmatic metastases with a 92 per cent correlation with the laparotomy findings. However, it consistently failed to detect intraperitoneal spread except when disease was gross or when it could be predicted by the presence of ascites. The correlation with laparotomy in this situation was only 36 per cent. This is to be expected as the size of most peritoneal deposits is below the resolution of ultrasound. These lesions, however, are easily detected by laparoscopy. These findings suggest that ultrasound has an important role in the management of advanced carcinoma of the ovary.