Surgical complications comparing extraperitoneal vs transperitoneal laparoscopic aortic staging in early stage ovarian and endometrial cancer

ObjectiveTo determine whether the extraperitoneal approach for paraaortic staging lymphadenectomy results in a lower rate of surgical complications compared to the transperitoneal approach, without compromising oncological outcomes.MethodsProspective randomized multicenter study of patients with early endometrial or ovarian cancer undergoing paraaortic lymphadenectomy in 2010–2019. Patients were randomized to minimally invasive surgery (laparoscopy or robotic-assisted) using an extraperitoneal or a transperitoneal approach. The primary end point measure was a composite outcome that included developing one or more of the following surgical complications: bleeding during paraaortic lymphadenectomy ≥500 mL, any intraoperative complication related to paraaortic lymphadenectomy, severe postoperative complication (Dindo ≥ IIIA), impossibility to complete the procedure, or conversion to laparotomy.ResultsThere were 103 patients in the extraperitoneal group and 100 in the transperitoneal group. Differences in the composite outcome (transperitoneal 26.0% vs, extraperitoneal 18.4%; P = 0.195) were not found. Differences in the operative time, conversion to laparotomy, intraoperative bleeding, or survival were not observed. A higher number of lymph nodes were retrieved through the extraperitoneal approached (median, interquartile range [IQR] 12 [7–17] vs, 14 [10–19]: P = 0.026). Older age and greater body mass index (BMI) or waist-to-hip ratio (WHR) increased the risk for surgical complications independently of the laparoscopic approach.ConclusionsThe extraperitoneal approach did not show differences regarding surgical and oncological parameters compared with the transperitoneal approach, although the number of aortic nodes retrieved was higher. The decision to use one or another laparoscopic route is a matter of the surgeon preference.Trial registration ClinicalTrials.gov.identifier: NCT02676726     

早期卵巢上皮性癌保留生育功能治疗

随着肿瘤发病年龄的年轻化，如何保留肿瘤患者生育功能已成为肿瘤治疗中的热点问题。卵巢癌是最常见的妇科恶性肿瘤之一，育龄期早期卵巢上皮性癌患者保留生育功能治疗日益受到关注。文章对早期卵巢上皮性癌患者保留生育功能相关问题进行阐述。     

Surgical management of epithelial ovarian cancer

Ovarian cancer affects approximately 21,880 women and accounts for over 13,000 deaths annually in the United States. Although survival rates have improved over the past several decades, directly as a result of advances in chemotherapy and surgery, ovarian cancer continues to have high mortality rates. Understanding the multiple roles of surgery throughout the disease course is the focus of this review.     

Surgical staging for epithelial ovarian tumors of low malignant potential

From January 1975 to December 1991, 34 patients with a diagnosis of epithelial ovarian tumors of low malignant potential (LMP) were admitted to the Istituto Nazionale Tumori of Milan. Eighteen of them (group 1) underwent complete staging laparotomy and retroperitoneal para-aortic and pelvic lymphadenectomy, as for ovarian cancer. In the remaining 16 cases (group 2), the surgical treatment ranged from unilateral oophorectomy to incomplete staging procedure. In group 1, nine patients (50%) were found to have retroperitoneal nodal involvement. In group 2, all patients had stage I disease. Patients were followed up for 20–222 months (mean 108, median 86). There were two recurrences in group 2 (after 5 years) and none in group 1 (NS). Currently all patients are alive and disease free. Nine of 18 group 1 patients were upstaged to stage III on the basis of lymph node involvement only. However, at least in this retrospective series, lymph node metastases did not affect prognosis or survival.     

Laparoscopic surgical staging of early ovarian cancer

Since its advent in the early 1990s, laparoscopic surgical staging for early ovarian cancer has been explored as an option with the potential to offer women equivalent cancer control and survival as provided by laparotomy but with the clear benefits of minimally invasive surgery. A limited but expanding body of literature suggests aggressive surgical staging can be performed with equivalent tissue assessment compared with laparotomy. Given the lack of randomized, controlled trials, the risks and benefits of such a procedure remain ambiguous. This review summarizes the current body of literature regarding the role of laparoscopy in upfront surgical staging of ovarian cancer. This review presents the history, rationale, and established benefits and risks of utilizing this approach in women who present with malignancy that appears confined to the ovary. Although retrospective data confirm the feasibility, safety, and efficacy of laparoscopic staging of early ovarian cancer, more prospective data will be required to confirm equivalent survival in a patient population that has the potential to be cured.     

Surgical and survival outcomes of laparoscopic staging surgery for patients with stage I ovarian cancer

Objective

To assess the feasibility and survival outcomes of laparoscopic staging for patients with stage I ovarian cancer.

Prognostic factors of stage IV epithelial ovarian cancer: a multicenter retrospective study

OBJECTIVE: In the present study, we conducted a multicenter retrospective analysis to elucidate the prognostic factors of stage IV epithelial ovarian cancer. METHODS: In November 1999, 24 Japanese institutions received questionnaires regarding stage IV epithelial ovarian cancer patients. Eligibility criteria included all patients with stage IV epithelial ovarian cancer who were surgically confirmed and initially treated in each institution between January 1990 and December 1997. Data were collected regarding age, performance status, tumor histologic subtype, site of metastasis, preoperative CA125, cytoreductive surgery, residual disease after cytoreductive surgery, and response to primary chemotherapy. Survival analysis and comparisons were performed by univariate and multivariate methods. RESULTS: Two hundred twenty-five patients with stage IV ovarian cancer were identified. The median age of the patients was 54 years. The most common site of extraperitoneal disease was malignant pleural effusion (39.6%). Of the 225 patients who underwent an attempt at surgical debulking, 70 (31.1%) were optimally cytoreduced. Most patients received platinum-based combination chemotherapy for primary chemotherapy. In multivariate analysis, performance status, histology, and residual disease after cytoreductive surgery were independent prognostic predictors of outcome. The overall median survival for optimally debulked patients was 32 months compared to 16 months for suboptimally debulked patients (P < 0.0001, hazard ratio: 0.415). CONCLUSION: Optimal surgical debulking, performance status, and histology appear to be important prognostic factors of survival in patients with stage IV epithelial ovarian cancer.     

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.     

Reflections on the FIGO surgical staging of invasive epithelial ovarian cancer

The main aims and requirements of any staging system are: to determine the anatomical extent of disease, to allow uniform reporting of treatment results, comparison of their efficacy and pooling of data from various institutions. It should be based on the mode of spread of the neoplasm, take into consideration prognostic risk factors and be of prognostic value. A critical review of the FIGO staging system for ovarian carcinoma indicates that these aims and requirements are not entirely fulfilled. Following are some examples. It does not include exact recommendations for comprehensive surgical staging in apparently early ovarian cancer and staging is therefore not performed uniformly. The presence of parenchymal liver and lung metastasis may be facilitated by modern imaging devices. However, according to FIGO rules only simple X-ray procedures are allowed preoperatively. The correlation between increasing stage and survival is inconsistent and sometimes contrary to that expected. Many known prognostic factors are not included in the present staging system. Although the aims of data pooling and of uniform reporting of treatment results have been achieved, the validity of some comparisons are questionable in view of the variations in staging. The intent of this review was not to belittle the major contribution of staging to research, understanding and management of ovarian carcinoma, but to highlight its deficiencies. New data have accumulated since the FIGO staging system of ovarian carcinoma has been adopted and should prompt consideration of modifications such as incorporation of modern diagnostic procedures and of some established prognostic markers and reshuffling of certain substages.     

Laparoscopic staging of apparent early stage ovarian cancer: Results of a large,retrospective, multi-institutional series

ObjectiveThe aim of this study is to analyze the safety, adequacy, perioperative and survival figures in a large series of laparoscopic staging of patients with apparent early stage ovarian malignancies (ESOM).Patients and methodsRetrospective data from seven gynecologic oncology service databases were searched for ESOM patients undergoing immediate laparoscopic staging or delayed laparoscopic staging after an incidental diagnosis of ESOM.Between May 2000 and February 2014, 300 patients were selected: 150 had been submitted to immediate laparoscopic staging (Group 1), while 150 had undergone delayed laparoscopic staging (Group 2) of ESOM. All surgical, pathologic, and oncologic outcome data were analyzed in each group and a comparison between the two was carried out.ResultsLonger operative time, higher blood loss, more frequently spillage/rupture of ovarian capsule and conversion to laparotomy occurred in Group 1. No significant differences of post-operative complications were observed between the two groups. Histological data revealed more frequently serous tumors (0.06), Grade 3 (p = 0.0007) and final up-staging (p = 0.001) in Group 1. Recurrence and death of disease were documented in 25 (8.3%), and 10 patients (3.3%%), respectively. The 3-year disease free survival (DFS) and overall survival (OS) rates were 85.1%, and 93.6%, respectively in the whole series. There was no difference between Group 1 and Group 2 in terms of DFS (p value = 0.39) and OS (p value = 0.27).ConclusionIn this very large multi-institutional study, it appears that patients with apparent ESOM can safely undergo laparoscopic surgical management.     

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.